Value of Addition of Troponin I to APACHE II Scoring System in Sepsis for Prediction of Mortality Rate in Medical Intensive Care Unit

Operating Room Extubation After Cardiac Surgery: A Promising Practice, or a Product of Selection Bias?

A subset of patients with NMDAR encephalitis is resistant to first-line and second-line immunotherapy and requires prolonged intensive care. The clinical definition of refractory, intensive care-dependent NMDARE (RI-NMDARE) is lacking, and its frequency, risk factors, and outcomes are unknown. The aim of this study was to define RI-NMDARE and compare its clinical and biomarker characteristics with those of severe NMDARE. This was a retrospective cohort study including patients with nonherpetic NMDARE admitted to intensive care units (ICUs) and diagnosed at the French National Reference Center, from 2005 to 2023. Favorable outcome was defined as a modified Rankin Scale (mRS) score < 2 at 24 months from onset. The study included 216 ICU-admitted patients with NMDARE (81% female, median age 21 years). Nearly 90% of patients were discharged from ICU within 3 months after initiation of second-line therapy; the remainder were defined as patients with RI-NMDARE (26/216 patients, 12%; 92% female; median age, 24 years-none younger than 15 years; median ICU stay, 5.7 months). Compared with the rest of the cohort, patients with RI-NMDARE were more frequently of non-White ethnicity (14/25, 56%, vs 55/156, 35%; p = 0.047) and had more frequent mechanical ventilation (26/26, 100%, vs 116/183, 63%; p < 0.001); ovarian teratoma (62% vs 22%, p < 0.001); and combination of seizures, hyperkinetic movement disorders, and dysautonomia (85% vs 33%, p < 0.001). They also had shorter times from onset to ICU admission (median 7 vs 14 days; p = 0.002) and significantly higher median CSF cell counts (72 vs 25/mm3, p < 0.001), CSF antibody titers (1,280 vs 60, p < 0.001), and serum neurofilament levels (230 vs 144 pg/mL, p = 0.028). Despite increased use of the cyclophosphamide-rituximab combination (85% vs 17%, p < 0.001) and earlier immunotherapy (median 10 days, range 1-82 vs 19 days, range 1-304; p = 0.001), patients with RI-NMDARE had poorer outcomes (mRS score ≥ 2 at 24 months, 72% vs 39%; p = 0.004) and higher mortality (19% vs 6.7%, p = 0.046) compared with non-RI-NMDARE patients. RI-NMDARE represents a distinct, high-risk subgroup with a severe clinical profile marked by rapid disease progression; the triad of seizures, movement disorders, and dysautonomia; and elevated biomarkers. RI-NMDARE is associated with poorer outcomes, underscoring the need for early recognition and tailored therapeutic strategies.

Study of Prescription Pattern of Antimicrobial Agents in the Medical Intensive Care Unit (MICU) of a Tertiary Care Hospital

Objective: To evaluate the feasibility, safety, and short-term efficacy of bicuspid pulmonary valve reconstruction using right atrial appendage tissue during complete repair of Tetralogy of Fallot. Methods: A prospective descriptive longitudinal study was conducted in 9 patients undergoing complete TOF repair with concomitant pulmonary valve reconstruction using right atrial appendage tissue at Hanoi Heart Hospital. Results: There was no early mortality. At the time of discharge, the majority of patients had no or only mild pulmonary regurgitation; one patient had moderate regurgitation, and no cases of severe pulmonary regurgitation were observed. The median peak gradient across the right ventricular outflow tract was 15 mmHg (range: 5–35 mmHg). Postoperative recovery and hospital course were uneventful, with a median intensive care unit stay of 5 days (range: 2–14 days) and a median postoperative hospital stay of 13 days (range: 6–27 days). At follow-up intervals of 1–6 months, six patients maintained mild pulmonary regurgitation, while three had moderate regurgitation, and no patient required reintervention. Conclusions: Bicuspid pulmonary valve reconstruction using autologous right atrial appendage tissue during complete repair of Tetralogy of Fallot is a safe technique with favorable early outcomes. These results suggest potential for expanding its indications to other conditions requiring right ventricular outflow tract and pulmonary valve reconstruction. Further medium- and long-term follow-up in larger cohorts is needed to confirm the value of this technique.

