Hennepin County Medical Center (HCMC) is a Level I adult and pediatric trauma center and safety net hospital in Minneapolis, Minnesota, the county seat of Hennepin County. The primary 484-bed facility is on six city blocks across the street from U.S. Bank Stadium, with neighborhood clinics in the Minneapolis Whittier and East Lake neighborhoods, and the suburban communities of Brooklyn Center, Brooklyn Park, Golden Valley, St. Anthony and Richfield. A new clinic in the North Loop neighborhood downtown opened in 2017. HCMC has recognized trauma surgery specialists, transplant services, stroke specialists, advanced endoscopy/hepatobilliary center, and hyperbaric oxygen chamber. A new outpatient clinic building opened in 2018. In March 2018, the provider that operates HCMC was rebranded as Hennepin Healthcare. However, the hospital retained the name HCMC..
Obesity is a global health challenge. An increasing number of patients with obesity are admitted to an intensive care unit. Airway management in these patients represents a unique challenge due to significant anatomical and physiological alterations. Increased adipose tissue in the face, cheeks, pharynx, hypopharynx, and neck narrows the upper airway, renders soft tissues more collapsible, and complicates airway management. In addition, the functional residual capacity is reduced, resulting in markedly shortened safe apnea time, contributing to severe hypoxemia during intubation. Non-invasive ventilation is effective in mitigating this risk and should be applied from pre-induction to laryngoscopy. Peri-intubation physiological optimization should include assessment of preload and cardiac contractility, with careful consideration of right ventricular strain. The transition from negative to positive intrathoracic pressure should be closely monitored, with cautious titration of positive end-expiratory pressure. Recognition of these anatomical and physiological challenges may prompt clinicians to consider awake intubation in selected patients. When rapid sequence induction is performed, both ketamine and etomidate are appropriate options; the choice between them should be guided by the clinical context, patient characteristics, local practice patterns and availability. Videolaryngoscopy increases the incidence of successful intubation on the first attempt and should be adopted routinely in the population with obesity. Several questions remain unanswered, including the safety and efficacy of pre-emptive vasopressor use to prevent post-intubation cardiovascular collapse and the optimal dosing of hypnotic agents to achieve ideal intubation conditions, while minimizing adverse events.
BACKGROUND:Assessing variant-specific coronavirus disease 2019 (COVID-19) vaccine effectiveness (VE) and severity can inform public health risk assessments and decisions about vaccine composition. BA.2.86 and its descendants, including JN.1 (referred to collectively as "JN lineages"), emerged in late 2023 and exhibited substantial divergence from co-circulating XBB lineages. METHODS:We analyzed patients hospitalized with COVID-19-like illness at 26 hospitals in 20 US states admitted 18 October 2023-9 March 2024. Using a test-negative, case-control design, we estimated effectiveness of an updated 2023-2024 (monovalent XBB.1.5) COVID-19 vaccine dose against sequence-confirmed XBB and JN lineage hospitalization using logistic regression. Odds of severe outcomes, including intensive care unit (ICU) admission and invasive mechanical ventilation (IMV) or death, were compared for JN versus XBB lineage hospitalizations using logistic regression. RESULTS:A total of 585 case-patients with XBB lineages, 397 case-patients with JN lineages, and 4580 control patients were included. VE in the first 7-89 days after receipt of an updated dose was 54.2% (95% confidence interval [CI], 36.1-67.1%) against XBB lineage hospitalization and 32.7% (95% CI, 1.9-53.8%) against JN lineage hospitalization. Odds of ICU admission (adjusted odds ratio [aOR], .80; 95% CI, .46-1.38) and IMV or death (aOR, .69; 95% CI, .34-1.40) were not significantly different among JN compared with XBB lineage hospitalizations. CONCLUSIONS:Updated 2023-2024 COVID-19 vaccination provided protection against both XBB and JN lineage hospitalization, but protection against the latter may be attenuated by immune escape. Clinical severity of JN lineage hospitalizations was not higher relative to XBB.
