Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation.

PURPOSE: Patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) frequently develop arterial hyperoxaemia, which may be harmful. However, lower oxygen saturation targets may also lead to harmful episodes of hypoxaemia. METHODS: In this registry-embedded, multicentre trial, we randomly assigned adult patients receiving VA-ECMO in an intensive care unit (ICU) to either a conservative (target SaO2 92-96%) or to a liberal oxygen strategy (target SaO2 97-100%) through controlled oxygen administration via the ventilator and ECMO gas blender. The primary outcome was the number of ICU-free days to day 28. Secondary outcomes included ICU-free days to day 60, mortality, ECMO and ventilation duration, ICU and hospital lengths of stay, and functional outcomes at 6 months. RESULTS: From September 2019 through June 2023, 934 patients who received VA-ECMO were reported to the EXCEL registry, of whom 300 (192 cardiogenic shock, 108 refractory cardiac arrest) were recruited. We randomised 149 to a conservative and 151 to a liberal oxygen strategy. The median number of ICU-free days to day 28 was similar in both groups (conservative: 0 days [interquartile range (IQR) 0-13.7] versus liberal: 0 days [IQR 0-13.7], median treatment effect: 0 days [95% confidence interval (CI) - 3.1 to 3.1]). Mortality at day 28 (59/159 [39.6%] vs 59/151 [39.1%]) and at day 60 (64/149 [43%] vs 62/151 [41.1%] were similar in conservative and liberal groups, as were all other secondary outcomes and adverse events. The conservative group experienced 44 (29.5%) major protocol deviations compared to 2 (1.3%) in the liberal oxygen group (P < 0.001). CONCLUSIONS: In adults receiving VA-ECMO in ICU, a conservative compared to a liberal oxygen strategy, did not affect the number of ICU-free days to day 28.

Assessment of Hearing in Patients with Head Injury: A Prospective Study.

Background: Hearing impairment is a well-known outcome of head trauma. The most prevalent site of injury is the peripheral structures. Hearing loss dissipates in most cases but can continue in some cases and may improve in some. Objectives: To evaluate the incidence of hearing loss and ascertain its type and degree in patients with head injury. To estimate the progression or regression of hearing loss in head injury patients during follow-up. Material and Methods: 60 patients with head injuries with any ear symptoms were included in the study. The severity of head injury is graded according to the Glasgow Coma Scale (GCS). Patients were subjected to High Resolution Computed Tomogram (HRCT) temporal bone, and Pure Tone Audiometry (PTA) was performed within 24 h of presenting. PTA repeated after 3 months. The degree of hearing loss and its progression or regression were assessed. Results: Of the 60 patients, 56 (93.3%) had hearing loss on PTA. 50 Cases (83.3%) showed conductive hearing loss (CHL). 6 (10%) had mixed hearing loss (MHL). 4 cases with MHL had a transverse temporal bone fracture on radiological evaluation. 41 (68.3%) had mild CHL, 4 (6.7%) had moderate MHL, and 2 (3.3%) had moderately severe MHL. PTA values reduced significantly from 1st to 2nd visit in both ears. Conclusion: In our study, there was significant improvement in hearing during follow-up, after 3 months of head injury indicating improvement in hearing. The improvement in hearing was noticed in all cases except for one case with transverse temporal bone fracture and moderately severe hearing loss. Routine otological examination should be considered in all patients with head injuries. Meticulous and timely management of these cases can significantly reduce morbidity in the patient.

Liberal or Restrictive Transfusion Strategy in Patients with Traumatic Brain Injury.