The inability to accurately predict PMV duration or determine the optimal timing of tracheostomy presents major barriers to progress in critical care. This was a single center, retrospective, observational study that included the years before, during, and after the COVID-19 pandemic. The purpose of our study was to assess the comparative effectiveness of "early" tracheostomy (performed within 10 days of intubation) for PMV based on 1) in-hospital mortality (including hospice transition), 2) patient-specific factors, and 3) discharge-to-home status. All 205 patients admitted to our adult mixed surgical and medical ICU who underwent bedside percutaneous tracheostomy were included from January 2018 to April 2023. During this study period, we observed a significant change in clinical practice over time, with tracheostomy rates increasing steadily from 1.8% to 5.6%. Based on the similarities of the APACHE II and SOFA scores, there were no discernable differences in the severity of illness. Early compared to late tracheostomy was associated with significantly fewer days on mechanical ventilation (p < 0.01) and ICU length of stay (p < 0.04). Time in the hospital was not different but a significantly higher percentage of patients with early tracheostomy were discharged home (p < 0.01). In a community hospital setting, the significant benefit of early tracheostomy was conditional upon certain patient characteristics. We recommend a personalized approach to tracheostomy timing based upon these patient factors.

Intermediate medical care units (IMCUs), positioned between general medical wards and intensive care units (ICUs), have seen increasing implementation in recent years. However, evidence regarding clinical outcomes in high-acuity patients remains limited. To describe outcomes of critically ill medical patients managed in an IMCU, stratified by severity and the number of organ failures and to compare these outcomes with those historically reported for similar populations treated in ICUs. Through a prospective cohort of patients consecutively admitted to an IMCU between January and December 2024, patients were stratified according to the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the number of organ failures at admission. The primary outcome was 72-h and 30-day mortality. A subpopulation potentially eligible for ICU care was also identified based on high APACHE II scores and/or the presence of multiple organ failures. A total of 678 patients were included. Of these, 30.7% met criteria for high clinical complexity (APACHE II >20 and/or three or more organ failures). The overall 30-day mortality was 13.7%. Specifically, mortality was 14.2% among patients with APACHE II scores between 10 and 20, and 31.5% in those with APACHE II >20. In the high-acuity subgroup (n = 208), the 30-day mortality was 24.5%. The outcomes observed were consistent with those reported in the literature for patients with similar clinical profiles managed in ICUs. This study shows real-world outcomes of managing acutely ill medical patients in an IMCU, aligning with ICU results and supporting IMCUs as a safe, effective bridge between general and intensive care.

Duration of intensive care unit admission to maintain mean arterial pressure goals following acute traumatic spinal cord injury.

Neonatal and infant aortic arch reconstruction remains a high-risk cardiovascular procedure requiring effective cerebral and myocardial protection. Variability in perfusion strategies may influence early hemodynamic stability and postoperative recovery. This study aimed to evaluate the early and short-term cardiovascular outcomes of a standardized beating-heart aortic arch reconstruction strategy incorporating simultaneous antegrade selective cerebral and continuous coronary perfusion. In this retrospective single-center cohort study, 31 consecutive neonates and infants undergoing aortic arch reconstruction between November 2022 and December 2025 were analyzed. A standardized surgical protocol was applied, consisting of extensive ductal tissue resection, interdigitating posterior end-to-end anastomosis, anterior autologous pericardial patch augmentation, and moderate hypothermic antegrade selective cerebral perfusion combined with continuous coronary perfusion via innominate artery cannulation. Early postoperative outcomes and short-term echocardiographic follow-up results were assessed. The cohort included 31 patients, 22.6% of whom had complex associated cardiac anomalies requiring concomitant procedures. Median cardiopulmonary bypass and aortic cross-clamp times were 119 and 64 min, respectively. There was no in-hospital mortality. Major complications were infrequent, and median intensive care unit stay was 5 days. During a median follow-up of 6.8 months, one patient (3.2%) developed recoarctation requiring reintervention. No late mortality was observed. A fully standardized beating-heart aortic arch reconstruction strategy incorporating simultaneous cerebral and coronary perfusion demonstrated favorable early cardiovascular and short-term outcomes, even in anatomically complex cases. Preservation of continuous coronary perfusion may be associated with improved myocardial stability and early postoperative recovery; however, these findings should be interpreted as observational and hypothesis-generating given the absence of a control group. Larger multicenter studies with longer follow-up are warranted to confirm these findings.

