Background:Delirium occurs in 45-80% of mechanically ventilated ICU patients and significantly worsens clinical outcomes. The impact of opioid analgesic selection on delirium risk remains unclear. We aimed to examine the association of oxycodone-based versus remifentanil-based analgesia with delirium incidence and duration in mechanically ventilated ICU patients. Methods:This single-center retrospective review of medical records included adults requiring invasive mechanical ventilation for >24 hours at a tertiary ICU in Suzhou, China (January-December 2025). Patients received oxycodone (n = 186) or remifentanil (n = 253) as the primary analgesic, as selected by the attending intensivist rather than by random assignment. Delirium was assessed twice daily via the Confusion Assessment Method for the ICU (CAM-ICU). Primary outcomes were delirium incidence and, among patients who developed delirium, delirium duration. Multivariable logistic regression, competing-risk analysis, and propensity score matching were applied to control for confounders; mechanical ventilation duration and ICU length of stay were prespecified as secondary, exploratory outcomes. Results:Among 439 patients (mean age 63.0 years; 61.0% male), oxycodone-based analgesia was associated with a lower observed delirium incidence (32.8% vs 48.6%; adjusted OR, 0.54; 95% CI, 0.36-0.80; P =0.002) and, among patients who developed delirium, a shorter delirium duration (median 2.20 vs 3.30 days; P <0.001). In unadjusted exploratory analyses, oxycodone was also associated with shorter mechanical ventilation duration (92.45 vs 127.00 hours; P <0.001) and ICU length of stay (8.60 vs 9.90 days; P =0.001). Mortality was comparable between groups (11.8% vs 11.5%). Constipation was more frequent with oxycodone (23.7% vs 15.8%); the study was not powered to establish equivalence or noninferiority for mortality or adverse events. Conclusion:In this single-center retrospective review of medical records, oxycodone-based analgesia was associated with a lower observed incidence of delirium and shorter delirium duration among patients who developed delirium compared with remifentanil-based analgesia. Given the nonrandomized treatment assignment, between-group differences in sedation depth and pain control, and the potential for residual confounding, these findings should be considered hypothesis-generating. Prospective studies using protocolized, equianalgesic treatment strategies are required before conclusions regarding comparative effectiveness or safety can be drawn.

ObjectiveThis study aimed to evaluate the predictive efficacy of the Naples prognosis score (NPS) in sepsis-associated acute kidney injury (SA-AKI) and explore its mechanistic link to renal injury, with the goal of providing a novel clinical tool for early SA-AKI risk assessment.MethodsOne-way ANOVA was applied to variables exhibiting normal distribution and homo-geneous variance. Spearman analysis was performed to assess relationships. Non-normal distribution variables were analyzed using the rank sum test. Binary and ordered logistic regression analyses were conducted to evaluate independent relationships with SA-AKI. Receiver operating characteristic (ROC) curve was employed to determine diagnostic accuracy. The survival curve was plotted by Kaplan Meier.ResultsThe NPS score was significantly higher in the SA-AKI group than in the non-AKI group (P < 0.001). Multivariate logistic regression showed that NPS was an independent predictor of SA-AKI (OR = 11.777, P < 0.001), with an area under the ROC curve (AUC) of 0.855. Correlation analysis indicated positive associations of NPS with renal injury markers (urea nitrogen, serum creatinine, cystatin C) and negative associations with platelet count and low-density lipoprotein. Subgroup analyses demonstrated that NPS effectively predicted SA-AKI regardless of vasopressor use or continuous renal replacement therapy (CRRT), with AUC values of 0.898 in the vasopressor group and 0.866 in the non-CRRT group.ConclusionNaples prognosis score serves as an independent predictor of SA-AKI, integrating inflammatory, nutritional, and metabolic markers to provide new insights into SA-AKI pathophysiology. Clinically, NPS offers a simple and feasible tool for early identification of high-risk SA-AKI patients, guiding personalized treatment strategies.

