BACKGROUND:Although the Hypotension Prediction Index (HPI) reduces intraoperative hypotension, improvements in patient-centered outcomes remain inconsistent. We performed a high-resolution signal analysis to describe the coexistence of arterial pressure, preload-related hemodynamic signals, and algorithm-derived hypotension risk during surgery. METHODS:We conducted a retrospective high-resolution signal analysis (20-second intervals) of 181 patients from the multicenter HYT trial. We quantified hypotension (mean arterial pressure [MAP] <65 mmHg), preload-dependent physiology (stroke volume variation [SVV] >13%), and their temporal relationship with HPI-derived risk signals. Patients were classified into four descriptive groups based on combinations of MAP and SVV burden. RESULTS:Overall hypotension exposure was low (median 1.3% of monitored time), whereas preload-dependent physiology was more frequent (approximately 10%) and often persisted during periods classified as low hypotension risk (HPI <80). SVV >13% preceded hypotensive events significantly earlier than HPI alerts (median 8.7 vs. 1.8 minutes; P=0.0119). Higher vasopressor burden was observed in patients with preserved MAP despite sustained SVV elevation. CONCLUSIONS:During HPI-guided care, preserved arterial pressure frequently coexists with sustained preload-dependent hemodynamic signals. These findings describe patterns of pressure and preload-related signal behavior during algorithm-guided hemodynamic management and should be interpreted as hypothesis-generating.
BACKGROUND:Postoperative delirium (POD) is a common complication following hepatectomy. However, there are no studies on the occurrence of POD in patients with hepatic steatosis undergoing hepatectomy. This study aimed to evaluate the incidence and risk factors for POD in patients with hepatic steatosis after hepatectomy, and investigate the related mechanisms. METHODS:This study was a single-center, retrospective cohort study. Adult patients who underwent hepatectomy at Beijing Tsinghua Changgung Hospital between June 2021 and June 2025 were selected as the study subjects. Patients were divided into two groups: the hepatic steatosis (HS) group and the non-hepatic steatosis (NHS) group. The primary outcome was the incidence of POD, whereas the secondary outcomes included the length of intensive care unit (ICU) stay, total length of stay, and 90-day mortality rate after surgery. Propensity score matching analysis was performed between the two groups. Finally, univariate and multivariable stratified Cox proportional hazards models were used to identify independent risk factors for POD. RESULTS:In the matched cohort, the incidence of POD was significantly greater in the HS group than in the NHS group (16.7% vs. 7.3%, P<0.001). There were no significant differences in the timing, location, or duration of POD between the two groups (P>0.05). The length of ICU stay (P<0.001) and total length of stay (P<0.05) were longer in the HS group than in the NHS group. The 90-day mortality rate was greater in the HS group than in the NHS group, although the difference was not statistically significant (6.3% vs. 2.7%, P=0.053). Multivariable stratified Cox regression analysis revealed that hepatic steatosis (HR: 2.57, 95% CI: 1.29-5.10, P=0.007), age (HR: 1.05, 95% CI: 1.01-1.09, P=0.013), and Child-Pugh class B/C (HR: 3.19, 95% CI: 1.34-7.59, P=0.009) were independent risk factors for the time to POD after hepatectomy. CONCLUSIONS:The incidence of POD was greater in patients with hepatic steatosis than in those without hepatic steatosis after hepatectomy. Whether preoperative optimization of liver status (e.g., a reduction in hepatic steatosis) can reduce the incidence of POD remains to be determined.
