The aim of the study was to evaluate the relationship between skin microcirculatory parameters and central and cerebral hemodynamic parameters during progressive blood loss.Materials and Methods. A randomized, prospective, controlled in vivo experimental study was performed using male Wistar rats (250–350 g, N=23) divided into two groups: «hemorrhagic shock» (HS, N=13), with blood loss of 15% and subsequently 35% of estimated circulating blood volume (CBV), and «sham-operated» controls (SO, N=10). After combined anesthesia, femoral artery catheterization, and craniotomy, the following were measured at baseline (stage 1): mean arterial pressure (MAP), cortical cerebral perfusion (LSCIbrain), and skin perfusion in the hindlimb (LSCIskin) using laser speckle contrast imaging (LSCI). These measurements were repeated after 15% CBV loss (stage 2) and 35% CBV loss (stage 3). Cerebral (CVCbrain=LSCIbrain/MAP) and cutaneous (CVCskin=LSCIskin/MAP) vascular conductance indices were calculated. At stage 3, parameters of post-occlusive reactive hyperemia (PORH) in hindlimb skin were additionally assessed. Statistical analysis was performed using STATISTICA 13.0 with non-parametric methods. Spearman's correlation coefficient (R) was used to assess associations between circulatory parameters.Results. A 15% CBV loss led to a 26% reduction in LSCIskin (P=0.003 vs SO), with no significant change in LSCIbrain. With further blood loss and a 43% reduction in LSCIskin (P<0.001 vs SO), LSCIbrain decreased by 14% (P0.001 vs SO). These changes were accompanied by a sustained increase in CVCbrain (P0.001 vs SO at stage 3), while CVCskin remained unchanged throughout the experiment. In the HS group, blood loss led to a significant decrease in PORH amplitude (P=0.003 vs SO), while microvascular flow reserve increased (P=0.036 vs SO). Before blood loss, moderate positive correlations were found between LSCIskin, CVCskin, and CVCbrain. In HS, LSCIbrain correlated with the degree of LSCIskin reduction (R=0.57, P=0.041), and skin microvascular flow reserve showed a strong positive correlation with arterial blood pH and base excess (BE) (R=0.84, P=0.001). The correlation between LSCIskin and MAP shifted from a moderate negative correlation at stage 1 to a strong positive correlation at stage 3.Conclusion. Skin microcirculation parameters (LSCIskin, CVCskin, and PORH), as assessed by laser speckle contrast imaging, are promising diagnostic markers of central and cerebral hemodynamic impairment during progressive blood loss and warrant further validation.
Medical emergencies. Critical care. Intensive care. First aid
Mehrdad Shahraki, Mahdi Kalantari, Sadra Amirpour Haradasht
et al.
Background: Medical emergencies may occur before, during, or after dental treatment and range from relatively benign events to life‑threatening conditions. This study used an Objective Structured Clinical Examination (OSCE) to assess senior dental students’ competence in managing medical emergencies.
Methods: In this cross-sectional study, sixty senior dental students at Zahedan University of Medical Sciences were assessed during the 2023–2024 academic year. Data were collected at OSCE stations using a two-part questionnaire and the required equipment. Part 1 recorded demographic characteristics (age, gender, grade point average [GPA], place of residence, and prior attendance at cardiopulmonary resuscitation [CPR] or basic life support [BLS] courses). Part 2 comprised author-developed items to evaluate competence in managing medical emergencies. Data were analyzed using SPSS version 26.0.
Results: Based on their performance, students were categorized into three groups: good (scores above nine), fair (scores between five and nine), and poor (scores below five). Overall, 27 students (45%) were rated as poor, 18 (30%) as fair, and 15 (25%) as good. Performance was significantly associated with academic standing (p = 0.039) and prior attendance at CPR/BLS courses (p = 0.043).
Conclusion: Senior dental students demonstrated limited knowledge and skills in managing medical emergencies. Additional basic life support training may improve preparedness among dental students and practicing dentists for life-threatening events in dental settings.
