Life Support Research Articles

Arterial Limb Complications of Femoral Venoarterial Extracorporeal Life Support in Adult and Pediatric Populations

Arterial Limb Complications of Femoral Venoarterial Extracorporeal Life Support in Adult and Pediatric Populations

Prevalence and Survival of Prolonged Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: An Analysis of the Extracorporeal Life Support Organization Registry.

To examine trends in utilization and outcomes among patients with the acute respiratory distress syndrome (ARDS) requiring prolonged venovenous extracorporeal membrane oxygenation (VV ECMO) support. Retrospective observational cohort study. Adult patients in the Extracorporeal Life Support Organization registry. Thirteen thousand six hundred eighty-one patients that required ECMO for the support of ARDS between January 2012 and December 2022. None. Mortality while supported with VV ECMO and survival to hospital discharge based on ECMO duration were examined utilizing multivariable logistic regression. Among the 13,681 patients supported with VV ECMO, 4,040 (29.5%) were supported for greater than or equal to 21 days and 975 (7.1%) for greater than or equal to 50 days. Patients supported with prolonged VV ECMO were less likely to be discharged alive from the hospital compared with those with short duration of support (46.5% vs. 59.7%; p < 0.001). However, among patients supported with VV ECMO greater than or equal to 21 days, duration of extracorporeal life support was not significantly associated with mortality (odds ratio [OR], 0.99; 95% CI, 0.98-1.01; p = 0.87 and adjusted OR, 0.99; 95% CI, 0.97-1.02; p = 0.48). Even in those supported with VV ECMO for at least 120 days (n = 113), 52 (46.0%) of these patients were ultimately discharged alive from the hospital. Prolonged VV ECMO support of ARDS has increased and accounts for a substantial portion of cases. Among patients that survive for greater than or equal to 21 days while receiving VV ECMO support, duration is not predictive of survival to hospital discharge and clinical recovery may occur even after very prolonged VV ECMO support.

E-Bicycle for Food Delivery

Abstract: The rise of urban food delivery services has led to an increased demand for efficient and environmentally sustainable transportation methods. This study explores the implementation of sustainable electric bicycles (e-bikes) for food delivery, examining their potential to reduce carbon emissions, traffic congestion, and operational costs. E-bikes, powered by rechargeable batteries, offer a viable alternative to traditional delivery vehicles, particularly in densely populated urban areas. Key factors influencing the adoption of e-bikes include battery life, charging infrastructure, load capacity, and regulatory support. The research also highlights successful case studies from various cities, demonstrating the environmental and economic benefits of integrating e-bikes into delivery fleets. The findings suggest that with proper investment and supportive policies, ebikes can significantly contribute to more sustainable urban logistics, promoting a greener and more efficient food delivery ecosystem.

Social support as a coping resource for psychosocial conditions in postpartum period: a systematic review and logic framework

PurposeThis review seeks to examine the current state of postpartum social support and psychosocial conditions among women around the world, as well as explore the relationship between these factors. Additionally, it aims to propose a logical framework for enhancing postpartum social support and psychosocial conditions in this population.MethodsFollowing the development of a search strategy, two databases, PubMed and Science Direct, were searched for studies published between January 2019 and May 2023. The search was conducted throughout the entire month of May 2023. The risk of bias in the included cross-sectional studies was assessed using the Newcastle–Ottawa Quality Assessment Scale, which was adapted for this specific study design. To determine if the main objective of the cross-sectional studies was to investigate the relationship between social support and postpartum psychosocial conditions, a review was conducted based on the AMSTAR checklist, PRISMA checklist and PRISMA flow diagram. Data extraction was performed with the consensus of two authors, and a narrative synthesis approach was chosen for data synthesis, following the guidelines provided by the Centre for Reviews and Dissemination (CRD).ResultsEleven cross-sectional studies were included in the final analysis. Our findings revealed that all reviewed studies provided evidence of a positive association between social support and healthy psychosocial conditions in postpartum period. However, due to the absence of standardized measurement indicators to identify and compare the outcomes of various studies, there was a need to develop a conceptual framework that could enhance our understanding of the postpartum psychosocial condition including anxiety, depression, unfavorable quality of life and social support status up to 24 month after child birth. This framework aimed to incorporate childbirth and motherhood as "stressful events," while considering social support as a crucial "coping resource." Furthermore, it acknowledged empowerment, help-seeking behavior, and peer support as important "coping actions," alongside implementing client-centered interventions. Lastly, it recognized postpartum mental health and optimal quality of life as significant "effects" of these factors.ConclusionsThe proposed conceptual framework could define postpartum women’s health as “the ability to adapt and self-manage.”