BACKGROUND: The effect of a liberal transfusion strategy as compared with a restrictive strategy on outcomes in critically ill patients with traumatic brain injury is unclear. METHODS: We randomly assigned adults with moderate or severe traumatic brain injury and anemia to receive transfusion of red cells according to a liberal strategy (transfusions initiated at a hemoglobin level of ≤10 g per deciliter) or a restrictive strategy (transfusions initiated at ≤7 g per deciliter). The primary outcome was an unfavorable outcome as assessed by the score on the Glasgow Outcome Scale-Extended at 6 months, which we categorized with the use of a sliding dichotomy that was based on the prognosis of each patient at baseline. Secondary outcomes included mortality, functional independence, quality of life, and depression at 6 months. RESULTS: A total of 742 patients underwent randomization, with 371 assigned to each group. The analysis of the primary outcome included 722 patients. The median hemoglobin level in the intensive care unit was 10.8 g per deciliter in the group assigned to the liberal strategy and 8.8 g per deciliter in the group assigned to the restrictive strategy. An unfavorable outcome occurred in 249 of 364 patients (68.4%) in the liberal-strategy group and in 263 of 358 (73.5%) in the restrictive-strategy group (adjusted absolute difference, restrictive strategy vs. liberal strategy, 5.4 percentage points; 95% confidence interval, -2.9 to 13.7). Among survivors, a liberal strategy was associated with higher scores on some but not all the scales assessing functional independence and quality of life. No association was observed between the transfusion strategy and mortality or depression. Venous thromboembolic events occurred in 8.4% of the patients in each group, and acute respiratory distress syndrome occurred in 3.3% and 0.8% of patients in the liberal-strategy and restrictive-strategy groups, respectively. CONCLUSIONS: In critically ill patients with traumatic brain injury and anemia, a liberal transfusion strategy did not reduce the risk of an unfavorable neurologic outcome at 6 months. (Funded by the Canadian Institutes of Health Research and others; HEMOTION ClinicalTrials.gov number, NCT03260478.).

Corrigendum to "Blend to Limit OxygEN in ECMO: A RanDomised ControllEd Registry (BLENDER) trial: Study protocol and statistical analysis plan" [Crit Care Resuscit 25 (2023) 118-125].

[This corrects the article DOI: 10.1016/j.ccrj.2023.06.001.].

A survey of Australian public opinion on using comorbidity to triage intensive care patients in a pandemic.

Objectives This study aimed to determine which method to triage intensive care patients using chronic comorbidity in a pandemic was perceived to be the fairest by the general public. Secondary objectives were to determine whether the public perceived it fair to provide preferential intensive care triage to vulnerable or disadvantaged people, and frontline healthcare workers. Methods A postal survey of 2000 registered voters randomly selected from the Australian Electoral Commission electoral roll was performed. The main outcome measures were respondents' fairness rating of four hypothetical intensive care triage methods that assess comorbidity (chronic medical conditions, long-term survival, function and frailty); and respondents' fairness rating of providing preferential triage to vulnerable or disadvantaged people, and frontline healthcare workers. Results The proportion of respondents who considered it fair to triage based on chronic medical conditions, long-term survival, function and frailty, was 52.1, 56.1, 65.0 and 62.4%, respectively. The proportion of respondents who considered it unfair to triage based on these four comorbidities was 31.9, 30.9, 23.8 and 23.2%, respectively. More respondents considered it unfair to preferentially triage vulnerable or disadvantaged people, than fair (41.8% versus 21.2%). More respondents considered it fair to preferentially triage frontline healthcare workers, than unfair (44.2% versus 30.0%). Conclusion Respondents in this survey perceived all four hypothetical methods to triage intensive care patients based on comorbidity in a pandemic disaster to be fair. However, the sizable minority who consider this to be unfair indicates that these triage methods could encounter significant opposition if they were to be enacted in health policy.

Evaluating the Impact of the COVID-19 Pandemic on First-Year Medical Student Nutrition.

BACKGROUND: Medical school students in high-stress environments have been shown to make poor personal health decisions ranging from less healthy selections of food to lower rates of exercise. With the emergence of the COVID-19 pandemic adding a major social and health challenge, it is important to examine the effect this new stressor has on the health habits of medical school students. METHODS: All first-year students at Albany Medical College completed a self-recorded three-day log of food intake and exercise modality and duration. Reported data included calories, carbohydrates, protein, lipids, sodium, calcium, and other micronutrients. The data was divided between pre-pandemic (2018-19) and mid-pandemic (2020-21) entries. T-tests and ANOVA tests were used to compare for significance. RESULTS: Students consumed significantly fewer calories during the pandemic compared to before. This reduction was primarily driven by the female cohort of students. Specifically, this reduction in calories appears to be driven by a decrease in carbohydrate consumption, rather than lipids or protein, which did not change. Additionally, there were significant decreases in sodium, calcium, and vitamin D intake. The mid-pandemic time span (2020-21) appears to be correlated with decreased caloric intake, as well as other important nutrients such as vitamin D and calcium. CONCLUSIONS: This study demonstrated a decrease in calories, carbohydrates, sodium, and alcohol consumption when comparing pre- and mid-pandemic dietary habits of first-year medical students. It also indicated less than the recommended amount of calcium and Vitamin D consumption. Such changes may indicate restrictive eating habits in times of stress.

