Medical Intensive Care Research Articles

Predicting reprisal of solid cancer treatment and 60-month survival after Medical Intensive Care. A single-centre cohort study.

Our study aimed to identify relevant features associated with the reprisal of antineoplastic treatment in patients with solid cancers after unplanned admittance to the intensive care unit (ICU) and to assess 60th-month survival in patients with solid neoplasms admitted to the ICU. This single-centre retrospective study of critically ill patients with active cancers was performed over a 13-year period (2005-2018). Patients' characteristics, overall survival and antineoplastic treatment reprisal were extracted from digital medical files and compared. 134 patients were included in the study. Solid neoplasms were mostly localised to the head and neck (n=53) followed by lung cancers (n=29). Sepsis was the leading cause of ICU admission (62.1%) with 41/82 patients presenting with septic shock. Antineoplastic treatments were resumed in 40 patients. An age ≤60 years and an Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≤1 were found to be predictors for treatment reprisal, with odd ratios of, respectively, 2.83 (95%CI, 1.15-6.99) and 5.45 (95%CI, 2.01-14.82); area under the ROC curve of 72% (95%CI, 63-81%). Survival after the immediate discharge from the ICU was 101/134 (75%) and the 60-month survival rate was 29% and significantly higher in the treatment-reprisal group. Age and ECOG PS were found to be predictors for treatment reprisal in patients with solid neoplasms admitted to the ICU. The latter benefit from better long-term survival.

Patient reported outcomes, control of hypertension and dyslipidemia: results of two epidemiological studies in Romania, conducted during pandemia (Snapshot-1) and post-pandemic (Snapshot-2)

Abstract Background Coexistence of hypertension and dyslipidemia is commonly found in daily practice. Patient reported outcomes (PRO) are increasingly used to guide clinical decision-making, as well as public reporting of health system performance. Purpose To assess patient reported outcomes (PRO: socio-economic factors, depression level, and treatment adherence) and control of blood pressure (BP) and LDL-cholesterol (LDL-C) during pandemia and in the post-pandemic period. Methods Two real-world, cross-sectional, multicentre, observational studies, with a similar design, were conducted in Romania during pandemia, in June 2021 (SnapShot-1), and post-pandemic, in June 2022 (SnapShot-2). They included 5004 consecutive outpatients diagnosed with both hypertension and dyslipidemia, addressing cardiologists, diabetologists, and general practitioners: 2469 in SnapShot-1 and 2535 in SnapShot-2. Patients completed a three-part questionnaire including: (1) questions on socio-economic factors; (2) Patient Health Questionnaire (PHQ-9) (Depression scale); and (3) Hill-Bone Medication Adherence Scale (HBMAS) for hypertension and dyslipidemia. Results Characteristics of patients were similar between studies: 65.0±10.0 years and 40.9% men (SnapShot-1), 63.6±10.7 years and 43.3% men (SnapShot-2). Most of the patients declared themselves as "adherent" to the prescribed treatment: 91.8% (SnapShot-1) and 93.0% (SnapShot-2) adherent to antihypertensive treatment; 89.6% (SnapShot-1) and 90.9% (SnapShot-2) adherent to lipid lowering treatment. Socio-economic factors were similar between studies, except education, with higher education rates in SnapShot-2 (Table 1). Compared to SnapShot-1, depression scores evaluated by PHQ-9 scale were lower in SnapShot-2, conducted post-pandemic: 5.9±4.9 for SnapShot-1, suggesting a "mild" depression level, vs. 4.9±4.6 for SnapShot-2, which is below the "mild" depression threshold. Similarly, the adherence scores measured by HBMAS were lower in SnapShot-1 vs. SnapShot-2: 33.8±3.0 vs. 34.0±2.9 for antihypertensive medication, and 33.5±3.5 vs. 33.7±3.4 for lipid lowering treatment (Table 2). Conclusion Data collected from two large epidemiological studies in Romania showed an improvement of post-pandemic depression rates, as well as an improvement of adherence scores. Use of PRO assessment in routine clinical practice could support identification of patients on risk for uncontrolled BP or LDL-C, in need of more intense medical care.