Public hospitals are in a position of growing economic pressure, and frugal resource management is necessary. Unfortunately, most traditional cost forecasting models do not capture healthcare costs' dynamic and non-linear nature. This paper offers a financial optimization framework based on AI with Ensemble Machine learning techniques that are interpretable. This methodology identifies the data preprocessing, feature engineering, and model training with the optimized Random Forest and XGBoost algorithms and SHAP (Shapley Additive exPlanations) analysis for model interpretability. The results report that generating our optimized XGBoost model led to an R² score of 0.89, outperforming Random Forest (R² = 0.88) and our baseline models. It also achieved a Mean Absolute Error (MAE) of 2502.36 and a Mean Squared Error (MSE) of 11230456.12, which is very high in predictive accuracy. Interpretability is achieved using SHAP (Shapley Additive exPlanations) analysis, which identifies key cost-driving factors such as smoking status, BMI, and age, enabling more transparent and informed decision-making by stakeholders. With the framework, we present a scalable predictive budgeting and decision-making solution in public healthcare institutions

Background:Acute kidney injury (AKI) exhibits considerable heterogeneity. The objective of the current study was to identify AKI subphenotypes in intensive care unit (ICU) patients using multivariate renal function trajectories. Methods:A retrospective study was performed on two independent datasets: the MIMIC-IV and eICU datasets. Using group-based multivariate trajectory modelling (GBMTM), we identified AKI subphenotypes based on trajectories of estimated glomerular filtration rate (eGFR) and urine output (UO). Multivariate Cox regression was applied to quantify the risk associated with the AKI subphenotype concerning clinical outcomes. Results:Our study enrolled a total of 17 113 ICU patients diagnosed with AKI, revealing four AKI subphenotypes via GBMTM. Subphenotype 1, characterized by a swift decrease in eGFR coupled with a gradual increase in UO, exhibited the highest mortality rates (24% in the MIMIC-IV cohort, 20% in the eICU cohort). Conversely, subphenotype 4, featuring a marked increase in eGFR alongside stable UO levels, demonstrated the most favourable prognosis (15% mortality in the MIMIC-IV cohort, 8% in the eICU cohort). Subphenotypes 2 and 3 shared similar eGFR trends, however, subphenotype 2 experienced a rapid decrease in UO, whereas subphenotype 3 maintained stability in this regard. Across both datasets, subphenotype 4 showed a significantly reduced risk of mortality compared with subphenotype 1 {hazard ratio [HR] 0.72 [95% confidence interval (CI) 0.60-0.81], P < .001 in the MIMIC-IV cohort; HR 0.49 [95% CI 0.37-0.64], P < .001 in the eICU cohort}. Conclusions:This study differentiated and stratified AKI subphenotypes among ICU patients by leveraging multivariate renal function trajectories, laying a foundation for personalized therapeutic strategies.

Background:Studies have shown that lymphocyte counts and lactate (LAC) levels have a certain relationship with the prognosis of COVID-19 patients. In the present study, we aimed to determine the predictive effects of new indicator lymphocyte change rate and LAC on the prognosis of COVID-19 patients. Methods:In the present study, we retrospectively analyzed the clinical data of 137 adult patients (≥ 18 years old) diagnosed with the COVID-19 Omicron variant, who were admitted to the comprehensive, respiratory, or infection ICU of our hospital, between November 2022 and February 2023. Cox regression and causal mediation analyses were used to evaluate the relationship between the clinical test data and patient prognosis. Results:A total of 137 patients with COVID-19 were included in the present study, 77.40% of whom were male, with an average age of 73 years and an overall mortality rate of 51.8%. Multifactorial logistic regression analysis showed that LAC (odds ratio [OR], 0.05; 95% confidence interval [CI], 0-0.1; P = 0.047] and the weekly rate of change in LYM (change in LMY over the course of a week/LYM on the day of admission) had a good predictive value for the prognosis of patients, while respiratory-related indicators had no significant relationship with prognosis (P > 0.05). The combined predictive value of LAC and the weekly rate of change in LYM was even greater, with an area under the curve of 0.7629. In terms of prognosis, 1.75 mmol/L was set as the cut-off value for LAC (sensitivity, 57.7%; specificity, 75.8%). The mortality rate of patients with LAC > 1.75 mmol/L was significantly higher than that those with LAC < 1.75 mmol/L, and NLR was found to have a mediating effect in lactate-mediated death. Conclusion:In summary, lymphocyte change rate combined with LAC had the greatest predictive value for COVID-19 ICU patient prognosis, while respiratory-related indicators had no significant relationship with prognosis, so we suggest the increase of LAC in COVID-19 patients may be caused by microcirculatory disturbances.

