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[This corrects the article DOI: 10.1016/j.jointm.2025.08.011.].
Individual differences exist in the recovery of muscle strength in critically ill patients with intensive care unit (ICU)-acquired weakness, but the characteristics of patients who do not recover muscle strength are unclear. To elucidate the factors associated with the nonrecovery of muscle strength in patients with ICU-acquired weakness. This prospective cohort study involved critically ill patients with ICU-acquired weakness. The patients' outcomes were categorized as recovery (Medical Research Council Sum Score [MRC-SS] ≥48 until hospital discharge or the time of stroke, death, or ICU readmission) or nonrecovery (MRC-SS <48). Separate logistic regression analyses adjusted for age and sex were performed for each candidate factor to identify factors associated with nonrecovery of muscle strength. A total of 111 patients were included in the analysis. Thirty patients were classified as having nonrecovery. Analysis using a logistic regression model showed that septic shock, duration of deep sedation, corticosteroid use, total amount of corticosteroids used, duration of mechanical ventilation, duration of renal replacement therapy, day of first out-of-bed mobilization, initial evaluation of MRC-SS, and length of ICU stay were age- and sex-adjusted predictors of nonrecovery of muscle strength. Patients with ICU-acquired weakness with the predictors identified in this study may not recover muscle strength. Future multicenter interventional studies should assess not only the timing of rehabilitation but also its intensity and the muscle groups specifically targeted.
Individuals with chronic kidney disease (CKD) are disproportionately admitted to the intensive care unit (ICU); however, the association between CKD severity and outcomes after ICU admission remains uncertain. To evaluate the association between CKD severity and health outcomes after ICU admission. This population-based cohort study was conducted from November 1, 2008, to February 28, 2021. Participants included 531 090 consecutive adult (≥18 years) residents of Ontario, Canada, admitted to an ICU during the study period who had a baseline outpatient serum creatinine measurement within 7 to 365 days prior to admission. Statistical analyses were conducted from July 23, 2025, to April 16, 2026. CKD severity was classified according to the baseline outpatient estimated glomerular filtration rate (eGFR) Kidney Disease Improving Global Outcomes criteria. Mortality (ICU, hospital, and 90-day mortality) and kidney replacement therapy (KRT) requirement in the ICU and dependence at 90 days. The study included 531 090 adults (mean [SD] age, 67 [15] years; 57% men) admitted to the ICU. One in 4 individuals had preexisting CKD: stage 3a CKD, eGFR 45 to 59 mL/min/1.73 m2 (12% of adults); stage 3b CKD, eGFR 30 to 44 mL/min/1.73 m2 (7% of adults); stage 4 CKD, eGFR 15 to 29 mL/min/1.73 m2 (3% of adults); non-dialysis-dependent stage 5 CKD, eGFR less than 15 mL/min/1.73 m2 (1% of adults); and undergoing maintenance dialysis (2% of adults). Compared with individuals without CKD, the severity of the disease among individuals with CKD was progressively associated with increased mortality risk up to non-dialysis-dependent stage 5 CKD. However, the risk of mortality was lower for individuals receiving maintenance dialysis (odds ratio [OR], 1.92 [95% CI, 1.82-2.04]) compared with those with non-dialysis-dependent stage 5 CKD (OR, 2.32 [95% CI, 2.14-2.52]). Risk for KRT initiation in the ICU increased with CKD severity relative to individuals without CKD: stage 3a (adjusted OR [AOR], 1.79 [95% CI, 1.68-1.90]), stage 3b (AOR, 3.02 [95% CI, 2.83-3.22]), stage 4 (AOR, 6.71 [95% CI, 6.23-7.22]), and non-dialysis-dependent stage 5 (AOR, 32.00 [95% CI, 29.07-35.22]). Among those who initiated KRT in the ICU and survived to 90 days, KRT dependence at day 90 increased progressively by CKD stage: no CKD, 7.2%; stage 3a, 14.2%; stage 3b, 22.5%; stage 4, 50.3%; and previously non-dialysis-dependent stage 5, 83.8%. In this cohort study of consecutive adults admitted to the ICU, the presence and severity of CKD were associated with adverse health outcomes. These findings can inform risk prognostication, discussions about goals of care, resource allocation, and health policy initiatives for this large portion of the ICU population.