Intraoperative Fluid Balance and Perioperative Complications in Ovarian Cancer Surgery.

Fluid overload and hypovolemia promote postoperative complications in patients undergoing cytoreductive surgery for ovarian cancer. In the present study, postoperative complications and anastomotic leakage were investigated before and after implementation of pulse pressure variation-guided fluid management (PPVGFM) during ovarian cancer surgery. A total of n = 243 patients with ovarian cancer undergoing cytoreductive surgery at the University Hospital Bonn were retrospectively evaluated. Cohort A (CA; n = 185 patients) was treated before and cohort B (CB; n = 58 patients) after implementation of PPVGFM. Both cohorts were compared regarding postoperative complications. Ultrasevere complications (G4/G5) were exclusively present in CA (p = 0.0025). No difference between cohorts was observed regarding severe complications (G3-G5) (p = 0.062). Median positive fluid excess was lower in CB (p = 0.001). This was independent of tumor load [peritoneal cancer index] (p = 0.001) and FIGO stage (p = 0.001). Time to first postoperative defecation was shorter in CB (CB: d2 median versus CA: d3 median; p = 0.001). CB had a shorter length of hospital stay (p = 0.003), less requirement of intensive medical care (p = 0.001) and postoperative ventilation (p = 0.001). CB received higher doses of noradrenalin (p = 0.001). In the combined study cohort, there were more severe complications (G3-G5) in the case of a PFE ≥ 3000ml (p = 0.034) and significantly more anastomotic leakage in the case of a PFE ≥ 4000ml (p = 0.006). Intraoperative fluid reduction in ovarian cancer surgery according to a PPVGFM is safe and significantly reduces ultrasevere postoperative complications. PFEs of ≥ 3000ml and ≥ 4000ml were identified as cutoffs for significantly more severe complications and anastomotic leakage, respectively.

Diagnostic role of high Sensitive-CRP and procalcitonin in hospitalized patients.

Objective: To assess these two biomarkers' effectiveness in admitted patients of Farooq Hospital Lahore, Pakistan. Study Design: Prospective study. Setting: Farooq Hospital Westwood, Lahore. Period: November 2023 to January 2024. Methods: The admitted patients of intensive care units, medical and cardiac care units, with acute kidney infection, chronic kidney disease, diabetes mellitus, hypertension, coronary artery bypass grafting, gastroenteritis, chronic obstructive pulmonary disease, liver disease, hepatitis, and bacterial infection were included. The automated analyzers analyzed the serum albumin, high-sensitive C-reactive protein (hs-CRP), and procalcitonin. Data was analyzed by using SPSS (v.25.0). Results: Among 73 patients, 83.56% were critical and 16.44% stable. It was found that the highest critical patients were under the age of 61 to 90 years. The hs-CRP and procalcitonin levels were non-significantly correlated with age group. The hs-CRP exhibited higher sensitivity than procalcitonin in critical patients (AUC: 0.872 vs. 0.725). Likewise, serum albumin had a significant association with patients having critical conditions (AUC: 0.685). Moreover, it was found that hs-CRP and procalcitonin have a significant association with the period of patient stay in the hospital. Conclusion: The present study concluded that patients with high levels of procalcitonin and hs-CRP had longer hospital stays and that both biomarkers are equally important in the treatment of critically ill admitted patients.

Divide and Save: A Critical Care Air Transport Team Case With Prolonged Field Care