Medical emergencies. Critical care. Intensive care. First aid
Margaret Samuels‐Kalow, Krislyn M. Boggs, Stephanie S. Loo
et al.
Abstract Objectives Pediatric readiness varies widely among emergency departments (EDs). The presence of a pediatric emergency care coordinator (PECC) has been associated with improved pediatric readiness and decreased mortality, but adoption of PECCs has been limited. Our objective was to understand factors associated with PECC implementation in general EDs. Methods We conducted semistructured qualitative interviews with a purposively sampled set of EDs with and without PECCs. Interviews were completed, transcribed, and coded until thematic saturation was reached. Themes were identified through a consensus process and mapped to the Consolidated Framework for Implementation Research (CFIR). Results Twenty‐four interviews were conducted and mapped to themes related to innovation, individuals and implementation process, outer setting (health system), and inner setting (hospital/ED). Addressing innovation, individuals, and implementation process, the primary theme was variability in how the PECC role was defined and who was responsible for implementing it. Regarding the outer setting, participants reported that limited system resources affected their ability to implement the PECC role. Key inner setting themes included concerns about limited visit volume, a lack of systems for measuring pediatric quality of care, and significant tension around change. Conclusions Implementation of the PECC role appears to be limited by heterogeneous interpretations of the PECC, de‐prioritization of pediatrics, and limited system resources. However, many participants described motivation to improve pediatric care and implement the PECC role in context of increasing pediatric visits; they offered strategies for future implementation efforts.
Medical emergencies. Critical care. Intensive care. First aid
Hamdah Hanifa, Hussein Alhussein, Lissa Mahmandar
et al.
Abstract Background During embryogenesis, the spleen undergoes intricate developmental processes, originating from mesenchymal cells in the dorsal mesentery. An accessory spleen, a common anomaly found in autopsies and abdominal CT scans, can often be mistaken for different types of tumors. To the best of our knowledge, this is the first case in Syria documenting the occurrence of 3 accessory spleens in a patient who had previously undergone splenectomy. Case presentation A 33-year-old male presented with right hypochondrium pain, sharp and radiating to the right flank, exacerbated by movement and large meals. Past medical history included mild Irritable Bowel Syndrome (IBS) and splenectomy due to a traumatic accident in childhood. On admission, vital signs were stable, with abdominal tenderness in the right upper quadrant. Laboratory investigations showed normal values. Ultrasound revealed a lobulated mass at the right adrenal gland (4.5 × 5 cm) with an isoechoic to hypoechoic texture. Multi-slice computed tomography (MSCT) Scan showed multiple nodules in the right adrenal gland, regular in shape, exerting a compressive mass effect, and significant lymphadenopathy around the abdominal aorta. Elevated metanephrine levels raised suspicion of an extra-adrenal pheochromocytoma. Laparoscopic surgery was performed, revealing accessory spleens and normal adrenal tissue with no malignancy. Conclusion Healthcare providers should consider accessory spleens as a differential diagnosis for masses near the adrenal glands. Multiple accessory spleens in the adrenal region can complicate cases. Accessory spleens in uncommon locations like the adrenal glands can be challenging to diagnose and manage.
Medical emergencies. Critical care. Intensive care. First aid
The purpose of this study was to explore the establishment of an auxiliary scoring model for patients with acute pulmonary embolism (APE) complicated with atrial fibrillation (AF) based on random forest (RF) and its application effect. A retrospective analysis was performed on the general data, underlying diseases, laboratory indicators, and cardiac indicators of 100 patients with APE admitted to our hospital from 2018 to 2021. The occurrence of atrial fibrillation in patients with pulmonary embolism was taken as a categorical variable, and the general data, underlying diseases, laboratory indicators, and cardiac indicators were taken as input variables. Then, the risk auxiliary scoring model for patients with APE complicated with AF was established based on RF and logistic regression. Finally, the accuracy, sensitivity, specificity, recall rate, accuracy, F1 value, and the receiver operator characteristic (ROC) curve were used to evaluate the predictive value of the models. After statistical analysis, the optimal node value was 3 and the optimal number of decision trees was 500 in the RF model. The importance of predictors in descending order were Hcy, diabetes mellitus, FT3 level, UA level, left atrial diameter, hypertension, and smoking history. The prediction accuracy of the RF model was 0.934, sensitivity 0.966, specificity 0.876, recall rate 0.9660, accuracy 0.934, and F1 value 0.950. The logistic regression model prediction accuracy was 0.816, sensitivity 0.915, specificity 0.125, recall rate 0.902, accuracy 0.811, and F1 value 0.896. The RF model and logistic regression prediction model AUC values were 0.984 and 0.883, respectively. From this, we conclude that the RF model was better than the logistic regression model in predicting AF in APE patients. So, the RF model had the clinical application value.