Intensive care following resuscitation from out-of-hospital cardiac arrest (OHCA) is based on a set of interventions, all of which are intended to reduce anoxic brain injury and improve outcomes, including sedation, mechanical ventilation, circulatory optimization, and temperature control protocols. The backrest position impacts intracranial pressure and cerebral blood flow in traumatic brain injury, and the optimal position for improving outcomes after OHCA is unknown; guidelines advocate for an elevated backrest position. This trial compared outcomes of two backrest positions. The Danish Out-of-Hospital Cardiac Arrest (DANOHCA) trial is an investigator-initiated, multicenter, randomized, controlled trial evaluating four interventions, including two different backrest positions, for improving outcomes. Comatose adult patients with OHCA of presumed cardiac cause and sustained return of spontaneous circulation will be included. Patients were randomized 1:1 to a backrest positioned at 5° or 35° straight elevation of backrest in the Semi-Fowler's position (elevated lower limb position) during the initial 72 h or until extubation. The primary outcome was mortality within 90 days of cardiac arrest. Inclusion began in June 2023, and the study aims to include 1000 patients from five sites over an estimated time period of 3-4 years. Kaplan-Meier curves with Cox regression will be used for statistical analyses. The trial is registered at clinicaltrials.gov (identifier: NCT05895838) and euclinicaltrials.eu (2024-515997-28-00). Post-resuscitation care of comatose cardiac arrest is complex, and each part should be tested in randomized trials. This part of the DANOHCA trial will provide evidence on one of these factors, namely position of the patients' head relative to the heart. EudraCT number 2016-003265-26; EU CTIS no 2024-515997-28-00; ClinicalTrials.gov identifier: NCT05895838.
The optimal timing for post traumatic Chest Wall Reconstruction (CWR) in severely injured / polytraumatized patients with severe chest wall instability remains a subject of debate. While early surgery within 72 h is associated with improved outcomes, the efficacy and safety of an even earlier "rapid sequence" approach on the day of admission are unclear. This study aims to compare outcomes of severely injured patients undergoing rapid sequence surgery (Day 0) versus early surgery (Days 1-3). A retrospective analysis was conducted using data from the TraumaRegister DGU® (2015-2023). Patients with serious chest wall injuries (AISThorax ≥3), an Injury Severity Score (ISS) ≥ 9, who survived the first 48 h and underwent CWR were included. Patients were stratified into a "Rapid Sequence" group (surgery on Day 0) and an "Early" group (surgery on Days 1-3). Propensity score matching (PSM) was performed to balance baseline characteristics, including injury patterns, demographics, and initial physiological status. Primary outcome was in-hospital mortality. Secondary outcomes included sepsis, multi-organ failure (MOF), and length of stay. From an initial cohort of 34,659 patients with severe chest wall injuries, 2,498 operatively treated patients with a known date of surgery were analyzed. 1,168 (46.8%) underwent rapid sequence surgery (Day 0) and 567 (22.7%) underwent early surgery (Days 1-3). Before matching, the Rapid Sequence group had a higher ISS (27.7 vs. 26.0), a higher incidence of severe head trauma (14.4% vs. 9.2%), and significantly higher mortality (8.4% vs. 4.1%). PSM yielded 500 matched pairs. Despite matching, the Rapid Sequence group retained a higher baseline injury burden (mean ISS: 28.1 vs. 26.2; mortality prognosis (Revised Injury Severity Classification, Version III (RISC III) Score): 16.2% vs. 10.7%). The primary outcome showed a nearly threefold higher mortality rate in the Rapid Sequence group (10.6% vs. 3.6%; p < .001). Rates of sepsis (14.6% vs. 12.0%) and MOF (33.6% vs. 28.3%) were also higher in the rapid group, though not statistically significant. In this large registry analysis, rapid sequence CWR on the day of admission identified a distinct subgroup of patients with more severe concomitant injuries and higher baseline risk. The higher mortality in this group likely reflects residual confounding by indication and survivorship bias, rather than a detrimental effect of rapid surgery per se. This suggests that the decision for immediate surgery is likely driven by life-threatening concomitant injuries not fully captured in the matching model, identifying a patient population with an intrinsically higher risk of death. Our findings therefore do not justify a blanket Day-0-for-all strategy, but are consistent with the broader literature suggesting that CWR performed within 72 h is beneficial when timing is individualized to overall injury severity and physiological stability.