ABSTRACT Critical care air transport teams (CCATTs) specialize in providing intensive medical and postoperative resuscitative care during air evacuations. In a 2014 mission, a seasoned CCATT was urgently deployed to evacuate 6 American service members with gunshot wounds. Despite only having 2 hours of premission preparation and no further injury or treatment details, CCATT secured additional equipment, medications, and blood supply. Upon arrival to a foreign nonmilitary hospital, they discovered that American ground commanders had lost trust in local medical capabilities. One patient experienced prolonged extremity tourniquet time and surgical delay. This led to acute renal failure, preventing immediate evacuation without continuous renal replacement therapy (CRRT). Deviating from the standard procedure, the CCATT obtained permission to split their team. The CCATT nurse attended 5 stabilized patients during unregulated critical care air transport with plans to swiftly return with CRRT equipment for the critical sixth patient. The physician and respiratory therapist remained at the foreign hospital for 2 days to provide prolonged field care. This case demonstrates the evolving mission scope of CCATT, which may encompass ground triage, prolonged field care, unregulated movement, and atypical CCATT equipment such as CRRT, occasionally necessitating a split team construct. To adapt to these evolving needs, updated policies and training now incorporate these diverse CCATT concepts, emphasizing the importance of flexibility in en route critical care missions.

Sepsis-Associated Acute Kidney Injury in Medical Intensive Care

Sepsis-Associated Acute Kidney Injury in Medical Intensive Care

Cholelithiasis in newborns — myth or reality?

Introduction: In the past, cholelithiasis in newborns was considered extreme a rare finding, but with increasing use of ultrasound (USG) examination the abdomen is also found more and more often in them. Objective: The objective of the presented work was to assess the frequency of occurrence at least as a guide cholecystolithiasis in newborns and to characterize its spontaneous development or capture it also the occurrence of complications from the biliary system in these children. Materials and Methods: The author examined the cholecyst using USG over four months in 339 newborns (including the period of the COVID-19 pandemic), of which 273 children with adequate postpartum adaptation (“physiological” newborns) and 66 children with postnatal adaptation disorders who required more intensive medical care and in whom they therefore occurred to an increased extent risk factors for the development of cholelithiasis (“pathological” newborns). Results: In 5 children from the first group (1.8 % of these children, of which 3 girls and 2 boys) and in 4 children from the second group (6.1 % of these children, of which 2 girls and 2 boys) was found ultrasound finding of echogenic material in the gallbladder. Among these children, 3 children went (1 from the first and 2 from the second group) o USG image of cholecystolithiasis, in 4 children (3 from the first and 1 from the second group) about the so-called USG image. “sludge-balls” and for 2 children (one from each group) o USG image “sludge”. Frequency of USG image of classic cholecystolithiasis it was thus 0.36 % in “physiological” and 3.0 % in “pathological” newborns. The obvious the predominance of the USG finding of echogenic material in the gallbladder in either gender not recorded by the author. It was found in all “physiological” newborns during subsequent USG checks with the original finding of echogenic material in the gallbladder confirmed spontaneous adjustment USG findings at the age of 1 month. In three of the original 4 “pathological” newborns with the original finding of echogenic material in the gallbladder, this USG persisted image even at the age of three months and at least one of them at the age of over one of the year. They were not observed clinically in any of the monitored newborns significant complications demonstrably related to the biliary system. Conclusion: USG finding of echogenic material in the cholecyst (and also cholecystolithiasis as such) therefore, it can be considered a relatively frequent finding with a good outcome in the newborn age prognosis and the very rare occurrence of complications, while the participation of risky factors in its formation is significant. Despite the good prognosis, USG follow-up should be recommended of these children in order to detect possible complications of cholelithiasis at an early stage.

JNK2-MMP-9 axis facilitates the progression of intracranial aneurysms

Intracranial aneurysm (IA) can cause subarachnoid hemorrhage or some other hemorrhagic stroke after rupture. Because of the poor outcome in spite of the intensive medical care after the onset of hemorrhage, the development of a novel therapeutic strategy like medical therapy to prevent the progression of the disease becomes a social need. As the reduction of arterial stiffness due to the degeneration of the extracellular matrix via Matrix Metalloproteinases (MMPs) becomes one of the central machineries leading to the progression of IAs through a series of studies, factors regulating the expression or the activity of MMPs could be a therapeutic target. In the present study, specimens from human IA lesions and the animal model of IAs were used to examine the expression of c-Jun N-terminal kinase (JNK) which might exacerbate expressions of MMPs in the lesions to weaken arterial walls resulting in the progression of the disease. In some human IA lesions examined, the expression of p-JNK, the activated form of JNK, could be detected mostly in the medial smooth muscle cells. In IA lesions induced in rats, the activation of JNK was induced during the progression of the disease and accompanied with the activation of downstream transcriptional factor c-Jun and importantly with the expression of MMP-2 or -9. The genetic deletion of Jnk2, not Jnk1, in mice significantly prevented the incidence of IAs with the suppression of the expression of MMP-2 or MMP-9. These results combined together have suggested the crucial role of JNK in the progression of IAs through regulating the expression of MMPs. The results from the present study provides the novel insights about the pathogenesis of IA progression and also about the therapeutic target.