Medical emergencies. Critical care. Intensive care. First aid
Abstract Background There is no consensus exists regarding the association between oxygen exposure (arterial oxygen tension or fraction of inspired oxygen) and outcomes for patients with mechanical ventilation. Additionally, whether the association remains persistent over time is unknown. We aimed to explore the association between exposure to different intensities of oxygen exposure over time and 28-day mortality in patients with mechanical ventilation. Methods We obtained data from the Medical Information Mart for Intensive Care IV (MIMIC-IV), which included adult (≥ 18 years) patients who received invasive mechanical ventilation for at least 48 h. We excluded patients who received extracorporeal membrane oxygenation (ECMO) or who initiated ventilation more than 24 h after ICU admission. The primary outcome was 28-day mortality. Piece-wise exponential additive mixed models were employed to estimate the strength of associations over time. Results A total of 7784 patients were included in the final analysis. Patients had a median duration of invasive mechanical ventilation of 8.1 days (IQR: 3.8–28 days), and the overall 28-day mortality rate was 26.3%. After adjustment for baseline and time-dependent confounders, both daily time-weighted average (TWA) arterial oxygen tension (PaO2) and fraction of inspired oxygen (FiO2) were associated with increased 28-day mortality, and the strength of the association manifested predominantly in the early-middle course of illness. A significant increase in the hazard of death was found to be associated with daily exposure to TWA-PaO2 ≥ 120 mmHg (Hazard ratio 1.166, 95% CI 1.059–1.284) or TWA-FiO2 ≥ 0.5 (Hazard ratio 1.496, 95% CI 1.363–1.641) during the entire course. A cumulative effect of harmful exposure (TWA-PaO2 ≥ 120 mmHg or TWA-FiO2 ≥ 0.5) was also observed. Conclusion PaO2 and FiO2 should be carefully monitored in patients with mechanical ventilation, especially during the early-middle course after ICU admission. Cumulative exposure to higher intensities of oxygen exposure was associated with an increased risk of death.
Medical emergencies. Critical care. Intensive care. First aid
Purpose Percutaneous iliosacral (IS) screw fixation for pelvic ring injuries is a minimally invasive technique that reduces the amount of blood loss and shortens the procedure time. Moreover, two unilateral IS S1 screws exhibit superior stability to a single IS screw and are also safer for neurological injuries than an S2 screw. Therefore, this study aimed to evaluate fixation using percutaneous two unilateral IS S1 screws for pelvic ring injuries and its subsequent clinical outcomes. Methods We retrospectively reviewed 38 patients who underwent percutaneous two unilateral IS S1 screw fixation for pelvic ring injuries. The procedure time, blood loss, achievement of bone union, radiological outcomes (Matta and Tornetta grade), and postoperative complications were evaluated. Results The mean procedure time, hemoglobin loss, bone union rate, and time to union were 40.1 minutes (range, 18–102 minutes), 0.6 g/dL (range, 0.3–1.0 g/dL), 100%, and 153.2 days (range, 61–327 days), respectively. The Matta and Tornetta grades were excellent, good, and fair in 24 (63.1%), 11 (28.9%), and three patients (7.9%), respectively, and the postoperative complications were S1 screw loosening, widening of the symphysis pubis (2.3 and 2.5 mm), lumbosacral plexopathy, and S1 radiculopathy in one (2.6%), two (5.3%), one (2.6%), and one patient (2.6%), respectively. However, all neurological complications recovered spontaneously. Conclusions Percutaneous two unilateral IS S1 screw fixation was useful for treating pelvic ring injuries. In particular, it involved a short procedure time with little blood loss and also led to 100% bone union and good radiological outcomes.