Determining Extracorporeal Membrane Oxygenation Outcomes in Obese Patients with ARDS

Extracorporeal membrane oxygenation (ECMO) is crucial for managing acute respiratory distress syndrome (ARDS) refractory to conventional therapy, but its impact on obese ARDS patients remains inadequately understood due to relative contraindications per the Extracorporeal Life Support Organization (ELSO) guidelines. This study aimed to analyze the association between obesity and ECMO outcomes in ARDS patients. Using five years of National Inpatient Sample data (2016–2020), we identified ARDS patients through ICD-10 codes, classifying those with a BMI &gt; 30 as obese. Univariate and multivariate analyses were performed to assess mortality, rates of left ventricular assist devices, and tracheostomy differences between obese and non-obese patients, with secondary outcomes examining the impact of obesity on length of stay (LOS) and total hospitalization charges (TOTCHG). Among 3,219 ARDS patients requiring ECMO, 8.2% were obese. While initial univariate analysis showed a non-significant 43% lower mortality odd in obese patients, adjusting for confounders revealed a statistically significant 46% lower odd of mortality compared to non-obese patients (adjusted odds ratio 0.54, 95% confidence interval 0.3-0.94, p 0.032). LOS and TOTCHG did not significantly differ between the two groups, nor did the rates of LVAD or tracheostomy. These findings suggest that obesity may confer a survival advantage in ARDS patients undergoing ECMO, potentially due to factors such as nutritional reserves and the obesity paradox observed in critical illnesses. Therefore, BMI alone should not preclude obese patients from ECMO treatment, emphasizing the need for further research to inform clinical decision-making in this population.

Enhancing Cardiac Arrest Skills: Exploring Student Nurses’ Journey through Mental Simulation to Self-efficacy

Objective: This study explores mental simulation (MS) as a potential tool for enhancing skill acquisition and readiness among student nurses in life-saving procedures, particularly in high-stress, time-sensitive situations like cardiac arrest. It aims to investigate the impact of MS on learning life support skills and creating self-officious students in nursing education. Methods: The study combines a theoretical framework grounded in social constructionism with qualitative research methods. We utilize a qualitative reflexive thematic analysis approach. Eleven pre-registration student nurses participated in interview-based investigations after engaging in a 4-week MS program. Data collection utilized open-ended questions, allowing participants to express their experiences and perceptions regarding MS for life support skill acquisition. Results: The research identified six key themes and sub-themes: “Motivation to learn”, “emulating reality”, “emulating real-world intensity”, “emotional resonance”, “harmonizing reflective practice”, and “empowering confidence”. Participants reported using MS to address self-efficacy challenges, creating vivid simulated experiences, inducing real-world intensity, personalizing visualizations, fostering reflective practice, enhancing team understanding, and demystifying cardiac arrest skills, ultimately empowering confidence in employing their cardiac arrest skills. Conclusion: The findings underscore MS’s potential as a valuable training tool in nursing education. MS not only bridges knowledge gaps but also prepares student nurses for real-life scenarios, demystifying cardiac arrests and enhancing self-efficacy. The study advocates for the integration of MS alongside traditional training methods to enhance preparedness and confidence among student nurses in critical life support situations. Further research could explore the broader implications of MS across various healthcare contexts.

Optimizing Advanced Trauma Life Support (ATLS®) to Maximize Readiness.