Necrotizing pneumonia (NP) represents an uncommon but severe complication of community-acquired pneumonia (CAP) in children, characterized by the destruction of lung parenchyma and formation of multiple thin-walled cavities. Despite its rarity, the incidence of pediatric NP has increased substantially over the past two decades, creating major diagnostic and treatment challenges. The COVID-19 pandemic has further altered the epidemiological landscape, with unique patterns of respiratory pathogen circulation. This narrative review synthesizes current evidence on pediatric necrotizing pneumonia through a comprehensive literature search of PubMed/MEDLINE, Embase, Web of Science, and the Cochrane Library for articles published between January 1994 and January 2025. Search terms included "necrotizing pneumonia," "necrotising pneumonia," and "cavitary pneumonia" paired with "child," "pediatric," or "paediatric," along with specific terms for etiology, diagnosis, treatment, and outcomes. We included English-language original research articles, systematic reviews, and case series with at least 10 patients. Streptococcus pneumoniae continues to dominate as the primary pathogen, accounting for 30-60% of cases, though the emergence of Mycoplasma pneumoniae as a major cause in Asia, with macrolide resistance exceeding 85%, presents new therapeutic challenges. Diagnostic approaches have evolved significantly, with lung ultrasound demonstrating comparable accuracy to CT (κ=0.85) while avoiding radiation exposure. Novel biomarkers including presepsin, copeptin, and fetuin-A show promise for early detection and prognostication. Treatment outcomes remain encouraging, with most cases (80%) successfully managed conservatively using prolonged antibiotics for a median duration of 28 days. Surgery is reserved for specific complications, and long-term outcomes are favorable with normal pulmonary function in 80-90% of children at one-year follow-up. While pediatric necrotizing pneumonia remains a serious condition, recent advances in non-invasive diagnostics, biomarker development, and understanding of post-pandemic epidemiology offer opportunities for improved outcomes. Future research should focus on validating AI-powered diagnostic tools, optimizing antimicrobial therapy in the era of resistance, and establishing evidence-based surgical intervention criteria. The integration of lung ultrasound as a radiation-free diagnostic modality represents a paradigm shift in pediatric pneumonia management.
Extracorporeal membrane oxygenation (ECMO) is an established life-saving therapy for severe acute respiratory distress syndrome and cardiogenic shock, yet it profoundly alters cardiopulmonary physiology and challenges conventional hemodynamic monitoring. Both venovenous (VV) and venoarterial (VA) ECMO modify venous return, ventricular loading conditions, pulmonary vascular resistance, and ventriculo-arterial coupling, leading to complex interactions between native and extracorporeal circulation. As a result, many standard monitoring techniques, particularly indicator-based and pressure-derived methods, lose validity or require careful reinterpretation under ECMO conditions. This review summarizes current evidence on hemodynamic monitoring during VV- and VA-ECMO and critically evaluates commonly used modalities, including echocardiography, invasive arterial pressure monitoring and pulse wave analysis, transpulmonary thermodilution, pulmonary artery catheterization, and microcirculatory monitoring. We highlight configuration-specific pathophysiology, key methodological limitations, and typical sources of misinterpretation for each technique. Particular emphasis is placed on the dissociation between macrocirculatory variables and tissue perfusion, the impact of parallel circulation and flow mixing in VA-ECMO, and the persistence of occult shock despite apparently adequate systemic targets. We propose a physiology-guided, multimodal monitoring framework that integrates pressure, flow, volumetric, and microcirculatory information with serial echocardiography. No single monitoring modality adequately captures the hemodynamic complexity of ECMO patients; instead, informed interpretation of complementary parameters and longitudinal trends is essential to guide individualized clinical decision-making and avoid delayed recognition of ventricular failure or regional hypoperfusion.
BACKGROUND:Diabetic peripheral neuropathy is a prevalent consequence of diabetes mellitus that impairs quality of life. This study aimed to investigate the impact of second generation capacitive-resistive non-invasive radiofrequency (transfer of energy capacitive and resistive, TECAR) therapy as a non-invasive modality to increase peripheral perfusion assessed using pulse oximetry by measuring the perfusion index (PI), and to improve pain in patients with painful diabetic peripheral neuropathy (PDPN). METHODS:A prospective interventional study was performed in the outpatient clinic of a tertiary care hospital. Twenty-three patients of both sexes, aged 40-70 years, with type 2 diabetes mellitus (T2DM) and PDPN in the lower limbs, with Visual Analogue Scale (VAS) ≥3 in the feet, were included in the study. All patients received 12 sessions of TECAR therapy over four weeks under PI monitoring of the big toe on the targeted side. The change in PI at the end of the first session was defined as a primary outcome. Pain scoring and analgesic effect at the end of all sessions were set as secondary outcomes. RESULTS:PI increased significantly after each session compared to the session before VAS showed significant improvement from the third session onward, lasting for one month after the 12th session. Tactile sensation showed significant improvement from the fourth session through the end of the sessions. By the end of the sessions, 18 patients (78.3%) achieved complete remission, with a significant Difference compared to baseline (P value <0.001). The Total Remission Rate was 82.08±11.33%. CONCLUSIONS:TECAR therapy is proposed as an effective, safe, and non-invasive approach for improving symptoms of peripheral neuropathy associated with T2DM.