Multidrug-resistant (MDR) Gram-negative infections pose a critical threat in intensive care units (ICUs) due to limited therapeutic options. Colistimethate sodium (colistin), a polymyxin antibiotic, is often used as a last-resort treatment despite concerns about its efficacy and safety. To evaluate the clinical profile and outcomes of patients receiving intravenous colistin for MDR Gram-negative infections in the Medical ICU (MICU) of a tertiary care hospital in Northern India. Prospective observational cohort study. This study was conducted in the MICU at a tertiary care hospital. Adult patients (≥18 years) administered intravenous colistin were included. Demographic data, severity scores (acute physiology and chronic health evaluation [APACHE] II, quick sequential organ failure assessment [qSOFA]), infection site, microbiological profile, and treatment details were recorded. Clinical success was defined as clinical improvement followed by discharge in a stable hemodynamic state. Clinical success rate and overall mortality. Fifty patients were included. The median age was 54.24 years. Bloodstream infections were most common (54%), predominantly due to Acinetobacter baumannii (50%), followed by Klebsiella pneumoniae and Pseudomonas aeruginosa. Colistin was used as monotherapy in 68% of patients, yielding a clinical success rate of 64%. Mortality occurred in 36% of patients, mainly those with higher APACHE II and qSOFA scores. Colistin demonstrated moderate clinical efficacy in critically ill patients with MDR Gram-negative infections. It remains a valuable salvage therapy; however, judicious use and further research are essential to enhance efficacy and minimize resistance and toxicity. Single-center design and small sample size limit generalizability. Nephrotoxicity and pharmacokinetic parameters were not assessed.

Antimicrobial stewardship programs (ASPs) are recommended to optimize antibiotic use in intensive care units (ICUs); however, many institutions lack infectious disease specialists and pharmacy expertise for full implementation. The COVID-19 pandemic further disrupted conventional stewardship. While tele-stewardship models have shown promise, evidence for hybrid programs operating without infectious disease specialist leadership remains limited, particularly outside high-income countries. We developed a hybrid ASP (hASP) collaboratively led by an on-site intensivist and an off-site faculty clinical pharmacist to reduce inappropriate antibiotic use and improve outcomes in a resource-constrained ICU. This prospective, single-center, pre-post study was conducted in the medical ICU of a 733-bed university teaching hospital in Seoul, South Korea. The pre-intervention period (August to October 2017) with no ASP was compared with the post-intervention period (August to October 2020) following hASP implementation. Stewardship activities were primarily performed off-site by trained clinical pharmacists via secured messaging, telephone, and video conferencing, with on-site rounds every other weekday. Key outcomes were inappropriate antibiotic prescriptions per 100 patient-days, 30-day all-cause mortality, ICU length of stay, preventable adverse drug events, and days of therapy, assessed using Delphi-derived appropriateness criteria. Thirty-three and 37 admissions were analyzed (364 and 251 patient-days). On-site activities were limited to three hours daily or less. Inappropriate prescriptions declined from 83.8 to 20.7 per 100 patient-days (p < 0.001), ICU length of stay from 14 to 6 days (p < 0.05), and preventable adverse drug events from 4.4 to 2.8 per 100 patient-days (p < 0.05). Thirty-day all-cause mortality was comparable (24.2% vs. 24.3%). The most frequent pharmacist interventions were dose optimization (47.8%) and antimicrobial discontinuation (40.6%), with an overall acceptance rate of 62.3%. Days of therapy for broad-spectrum antibiotics targeting multidrug-resistant organisms declined while those for narrower-spectrum agents increased, suggesting a shift toward targeted therapy. The hASP, collaboratively led by an intensivist and a faculty clinical pharmacist with off-site pharmacist-led interventions via virtual communication, significantly reduced inappropriate prescribing, ICU length of stay, and preventable adverse drug events. Hybrid stewardship models may serve as a feasible alternative to on-site programs in resource-limited settings.