The Army utilizes Individual Critical Task Lists (ICTLs) to track and ensure competency and deployment readiness of its medical service members. ICTLs are the various skills and procedures that the Army has deemed foundational for each area of concentration (AOC)/military occupational specialty (MOS). While many ICTLs involve the patient care that military medical providers regularly provide, some procedures are not as commonly performed. This, when coupled with lower patient volume at military treatment facilities (MTF), poses a challenge for maintaining skill competency and deployment readiness. Fort Campbell's Blanchfield Army Community Hospital (BACH) has created a holistic and unique solution to meet many of these standardized requirements and support a ready medical force. By optimizing the Advanced Trauma Life Support (ATLS®) course curriculum to facilitate ICTL completion, BACH has increased its ICTL completion rates, ATLS® course exposure, and streamlined training requirements. The purpose of this article is to describe this best practice and suggest its applicability to other MTFs. By cross-referencing the ATLS® course curriculum and appendices with ICTLs, BACH has augmented ATLS® course certification with the additional completion of 12 ICTLs. This new approach not only increases ICTL completion, but also increases ATLS® curriculum exposure to medical providers, such as Registered Nurses or Nurse Practitioners, who would not typically take ATLS®. Since starting this new approach in April 2021, 73 military medical personnel have completed the ATLS® course at BACH, with 24 different medical specialties represented. A total of 361 ICTLs have been completed with specific ICTL completion counts ranging from 13 to 48. Each ICTL tested was completed 100% of its annual requirement. ATLS® is a mandatory joint interoperability standard for military physicians and it is also an Army ICTL for many AOCs/MOSs. Only counting completion of this course as one ICTL is a missed opportunity for the time spent by Army medical providers and limits the exposure of ATLS® to select AOCs/MOSs. This optimized and novel approach has been successful at BACH, suggesting its applicability at other MTFs that serve as ATLS® testing sites.

Symbolism of Natural Imagery in Prose of Russian Émigré Writers (E. Yu. Skobtsova, N. D. Gorodetskaya, V. A. Nikiforov-Volgin)

This study explores the issue of symbolization of natural imagery in an ontological, existential sense through the works of authors belonging to the first wave of Russian literary emigration. It is noted that in E. Yu. Skobtsova’s novel “Russian Plain”, a mythologized image of spiritualized space is created, encompassing an expressively colored image of the motherland, calling on children to respond to universal pain. In the autobiographical prose of N. D. Gorodetskaya, past and present converge in a unified sense of gratitude: the gracious, invaluable past seems to merge into the present, giving it integrity and significance, with the native surrounding world in the past becoming the writer’s main life support, a great ontological value. V. A. Nikiforov-Volgin’s works reveal a typologically similar mythologization of space in an original individual-authorial perception, accentuating the motif of the sacredness of the latter, expressing the drama of the years of adversity; with N. D. Gorodetskaya, the writer is united by a perception of the harmony of the native surrounding world with a child’s soul. The analysis conducted convinces that the artistic thinking of E. Yu. Skobtsova, N. D. Gorodetskaya, V. A. Nikiforov-Volgin developed in a typological stream of neorealistic artistic consciousness characterized by a multifaceted synthesis of various artistic elements.

To Determine the Accuracy and Reliability of Broselow Tape in Comparison with Actual Weight and Advance Pediatric Life Support Formula Weight Assessment among the Pediatric Population Presenting to Emergency Department of a Low Income Setting