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Middle cerebral artery aneurysm is a common type of intracranial aneurysm in neurosurgery, accounting for about 20% of intracranial aneurysms, and is the third most common site of intracranial aneurysms. The surgical success rate and postoperative recovery ability of today’s treatment plans are not satisfactory. Therefore, this paper designs a health model based on data analysis to clinically apply clipping surgery for cerebral aneurysm. This paper studies data analytics health models in the context of big data analytics. The model combines the characteristics of cerebral aneurysms for targeted analysis, and then through the understanding of the clipping treatment of cerebral aneurysms, this paper combines the deep learning in the neural network to train the treatment plan under the data analysis health model. Finally, this paper designs a therapeutic plan for clipping treatment of cerebral aneurysm based on a data analysis health model. To verify its data analysis ability, this paper designs experiments on unbalanced data sets and experiments to improve the execution efficiency of the algorithm. After analyzing the results obtained from the experiment, this paper will apply them to the clinic. The final experiment showed that the surgical success rate of the clipping treatment for cerebral aneurysm based on the data analysis health model was increased by 21.84% compared with the traditional clipping treatment for cerebral aneurysm.
Medical emergencies. Critical care. Intensive care. First aid
Critical Care Medicine www.ccmjournal.org 1 This month’s issue of Annals of the ATS features a special article by a group of editors from top pulmonary, sleep, and critical care journals—including Critical Care Medicine—that provides guidance for authors of observational studies (1). Spurred in part by a perceived uptick in the number of submissions of this type, the article aims to build common ground for both authors and readers alike, encouraging the use of modern statistical methods, the transparent reporting of results, and a measured interpretation of findings. The guidance does not apply to observational studies that are purely descriptive, that identify associations only, or that develop predictive models, but rather is intended specifically for those that focus on causal inference. Although Critical Care Medicine endorses the article’s main principles—outlined below and unpacked more fully in the article itself—they are not intended to be strict requirements; as with any submission, observational studies are considered individually on a case-by-case basis and proceed through the editorial process based on their merits. Why generate this document now? Observational studies in critical care are on the rise. A cursory Pubmed search suggests that their ranks have increased in the last 5 years and that as of 2015, these outnumber studies identified as randomized controlled trials (Fig. 1). A few key factors may account for this trend. First, a dearth of actionable evidence from interventional trials—most of which are costly and difficult to carry out—has in some circles cast observational studies in a new and favourable light (2). Although they generate a different class of evidence, observational studies may be cheaper, easier, and faster to conduct than interventional ones, especially when retrospective datasets are used. There are also cases where randomization poses ethical challenges, where the event of interest is rare, where the research question itself pertains specifically to real-world practices, or where the effects of long exposures are being examined, in which observational studies may be the design of choice. Second, the proliferation of new sources of data, including electronic medical records, patient registries, and administrative databases, ensure that fodder for observational studies is now in ample supply. Secular trends encouraging data sharing and open access have also made such datasets more readily available to researchers, including those who were not involved in the data collection itself. One illustrative example of this phenomenon is the Medical Information Mart for Intensive Care (MIMIC) database, which includes granular data collected from tens of thousands of ICU admissions at a single center, and has been used as a data source for hundreds of publications (3). Third, the analytic tools used in observational studies, including current popular statistical programming languages, are readily available (and in some cases open source), with both the clinical and academic workforces becoming increasingly adept at using them.
Kazuhiko Omori, Youichi Yanagawa, Ken‐ichi Muramatsu
et al.