Abstract Background Understanding of the early immune response in severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) breakthrough infections is limited. Methods Ninety‐eight patients with coronavirus disease 2019 (COVID‐19) breakthrough infections were divided into two groups, with intervals from receiving the second dose of inactivated vaccine to the onset of illness <60 or ≥60 days. Results The median lymphocyte count and the median anti‐SARS‐CoV‐2 spike immunoglobulin G (IgG) and immunoglobulin M (IgM) titers were higher in the <60‐day interval group compared with the corresponding medians in the ≥60‐day interval group (p = 0.005, p = 0.001, and p = 0.001, respectively). The median interleukin‐6 (IL‐6) level in the <60‐day interval group was significantly lower than the median IL‐6 level in the ≥60‐day interval group (p < 0.001). Conclusions Our results highlight the different anti‐SARS‐CoV‐2 spike IgG and IgM antibody titers among patients with different intervals from receiving the second dose of inactivated vaccine to the onset of illness.

Background Helicobacter pylori bacteremia is rare and difficult to make a definite diagnosis. Case Presentation This is a 40-year-old woman represented as fever and unconsciousness accompanied by tics. She was diagnosed as Helicobacter pylori bacteremia and received emergency endotracheal intubation and antibiotics. Her symptoms resolved and she was discharged from ICU at the sixth day. ConclusionsHelicobacter pylori bacteremia is rare and hard to identify. Varied clinical manifestations leading to more difficult to make a definite diagnosis.

Acquired thrombotic thrombocytopenic purpura (aTTP) is a fatal hematologic disease. Despite the currently high standards of care, some patients who develop refractory or recurrent disease still have a poor prognosis. Although N-acetylcysteine (NAC) is recommended for the treatment of aTTP, its use in aTTP treatment is still controversial. We aimed to evaluate the association of NAC with mortality in patients with aTTP. This was a retrospective cohort study of patients with aTTP with in-hospital mortality as the primary outcome and time to platelet recovery and neurological recovery as secondary outcomes. We used multifactorial COX regression analysis to check for an association of NAC with mortality. Moreover, we performed a sensitivity analysis check the stability of our results. Finally, 89 patients with aTTP were enrolled. After adjusting for potential confounders, we found NAC to be associated with 75

Incidence of antimicrobial-resistant infections has increased dramatically worldwide in the past few decades. To combat this alarming problem, strategies preventing colonization with resistant pathogens have been proposed. Fecal microbiota transplantation(FMT)may help in decolonizing multidrug-resistant organisms(MRO) and in preventing recurrent infections. In this study, efficacy of FMT against multidrug resistance was assessed. Three patients that suffered from multidrug resistance complicated with diarrhea were enrolled from January 2019 to September 2020. All had severe pulmonary infections. Standard FMT was given, and whole metagenome sequencing of stool was conducted before and after FMT.All patients accepted FMT, and 12 samples were harvested. All treatments were successful, and there were no adverse events. All patients showed a decrease in species of intestinal flora, but FMT could recover some of the diversity. Normal people had the lowest abundance of antimicrobial-resistant genes (ARGs), but the patients had the highest abundance before FMT. FMT decreased ARGs to some extent. Nineteen ARG subtypes were significantly different between the normal group and the patients.Patients with MRO infections had increased abundance of ARGs and low bacterial diversity. FMT eradicated ARGs and restored microbial diversity, and there were no serious adverse events.

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.