Transmission chains and molecular characterizations of extended-spectrum β-lactamase producing Enterobacteriaceae at a veterinary hospital in Chengdu, China

The rapid emergence of Extended-spectrum β-lactamase producing Enterobacteriaceae (ESBL-E) is a major global public health concern. Previous studies have identified that intensive medical care of dogs and cats in veterinary hospitals have accelerated the infections and spread of ESBL-E. To investigate the spread of ESBL-E in a veterinary hospital, a total of 202 samples including hospitalized animals, veterinary healthcare workers and environment were collected from a veterinary hospital in Chengdu, China. ESBL-E were identified by antimicrobial susceptibility testing and 16 s rRNA sequencing and were further conducted on ESBL gene detection and multilocus sequence typing (MLST). At last, strains with transmission potential were analyzed by whole genome sequencing (WGS). Our results showed that the overall prevalence of ESBL-positive isolates was 34.7% (70/202), with 55.3% (26/47) in animals, 29.3% (12/41) in healthcare workers and 28.1% (32/114) in environment swabs. Twenty diverse MLST types were detected, with ST744, ST231 as the most prevalent ones. Transmission chains of two ESBL-E.coli (ST744 blaCTX-M-18, blaTEM-1) from cat_21 to cat_14, and two ESBL-Kp (ST231 blaCTX-M-27, blaTEM-1, blaSHV-1) from cat_20 to cat_37 were further confirmed by WGS. Furthermore, interdisciplinary investigation and cooperation of AMR are needed to better limit the transmissions of high-risk strains and to implement effective public health interventions.

Prolonged weaning after long-term ventilation due to SARS-CoV-2 infection: a multicenter retrospective analysis

Patients (n=751) with prolonged weaning (reason for ventilation "pneumonia" and "acute respiratory failure") from four centers for the period 2011-23 from the "WeanNet" registry were used as a matched group. The median duration of intensive medical care was 39 (25-68) days. In 19% (37/193) of patients, ECMO support was necessary for a median of 27 (18-51) days. In-hospital mortality was 8.3% (2.7% with vs. 9.6% without ECMO) and 6.8% died in the comparison group. At discharge, 84% (vs. 77% in the control group) were completely weaned and 2.6% (vs. 17.6% in the control group) of patients received non-invasive treatment. Invasive ventilation was still necessary in 7.8% (control group 15.7%). In the observation period of 6 months after discharge, 22.4% of patients required inpatient care and a further 14.1% after 12 months. The overall mortality at 12-month follow-up was 20,6% (5.6% with vs. 24.6% without ECMO). The mortality rate of ventilated patients with COVID-19 was very low at 8.3% in the four weaning centers studied. The mortality rate of patients with ECMO treatment was only 2.7%. The mortality rate in the control group was 7.3%. The lower mortality of patients with ECMO treatment was also evident at follow-up of up to 12 months.Patients with prolonged weaning who received invasive ventilation due to COVID-19 showed comparable results in terms of successful weaning and mortality compared to a control group from the WeanNet registry. The long-term results with a survival of more than 80% for the first year after discharge were encouraging.