Objective: To explore the perinatal outcomes and cost-effectiveness of posterior uterus approach combined with vascular occlusion in placenta percreta (PP). Methods: This study was a retrospective cohort study. Clinical data of 475 pregnant women with PP from six tertiary medical centers in China from January 2018 to April 2023 were collected. After propensity score matching, 324 pregnant women were included and divided into study group (posterior uterus approach combined with vascular occlusion, 162 cases) and control group (abdominal aortic balloon occlusion, 162 cases). The baseline characteristics, maternal and neonatal outcomes [including hysterectomy rate, intraoperative blood loss, blood transfusion rate, length of hospital stay, intensive care unit (ICU) transfer rate] and hospitalization costs were compared between the two groups. Incremental cost-effectiveness ratio (ICER) was used for cost-benefit analysis, and the willingness-to-pay threshold was set at 1 times of gross domestic product per capita in 2023 (CNY 91 700.0). Results: There were no significant differences in baseline characteristics of PP pregnant women between the two groups after matching. The hysterectomy rate (46.9% vs 16.1%), intraoperative blood loss (median: 1 450 vs 800 ml) and blood transfusion rate (77.8% vs 47.5%) in the study group were significantly higher than those in the control group, and the hospital stay was longer (median: 10 vs 7 days). However, the rate of postoperative ICU transfer (3.7% vs 13.6%) and secondary operation (0.0% vs 7.4%) in the study group were significantly lower than those in the control group (all P<0.05). There was no maternal death in the two groups, and there were no statistically significant differences in the incidence of urinary system injury, thrombosis and infection between the two groups (all P>0.05). The rate of neonatal intensive care unit (NICU) admission in the study group was significantly higher than that in the control group (50.6% vs 28.4%, P<0.001). In terms of hospitalization costs, the total hospitalization costs of the study group were significantly lower than those of the control group (median: CNY 29 361.8 vs 35 704.3, P<0.001). Cost-benefit analysis showed that taking non-ICU hospitalization as the effectiveness index, the cost of avoiding one case to be transferred to ICU in the study group was lower than that in the control group (CNY 29 996.5 vs 38 372.8), and the ICER was CNY 84 780.5, which was lower than the willingness-to-pay threshold, and the study group had economic advantages. Conclusions: It is effective for treating PP in posterior uterus approach combined with vascular occlusion. Although it is associated with higher hysterectomy rates and greater blood loss, it is relatively simpler to perform, and results in lower total hospitalization costs. It is suitable for areas with limited medical resources. 目的： 探讨经子宫后路修补术联合止血带血管阻断术用于治疗穿透型胎盘植入（PP）孕妇的母儿结局及成本效益。 方法： 本研究为回顾性队列研究，收集2018年1月至2023年4月期间来自中国6家三级医疗中心的475例PP孕妇的临床资料。经过倾向性评分匹配后，共纳入324例孕妇，分为研究组（经子宫后路修补术联合止血带血管阻断术，162例）和对照组（腹主动脉球囊阻断术，162例）。比较两组孕妇的基线特征、母儿结局［包括子宫切除率、术中出血量、输血率、住院时间、转入重症监护病房（ICU）率］及住院费用。采用增量成本效益比（ICER）进行成本效益分析，支付意愿阈值设定为2023年人均国内生产总值的1倍（91 700.0元）。 结果： 匹配后研究组与对照组PP孕妇的基线特征分别比较，差异均无统计学意义（P均>0.05）。研究组与对照组比较，子宫切除率（分别为46.9%、16.1%）、术中出血量（中位数分别为1 450、800 ml）和输血率（分别为77.8%、47.5%）均较高，住院时间也更长（中位数分别为10、7 d），但研究组与对照组比较，术后转入ICU率（分别为3.7%、13.6%）和二次手术率（分别为0.0%、7.4%）均较低（P均<0.05）。两组均无孕产妇死亡，两组的泌尿系统损伤、血栓及感染发生率分别比较，差异均无统计学意义（P均>0.05）。研究组新生儿转入新生儿重症监护病房（NICU）率显著高于对照组（分别为50.6%、28.4%，P<0.001）。住院费用方面，研究组总住院费用显著低于对照组（中位数分别为29 361.8、35 704.3元，P<0.001）。成本效益分析显示，以非ICU住院作为有效性指标，研究组避免1例转入ICU的成本比对照组低（分别为29 996.5、38 372.8元），ICER为84 780.5元，低于支付意愿阈值，研究组更具经济优势。 结论： 经子宫后路修补术联合止血带血管阻断术是治疗PP的有效方法，虽然子宫切除率和术中出血量较高，但操作相对简便，费用更低，适用于医疗资源有限的地区。.
ObjectivePediatric head trauma is common, but computed tomography exposes children to ionizing radiation. This systematic review and meta-analysis evaluated the diagnostic accuracy of point-of-care ultrasound for pediatric skull fractures and clarified its role as an adjunct to clinical assessment rather than a replacement for computed tomography when intracranial injury is suspected.MethodsWe conducted a systematic review and bivariate random-effects diagnostic test meta-analysis guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement and registered in the International Prospective Register of Systematic Reviews (Registration Number: CRD420251139217). PubMed, Embase, the Cochrane Library, and Web of Science were searched from inception through 3 September 2025. Two reviewers independently screened studies, extracted 2 × 2 diagnostic data, and assessed risk of bias using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.ResultsNine studies conducted in emergency department settings met the inclusion criteria. Point-of-care ultrasound demonstrated a pooled sensitivity of 0.90 (95% confidence interval: 0.84-0.94), specificity of 0.98 (95% confidence interval: 0.94-0.99), and an area under the summary receiver operating characteristic curve of 0.96 (95% confidence interval: 0.94-0.97). The summary positive likelihood ratio was 41.73 (95% confidence interval: 15.85-109.87), and the negative likelihood ratio was 0.10 (95% confidence interval: 0.07-0.17). Deeks' funnel plot showed no evidence of small-study effects (P = 0.80).ConclusionsPoint-of-care ultrasound shows high diagnostic accuracy for detecting pediatric skull fractures and may support bedside risk stratification in selected children with low- or intermediate-risk mild head trauma. However, most isolated linear skull fractures are managed conservatively, and point-of-care ultrasound does not evaluate intracranial injury. Computed tomography decisions should therefore remain anchored in neurological status, injury mechanism, validated pediatric head injury decision rules, and clinician judgment.