Background: Near precise weight assessment among sick pediatric patients remains a dilemma and conventionally accepted weight assessment methods, in busy ED might be inaccurate or unreliable. Children have different weights at different ages, and accurate/precise weight measurement is of utmost importance for weight-related dose calculation of drugs/fluids, equipment sizes, an accurate dose of electrical currents during cardiac shock, etc. Several weight estimation methods are available and are dependent on the child's age, length, or both. However, length or length-and-age-based methods may have greater accuracy than merely age-based, still precise weight measurement while children are recumbent (length) has its own challenges. Objective: We determined the accuracy and reliability of BT by comparing it with actual weight and advanced pediatric life support formula (APLS) among the pediatric population presenting to the emergency department. Methods: This was a single-center, cross-sectional study design. This study was conducted at pediatric emergency of an urban tertiary care hospital after ethics committee approval and written consent from parents/caregivers during July 2021- June 22. Pediatric patients aged 1 month to 12 years, weight 3-36 kg, and height 46.5-142.5 cm on BT were included. Actual weight was measured on a standard weighing machine. We use Broselow pediatric emergency tape (2017 edition), APLS formula was also used to measure the estimated weight by using the age provided by parents. Descriptive analysis, mean and standard deviation were calculated, frequencies and percentages were calculated for categorical variables. Cronbach’s alpha and Passing-Bablok regression analysis was applied to assess the reliability and identify systematic biases between actual body weights with estimated BT. Bland–Altman analysis was also performed to measure the precision, accuracy, and bias. Results: 250 children were included with equal gender distribution and were divided in to three categories as per the weight estimation by BT in to &lt;10 kg (n=58, 23.2%), 10-18 kg (n=151, 60.4%) and &gt;18 kg (n=41, 16.4%). The mean age was 5.26 (±2.37) years, majority of children were below 5 years of age (n=144, 58%). Positive agreement between BT weight with actual weight and other formulas in weight category of &lt;10 kg, however as weight increases from 10 kg, onward results are not significant. Passing and Bablok Regression analysis showed a positive correlation between the estimated and actual (AW) body weight (r=0.9280, p&lt;0.001) and accuracy (r2=0.929), and the accuracy of BT weight decreases with the increasing weight of children. Similarly, 95% agreement limit and mean biased was 0.465 to 1.113 and 0.789±2.602 between BT and APLS, BT with AW was -0.50 to -0.28 and -0.39±0.885. Comparing and correlating weight assessment of APLS formula vs LF and TF didn't show significance with a p-value of 0.041 and 0.034 respectively. Bland-Altman plot between BT measurement with AW demonstrates a bias equal to 1.096 kg with a limit of 0.870 to 1.815. Conclusion: BT may be an accurate and time bound method of weight measurement as compared to other methods of weight estimation, however the accuracy of BT may be adversely affected with age exceeding 95 months and weight &gt;26 kg. BT may be safely used in the younger pediatric population. Health care professionals may consider this information while using BT to estimate weight for pediatric resuscitation, however, this is a single center hospital based study with limited cases, we recommend to have a large scale community based study or a census before to generalize these results to general population.

Triage implementation in Pakistan: a case of broken healthcare system

Madam, The death toll due to road traffic accidents (RTA) in Pakistan reached 28,170 in 2020, according to WHO. This accounts for 1.93% of all deaths in the World. (1) Mortality due to RTA is an ever-increasing concern and its management, especially in Pakistan, is still a bigger concern. The efficient way of dealing with Trauma is by following globally accepted evidence-based “Advanced Trauma Life Support” guidelines. Triage being the first step in ATLS literally means “to sort”. In other words, identifying the greatest good for greatest numbers. The Emergency Department (ED) rule must be to manage patients based on the severity of problems and not on the order of arrival. Death can be prevented in the patients who benefit the most by getting medical attention the earliest. All the patients escorted and rescued from the place of incident should be sorted rapidly and given a colour-coded tag based on urgency. Onsite triage is the most critical life saving measure. A Karachi based study concluded that most paramedics in ambulances had poor knowledge of pre-hospital management and 72.3% thought they could not do triage. (2) Similarly, another study at the emergency department of a tertiary care hospital in Karachi showed concerningly poor knowledge of triage.(3) Only 5 CPSP accredited public hospitals in Pakistan have emergency medicine as a separate field which results in lack of triage implementation as EDs of most hospitals are run by internal medicine professionals and general surgeons. Simply, implementing triage has shown to reduce and ED mortality (by 3.80%), resources’ utilisation, and length of stay.(4) Punjab, the development hub of Pakistan, provides 22 public hospitals, including only 12 fully functional ones, for dealing with trauma patients. DHQs bearing the burden of all trauma patients of districts are level-III trauma centres lacking in specialised surgical care and categorization of paediatric and adult patients. Other independent trauma care facilities are level-IV trauma centres which act as a relay to stabilise the patients before they are transferred to a better facility. A level-I trauma centre alone can increase 25% survival rate of trauma patients, but unfortunately Pakistan does not have a single level-I trauma centre. (5) Therefore, all Rescue staff must be trained regularly for future enactment of triage to alleviate RTA associated mortality along with upgrading of trauma centres to level-I.