2203 Avoiding therapeutic nihilism in critically ill older adults: a single Centre approach to enhanced care in patients with frailty

Abstract Introduction Enhanced care units (ECU) are a novel concept, targeting the gap between ward-level and critical care. They care for patients requiring intensive medical or nursing care, who may not require, desire, or be suitable for, escalation above ward care (Society of Acute Medicine and Intensive Care Society, 2022). The ECU at Barnet Hospital opened in March 2022, and, because of the local population demographic, admits a high number of older patients living with frailty. We aimed to assess the performance of the ECU for this subset of patients. Methods A retrospective audit of electronic records of 75 randomly selected patients admitted to ECU between March and August 2023. Data were gathered on Clinical Frailty Score (CFS) at baseline, comorbidity, escalation status, APACHE II illness severity score, and outcome measures. Results The majority of patients in the sample, 52 of 75 (69.3%), were over 65 years of age with an average of 69.1 years. Baseline frailty score was high, with a modal CFS of 6. Of these patients, 32 (61.5%) had a DNACPR, and 17 (32.7%) had treatment ceiling at ECU level. Illness severity was similar across CFS groups, with a mean APACHE II score of 15.2 (representing a 25% mortality risk). Overall mortality in the over 65 s was 23.1% (12/52), without significant change when stratified by CFS. Mortality in the under 65 s was 8.7% (2/23). Conclusions Acutely unwell patients with frailty may benefit from ECU level care. In our centre, we found no significant increase in mortality linked to a higher frailty score. We suggest that this may represent good case selection by clinicians experienced in working with frailty: admitting patients with more reversibility and targeting therapies towards reversible causes. Limitations remain, especially in assessing illness severity, as the assessment tools are not targeted to this cohort.

Prescribing Trend of Antibiotics Among the Patients Admitted in Intensive Medical Care Unit: A Prospective Observational Study.

Intensive medical care units (IMCUs) usually admit patients who are in critical medical need and require the utmost attention of healthcare professionals, along with the best treatment options available. These patients are prone to infections and require various antibiotics for the treatment. Varying costs of antibiotics, variable dosage forms, and antibiotic resistance cause an economic burden on patients Methodology: This study was designed and conducted prospectively to evaluate the prescribing pattern of antibiotics at the IMCU in a tertiary care hospital. A total of 102 patients were included in the study based on the exclusion and inclusion criteria, and the collected data was tabulated in an Excel sheetand analyzed using Prism GraphPad software. Data were presented as numbers and percentages. Most of the patients were in the age group of 41-50 years. The number of male patients was slightly more than that of female patients. The majority of the patients admitted to the IMCU had acute pulmonary edema and cerebrovascular accidents. Most antibiotics were prescribed empirically and administered parenterally, of which Amoxicillin + Potassium clavulanate was the most commonly used antibiotic. Tigecycline had the highest daily defined dose per 100 bed days value, and injection Sulbactam + Cefoperazone was the costliest of all antibiotic therapy. Antibiotic therapy used in the IMCU consisting of Sulbactam + Cefoperazone was found to be costlier, and Amoxicillin + Potassium clavulanate were the commonly prescribed antibiotics among the other prescribed antibiotics. The average cost of antibiotics was found to be higher, which increased the economic healthcare burden for patients and their families.

Critical illness-related corticosteroid insufficiency: latest pathophysiology and management guidelines.

Intensive care unit (ICU) admissions in the United States exceed 5.7 million annually, often leading to complications such as post-intensive care syndrome and high mortality rates. Among these challenges, critical illness-related corticosteroid insufficiency (CIRCI) requires emphasis due to its complex, multiple-cause pathophysiology and varied presentations. CIRCI, characterized by adrenal insufficiency during critical illness, presents in up to 30% of ICU patients and may manifest as an exaggerated inflammatory response. Factors such as dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered cortisol metabolism, tissue corticosteroid resistance, and drug-induced suppression contribute to CIRCI. Diagnosis is a complex process, relying on a comprehensive assessment including clinical presentation, laboratory findings, and dynamic stimulatory testing. Treatment involves intensive medical care and exacting glucocorticoid therapy. Recent guidelines advocate for individualized approaches tailored to patient presentation and etiology. Understanding the pathophysiology and treatment of CIRCI is vital for clinicians managing critically ill patients and striving to improve outcomes. This research paper aims to explore the latest developments in the pathophysiology and management of CIRCI.