Meningitis and encephalitis affect all ages, are prone to misdiagnosis and outcome can be devastating. We provide this common primer for all in the sepsis "chain-of-survival." Meningitis equals inflammation/infection of the protective membranes that cover the brain; whereas encephalitis affects the brain parenchyma. Meningitis is more common, but they can co-exist as meningoencephalitis. Encephalitis can also affect the spinal cord (encephalomyelitis). Worldwide, meningitis affects 2.5 million people annually, and kills over 200,000. Central nervous system (CNS) infections account for 3.9% of all UK intensive care unit (ICU) infections, and 0.7% of adult ICU admissions. While this means these are not common causes for admission, they do have high morbidity and mortality. The median ICU stay is 4 days, of which 3 days was the median spent requiring advanced respiratory support or support for more than one organ. The median in-hospital stay is 20 days. Most admissions come through the emergency department (ED). Signs and symptoms can be vague and varied; hence potential misdiagnosis as flu, psychiatric disorders, intoxication, even hangover. The median time between hospital admission and transfer to ICU is 1 day, and by this time approximately one-third are comatose and one-sixth need respiratory support. The risk of misdiagnosis matters given high mortality and morbidity: 18%-25% die in hospital and 1-in-10 survivors lose independence. During the past 20 years mortality has fallen, but those left with some form of permanent disability remains constant at nearly 40%. Fortunately, early recognition and treatment can greatly improve outcome. Regarding diagnosis, history and physical examination still have great value. Next, lumbar puncture (LP) should be expedited unless contraindicated by coagulopathy, skin infection, or raised ICP. LP testing should incorporate opening pressure, microscopy, culture and cell count, glucose and protein and often polymerase chain reaction (PCR) for meningococcus, pneumococcus, herpes simplex virus (HSV1&2), varicella (VZV) and enterovirus. Radiologically, head computed tomography (CT) is first line. It may reduce the risk of LP by excluding pathologies likely to trigger herniation. CT is indicated if their Glasgow Coma Score (GCS) is falling or ⩽9, or if seizures, focal neurological signs or papilloedema. Normal CT cannot rule out raised ICP, but LP is avoided if the CT shows herniation, basal cistern or foramen magnum effacement, cerebral swelling, intracranial lesions/collections with mass effect or obstructive hydrocephalus. Magnetic resonance imaging (MRI) is logistically tougher but better at detecting meningitis/encephalitis. MRI can suggest the causative organisms, along with complications such as infarct, pus and parenchymal changes. Treatment centres on prompt antimicrobials: usually a third-generation intravenous (IV) cephalosporin, typically within 1 h, and at an increased (i.e. "meningitis") dose. Intravenous amoxicillin is added in the elderly or immunocompromised, plus aciclovir if viral encephalitis is plausible. Treatment delays (over 4 h) are associated with increased mortality. Over half (57%) of patients that require ICU develop intracranial complications, most frequently ischaemia, cerebral oedema and ventriculitis. In short, these diseases are life-threatening but manageable if we do the simple stuff right. . .and right away.