C.4 Neurologic injury in pediatric patients cannulated for rescue extracorporeal life support

Background: Historical literature suggests the risk of neurologic injury in children supported by extracorporeal life support (ECLS) is between 10-20%, however recent studies suggest the incidence may be much higher. Methods: The Alberta Children’s Hospital (ACH) Rescue ECLS program cannulates patients who are then transferred to the partner program at Stollery Children’s Hospital. Data was systematically collected from all patients cannulated for Rescue ECLS at ACH October 2011 and May 2023. Neuroimaging (CT, MR) performed after cannulation was reviewed for evidence of ischemic and hemorrhagic strokes and hypoxic-ischemic brain injury. Results: Seventy-one patients were included in the Rescue ECLS cohort. Median age at cannulation was 1.74 years (range 0-17.6 years, 51% female). Survival to hospital discharge was 65%. Primary indication for ECLS included cardiac (42%), respiratory (33.3%), extracorporeal cardiopulmonary resuscitation (ECPR; 23.2%) and trauma (1.4%). Seventy four percent of the cohort underwent neuroimaging, of whom 67% had evidence of neurologic injury including stroke (ischemic 67%; hemorrhagic 50%) or hypoxic-ischemic injury (33%). Risk of neurologic injury did not differ by indication for ECLS. Conclusions: Neuroimaging abnormalities are present in most pediatric patients imaged post-cannulation for Rescue ECLS. Further research into modifiable risk factors for specific ECLS-related brain injuries may help to improve outcomes for survivors.

Enhancing Physicians' Autonomy through Practical Trainings.

In medical emergencies adherence to standardized clinical protocols is crucial to ensure a better outcome for patients. Newly qualified physicians may play several roles in serving the National Health Service (substituting general practitioners, on-call duty, working in emergency rooms, etc.) in Italy. In these situations, the physician may have to manage critical patients autonomously. Moreover, newly qualified physicians may show a considerable deficiency in routine medical activities. In fact, many universities do not provide a practical simulation training programme, which is why a substantial number of students only face clinical emergencies when they start working after graduation. A cross-sectional study was performed by engaging medical doctors. Both experienced physicians and newly licensed physicians (graduated less than 24 months ago) were included in the study. A questionnaire was distributed to each participant during SIMED's Courses from June 2021 to December 2022. The questionnaire consisted of two sections. The first one analyzed participation in standardized practical courses on medical emer gencies (Basic Life Support, Advanced Cardiac Life Support, International Trauma Life Support and a course on Advanced Airway Management). The second section analyzed the perceived autonomy of health professionals in the management of five different work settings, using a 5-point likert scale. 2,168 questionnaires were analyzed, of which 68.7% were from newly qualified doctors and 31.3% from more experienced doctors The highest rate of physicians who undertook training courses was achieved for the basic life support course (77.5%) and the lowest rate for the advanced trauma course (15.9%). Physicians perceive themselves the highest autonomy in Primary Care setting (63.1%), while in the Emergency Department they perceive themselves with less autonomy (24.0%). In the analyzed sample, experienced physicians show a higher percentage of autonomy than newly qualified doctors (31.4% vs 8.1%) in all scenarios. Our analysis shows a possible correlation between the self-perceived autonomy of physicians and attending practical simulation courses. Although the role of training through practical courses is relevant, the percentage of trained professionals is insufficient and therefore the implementation of practical training projects has to be encouraged.

#2931 Advancing personalized extracorporeal therapies for albumin bound toxins through serum albumin binding function