SLE is a heterogeneous systemic autoimmune disease with diverse clinical manifestations. We aimed to identify clinical subgroups of SLE patients using cluster analysis at diagnosis and at the last follow-up and to evaluate their prognostic implications for disease activity, organ damage and mortality. In this single-centre retrospective cohort study, 199 patients with SLE who fulfilled the 1997 American College of Rheumatology (ACR) classification criteria and were regularly followed at the Rheumatology Clinic of Kocaeli University Hospital were included. Patients were divided into clusters based on their clinical involvement at diagnosis and the last visit using the Gower distance and the Partitioning Around Medoids algorithm. Differences between clusters were assessed using one-way analysis of variance, Kruskal-Wallis and χ2 analyses. Analyses were performed using SPSS V.29.0 (IBM Corp, Armonk, New York, USA) and R V.4.3.0. At diagnosis, three clusters were identified: Cluster 1 (n=108) with predominant arthritis; Cluster 2 (n=49) with renal and haematological involvement and highest disease activity (SLE Disease Activity Index 2000, p=0.004); Cluster 3 (n=42) with mucocutaneous manifestations, often accompanied by haematological involvement. After a median follow-up of 168 months, four clusters were identified. Cluster 4', a heterogeneous group with mucocutaneous, articular and renal involvement, had significantly higher Systemic Lupus International Collaborating Clinics (SLICC)/ACR Damage Index (SDI) scores (median 4.0 (0-8), p<0.001), indicating poor prognosis. During follow-up, 29.6% of Cluster 1, 22.4% of Cluster 2 and 42.9% of Cluster 3 transitioned to Cluster 4'. Patients with mucocutaneous-predominant disease at diagnosis had a twofold increased risk of transitioning to the poor-prognosis cluster (OR 2.05, 95% CI 1.01 to 4.16, p=0.046). Mortality did not differ significantly between clusters. Cluster analysis based on clinical involvement in SLE can identify homogeneous patient subgroups and predict long-term outcomes. Patients with mucocutaneous-predominant onset, often receiving less intensive treatment, may have a worse prognosis, highlighting the importance of individualised monitoring and management strategies.
The cardiovascular intensive care unit (CVICU) presents unique opportunities and challenges for integrating palliative care. A growing population of patients living longer with advanced cardiac disease, persistent symptoms, and functional limitations may benefit from early palliative involvement. With increasing use of advanced therapies such as mechanical circulatory support, many patients die in the CVICU, while survivors often experience long-term physical and psychosocial burdens. Despite evidence that early palliative care improves quality of life and reduces nonbeneficial interventions, it remains underutilized because of prognostic uncertainty and inconsistent referral guidance. This review explores therapies, palliative roles, and end-of-life practices in the CVICU.
Early identification of pediatric trauma patients at high risk of mortality remains challenging despite advances in critical care management. Systemic inflammatory response and subsequent organ dysfunction play a central role in trauma-related mortality. Recently, the lactate/albumin ratio (LAR) and inflammatory biomarkers such as the neutrophil-to-lymphocyte ratio (NLR) have emerged as potential prognostic indicators; however, their independent predictive value in pediatric trauma remains incompletely defined. In this retrospective cohort study, 272 pediatric trauma patients admitted to a tertiary pediatric intensive care unit (PICU) were screened. After excluding 28 patients who died within the first 24 h and 34 patients with incomplete laboratory data, 210 patients were included in the final analysis. Demographic, clinical, and laboratory parameters were collected at admission. The primary outcome was in-hospital mortality. Receiver operating characteristic (ROC) curve analysis and multivariable logistic regression were performed to evaluate independent predictors of mortality. Among 210 patients, 27 (12.9%) died during PICU stay. Non-survivors had significantly higher PRISM III scores and prolonged mechanical ventilation duration. LAR demonstrated the highest discriminatory performance for mortality (AUC 0.918, 95% CI: 0.839-0.978), followed by NLR (AUC 0.900) and PRISM III score (AUC 0.884). In multivariable analysis, LAR emerged as a prominent independent predictor of mortality (OR 12.22, 95% CI: 3.08-48.49, p < 0.001), while NLR and PRISM III score remained independently associated with adverse outcomes. The lactate/albumin ratio was independently associated with in-hospital mortality and improved risk discrimination when added to PRISM III in this selected cohort of pediatric trauma patients. As a simple and readily available biomarker, LAR may complement established severity scoring systems and support early risk stratification, although external validation is required before clinical application. • Serum lactate and inflammatory indices such as the neutrophil-to-lymphocyte ratio are associated with poor outcomes in pediatric trauma, but their independent prognostic value is incompletely defined. • Established severity scores like PRISM III predict mortality but may not fully capture the combined effects of tissue hypoperfusion and inflammation. • The lactate/albumin ratio independently predicted in-hospital mortality and showed the highest discrimination (AUC 0.918) among tested markers in PICU-admitted pediatric trauma patients. • Adding the lactate/albumin ratio to PRISM III improved risk discrimination, supporting its role as a simple adjunct forearly stratification pending external validation.