Importance:As SARS-CoV-2 JN.1 lineage descendants continue to evolve, evaluating COVID-19 vaccine effectiveness (VE) against severe COVID-19 remains important to guide vaccination strategies. Objective:To estimate the VE of the 2024-2025 COVID-19 vaccines against COVID-19-associated hospitalization and severe in-hospital outcomes overall and by time since dose (7-89, 90-179, and ≥180 days), JN.1 descendant lineage (KP.3.1.1, XEC, LP.8.1), and spike protein mutations associated with immune evasion. Design, Setting, and Participants:This multicenter, test-negative, case-control study conducted by the Investigating Respiratory Viruses in the Acutely Ill Network included adult patients (aged ≥18 years) hospitalized between September 1, 2024, and April 30, 2025, at 26 hospitals in 20 US states. Case patients presented with COVID-19-like illness and positive SARS-CoV-2 nucleic acid or antigen test results; control patients had COVID-19-like illness but tested negative for SARS-CoV-2. Exposure:Receipt of a 2024-2025 COVID-19 vaccine at least 7 days before illness onset. Main Outcomes and Measures:Main outcomes were COVID-19-associated hospitalization and severe in-hospital outcomes (supplemental oxygen therapy, acute respiratory failure, intensive care unit admission, and invasive mechanical ventilation or death). Logistic regression was used to estimate the odds of vaccination in case and control patients, adjusting for demographics, clinical characteristics, and enrollment region. The VE was estimated as (1 - adjusted odds ratio) × 100%. Results:A total of 8493 patients (median [IQR] age, 66 [54-76] years; 4338 female [51.1%]), including 1888 case patients with COVID-19 (among whom 951 [50.4%] had successful whole-genome sequencing, including 348 [36.6%] with KP.3.1.1, 218 [22.9%] with XEC, and 134 [14.1%] with LP.8.1 infections) and 6605 control patients were enrolled. Vaccine effectiveness against COVID-19-associated hospitalization was 40% (95% CI, 27%-51%), and protection was sustained through 90 to 179 days after vaccination. Vaccine effectiveness was higher against the most severe outcome of invasive mechanical ventilation or death at 79% (95% CI, 55%-92%). It was 49% (95% CI, 25%-67%) against hospitalization with KP.3.1.1, 34% (95% CI, 4%-56%) against XEC, and 24% (95% CI, -19% to 53%) against LP.8.1, with increasing median time since dose receipt among vaccinated case patients due to sequential circulation patterns (60, 89, and 141 days, respectively). The VE was similar against lineages with spike protein S31 deletion (41% [95% CI, 22%-56%]) and T22N and F59S substitutions (37% [95% CI, 9%-57%]). Conclusions and Relevance:In this multicenter, case-control analysis of VE, 2024-2025 COVID-19 vaccines may have provided protection against hospitalizations and severe in-hospital outcomes as multiple JN.1 descendant lineages circulated. Monitoring COVID-19 VE, including stratifying by SARS-CoV-2 lineage and spike protein mutations, remains important to guide COVID-19 vaccine composition and recommendations.
Prehospital airway and ventilatory management is a frequent, high-stakes and technically demanding component of emergency care. Environmental constraints, limited resources, and variable provider experience make it particularly challenging, and prehospital care systems differ substantially across countries, from paramedic-based to physician-led models, contributing to heterogeneity in clinical practices and patient outcomes. In this narrative review, we discuss evidence-based best practice, including indications, timing, physiological optimization, procedural conduct, and post-intubation management of prehospital tracheal intubation or non-invasive ventilation and high-flow nasal oxygen. Tracheal intubation remains the definitive airway management strategy when performed for appropriate indications by adequately trained providers. Indications span major trauma, traumatic brain injury, out-of-hospital cardiac arrest, and comatose patients, though its role in comatose poisoned patients is increasingly questioned. Physiology optimization before intubation is a critical and frequently underappreciated determinant of outcome, encompassing preoxygenation with non-invasive positive pressure ventilation, bag-valve-mask ventilation between induction and laryngoscopy, and careful sedative selection to limit peri-intubation hemodynamic compromise. When intubation fails, a structured escalation strategy including videolaryngoscopy, supraglottic airway devices, and emergency front-of-neck access must be rehearsed and immediately available. In out-of-hospital cardiac arrest, supraglottic airways represent a valid primary alternative with equivalent neurological survival and faster placement. Non-invasive ventilation (primarily CPAP and BiPAP) has a well-established role in acute cardiogenic pulmonary edema and COPD exacerbations, reducing intubation rates and mortality. High-flow nasal oxygen is an emerging modality with strong in-hospital evidence, but prehospital data remain extremely limited and logistical constraints restrict its routine use. Non-invasive support must never delay intubation when clinical deterioration demands it. Specific contexts require tailored adaptations: altitude physiology in helicopter transport, obesity-specific positioning, cervical spine precautions in neurological injury, comfort-focused strategies in palliative patients, and proactive stabilization before prolonged transport. Evidence gaps remain, particularly regarding prehospital high-flow nasal oxygen.
Propofol is the most commonly used intravenous anesthetic for endoscopic surgery, although it comes with various adverse effects. Research indicates that Remimazolam, which is considered a safe general anesthetic, is being increasingly adopted as an alternative to propofol in clinical settings. Our meta-analysis sought to evaluate whether the rate of adverse reactions associated with Remimazolam in gastrointestinal endoscopic procedures is acceptable, and whether its surgical success rate is at least comparable to that of propofol. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched five electronic databases (PubMed, Scopus, Cochrane Library, Embase, and Web of Science) to identify eligible studies published up to January 2025. Using R version R.4.4, we reported outcomes as risk ratios (RRs) or mean differences (MDs) and confidence intervals (CIs). A P-value of ≤ 0.05 is considered statistically significant. Our meta-analysis included 37 studies encompassing 8533 patients. The results, analyzed using a random effects model, demonstrated no statistically significant difference in induction time between the two sedative groups, with an overall MD of 0.11 min (95