Interstitial Thermal Therapy in Mesial Temporal Lobe Epilepsy Original Article Citation: Landazuri P, Cheng JJ, Leuthardt E, Kim AH, Southwell DG, Fecci PE, Neimat J, Sun D, Lega B, Panov F, Chiang V, Abel T, Ben-Haim S, Piccioni DE, Shih JJ, Palys V, Rodriguez A, Bandt SK, Petronio J, Lacroix M, Baumgartner J. JAMA Neurology. 2025;82(9):915-924. Importance Laser interstitial thermal therapy (LITT) is a surgical tool used to ablate epileptic foci and brain tumors. Understanding clinical and procedural outcomes of LITT for mesial temporal lobe epilepsy (MTLE) is relevant to clinicians and patients. Objective To describe seizure outcomes, procedural outcomes, and safety data of MTLE LITT. Design, setting, and participants Laser Ablation of Abnormal Neurological Tissue Using Robotic NeuroBlate System (LAANTERN) is a prospective multicenter registry with up to 5 years of follow-up lasting from October 2015 to March 2023 at LAANTERN epilepsy sites, which are all level IV National Association of Epilepsy Centers in the United States. Adult and pediatric LAANTERN enrollees undergoing LITT for drug-resistant MTLE with at least 6 months of follow-up were included. Those with epilepsy related to a malignant lesion were excluded. Intervention LITT for drug-resistant MTLE. Main outcomes and measures Demographic, epilepsy, and seizure characteristics; procedural data; postsurgical seizure outcomes; safety data; and quality of life (QOL) scores were prospectively collected. Results Fifteen centers enrolled 145 patients (73 [50.3%] female) with MTLE undergoing LITT, with 77 reaching 2-year follow-up. The mean (SD) age was 39.2 (15.4) years at the time of LITT, with 14 of 145 in the pediatric range (younger than 22 years). The 2 most common etiologies were mesial temporal sclerosis (n = 74) and unknown etiology or magnetic resonance imaging normal (n = 31). Mean (SD) ablation volume was 28.2 (29.8) mL. Mean (SD) surgery duration was 4.3 (2.1) hours, and mean (SD) blood loss was 22 (17.6) mL. Median (IQR) length of stay was 1 (1-3) day, and 33 patients (23%) had no intensive care unit stay postprocedure. Median (IQR) intensive care unit time was 22 (19.2-28.8) hours. Mean (SD) discharge head pain score was 2.1 (2.6) on a 0–10 scale. Most patients (n = 140 [96.6%]) were discharged home. Two-year seizure outcomes were 45 of 77 (58.4%) and 44 of 77 (57.2%) for Engel 1 and International League Against Epilepsy 1/2, respectively. No clinical characteristics were associated with seizure outcome. Adverse events were seen in 24 patients (16.5%), most being mild and transient. Pediatric seizure outcomes were similar to adult outcomes. One-third of patients stopped or decreased their antiseizure medicines. Improvements in QOL scores were seen at almost all time points assessed. Conclusions In the largest prospective multicenter MTLE LITT cohort, LITT was found to be well tolerated with clinically meaningful seizure outcomes and QOL improvements. These findings indicate that LITT may be considered as a treatment option for drug-resistant MTLE.

Optimal timing of initiation of pharmacologic venous thromboembolism (VTE) prophylaxis following intracerebral hemorrhage is controversial. This study aims to assess the association between the timing of pharmacologic VTE prophylaxis initiation and the risk of VTE and hemorrhagic complications. This was a multicenter, retrospective cohort study completed at 7 community hospitals. This study included patients with nontraumatic intracerebral hemorrhage admitted from August 1, 2023, to July 31, 2024. A total of 111 patients were assessed and categorized based on the administration of early (≤48h) versus delayed (>48h) initiation of VTE prophylaxis. Findings showed no statistically significant difference in the primary outcome of the incidence of VTE with early versus delayed initiation of VTE prophylaxis (5% vs. 8%, P=0.713). Secondary outcomes included incidence of deep vein thrombosis (5% vs. 8%, P=0.713), pulmonary embolism (0% vs. 0%), hematoma enlargement (16% vs. 15%, P=0.623), median intensive care unit (ICU) length of stay (3 vs. 3.5d, P=0.670), hospital length of stay (7 vs. 8d, P=0.724), inpatient all-cause mortality (8% vs. 7%, P=1.000), and discharge disposition. Early pharmacologic VTE prophylaxis (≤48h from ICH onset) was not found to be statistically significant in lowering the incidence of VTE. This occurred with no statistically significant differences in hematoma enlargement, increased inpatient mortality, or increased length of ICU/hospital stay. Additional adequately powered studies are needed to determine if early pharmacologic VTE prophylaxis is associated with a lower incidence of VTE.

An integrated approach is essential in combating antibiotic and antimicrobial resistance. Chlorhexidine digluconate (CHG), a widely used antiseptic in medical intensive care units (MICU), has recently come under scrutiny. However, studies of CHG tolerance, particularly in interconnected indoor environments, are limited. We comprehensively explored CHG tolerance in MICU environments from chemical, microbial, and molecular perspectives. Using microcosm experiments and field surveys, we demonstrated that CHG, if transferred from patient skin to environments, can persist on surfaces despite cleaning and disinfection and decrease to sublethal levels for clinically relevant bacteria. We detected widespread CHG-tolerant bacteria (≥18.75 μg/mL), including opportunistic pathogens (e.g., Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Elizabethkingia miricola), with minimum inhibitory concentrations up to 512 μg/mL. Sink drains emerged as critical hotspots, and indoor air as a potential transport mechanism. We observed indications of bacterial persistence, increased tolerance, in situ evolution, and dissemination across MICU rooms. Molecular analyses revealed heterogeneous and largely unexplored CHG resistance mechanisms and identified resistance determinant candidates, particularly qacEdelta1-carrying, plasmid-borne multidrug-resistant cassettes. Our findings underscore the importance of understanding human-environment and chemical-microbe interactions to preserve chlorhexidine's efficacy and inform infection prevention strategies. We advocate for integrated environmental management and clinical interventions.