Abstract Background and Aims Liver failure poses a significant clinical challenge with compromised functionality of the liver and accumulation of toxic metabolites. The lack of bedside-compatible methods to evaluate treatment response during therapy underscores the urgent need for refined diagnostic tools. Albumin, the principal transport protein, reflecting the elevated toxin and metabolite levels in liver failure, assumes a critical role in assessing the severity of hepatic dysfunction. This research introduces a novel method centered on a dansylsarcosine-based kinetic modeling of serum albumin binding, aiming to improve therapeutic decision-making in hepatic failure. This biomarker is designed to offer critical insights into albumin's dynamic interactions, essential for assessing liver function and effectiveness of therapeutic interventions. The study aims to supplement existing diagnostic methods, providing a more comprehensive evaluation of irreversible damages of albumin in liver failure and guiding more effective treatment strategies. Method In this study, we employed a novel method for measuring binding affinity at varying levels of dansylsarcosine, aiming to describe the kinetic properties of the Sudlow II binding site. The binding behavior of albumin under various concentrations of dansylsarcosine was characterized using a modified Michaelis-Menten kinetic model. To enhance accuracy, a formula correction was employed for both intrinsic absorbance and the influence of dansylsarcosine. The method facilitates kinetic modeling, exploring the behavior of the binding site under diverse ligand concentrations. Emerging from this are two key players: Bmax and Kd. Bmax quantifies the maximum capacity of binding sites available for occupation by dansylsarcosine. Kd signifies the concentration of dansylsarcosine at which half of the Sudlow II binding sites are saturated. The method was applied to a patient database of patients with hepatic failure treated with OPAL or MARS liver support systems (albumin dialysis with albumin regeneration). The applied analysis focused on the correlation with existing clinical scores and the description of therapeutic effects. Results The new method correlates with established markers, scores and therapeutic effects. For Patient samples from the OPALESCE database, Bmax and Kd exhibited correlations with established albumin biomarkers. Subgroup analysis revealed associations with clinical scores such as GCS, SOFA, MELD, ACLF, CLIF-OF and ABiC emphasizing the clinical relevance of Bmax and Kd values. Therapeutic effects were assessed using the OPALESCE database, demonstrating the capability of Bmax and Kd to describe therapy outcomes. Significant differences between the start and end of the first treatment were detected for MARS with Bmax and OPAL with Kd. Bmax and Kd values proved to be valuable indicators for therapeutic effects, aligning with established parameters such as ABiC and the CLIF-OF Score. These findings underscore the potential clinical utility of Bmax and Kd as robust markers for assessing therapy outcomes in liver support interventions. Conclusion The results help to provide a comprehensive understanding of albumin binding dynamics in patients with hepatic failure, offering a valuable tool for therapeutic decisions. The impact of therapy can be described using Bmax and Kd, both of which correlate with established clinical scores within the patient population. Bmax unveils irreversible damages to the albumin molecule, showcasing its potential to identify scenarios where applied therapies fail to enhance albumin binding functions. This insight prompts the consideration of alternative therapeutic pathways, including the consideration of therapeutic plasma exchange when extracorporeal methods are insufficient, showcasing the biomarker's utility in guiding precision therapeutic decisions for improved outcomes in hepatic failure management. The significance of albumin function for uraemic toxins needs to be further investigated. Optimization of dialysis for patients with renal insufficiency appears possible.

#1563 Family feedback survey on quality of dialysis withdrawal and end-of-life care on hemodialysis patients in an ICU – a single-center study from India