Background Fujifilm (Tokyo, Japan) developed a portable X‐ray system called the CALNEO Xair, which can be carried by a physician. The X‐ray radiation machine weighs 3.5 kg. The dimensions are: height, 144 mm; length, 148 mm; width, 258 mm. Case Presentation When a 33‐year‐old woman driving a car made a right turn at a crossroad, her car hit another car, causing her vehicle to tip onto its side. Staff of the doctor helicopter checked her at the scene, and the findings of chest and pelvic X‐ray were all negative. She received a diagnosis of cervical sprain and pelvic contusion and was transferred to a local hospital by ambulance. Conclusion This is the first report of a case evaluated by a portable X‐ray system at the scene, under transportation by a doctor helicopter. This system could be useful for undertaking prehospital assessment and medical treatment.
Medical emergencies. Critical care. Intensive care. First aid
Background and Objectives: Cervical cancer is one of the five most common cancers in Iranian women. Considering the impact of HIV on cervical cancer and the low rate of cervical cancer screening in HIV positive women, this study was conducted to review the barriers to cervical cancer screening in HIV positive women.
Methods: In this systematic review, data were retrieved from Magiran, SID, Irandoc, Prequest, OVID, ScienceDirect, PubMed, Web of Science and Scupos databases from January 2000 to January 2018. The following keywords and their combination were used: cervical cancer screening, Pap smear, HIV-positive women, and barriers. The NOS (Newcastle-Ottawa Scale) checklist was used to evaluate the quality of the selected articles and the articles that scored more than six were included in the study.
Results: From 145 selected articles, 21 were included in the review based on the inclusion criteria. The most common reported screening barriers were the costs of test, lack of awareness, low education level, younger age, lack of information about screening centers, and fear of sampling.
Conclusion: Considering the barriers to cervical cancer screening, increasing the level of awareness of the HIV-positive women, preparing free Pap smear services, and providing easier access to health centers for this high risk group could lead to early detection of cervical cancer.
Medical emergencies. Critical care. Intensive care. First aid
Patients with life-threatening illness often require admission to intensive care units (ICUs) to receive life sustaining interventions. This is an expensive health care resource with specialized physical space, equipment and healthcare worker expertise. Due to constraints imposed by a limited resource, various guidelines for admission to the ICU have been proposed [1], including triage decisions if demand exceeds supply [2]. Institutions likely have their own more specific admission and discharge criteria for individual ICUs. These guidelines are subject to interpretation and, especially when combined with individual treatment decisions, introduce the possibility of subjectivity and bias. Whether such inequities in access to ICU care exist is not clearly known, or easy to study. A prospective, multicentre, cohort study from Europe found age but not gender was an independent predictor for refusal of admission to ICU [3]. A population study using a large administrative dataset in Ontario, Canada reported that female sex was associated with lower likelihood of ICU admission and fewer ICU interventions [4]. Another population study using administrative data of hospitalized patients reported men were more likely to receive ICU admission and invasive mechanical ventilation but women who received ventilation were more likely than men to have non-invasive ventilation [5]. Females were less likely to receive early, goal-directed treatment (defined as measurement of ScVO2 through central line) in a single centre cohort study [6]. Although this latter study was conducted in an emergency department, it may be considered an ICU-level intervention. Female sex was also associated with the decision to forego life-sustaining therapies once admitted to the ICU [7]. Race, culture and ethnicity are other potential biases that might influence decisions to provide ICU care. In a secondary analysis of a prospective cohort study, black adults were less likely than white adults to be admitted to a coronary care unit (CCU) and had fewer CCU days when they were admitted [8]. To ensure that healthcare access is equitable for all members of our populations, it is important to have valid methods to measure this. This is not a simple task, since the admission process is complex. ICU admissions usually come from the ward, operating room or emergency department and require a referral from the appropriate physician to the intensivist, who must then assess if the patient meets the ICU admission criteria. Critical care rapid response or medical emergency teams may influence this process in hospitals where they exist. In a study by Garland and coworkers [9], the authors assert that multiple factors can affect the decision for the patient to