Introduction: Hypertensive emergencies represent lifethreatening conditions characterised by acute elevations in blood pressure with evidence of target organ damage. They remain a significant contributor to cardiovascular, neurological, and renal morbidity and mortality, often leading to hospitalisation. Early detection of end-organ involvement is therefore crucial to prevent irreversible damage and improve clinical outcomes. Aim: To study the association between patients presenting with hypertensive emergency in the Medical Intensive Care Unit (MICU) and target end-organ damage across different genders and age groups. Materials and Methods: The present cross-sectional study was conducted among adult patients aged 18-80 years presenting with blood pressure ≥180/120 mmHg at R. D. Gardi Medical College and Charitable Hospital, Ujjain, Madhya Pradesh, India, over a period of six months, from June 2024 to November 2024. Demographic data, medical history, and other clinical information, including Electrocardiography (ECG), Two Dimensional (2D) echocardiography, chest X-ray, funduscopic examination, ultrasonography of the abdomen, and neuroimaging studies, were collected. Data were analysed using SPSS software (Statistical Package for the Social Sciences (SPSS) Inc., Chicago, IL), version 29.0.10, with a p-value &lt;0.05 considered statistically significant. Results: Among the 96 patients, 58 (60%) were male and 38 (40%) were female. The mean {±Standard Deviation (SD)} age was 58.66±12.62 years (range: 18-80 years). A past history of hypertension was present in 58 (60.4%) patients, with a mean duration of 6.51±4.34 years (range: 1-20 years). The most common forms of acute target organ damage were Cerebrovascular Accident (CVA) with retinopathy in 24 patients (25%), followed by Myocardial Infarction (MI) with retinopathy in 15 (15.6%), retinopathy alone in 13 (13.5%), retinopathy with pulmonary oedema and acute heart failure in 11 (11.5%), and MI alone in 10 patients (10.4%). Conclusion: Hypertensive emergencies were more frequent among middle-aged and elderly males, most of whom had a prior history of hypertension. CVAs and retinopathy were the leading complications, followed by MI either alone or in combination with retinopathy. Strengthening early detection and ensuring strict blood pressure control are essential to reduce the burden of target organ damage in these patients.

Transitions of care from the intensive care unit (ICU) are high-risk periods for interruptions in nutrition therapy and inadequate nutrient delivery, which may impair recovery following critical illness. As patients leave the ICU, changes in metabolic demand, functional status, feeding tolerance, and discharge setting necessitate deliberate reassessment and coordinated nutrition planning. This narrative review outlines practical strategies to optimize nutrition support during ICU transitions, including reassessment of nutrition status, reevaluation of energy and protein needs, selection of appropriate feeding routes and schedules, and early integration of nutrition into transition of care and discharge planning. We present four patient cases to illustrate application of these strategies across diverse clinical scenarios and discharge destinations including a lung transplant recipient, a patient in a medical ICU, a patient in a neuro ICU, and a patient in a trauma ICU. Collectively, these cases demonstrate that proactive reassessment, timely adjustment of feeding regimens, and early discharge planning can reduce avoidable interruptions in nutrition therapy and support continuity of care across ICU transitions.

Medical device-related pressure injuries are a significant and largely preventable patient safety problem, yet existing pressure injury risk scales do not adequately capture device-specific risk factors in adults. This methodological study developed and psychometrically evaluated a standardized risk assessment scale to identify medical device-related pressure injury risk in hospitalized adult patients. An initial item pool was generated from an extensive literature review and clinical expertise, and content validity was assessed by seven experts using the Davis technique (content validity index = 0.96). The scale was administered to 160 adults receiving at least one medical device in medical, surgical and oncology wards and intensive care units of a university hospital. Construct validity was evaluated using binary logistic regression, exploratory factor analysis, and receiver operating characteristic curve analysis, demonstrating strong discrimination (area under the curve = 0.844, 95% confidence interval 0.728-0.961) with an optimal cut-off score of 14.5 (sensitivity 70.6%, specificity 88.8%). Exploratory factor analysis of the final version of the MedRAS (Kaiser-Meyer-Olkin = 0.792) revealed a two-factor structure (Device and Mechanical Factors; Patient and Tissue Factors) explaining 50.92% of the total variance, with all factor loadings above 0.30. The scale showed good internal consistency (Cronbach's alpha = 0.80) and very good inter-rater reliability (Cohen's kappa = 0.806, p < 0.001). This device-focused scale may support early risk identification and targeted preventive nursing interventions, with potential to improve patient safety and quality of care in inpatient/critical care settings.