Management of alcohol withdrawal syndrome (AWS)

Alcohol withdrawal syndrome (AWS) is a complex set of symptoms that occur in alcohol-dependent individuals after sudden withdrawal or a significant reduction in alcohol consumption. AWS symptoms occur in about 50% of alcohol abusers. These symptoms may include restlessness, tremor, nausea, nervousness, tachycardia, elevated blood pressure, hyperhidrosis, insomnia, hyperactivity, and hallucinations. In some cases, seizures may occur and delirium tremens may develop, which is life-threatening and an absolute indication for hospitalization of the patient. Effective treatment of AWS is the key to prevent complications and to reduce the risk of death. Treatment of alcohol withdrawal syndrome requires a complex approach that combines properly performed diagnosis, careful monitoring of the patient's condition, pharmacotherapy, equalization of electrolyte disorders, adequate hydration of the patient, supplementation of thiamine deficiencies and, in the case of symptoms of alcoholic delirium, intensive medical care. Pharmacological treatment plays a key role, with the first line of treatment being benzodiazepines, which reduce the risk of epileptic seizures and delirium tremens, and reduce mortality in the course of AWS. Individualized therapy adjustment and patient monitoring are crucial to ensure effective and safe treatment.

Current Aspects of Intensive Medical Care for Traumatic Brain Injury - Part 2 - Secondary Treatment Strategies, Long-term Outcome, Neuroprognostics and Chronification

This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the "cross-talk" of the organs, which has a significant influence on further intensive medical care.

Current Aspects of Intensive Medical Care for Traumatic Brain Injury - Part 1 - Primary Treatment Strategies, Haemodynamic Management and Multimodal Monitoring

This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the "cross-talk" of the organs, which has a significant influence on further intensive medical care.

Perspective of Pneumonia in the Health-Care Setting

Pneumonia is a major worldwide health issue, impacting millions of individuals annually and leading to a significant number of hospitalizations and fatalities. Pneumonia is the leading infectious cause of mortality in children globally, responsible for almost 15% of all fatalities in children under 5 years old, as stated by the World Health Organization (WHO). Pneumonia is a prominent reason for hospitalization in the United States, resulting in around 1.5 million hospital admissions annually. Pneumonia is most prevalent in the elderly population, especially those who are 65 years old and above, and persons with preexisting medical disorders such as chronic obstructive pulmonary disease (COPD), heart disease, diabetes, or a compromised immune system. Pneumonia can vary in severity, ranging from a minor case that can be managed at home to a severe and life-threatening infection that necessitates hospitalization and intense medical care. The symptoms and severity of pneumonia might vary based on the underlying cause, the individual's age and overall health status, and other factors. Pneumonia is a severe respiratory infection that can be caused by several pathogens, such as bacteria, viruses, fungi, and unusual microorganisms. It is defined by the presence of inflammation in the alveoli, which are the small air sacs in the lungs responsible for gas exchange. This inflammation can result in the buildup of fluid or pus, which can hinder the lungs' functionality and impede the body's capacity to obtain sufficient oxygen. The significant burden of pneumonia globally, especially on vulnerable populations like children and the elderly, underscores the need for improved prevention, early detection, and effective treatment strategies. The range in severity highlights the importance of timely and appropriate medical care, as well as the need for patient education on recognizing and seeking treatment for pneumonia. Understanding the diverse etiologies and risk factors for pneumonia can inform the development of targeted interventions and public health measures to reduce the impact of this major respiratory illness.

Integrating Palliative Care and Hematologic Malignancies: Bridging the Gaps for Our Patients and Their Caregivers.