Aims: The increase of arterial stiffness is an independent risk factor for cardiovascular diseases (CVD). Fish oil supplementation was shown to reduce the risk of CVD outcomes. However, the effects of fish oil on arterial stiffness remains controversial. This meta-analysis summarized existing randomized clinical trials (RCTs) to determine whether fish oil can affect arterial stiffness in adults. Data synthesis: Systematic searches were performed using the PubMed/Medline, EMbase, Cochrane database, Clinical trials, and Web of Science. All RCTs assessed the effect of fish oil intervention on carotid to femoral-Pulse Wave Velocity (cf-PWV), brachial to ankle-PWV (ba-PWV), augmentation index (AIx) and AIx75 were considered. A fixed-effect model was used to calculate the pooled effect. A total of 14 RCTs were included. The pooled data analysis showed that fish oil significantly reduced PWV levels (SMD: -0.145, 95%CI: -0.265 to -0.033, P = 0.012) compared to the control group. In subgroup analyses, a significant decrease in PWV was found in trials that fish oil with low dosages (<1.8 g/d), short time (<24 weeks), low DHA to EPA ratio (DHA/EPA<1) and among young participant (<50 years old). Besides, the effect of fish oil was more obvious in ba-PWV compared to cf-PWV. In contrast, the effect of fish oil supplementation on AIx (WMD: -0.588%, 95% CI: -2.745 to 1.568, P = 0.593) and AIx75 (WMD: 0.542%, 95% CI: -1.490 to 2.574, P = 0.601) was nonsignificant. Conclusions: The current study showed that fish oil supplementation had a beneficial effect on pulse wave velocity. ? 2021 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.

BACKGROUND: Corticosteroid therapy is used commonly in patients with COVID-19, although its impact on outcomes and which patients could benefit from corticosteroid therapy are uncertain. RESEARCH QUESTION: Are clinical phenotypes of COVID-19 associated with differential response to corticosteroid therapy? STUDY DESIGN AND METHODS: Critically ill patients with COVID-19 from Tongji Hospital treated between January and February 2020 were included, and themain exposure of interest was the administration of IV corticosteroids. The primary outcome was 28-day mortality. Marginal structural modeling was used to account for baseline and time-dependent confounders. An unsupervised machine learning approach was carried out to identify phenotypes of COVID-19. RESULTS: A total of 428 patients were included; 280 of 428 patients (65.4%) received corticosteroid therapy. The 28-day mortality was significantly higher in patients who received corticosteroid therapy than in those who did not (53.9% vs 19.6%; P <.0001). After marginal structural modeling, corticosteroid therapy was not associated significantly with 28-day mortality (hazard ratio [HR], 0.80; 95% CI, 0.54-1.18; P = .26). Our analysis identified two phenotypes of COVID-19, and compared with the hypoinflammatory phenotype, the hyperinflammatory phenotype was characterized by elevated levels of proinflammatory cytokines, higher Sequential Organ Failure Assessment scores, and higher rates of complications. Corticosteroid therapy was associated with a reduced 28-day mortality (HR, 0.45; 95% CI, 0.25-0.80; P = .0062) in patients with the hyperinflammatory phenotype. INTERPRETATION: For critically ill patients with COVID-19, corticosteroid therapy was not associated with 28-day mortality, but the use of corticosteroids showed significant survival benefits in patients with the hyperinflammatory phenotype.

Purpose: Measurement of central venous pressure (CVP) can be a useful clinical tool. However, the formal utility of CVP measurement in preventing mortality in septic patients has never been proven. Methods: The Medical Information Mart for Intensive Care III (MIMIC-III) database was searched to identify septic patients with and without CVP measurements. The primary outcome was 28-day mortality. Multivariate regression was used to elucidate the relationship between CVP measurement and 28-day mortality, and propensity score matching (PSM) and an inverse probability of treatment weighing (IPTW) were employed to validate our findings. Results: A total of 10275 patients were included in our study, of which 4516 patients (44%) underwent CVP measurement within 24 h of intensive care unit (ICU) admission. The risk of 28-day mortality was reduced in the CVP group (OR 0.60 (95% CI 0.51-0.70; p<0.001)). Patients in the CVP group received more fluid on day 1, and had a shorter duration of mechanical ventilation and vasopressor use, and the reduction in serum lactate was greater than that in the no CVP group. The mediating effect of serum lactate reduction was significant for the whole cohort (p=0.04 for the average causal mediation effect (ACME)) and patients in the CVP group with an initial CVP level below 8 mmHg (p=0.04 for the ACME). Conclusion: CVP measurement was associated with decreased risk-adjusted 28-day mortality among patients with sepsis and was proportionally mediated through serum lactate reduction.