BACKGROUND:Individuals who survive acute respiratory distress syndrome (ARDS) often face prolonged cognitive impairments. Comparable consequences have been observed in chronic hypoxic conditions, like COPD and obstructive sleep apnea syndrome, which have been linked to reduced gray matter volume. We hypothesized that ARDS patients display similar cerebral findings, but those treated with extracorporeal membrane oxygenation (ECMO) show greater structural brain alterations than those treated conservatively, reflecting the severity of hypoxemia. METHODS:Eighteen ARDS survivors, seven conservatively treated (ARDS-conv), and eleven treated with ECMO (ARDS-ECMO) were studied and compared with healthy controls. Structural magnetic resonance imaging (MRI) was analyzed using voxel-based morphometry (VBM). Total intracranial volume (TIV), gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF) volumes were quantified and compared between groups. RESULTS:ARDS patients had lower TIV than healthy controls (1516.50 mL [95% CI 1380.85-1618.72] vs. 1664.07 mL [95% CI 1558.41-1776.06], P=0.008). While intracranial volumes of GM, WM, and CSF were not different between ARDS-conv and healthy controls, CSF volume of ARDS-ECMO was lower than in healthy controls, while GM and WM were comparable. Compared to ARDS-ECMO, ARDS-conv had lower GM volumes (ARDS-conv 37.9% [95% CI 36.3-39.2] vs. ARDS-ECMO 41.4% [95% CI 39.9-43.8]; P=0.036), WM and CSF were comparable. VBM also revealed distinct clusters of reduced GM in ARDS-conv patients compared to healthy controls (TFCE, FWE-corrected P<0.05). CONCLUSIONS:ARDS survivors exhibit structural brain changes suggestive of hypoxia-related injury. ECMO treatment may mitigate gray matter loss, supporting early initiation of ECMO in severe ARDS to reduce long-term neurological sequelae. Extracorporeal membrane oxygenation may prevent preterm cerebral atrophy in survivors of acute respiratory distress syndrome: a pilot trial.
Rib fractures are a common injury with several etiologies. Various techniques for managing pain with rib fractures have evolved over the past few decades. Pain control is key in reducing further complications of this traumatic injury. In this regard, cryoneurolysis is a form of interventional pain management that involves applying freezing temperatures to disrupt the signaling pathways of nerves, hence reducing pain. Alternative forms of pain management, such as cryoneurolysis, are being studied to find less invasive techniques and to reduce dependence on opioids and other potentially addictive forms of analgesia. The present investigation focuses on the overall efficacy of cryoneurolysis in pain management of rib fractures. In this review, we discuss the clinical significance of rib fractures, the mechanism and outcome of cryoneurolysis, and the safety profile of cryoneurolysis in clinical treatment.
BACKGROUND:We aimed to evaluate the efficacy of rectus sheath block (RSB) for open abdominal surgery. METHODS:We searched PubMed/MEDLINE, Scopus, Embase, and Cochrane Library from inception until June 1, 2025, focusing on both cohort studies (CS) and randomized controlled trials (RCTs). Meta-analysis was restricted to midline laparotomy. The primary endpoint was resting pain scores at one, 12, and 24 hours postoperatively. The secondary endpoints included pain scores during movement/cough at the same timepoints and 24-hour opioid consumption. Standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs) were calculated. RESULTS:Fifteen RCTs and nine CS were included (N.=1638). RSB was associated with lower resting pain scores at one hour in both RCTs (SMD, -0-73, 95% CI, -1.24 to -0.22, P=0.005, I2 =69%) and CS (SMD, -1.01, 95% CI, -1.53 to -0.49, P=0.0001, I2=84%). From RCTs, resting pain was lower in the RSB group at 12 h (SMD, -0.85, 95% CI, -1.23 to -0.47, P<0.0001, I2=24%); and at 24 h, but only when the design was placebo-controlled (SMD, -0.67, 95% CI, -1.16 to -0.18, P=0.007, I2=0%). The type of comparator, local anesthetic infusion method, and urgency of surgery were the primary factors contributing to heterogeneity. CONCLUSIONS:RSB provides adequate early postoperative analgesia in midline laparotomy, but its clinical impact is modest and uncertain due to study heterogeneity and effect sizes that fall below a meaningful Minimal Clinically Important Difference.