Abstract Background and Aims End-of-life care in hemodialysis is emerging, with limited implementation in developing countries. There is a sparsity of data on dialysis withdrawal and the quality of end-of-life care in these regions. Developing countries differ in their cultural, social, and spiritual practice compared to the Western world and family plays a major role in decision-making. No survey has been done on family's perception of dialysis withdrawal and end-of-life care in our settings. So, we studied feedback from families regarding the quality of dialysis withdrawal and end-of-life care provided to maintenance hemodialysis (MHD) patients admitted to our intensive care unit (ICU). Method This study was conducted at Kasturba Medical College, Manipal, MAHE, Manipal, India between January 2020 to October 2022 involving the data from end-stage kidney disease (ESKD) patients on MHD admitted in the ICU, who had withdrawn from dialysis before death and received end-of-life care as per the hospital policy (Blue Maple) from Renal supportive and Palliative care team. The baseline data was collected for all patients and indications for withdrawal of dialysis and ICU treatment and end-of-life care provided were collected. The next of kin were interviewed by telephone by a single interviewer using a modified Quality of Death and Dying questionnaire. The data was analyzed using SPSS 20 Results Among 98 ESKD patients on maintenance hemodialysis who died in our ICU, 23 were referred to Palliative care, counselled, had withdrawal of dialysis at least 48 hours before death and received end-of-life care. Table 1 outlines baseline characteristics. The mean age was 57 ± 12.09 years, with a male predominance (82.6%). Common comorbidities included hypertension (100%), type 2 diabetes (69.5%), and ischemic heart disease (65.2%). The primary cause for ICU admission was infectious disease (47.8%). The majority of reasons for dialysis withdrawal and end-of-life care were worsening hemodynamic status (82.6%) and illness deterioration (69.5%). After consent and establishment of futility, dialysis withdrawal was done for all patients (100%), No CPR for 100%, withdrawal of inotropes in 50%, and withdrawal of ventilator was done in 80% of the patients. A successful telephonic interview/survey was conducted with 21 out of the 23 subjects, with the majority of next of kin being the spouse (47.6%) followed by children (33.3%) and siblings (14.3%). The questionnaire and response are given in Table 2. All expressed a need for palliative care involvement. 82% accepted the decision of dialysis withdrawal and end-of-life care put forth by the doctor's team without difficulty;74% of families were present with the patient in their final hours and were grateful for the same 20% had their spiritual leader to visit during the end-of-life event. None of the family members (100%) interviewed had a guilty feeling and all had a positive rating on the involvement of the palliative care team and the need to ease patients' distress and suffering during their final hours (100%). Unfortunately, none of the patients had prior discussions of advance care planning (ACP) with their doctors regarding end-of-life care before the specific event Conclusion Our study highlights that families agree with the withdrawal of artificial life support measures, such as MHD, CPR, withdrawal of inotropes, and/withdrawal of ventilator in ICU settings when these interventions are considered futile for end-of-life care in ESKD patients. It also emphasizes the need for ACP, and early integration of palliative care for discussions about dialysis withdrawal, and withholding futile interventions at end-of-life care in ESKD patients, especially in resource-constrained settings like ours, for high-quality end-of-life care. This will also lead to better end-of-life care outcomes and improved patient and family satisfaction with care.

An exploration of the experiences and attitudes of healthcare professionals towards enteral tube feeding for adults living in the community following stroke.

Guidelines recommend enteral feeding via gastrostomy should be considered for adult survivors of stroke with dysphagia who cannot eat or drink sufficiently for >4 weeks. Many people continue long-term tube-feeding via this route in the community where healthcare professionals contribute to their care and nutritional management, although little is known about their experiences of or attitudes towards enteral feeding in this situation. The present study aimed to explore the experiences and attitudes of healthcare professionals working with this patient group. Healthcare professionals were invited to complete a questionnaire devised for the study which comprised closed and open questions about tube-feeding including their patients' participation in feeding processes and mealtimes and how these might be improved. Responses to closed questions were analysed descriptively and free-text responses analysed using thematic analysis. Fifty-seven participants met the inclusion criteria. They identified patients' quality of life (77% of respondents) and nutritional support (75%) as the most important aspects of tube-feeding. Good communication and training with healthcare teams and carers were considered important. Their patients' participation in tube-feed administration and mealtime involvement were described as variable and potentially beneficial, but both were related to patients' choice and health impairment. Blended tube-feeding was considered an option by 89% provided practical and safety conditions were met. Participants' experiences of and attitudes towards tube feeding in adults living with stroke in the community in the sample in the present study are varied and focussed on individual patients' needs, safety and professional standards.

Correction to: 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.

Correction to: 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.

Internet addiction and suicidal ideation in Chinese college students: The role of meaning in life and social support

Worldwide, internet addiction and suicidal ideation have become serious issues in public health. However, little is known about the underlying mechanisms in the relationship between internet addiction and suicidal ideation. This study aimed to investigate the relationship between internet addiction and suicidal ideation, and the role of meaning in life (MIL) and social support in this relationship. A total of 714 (female= 53.78%; mean age = 18.29 years, SD = 0.68 years) completed internet addiction, suicidal ideation, MIL, and social support measures. Results from PROCESS Model analysis showed higher internet addiction to be associated with a higher risk for suicidal ideation. This association was fully mediated by MIL so that internet addiction predicts suicidal ideation by reducing MIL. Social support moderated the effect of loss of MIL on suicidal ideation; namely, a lower sense of MIL was associated with higher suicidal ideation at low levels of social support, while high social support eliminated the effect of meaninglessness on suicidal ideation among college students. These findings imply a need for intervention in order to prevent suicidal ideation in college students in the digital era.