arrive at the hospital in the first place, which is an idea based on Andersen's Behavior Model [10]. Population-based studies are likely to become more prevalent and can provide important insights. For example, it was recently reported that recent immigrants received more aggressive end of life care than long-standing immigrant residents [11]. Associations made from observational studies will always be subject to unrecognized and unmeasured residual confounding. When rates are examined and compared, it is vital to select the appropriate denominator. Garland and coworkers [9] propose that this denominator should be the number of patients eligible for ICU care in the community for two main reasons. First, the general population is not the appropriate denominator since the predisposition to critical illness is not uniform. Second, a hospital-based denominator is not appropriate since potential biases leading to inequitable access may be expressed at any point in the illness trajectory, including the decision to consider hospital admission. Since a prevalence measure of critical illness or predisposition to ICU in the general population is not available, they explored the use of population-based palliative care deaths as a surrogate for critical illness and potential ICU admissions. With this approach, the apparent bias for ICU admission due to sex disappeared while noting lower ICU admission for people in lower income strata. Population health studies are largely based on administrative data and therefore dependent on the accuracy of the coding and algorithms used for analysis. Themes such Correspondence: cmartin1@uwo.ca Division of Critical Care Medicine, Department of Medicine, Schulich School of Medicine & Dentistry, Victoria Hospital, London Health Sciences Centre, Western University, 800 Commissioners Rd E, London, ON N6A 4S2, Canada
It is my great honor and concurrently challenging task to make this statement as the new Editor-in-chief of the Journal of Intensive Care. To date, this Journal, which was launched in October 2013, as the official journal of the Japanese Society of Intensive Care Medicine (JSICM), has been outstandingly led by Professor Satoshi Gando, the founding Editor-in-chief. Being an international journal, the members of Advisory and Editorial Board embrace many worldwide leaders in the intensive care field. Based on their continuous and persevering efforts, in addition to the enthusiastic contribution by all authors and/or researchers, we are proud of a number of remarkable and significant articles published in the first stage of this newborn journal. In the first 2 years after its launch, more than 55% of the submissions came from Japanese researchers and/or intensivists; now, almost 75% of the submissions come from researchers in other areas of the world, including North America and Europe, as well as Asia, Middle East, and Oceania (Fig. 1). Recently, there has been a notable increase in the number of submissions. Last year, the Journal of Intensive Care received 341 submissions, which amounts to an approximately 35% increase in comparison to the previous year (Fig. 2). Predictably, the overall acceptance rate is decreased to 21.3% last year, while 19.7% of research articles submitted were finally accepted for publication. Furthermore, I dare to declare that we have continued to accept the submission of case reports on cases showing an extraordinary clinical course in which the discussion is informative to the readers; however, the acceptance rate of case reports is currently 7.3%. It should also be noted that the average intervals from the formal receipt of a manuscript to the dates of the first and final decisions were 16.7 and 33.4 days, respectively. Although nobody can conclude whether the current editorial and reviewing processes are short enough to satisfy the authors/researchers, I believe that both highquality reviewing and prompt publication are indispensable for a medical journal. On behalf of the Editorial Board Members, I would like to express my sincere appreciation to all peer reviewers for their persistent, patient, and noble contribution to this Journal. Owing to the countless journals that have been launched in the last decade, international journals must now compete with each other within the same field of medicine. By the end of 2017, there were 57 and 137 journals including the term, intensive care and critical care, respectively. To prevail and thereby step forward in these types of struggles between the journals, we must continue to work hard on improving both the academic and clinical quality of this journal by publishing high-quality articles and simultaneously providing more constructive peer-review processes. To date, all articles published in the Journal of Intensive Care are indexed in worldwide services such as DOAJ, PubMed, PubMed Central, and Scopus. Now, based on continuous and overall assessment, our journal has been uploaded on the Emerging Sources Citation Index (ESCI), implying that the journal is close to obtaining Social Sciences Citations Index value (i.e., impact factor).