Patients with hematologic malignancies (HMs) struggle with immense physical and psychological symptom burden, which negatively affect their quality of life (QOL) throughout the continuum of illness. These patients are often faced with substantial prognostic uncertainty as they navigate their illness course, which further complicates their medical decision making, especially at the end of life (EOL). Consequently, patients with HM often endure intensive medical care at the EOL, including frequent hospitalization and intensive care unit admissions, and they often die in the hospital. Our EOL health care delivery models are not well suited to meet the unique needs of patients with HMs. Although studies have established the role of specialty palliative care for improving QOL and EOL outcomes in patients with solid tumors, numerous disease-, clinician-, and system-based barriers prevail, limiting the integration of palliative care for patients with HMs. Nonetheless, multiple studies have emerged over the past decade identifying the role of palliative care integration in patients with various HMs, resulting in improvements in patient-reported QOL, symptom burden, and psychological distress, as well as EOL care. Importantly, these studies have also identified active components of specialty palliative care interventions, including strategies to promote adaptive coping especially in the face of prognostic uncertainty. Future work can leverage the knowledge gained from specialty palliative care integration to develop and test primary palliative care interventions by training clinicians caring for patients with HMs to incorporate these strategies into their clinical practice.

German guidelines for airway management 2023.

The German airway management guidelines are intended to serve as an orientation and decision-making aid and thus contribute to the optimal care of patients undergoing anesthesiologic- and intensive medical care. As part of the pre-anesthesiologic evaluation, anatomical and physiological indications for difficult mask ventilation and intubation shall be evaluated. This includes the assessment of mouth opening, dental status, mandibular protrusion, cervical spine mobility and existing pathologies. The airway shall be secured while maintaining spontaneous breathing if there are predictors or anamnestic indications of difficult or impossible mask ventilation and/or endotracheal intubation. Various techniques can be used here. If there is an unexpectedly difficult airway, avideo laryngoscope is recommended after unsuccessful direct laryngoscopy, consequently avideo laryngoscope must be available at every anesthesiology workplace. The airway shall primarily be secured with avideo laryngoscope in critically ill- and patients at risk of aspiration. Securing the airway using translaryngeal and transtracheal techniques is the "ultima ratio" in airway management. The performance or supervision of airway management in the intensive care unit is the responsibility of experienced physicians and nursing staff. Appropriate education and regular training are essential. Clear communication and interaction between team members are mandatory before every airway management procedure. Once the airway has been secured, the correct position of the endotracheal tube must be verified using capnography.

Congenital CMV infection in a Brazilian neonatal intensive care unit: high prevalence among twin newborns

BackgroundCytomegalovirus (CMV) is one of the most important pathogens associated with congenital infection worldwide. Most congenital CMV-infected infants are asymptomatic at birth; however, some can develop delayed sequelae, especially hearing loss.MethodsThis study aimed to investigate the prevalence of congenital CMV infection in a neonatal intensive care unit in a low-income region of Brazil. The objectives extended to identifying associated factors, assessing the clinical status of infected newborns, and undertaking a two-year follow-up to discern potential long-term consequences in the affected infants. This cross-sectional prospective study enrolled newborns up to three weeks of life requiring intensive medical care. We employed a convenience sampling method to include 498 newborns and 477 mothers in the study. Categorical variables underwent analysis employing Fisher’s exact test, whereas the examination of continuous variables involved the Mann‒Whitney test.ResultsCMV DNA was detected in saliva/urine samples from 6 newborns (1.21%), confirming congenital infection. We noted a significantly greater incidence (OR: 11.48; 95% CI: 2.519–52.33; p = 0.0094) of congenital infection among twins (7.14%) than among nontwins (0.66%). The twin patients exhibited discordant infection statuses, suggesting that only one of the babies tested positive for CMV. Most of the infected children were born to mothers who initiated sexual activity at a younger age (p = 0.0269). Only three out of the six newborns diagnosed with CMV infection underwent comprehensive clinical assessments and received continuous follow-up until they reached two years of age. Only one of the children had weight and height measurements below the norm for their age, coupled with developmental delays.ConclusionsThe prevalence of congenital CMV infection among newborns admitted to the NICU was low and similar to that in the general population. However, we found a significantly greater incidence of congenital CMV infection in twins than in singletons. Interestingly, the twin-infected patients exhibited discordant infection statuses, suggesting that CMV was present in only one of the babies. We also found that most of the infected children were born to mothers who initiated sexual activity at a younger age. Diagnostic accessibility and comprehensive surveillance programs are imperative for effectively managing and preventing congenital CMV infections.