Abstract Background: Whether patients presented with hypotension and hyperlactatemia can benefit from timely lactate measurement and further lactate-guide resuscitation were not fully understood.Methods: This was a retrospective observational study based on the data from the Medical Information Mart for Intensive Care (MIMIC)-III Database and the eICU Collaborative Research Database (eICU). Patients with hypotension (defined as a minimal systolic blood pressure ≤90 mm Hg or minimal mean arterial pressure ≤65 mm Hg or requiring any vasopressors support during the first 24 h after ICU admission) and hyperlactatemia (defined as an initial lactate level > 2.0 mmol/L after ICU admission) were eligible.The primary exposure was the timely lactate measurement, which was defined as an initial lactate level measured within 1 h after ICU admission. The primary outcome was in-hospital mortality. The statistical approaches included multivariate regression, propensity score matching (PSM) and an inverse probability of treatment weighing (IPTW) and causal mediation analysis (CMA) were utilized to elucidate the relationship between timely lactate measurement and in-hospital mortality. Results: A total of 9978 patients were identified, of which 4257 in MIMIC-III and 5721 in eICU. Timely lactate measurement was associated with lower risk-adjusted in-hospital mortality both in MIMIC (OR 0.70 (95%CI 0.58-0.85; p<0.001)) and eICU (OR 0.75 (95%CI 0.64-0.88; p<0.001)). Time to initial intravenous fluid (IVF) in MIMIC mediated 6.7% (95%CI 1.4%-38%; p<0.001) of the beneficial effect of timely lactate measurement (p<0.001 for average causal mediation effect (ACME)) in terms of in-hospital mortality. Finally, delayed initial lactate measurements are also associated an increased in-hospital mortality in MIMIC and eICU.Conclusions: Timely lactate measurement is associated with a lower risk-adjusted in-hospital mortality among patients with hypotension and hyperlactatemia, which was proportional mediated through shortening the time to IVF. Delay in initial lactate measurement showed a positive association with in-hospital mortality.

Purpose: With the proper insights, measurement of central venous pressure (CVP) can be a useful clinical aid. However, the formal utility of CVP measurement on mortality in septic patients has never been proved.Methods: The Medical Information Mart for Intensive Care III (MIMIC-III) was applied to identify septic patients who had and did not have CVP measured. The primary outcome was 28-day mortality. The statistical approaches including multivariate regression, propensity score matching (PSM) and an inverse probability of treatment weighing (IPTW) and causal mediation analysis (CMA) were utilized to elucidate the relationship between CVP measurement and 28-day mortality.Results: A total of 10275 patients were included in our study, of which 4516 patients (44%) had CVP measured within 24 h after ICU admission. A significant beneficial effect of CVP measurement in terms of 28-day mortality was observed (OR 0.60 (95% CI 0.51–0.70; p<0.001)). Patients in CVP group received more fluid on day 1, had a shorter duration of mechanical ventilation and vasopressor use, and the reduction of serum lactate was higher than that in the no CVP group. The mediation effect of serum lactate reduction was significant for the whole cohort (p=0.04 for average causal mediation effect (ACME)) and patients in the CVP group with an initial CVP level below 8mmHg (p=0.04 for ACME).Conclusion: CVP measurement is associated with a lower risk-adjusted 28-day mortality among patients with sepsis, which is proportionally mediated through serum lactate reduction.