Conservative Management of a Case of Peripartum Cardiomyopathy in a Young Multigravida.

Peripartum cardiomyopathy (PPCM) is a rare disorder that generally affects the elderly multigravida females. It is a type of dilated cardiomyopathy that generally affects the last trimester of pregnancy or early postpartum period. Several risk factors are associated with the development of PPCM. Even though PPCM has greater morbidity, if managed promptly, it can be reverted with minimal morbidity or mortality. We present a case of a young woman, multigravida, with moderate anemia corrected, who was taken for emergency lower segment cesarean section, without previous cardiac evaluation, and ended up with pulmonary edema intraoperatively. Later on, her evaluation was done which came out to be PPCM. She was managed conservatively thereafter with no significant morbidity and a good maternal and perinatal outcome. We should be alert in diagnosing a case of PPCM with prompt treatment to reduce mortality. Cardiovascular conditions cause approximately 26 percent of pregnancy-related deaths which include valvular heart disease and congenital heart disease. Appropriate diagnosis and management are necessary for preventing mishaps.

Mechanical properties of tissue adhesives used for retaining extraoral silicone prostheses in maxillofacial defects: A systematic review.

STATEMENT OF PROBLEM: Different tissue adhesives are available for retaining extraoral silicone prostheses in maxillofacial defects. Comparative assessment of their mechanical properties will help the clinician select the right product for a specific clinical situation, but a systematic review is lacking. PURPOSE: The purpose of this systematic review was to analyze the existing data in the literature regarding 5 mechanical properties of tissue adhesives for extraoral silicone prostheses: peel strength, tensile strength, shear strength, torsional strength, and tack. MATERIAL AND METHODS: A manual and electronic search was performed in appropriate databases to identify relevant publications with specific inclusion and exclusion criteria. The retrieved studies were screened for eligibility using the title, abstract, and published full texts. To evaluate the risk of bias, a methodological quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklists for Randomized Controlled Trials. A custom data extraction template was used, and the results pooled using descriptive methods. RESULTS: After screening, 15 articles, 5 in vitro studies, and 10 clinical studies were eligible for data extraction. In vitro studies assessed tack and peel bond strength. In contrast, clinical studies assessed peel strength, tensile strength, shear strength, and torsional strength through direct comparisons and in diverse settings. CONCLUSIONS: The assessed studies showed considerable methodological heterogeneity. When silicone-based tissue adhesives (Secure2 Medical Adhesive; Factor II, Hollister Colostomy Adhesive; Hollister Inc, Dow Corning 355 Medical adhesives; Dow Corning Europe Inc) were compared with water-based adhesives (Pros-Aide Adhesive; ADM Tronics Inc, PSA 1; Cosmedica Ltd, Daro adhesive; Factor II, Epithane-3; Daro Products), the silicone-based adhesives showed a higher peel bond strength (PBS), while double-sided medical adhesive tapes showed lower PBS. A few studies evaluated variations in the PBS as being affected by the addition of stone wool fibers, immersion in water, application of skin protective dressings and adhesive removers, application of multiple layers of adhesive, and usage of urethane liner.

An Unusual Presentation of Villoglandular Papillary Adenocarcinoma in a Perimenopausal Woman.

Villoglandular papillary adenocarcinoma (VPA) or villoglandular adenocarcinoma (VGA) is a rare but well-recognized subtype of cervical carcinoma. It exhibits a favorable prognosis, particularly within the childbearing age group, and is considered a rare manifestation of mucinous adenocarcinoma typically observed in individuals of reproductive age. In comparison to other adenocarcinomas, VPA generally demonstrates a more optimistic prognosis. This report details the case of a 46-year-old perimenopausal woman who presented with complaints of irregular menses and a protruding mass from the vagina. Upon examination, an exophytic growth was identified, replacing the cervix. A biopsy confirmed the diagnosis of VPA. Subsequently, the patient underwent a radical hysterectomy, followed by post-operative radiation therapy.