Hemoadsorption is considered currently as an adjunct therapy for the treatment of rhabdomyolysis and acute kidney injury (AKI) although the exact timing is not yet determined. We hypothesised that earlier start of hemoadsorption in patients with ischemia/reperfusion caused rhabdomyolysis and AKI leads to a better clinical improvement and recovery of kidney function. We conducted a single-center, retrospective cohort study. Treatment was defined as the use of hemoadsorption with CytoSorb® in combination with continuous renal replacement therapy (CRRT) compared to patients who were treated only with CRRT. Patients were divided in early and late initiation of hemoadsorption subgroups by less or more than 12 hours after developing acute kidney injury. Myoglobin and creatine kinase plasma levels were measured shortly before, 12 hours after the start of treatment, and 24, 48, and 72 hours after initiation. The follow-up lasted until the last enrolled patient reached 60 days after first hemoadsorption procedure. Overall, 30 patients were included in the treatment arm and 25 patients in the control group. Significant decrease of myoglobin levels was observed in the hemoadsorption treated group in all time points when compared with the control group. Logistical regression analysis found the association of hemoadsorption use and shorter duration of AKI (OR 3.46) and less acute kidney disease (AKD) (OR 2.85). Earlier start of hemoadsorption was associated with a statistically significant shorter duration of AKI (OR 3.22) and less AKD (OR 3.10). Patients treated early with hemoadsorption survived significantly longer than patients treated late (49.2 vs 15.3 days; p < 0.001). Early start of combined CRRT and hemoadsorption therapy with CytoSorb was safe and associated with improved kidney recovery and survival in patients with ischemic/reperfusion rhabdomyolysis and AKI. Early start of hemoadsorption might prevent renal failure and acute kidney disease and shorten the CRRT dependency in patients who develop AKI.
Hemodynamic management after out-of-hospital cardiac arrest (OHCA) is critical, yet the impact of vasopressor-driven mean arterial pressure (MAP) targets on pulmonary circulation and right ventricular (RV) function remains unclear. In this substudy of the randomized, double-blinded BOX trial, comatose OHCA survivors were allocated to low (63 mmHg) or high (77 mmHg) MAP targets. Pulmonary artery catheters (PAC) were used for serial hemodynamic assessment for 48 h after Intensive Care Unit admission. The primary endpoint was calculated pulmonary vascular resistance (PVR), secondary endpoints included pulmonary capillary wedge pressure (PCWP), pulmonary artery pulsatility index (PAPi), and RV cardiac power output (RV-CPO)-a measurement of RV pumping function. Among 730 included patients (median time randomization to PAC insertion 1.3 h), mPAP was consistently higher in the high-MAP group (mean difference 1.11-1.71 mmHg, 95% CI range 0.12-2.59). Calculated PVR was transiently lower in the high-MAP group during the first 24 h (mean difference -0.16 to -0.30, 95% CI range -0.31 to 0.11), before converging between groups. RV-CPO was lower in the low-MAP group throughout the observation period (mean difference 0.01-0.04 W [95% range 0.00-0.07], with the largest difference at 48 h. PCWP decreased in both groups but was significantly lower in the low-MAP group during the first 12 h (mean difference 1.06-1.40 mmHg, 95% CI range 0.25-2.38). In comatose OHCA survivors, targeting a higher MAP increased pulmonary artery pressures, PCWP, RV-CPO, heart rate, and cardiac output. The proportionally greater increase in cardiac output over pulmonary artery pressures resulted in a decreased calculated PVR. ClinicalTrials.gov identifier: NCT03141099. In this secondary analysis of a subgroup in the BOX out of hospital cardiac arrest treatment trial for oxygen level targets, blood pressure treatment target levels, higher or lower were analyzed, including central circulatory outcomes, using a pulmonary artery catheter. The higher blood pressure target group had accompanying higher pulmonary artery pressures and cardiac output, with initially a small reduction in calculated pulmonary vascular resistance.