BACKGROUND:To develop an inflammatory biomarker-based, simple-to-use nomogram for the early identification of septic patients at high risk of mortality in the emergency department (ED). METHODS:All patients diagnosed with sepsis admitted to the intensive care unit (ICU) from the ED were screened from the Medical Information Mart for Intensive Care III database and divided into two cohorts: the primary cohort and the validation cohort. We used bivariate logistic regression analysis to determine independent risk factors and to construct a predictive nomogram and subsequently evaluated the calibration, discrimination and clinical usefulness of the nomogram. The gradient boosting machine (GBM) model was used to more accurately evaluate these variables. RESULTS:A total of 5663 admissions were enrolled, of which 3964 comprised the primary cohort and 1699 comprised the validation group, with 28-day mortality rates of 21.2% and 20.4%, respectively. Age > 69, neutrophil-to-lymphocyte ratio (NLR) > 9.8, platelet-to-lymphocyte ratio (PLR) > 249.89, lymphocyte-to-monocyte ratio (LMR) ≤ 2.18, and red cell distribution width (RDW) were detected as important determinants of 28-day mortality and included in the nomogram. The calibration plot revealed an adequate fit of the nomogram for predicting the risk of 28-day mortality. Regarding discriminative ability, receiver operating characteristic curve analysis showed that the nomogram had an area under the curve (AUC) of 0.826 (95% CI: 0.811-0.841, P < 0.001) in the primary cohort, which was greater than that of all individual parameters and other scores. Decision curve analysis also indicated that our nomogram was feasible in clinical practice, as the threshold probabilities were 0-0.62 for the primary cohort. The GBM model yielded a significantly greater AUC of up to 0.867. CONCLUSIONS:This proposed simple-to-use nomogram based on age, NLR, PLR, LMR and RDW provides a relatively accurate mortality prediction for septic patients in the ED.

Background The optimal timing of lactate measurement for septic patients in the intensive care unit (ICU) remains controversial, and whether initiating and repeating the lactate measurement earlier could make a difference for septic patients with an elevated lactate level remains unexplored. Methods This was a retrospective observational study that included septic patients with an initial lactate level > 2.0 mmol/L after ICU admission, and all data were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The main exposure of interest was the early lactate measurement, which was defined as an initial lactate level measurement within 1 h after ICU admission. The primary outcome was 28-day mortality. Results A total of 2642 eligible subjects were enrolled, including 738 patients who had initial lactate measurements completed within 1 h (EL group) and 1904 patients who had initial lactate measurements completed more than 1 h after ICU admission (LL group). A significant beneficial effect of early lactate measurement in terms of 28-day mortality was observed: the adjusted odds ratio (OR) was 0.69 (95% CI 0.55–0.87; p = 0.001), and the mediation effect of the time to initial vasopressor administration was significant (average causal mediation effect (ACME) − 0.018; 95% CI − 0.005 approximately to − 0.036; p < 0.001). A strong relationship between delayed initial lactate measurement and risk-adjusted 28-day mortality was noted (OR 1.04; 95% CI 1.02–1.05; p < 0.001). Each hour of delay in remeasuring the lactate level was associated with an increase in 28-day mortality in the EL group (OR 1.09; 95% CI 1.04–1.15; p < 0.001). Further analysis demonstrated that repeating the measurement 3 h after the initial lactate measurement led to a significant difference. Conclusions Early lactate measurement is associated with a lower risk-adjusted 28-day mortality rate in septic patients with lactate levels > 2.0 mmol/L. A shorter time to the initial vasopressor administration may contribute to this relationship. Repeating the lactate measurement within 3 h after the initial measurement is appropriate for patients whose lactate levels were measured within 1 h of admission.

This study was designed to investigate the prognostic value of circulating blood cell counts and subsets for patients with advanced gastric cancer (AGC) treated with neoadjuvant chemotherapy (NAC) and the factors determining pathological complete response (pCR). In 112 patients with AGC, we retrospectively examined the ratios of lymphocyte, monocyte, and neutrophil during and after NAC before surgery, and the percentages of CD3+, CD3+ CD4+, CD3+ CD8+ and CD4+/CD8+ lymphocytes as well. We also investigated their associations with the pCR rate and overall survival (OS). The ratios of lymphocyte taken before and after NAC were significantly greater in forty-four pCR cases than that in sixty-eight non-pCR cases. During NAC, the proportion of lymphocyte and the percentages of CD3+, CD3+ CD4+, and CD3+ CD8+ lymphocytes were dramatically increased in pCR group. The lymphocyte ratio showed an independent association with pCR by multivariate analysis and maintained at a relatively high level in pCR cases. By mean of 31.53% lymphocyte ratio before-NAC and 41.68% after-NAC, cases with high lymphocyte ratio showed significantly better outcome in OS. High circulating lymphocyte ratios, both before and after NAC, are positively associated with pCR and improved OS in advanced gastric cancer, which may be considered as a new prognostic biomarker.