Non-invasive Estimation of Pressure Drop Across Aortic Coarctations: Validation of 0D and 3D Computational Models with In Vivo Measurements.

Blood pressure gradient ( Δ P ) across an aortic coarctation (CoA) is an important measurement to diagnose CoA severity and gauge treatment efficacy. Invasive cardiac catheterization is currently the gold-standard method for measuring blood pressure. The objective of this study was to evaluate the accuracy of Δ P estimates derived non-invasively using patient-specific 0D and 3D deformable wall simulations. Medical imaging and routine clinical measurements were used to create patient-specific models of patients with CoA (N = 17). 0D simulations were performed first and used to tune boundary conditions and initialize 3D simulations. Δ P across the CoA estimated using both 0D and 3D simulations were compared to invasive catheter-based pressure measurements for validation. The 0D simulations were extremely efficient ( ∼ 15 s computation time) compared to 3D simulations ( ∼ 30 h computation time on a cluster). However, the 0D Δ P estimates, unsurprisingly, had larger mean errors when compared to catheterization than 3D estimates (12.1 ± 9.9 mmHg vs 5.3 ± 5.4 mmHg). In particular, the 0D model performance degraded in cases where the CoA was adjacent to a bifurcation. The 0D model classified patients with severe CoA requiring intervention (defined as Δ P ≥ 20 mmHg) with 76% accuracy and 3D simulations improved this to 88%. Overall, a combined approach, using 0D models to efficiently tune and launch 3D models, offers the best combination of speed and accuracy for non-invasive classification of CoA severity.

Severe Acute Kidney Injury Postheart Transplantation: Analysis of Risk Factors.

Background: Acute kidney injury (AKI) is a common complication postheart transplantation and is associated with significant morbidity and increased mortality. Methods: We conducted a single-center, retrospective, observational cohort study of 109 consecutive patients undergoing heart transplantation between September 2019 and September 2021 to determine major risk factors for, and the incidence of, severe postoperative AKI as defined by Kidney Disease Improving Global Outcomes criteria in the first 48-h posttransplantation and the impact that this has on mortality and dialysis dependence. Results: One hundred nine patients were included in our study, 83 of 109 (78%) patients developed AKI, 42 (39%) developed severe AKI, and 37 (35%) required renal replacement therapy in the first-week posttransplantation. We found preoperative estimated glomerular filtration rate (eGFR), postoperative noradrenaline dose, and the need for postoperative mechanical circulatory support to be independent risk factors for the development of severe AKI. Patients who developed severe AKI had a 19% 12-mo mortality compared with 1% for those without. Of those who survived to hospital discharge, 20% of patients in the severe AKI group required dialysis at time of hospital discharge compared with 3% in those without severe AKI. Conclusion: Severe AKI is common after heart transplantation. Preoperative kidney function, postoperative vasoplegia with high requirements for vasoactive drugs, and graft dysfunction with the need for mechanical circulatory supports were independently associated with the development of severe AKI in the first-week following heart transplantation. Severe AKI is associated with a significantly increased mortality and dialysis dependence at time of hospital discharge.

A pilot feasibility randomised controlled trial of bone antiresorptive agents on bone turnover markers in critically ill women.

Critical illness is associated with increased bone turnover, loss of bone density, and increased risk of fragility fractures. The impact of bone antiresorptive agents in this population is not established. This trial examined the efficacy, feasibility, and safety of antiresorptive agents administered to critically ill women aged fifty years or greater. Women aged 50 years or greater admitted to an intensive care unit for at least 24 h were randomised to receive an antiresorptive agent (zoledronic acid or denosumab) or placebo, during critical illness and six months later (denosumab only). Bone turnover markers and bone mineral density (BMD) were monitored for 1 year. We studied 18 patients over 35 months before stopping the study due to the COVID-19 pandemic. Antiresorptive medications decreased the bone turnover marker type 1 cross-linked c-telopeptide (CTX) from day 0 to 28 by 43% (± 40%), compared to an increase of 26% (± 55%) observed with placebo (absolute difference - 69%, 95% CI - 127% to - 11%), p = 0.03). Mixed linear modelling revealed differences in the month after trial drug administration between the groups in serum CTX, alkaline phosphatase, parathyroid hormone, and phosphate. Change in BMD between antiresorptive and placebo groups was not statistically analysed due to small numbers. No serious adverse events were recorded. In critically ill women aged 50-years and over, antiresorptive agents suppressed bone resorption markers without serious adverse events. However, recruitment was slow. Further phase 2 trials examining the efficacy of these agents are warranted and should address barriers to enrolment.Trial registration: ACTRN12617000545369, registered 18th April 2017.

Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Meta-Analysis.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) for high-risk pulmonary embolism (HRPE) with haemodynamic instability or profound cardiogenic shock has been reported. Guidelines currently support the use of ECMO only in patients with cardiac arrest or circulatory collapse and in conjunction with other curative therapies. We aimed to characterise the mortality of adults with HRPE treated with ECMO, identify factors associated with mortality, and compare different adjunct curative therapies. METHODS: We conducted a systematic review and meta-analysis, searching four international databases from their inception until 25 June 2023 for studies reporting on more than five patients receiving ECMO for HRPE. Random-effects meta-analyses were conducted. The primary outcome was in-hospital mortality. A subgroup analysis investigating the outcomes with curative treatment for HRPE was also performed. The intra-study risk of bias and the certainty of evidence were also assessed. This study was registered with PROSPERO (CRD42022297518). RESULTS: A total of 39 observational studies involving 6409 patients receiving ECMO for HRPE were included in the meta-analysis. The pooled mortality was 42.8% (95% confidence interval [CI]: 37.2% to 48.7%, moderate certainty). Patients treated with ECMO and catheter-directed therapy (28.6%) had significantly lower mortality (p < 0.0001) compared to those treated with ECMO and systemic thrombolysis (57.0%). Cardiac arrest prior to ECMO initiation (regression coefficient [B]: 1.77, 95%-CI: 0.29 to 3.25, p = 0.018) and pre-ECMO heart rate (B: -0.076, 95%-CI: -0.12 to 0.035, p = 0.0003) were significantly associated with mortality. The pooled risk ratio when comparing mortality between patients on ECMO and those not on ECMO was 1.51 (95%-CI: 1.07 to 2.14, p < 0.01) in favour of ECMO. The pooled mortality was 55.2% (95%-CI: 47.7% to 62.6%), using trim-and-fill analysis to account for the significant publication bias. CONCLUSIONS: More than 50% of patients receiving ECMO for HRPE survive. While outcomes may vary based on the curative therapy used, early ECMO should be considered as a stabilising measure when treating patients with HRPE. Patients treated concurrently with systemic thrombolysis have higher mortality than those receiving ECMO alone or with other curative therapies, particularly catheter-directed therapies. Further studies are required to explore ECMO vs. non-ECMO therapies in view of currently heterogenous datasets.

Comparison of Pre- and Posttreatment Airway Volume in Patients with Temporomandibular Joint Disorders Treated with Ultra-Low Frequency Transcutaneous Electrical Nerve Stimulation Using Cone Beam Computed Tomography

Abstract Introduction Temporomandibular joint disorders (TMD) present with a multitude of symptoms that can range from headaches to shoulder pain. Patients frequently present with pain in the ear, dizziness, and vertigo. It is noted that some patients who report TMDs also have a history of sleep disturbances, which is noted in cone beam computed tomography (CBCT) as a reduction in the oropharyngeal airway volume. Objective To evaluate the airway volume in pre- and posttreatment of TMD with the use of neuromuscular orthotics made with ultra-low frequency transcutaneous electrical nerve stimulation (ULF-TENS). Methods A total of 15 patients were evaluated for TMDs using the related criteria. Those included were treated with ULF-TENS with evaluation of the airway volume both pre- and posttreatment using CBCT and the Dolphin 3D volume analysis software. Results While the symptoms were shown to be significantly reduced in patients who were treated with this particular modality, the airway volume varied in those who reported a reduction after a period of 3 months and those that reported after a period of 6 months. Conclusion Posttreatment evaluation of the airway should be done after a period of 6 months for a more objective evaluation. A multidisciplinary evaluation of the patient is required in such cases.