Acute kidney injury (AKI) is frequent and influences the prognosis of intensive care unit (ICU) patients. AKI may be categorised as contrast-associated AKI (CA-AKI). We investigated the development of CA-AKI, including temporal and dose-response relationships. Adult patients admitted between 2010 and 2015 with a minimum ICU stay of 54 h were eligible for inclusion. AKI was scored on an hourly basis to enable temporal analyses. CA-AKI was defined as an increase in Kidney Disease: Improving Global Outcomes (KDIGO) AKI stage occurring within 48 h of contrast media administration. For the matched analysis, contrast-exposed patients were matched to unexposed patients on duration of stay and renal function. Of 1057 patients, 277 patients were exposed to contrast media. Sixteen percent (n = 43) developed CA-AKI (KDIGO AKI stage 1/2/3: 63%/23%/14%). AKI preceded contrast in 76.2% of cases (95% confidence interval [CI]: 66%-85%, p < 0.001). After contrast exposure, AKI reversal occurred in 65 cases. The proportion of CA-AKI was similar between dose quartiles (p = 0.746). The length of ICU stay (length of stay [LOS]) was longer in the exposed group (10.9 vs. 5.5 days, p < 0.001) regardless of CA-AKI status. In the matched analysis, exposed patients had longer remaining LOS (mean difference 1.47 days, 95% CI: 1.35-1.60) and higher ICU mortality (OR: 1.67, 95% CI: 1.1-2.6), but use of renal replacement therapy (RRT) was similar. CA-AKI was observed in one of six ICU patients exposed to contrast media and associated with higher mortality and ICU LOS. However, AKI most often precedes contrast. AKI reversal was more common than AKI following exposure. No clear evidence of a dose-response relationship was found. The findings question whether AKI in an ICU population is related to contrast media exposure, but the observational design precludes ruling out contrast media as a cause of AKI. This ICU cohort analysis presents kidney injury findings where there is intravenous contrast exposure. Where some kidney injury was sometimes present before contrast exposure, this makes exploring the relation of contrast to injury and recovery more complex.
To evaluate the cost-effectiveness of implementing an extracorporeal cardiopulmonary resuscitation (ECPR) strategy for refractory out-of-hospital cardiac arrest (OHCA) compared with current practice in Singapore, where it is not routinely used. We performed a simulation-based cost-effectiveness analysis using a decision tree to model acute phase and a Markov model for long-term outcomes over a lifetime horizon, from a healthcare provider perspective. Singapore healthcare system. Nontraumatic adult OHCA patients from Singapore with initial shockable rhythm and no prehospital return of spontaneous circulation were analyzed. We modeled the implementation of an ECPR strategy and compared it with current practice using only conventional cardiopulmonary resuscitation. Transition probabilities of existing practice were derived from the nationwide Singapore OHCA registry (Pan-Asian Resuscitation Outcomes Study: PAROS), (2010-2016), while ECPR outcomes were based on the Comprehensive Registry of Intensive Care for OHCA Survival in Osaka (Osaka CRITICAL study) (2012-2019). Costs and quality-adjusted life-years (QALYs) were compared between strategies, with scenario analyses conducted to assess the impact of lower age eligibility thresholds and increased transport time to extracorporeal membrane oxygenation-capable hospitals. Incremental cost-effectiveness ratios (ICERs) were estimated using a willingness-to-pay threshold of S$45,000 per QALY. A total of 1462 OHCA cases from Singapore were analyzed; the mean age of patients was 57 years (sd, 11 yr), and 87% were male. In base-case analysis, ICER was estimated at $34,320/QALY, with a positive net monetary benefit of $8,532. Scenario analyses demonstrated that an age-restricted ECPR strategy (< 65 yr) yielded a similar ICER ($33,469/QALY) to the base case. In contrast, incorporating a 10-minute transport extension slightly exceeded the willingness-to-pay threshold ($47,158/QALY). In this modeling study, adopting an ECPR strategy for OHCA in Singapore was likely to be cost-effective across different age-based eligibility thresholds; however, it was sensitive to delays in transport time. Further implementation research is important to guide scale-up and policy decisions.