Well-Being Domains in U.S. Military Veterans: Identifying Modifiable Factors to Promote Whole Health.

The U.S. Department of Veterans Affairs is actively transitioning away from a disease-centric model of healthcare to one that prioritizes disease prevention and the promotion of overall health and well-being. Described as Whole Health, this initiative aims to provide personalized, values-centered care that optimizes physical, behavioral, spiritual, and socioeconomic well-being. To inform this initiative, we analyzed cross-sectional data from a nationally representative sample of primarily older U.S. military veterans to estimate levels of well-being across these domains, and identify sociodemographic, military, and potentially modifiable health and psychosocial correlates of them. Results revealed that, overall, veterans reported high domain-specific well-being (average scores ranging from 6.7 to 8.3 out of 10), with the highest levels in the socioeconomic domain and lowest in the physical domain. Several modifiable factors, including purpose in life, resilience, and social support, were strongly associated with the examined well-being domains. Interventions targeting these constructs may help promote well-being among U.S. veterans.

Clinical Practice of Pre-Assembling and Storing of Extracorporeal Membrane Oxygenation Systems

According to the Extracorporeal Life Support Organization (ELSO) guidelines, pre-assembled and already primed extracorporeal membrane oxygenation (ECMO) systems can be safely stored for up to 30 days under specific conditions. This study gives a detailed overview of existing pre-assembly practices. An anonymous online survey was conducted among chief perfusionists at German ECMO centers. Forty-four of a total of 83 ECMO centers (53%) completed the survey. Thirty-three percent do not preassemble ECMO systems. Seventy-seven percent (n = 34) reported having preassembled ECMO systems readily available (30% dry preassembly/20% wet preassembly/27% wet preassembly with circulation). Half of the participating centers (50%) reported having a standard operating procedure (SOP) and the majority (57%) of chief perfusionists expressed a need for an evidence-based SOP. A maximum storage time for wet preassembled ECMO systems is established in 88% of departments. On average, wet preassembled systems are discarded after 20 days, which is below the ELSO’s safe limit of 30 days. Overall, this survey reveals a heterogeneous approach regarding the practice of provisioning preassembled ECMO systems. The demand for an evidence-based SOP for the preassembly and storing of ECMO systems becomes evident, necessitating the determination of hygienic standards, regular training, and a reliable maximum storage period.

Empirical meropenem versus piperacillin/tazobactam for adult patients with sepsis (EMPRESS) trial: Protocol.

Piperacillin/tazobactam may be associated with less favourable outcomes than carbapenems in patients with severe bacterial infections, but the certainty of evidence is low. The Empirical Meropenem versus Piperacillin/Tazobactam for Adult Patients with Sepsis (EMPRESS) trial is an investigator-initiated, international, parallel-group, randomised, open-label, adaptive clinical trial with an integrated feasibility phase. We will randomise adult, critically ill patients with sepsis to empirical treatment with meropenem or piperacillin/tazobactam for up to 30 days. The primary outcome is 30-day all-cause mortality. The secondary outcomes are serious adverse reactions within 30 days; isolation precautions due to resistant bacteria within 30 days; days alive without life support and days alive and out of hospital within 30 and 90 days; 90- and 180-day all-cause mortality and 180-day health-related quality of life. EMPRESS will use Bayesian statistical models with weak to somewhat sceptical neutral priors. Adaptive analyses will be conducted after follow-up of the primary outcome for the first 400 participants concludes and after every 300 subsequent participants, with adaptive stopping for superiority/inferiority and practical equivalence (absolute risk difference <2.5%-points) and response-adaptive randomisation. The expected sample sizes in scenarios with no, small or large differences are 5189, 5859 and 2570 participants, with maximum 14,000 participants and ≥99% probability of conclusiveness across all scenarios. EMPRESS will compare the effects of empirical meropenem against piperacillin/tazobactam in adult, critically ill patients with sepsis. Due to the pragmatic, adaptive design with high probability of conclusiveness, the trial results are expected to directly inform clinical practice.