To investigate whether preoperative noninvasive measurement of right ventricle-to-pulmonary artery coupling, assessed by the tricuspid annular plane systolic excursion-to-pulmonary artery systolic pressure (TAPSE:PASP) ratio, is associated with perioperative outcomes following pulmonary endarterectomy (PEA). Retrospective, single-center cohort study. Tertiary university hospital: national center for chronic thromboembolic pulmonary hypertension (CTEPH) treatment. Patients with CTEPH eligible for PEA. Patients underwent transthoracic echocardiography and right heart catheterization before undergoing PEA. The TAPSE:PASP ratio was calculated from preoperative echocardiography and dichotomized at 0.17 mm/mmHg. The primary outcome was intensive care unit (ICU) length of stay (LOS). Secondary outcomes included vasoactive and inotropic therapy, representing perioperative hemodynamic instability. Sixty patients were included. The median TAPSE:PASP ratio was 0.20 mm/mmHg (interquartile range [IQR], 0.15-0.29 mm/mmHg); 38% of patients had ratios below 0.17 mm/mmHg. A lower TAPSE:PASP ratio was associated with higher N-terminal pro-brain natriuretic peptide levels and pulmonary vascular resistance, as well as greater right ventricular dilatation. The median ICU LOS was longer in patients with a TAPSE:PASP ratio below 0.17 mm/mmHg (96 hours [IQR, 60-218 hours] v 63 hours [IQR, 41-93 hours], p = 0.0044), with an odds ratio (OR) of 3.45 (95% confidence interval [CI], 1.16-11.11) for ICU LOS greater than 72 hours. Patients with lower TAPSE:PASP ratios had a higher (OR, 3.33; 95% CI, 1.11-10.00; p = 0.032) and prolonged (OR, 3.70; 95% CI, 1.23-11.11; p = 0.019) need for vasoactive and inotropic therapy. A lower preoperative TAPSE:PASP ratio was associated with prolonged ICU stay and hemodynamic compromise after PEA. The TAPSE:PASP ratio may serve as a valuable, noninvasive tool for preoperative risk stratification in patients with CTEPH undergoing surgical treatment.

Higher caloric intake may reduce hospital mortality in critically ill patients at high nutritional risk, but the optimal dose for short-term outcomes remains uncertain and evidence on long-term effects is limited. This study evaluated the association between caloric intake and one-year mortality and identified subgroups that may benefit from higher intake. We conducted a retrospective cohort study in a tertiary medical ICU (2015-2019) including adults receiving mechanical ventilation; ICU stays <48 h were excluded. The exposure was mean caloric intake during ICU days 1-7, defined as total energy from enteral and parenteral routes normalized to body weight. Outcomes included ICU length of stay, ventilator days, and one-year mortality from the Taiwan National Health Insurance Database. Multi-variable Cox models adjusted for age, sex, albumin, hemoglobin, blood glucose, ICU admission etiology, APACHE II score, shock category, mNUTRIC score, renal replacement therapy, and cumulative day-1-7 fluid balance. Among 3,764 patients (mean age 67.1 years; mean Acute Physiology and Chronic Health Evaluation II score 26.5), older age, male sex, lower albumin and hemoglobin, shock requiring multiple vasopressors, greater positive fluid balance, and lower caloric intake were associated with higher one-year mortality. Subgroup analyses showed that patients younger than 65 years, those with an APACHE II score ≥26, and those with refractory shock derived greater benefit from higher caloric intake. Higher first-week caloric intake was associated with lower one-year mortality, particularly in younger patients, in those with greater illness severity, and in those requiring multiple vasopressors.