Hand-Held Vital Microscopy (HVM) has been utilized in clinical investigations to measure microcirculation, providing valuable insights into the pathophysiology of critical illness and its treatment. However, its clinical implementation has been hampered by several shortcomings. These included the need for automatic analysis software, for instant image stabilization, and for information regarding microcirculatory oxygenation. The aim of this study is to describe an HVM which has realized these research objectives. This preclinical study introduces the OxyCam, a novel HVM device. OxyCam stabilizes images during recording and subsequently provides essential microcirculatory functional parameters through automatic analysis. Green and blue illuminated images, sequentially recorded and ratio imaged, allow calculation of the hemoglobin (Hb) oxygen saturation (µHbO2sat) of RBCs and are presented in pseudo color images. We validated the OxyCam on the hindlimb muscle of 9 male Wistar albino rats, mechanically ventilated at different levels of inspired oxygen (FiO2). Comparison was made between OxyCam-green and blue images and to its predecessor the Cytocam. OxyCam-generated µHbO2sat values were compared to HbO2sat fiber spectrophotometry (O2C). Green and blue illumination from the OxyCam yielded higher total vessel density (OxyCam green [31.4±4.3] mm/mm2; OxyCam blue [32.5±4.2] mm/mm2, Cytocam [28.5±3.6] mm/mm2) and functional capillary density (OxyCam green [25.4±6.4] mm/mm2; OxyCam blue [26.2±7.9] mm/mm2; Cytocam [23.0±4.5] mm/mm2) than the Cytocam images OxyCam-blue gave higher tissue RBC perfusion values (OxyCam green [55.3±18.0] µm/min; OxyCam blue [69.5±25.5] µm/min; Cytocam [58.3±15.3] µm/min) than the OxyCam-green or Cytocam images. OxyCam-blue and green images gave better image quality than the Cytocam images. µHbO2sat imaging with the OxyCam was validated by demonstrating expected changes in µHbsat during different FiO2 levels (100%, 60%, 21%, 0%). Furthermore, a correlation between the mean µHbO2sat of images and independently measured µHbsat by tissue spectrophotometry during different levels of FiO2 was found. Finally, µHbO2sat images in pseudo-color (red to blue) are shown for the individual microvessels at different FiO2 levels. The OxyCam has been validated for measuring tissue perfusion and oxygenation and can be considered for point-of-care diagnosis of the microcirculation at the bedside.
Background/Objectives: Early enteral nutrition (EN) initiation and progressive EN advancement are critical components of nutritional care in critically ill patients; however, not all patients achieve successful early EN advancement in real-world intensive care unit (ICU) settings. We investigated clinical predictors of early EN initiation and successful early EN advancement at ICU admission in a retrospective cohort study at a single tertiary academic medical center in South Korea. Methods: A total of 2112 critically ill adults receiving EN between January 2020 and December 2024 were included. Successful early EN advancement was defined as EN initiation within 48 h of ICU admission, followed by progressive advancement without any reduction or discontinuation during the subsequent seven days. Using a two-stage multivariable logistic regression approach, we identified predictors of each outcome. Results: Among the total cohort, 722 patients (34.2%) achieved early EN initiation, of whom 449 (62.2%) subsequently achieved successful early EN advancement, representing 21.3% of the total cohort. Male sex (adjusted odds ratio [aOR] 0.87, 95% CI 0.78-0.96), higher admission lactate (aOR 0.85, 95% CI 0.74-0.96), prior surgery (aOR 0.81, 95% CI 0.70-0.93), and higher APACHE II score (aOR 0.88, 95% CI 0.79-0.99) were identified as significant negative predictors (all p < 0.05). Admission-time variables (male sex, elevated lactate, prior surgery, and higher APACHE II scores) effectively identify patients at risk of early EN failure. Conclusions: Reflecting distinct predictor profiles between ICU types, the preliminary nomogram can guide tailored nutritional strategies, although prospective external validation remains essential before clinical implementation.
Aquaporin 5 (AQP5) is crucial for salivary secretion, composition and enamel mineralization. Genetic variations in AQP5 may influence susceptibility to dental diseases such as caries. This study investigated the association between AQP5 single nucleotide polymorphisms (SNPs), AQP5 mRNA expression, and caries severity in a dental practice cohort. A total of 246 patients were enrolled. Caries experience was assessed using the decayed, missing, and filled (DMF) index, and salivary AQP5 mRNA expression was quantified by RT-qPCR. Genotyping included rs2878771, rs296763, rs3736309, and rs3759129. Statistical analyses comprised Chi-square testing, ROC analysis with Youden Index determination, and binary logistic regression adjusted for age and sex. The A allele of rs3736309 was associated with an increased risk of severe caries, particularly in patients over 60 years of age. AQP5 mRNA expression was higher in individuals with severe caries and in carriers of the C allele of rs2878771. ROC analysis identified an AQP5 expression cut-off (0.11274) that discriminated between severe and non-severe caries (AUC = 0.578, p = 0.048). Logistic regression confirmed AQP5 expression as an independent predictor of severe caries (p = 0.005). AQP5 expression and genetic variation appear to contribute to caries susceptibility in an age-dependent manner with moderate effects. The intronic variant rs3736309 was associated with caries severity. The biological mechanisms underlying this association remain unclear and require functional investigation. These findings support a potential role of AQP5 as an exploratory biomarker candidate for caries risk, particularly in elderly individuals.Trial registration: German Clinical Trial Registry No. DRKS00032425, date of registration: 2023-08-16.
What are the measurement properties of the Chelsea Critical Care Physical Assessment tool (CPAx) for evaluating physical function and activity for rehabilitation of patients who are critically ill? A systematic search was conducted in five databases to 12 January 2026. Two reviewers independently screened studies, extracted data and assessed quality for each measurement property (COSMIN Risk of Bias checklist); quality of each available measurement property was independently evaluated by any two reviewers who judged the quality as very good, adequate, doubtful or inadequate. Data were synthesised according to COSMIN guidelines, with random-effects meta-analyses for intraclass correlation coefficients (ICCs). Pooled results were rated and the evidence graded as very low, low, moderate or high quality. 27 studies investigated 71 measurement properties (inadequate to very good). The CPAx was feasible, with small floor and ceiling effects across the trajectory of recovery. Content validity was high (pooled index 0.94; high-quality evidence). The CPAx demonstrated excellent inter-rater reliability (pooled ICC 0.99, 95% CI 0.98 to 1.00, six studies, high-quality evidence), intra-rater reliability (ICC 0.95, 95% CI 0.82 to 0.97, one study, low-quality evidence) and acceptable standard error of measurement (pooled SEM 1.36, five studies) corresponding to a smallest detectable change of 3.76 (sufficient rating, high-quality evidence). Construct validity was supported with 26 out of 34 predefined hypotheses accepted (76%, sufficient, 10 studies, moderate-quality evidence) and responsiveness with five out of six predefined hypotheses accepted (83%, sufficient, five studies, very low-quality evidence). Moderate- to high-quality evidence indicates that the CPAx is a valid and reliable instrument for evaluating physical function and activity of critically ill patients. Further research is needed to evaluate responsiveness. PROSPERO CRD420250655518.
Chest radiography remains central to post-procedural assessment of central venous catheter (CVC) placement in intensive care units. Multimodal large language models (MLLMs) can process medical images, but their reliability for practical radiography tasks remains uncertain. This study assessed the diagnostic performance of MLLMs and intensivists for CVC access classification, CVC tip assessment, and pneumothorax-related radiographic findings. In this retrospective diagnostic performance study, consecutive portable anteroposterior chest radiographs obtained after CVC placement in adult critically ill patients were independently evaluated by four intensivists and five MLLMs. A radiologist consensus served as the reference standard. Interobserver agreement and diagnostic performance were assessed using Fleiss' kappa, Gwet AC1, Cohen's kappa, accuracy, sensitivity, specificity, precision, F1 score, balanced accuracy, and Matthews correlation coefficient. The final cohort included 183 unique radiographs. Intensivist reviewers showed high performance for CVC access classification but lower and more heterogeneous performance for CVC tip-position assessment. Among MLLMs, CVC access accuracy ranged from 0.339 to 0.874, whereas CVC tip assessment was dominated by almost universal classification of tips as appropriate, with near-zero specificity and chance-level balanced accuracy. For pneumothorax-related findings, all MLLMs classified every case as negative. Intensivist reviewers had higher balanced accuracy than MLLMs for CVC access classification (difference, 0.420; 95% CI, 0.349-0.490; p < 0.001) and CVC tip assessment (difference, 0.247; 95% CI, 0.205-0.290; p < 0.001). Pneumothorax analyses were exploratory because only five positive cases were present. The evaluated MLLMs showed unreliable diagnostic performance compared with experienced intensivists. Apparent performance was influenced by class imbalance and dominant-response behavior, supporting cautious task-specific validation and complete diagnostic performance reporting.
Background and Objectives: Preoperative anaemia represents a key modifiable risk factor in obstetrics. Within the framework of Patient Blood Management (PBM), establishing precise hemoglobin (Hb) thresholds is essential for optimal clinical decision-making. This study aimed to assess the predictive value of preoperative hemoglobin levels and to determine the optimal cutoff associated with transfusion risk. Materials and Methods: A retrospective analysis was performed on 932 pregnant women. The association between preoperative hemoglobin, anticoagulant therapy, mode of delivery and maternal age with the need for red blood cell transfusion was evaluated using binary logistic regression and Receiver Operating Characteristic (ROC) curve analysis with the Youden index. Results: Red blood cell transfusion was required in 5.2% (n = 48) of the study population. Logistic regression identified preoperative hemoglobin as the strongest independent predictor (p < 0.001, OR = 0.216, 95% CI: 0.153-0.306), indicating that each 1 g/dL increase in Hb reduced the likelihood of transfusion by 78.4%. Anticoagulant therapy and age were not significant independent predictors (p > 0.05). ROC analysis demonstrated excellent predictive performance, with an Area Under the Curve (AUC) of 0.875 (95% CI: 0.823-0.927, p < 0.001). The optimal threshold for predicting transfusion risk was 10.9 g/dL (sensitivity: 89.6%, specificity: 60.5%). Conclusions: Preoperative hemoglobin concentration is the primary determinant of transfusion risk, outweighing the influence of clinical comorbidities. The integration of PBM protocols designed to sustain hemoglobin levels above 10.9 g/dL is essential to reduce perioperative transfusion requirements and to promote improved maternal safety and clinical outcomes.