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Background Weaning of patients from the mechanical ventilation remains one of the critical decisions in intensive care unit. This study aimed to evaluate the accuracy of thoracic fluid content (TFC) as a predictor of weaning outcome. Methods An observational cohort study included 64 critically ill surgical patients who were eligible for extubation. Before initiating the spontaneous breathing trial, the TFC was measured using the electrical cardiometry technology. Patients were followed up after extubation and divided into successful weaning group and failed weaning group. Both groups were compared according to respiratory and cardiovascular parameters. Receiver operating characteristic (ROC) curves were constructed to evaluate the ability of TFC to predict weaning outcome. Results The number of successfully weaned patients was 41/64 (64%). Twenty (31%) patients had impaired cardiac contractility, and of them, 13/20 (64%) patients were successfully extubated. Both groups, successful weaning group and failed weaning group, were comparable in most of baseline characteristics; however, the TFC was significantly higher in the failed weaning group compared to the successful weaning group. The area under the ROC curves (AUCs) showed moderate predictive ability for the TFC in predicting weaning failure (AUC [95% confidence interval] 0.69 [0.57–0.8], cutoff value > 50 kΩ −1 ), while the predictive ability of TFC was excellent in the subgroup of patients with ejection fraction < 40% (AUC [95% confidence interval 0.93 [0.72–1], cutoff value > 50 kΩ −1 ). Conclusions Thoracic fluid content showed moderate ability for predicting weaning outcome in surgical critically ill patients. However, in the subgroup of patients with ejection fraction less than 40%, TFC above 50 kΩ −1 has an excellent ability to predict weaning failure.

Background Endotracheal intubation requires optimum position of the head and neck. In obese females, the usual ramped position might not provide adequate intubating conditions. We hypothesized that a new position, termed modified-ramped position, during induction of anesthesia would facilitate endotracheal intubation through bringing the breasts away from the laryngoscope and would also improve the laryngeal visualization. Methods Sixty obese female patients scheduled for general anesthesia were randomly assigned into either ramped or modified-ramped position during induction of anesthesia. In the ramped position ( n =  30), the patient head and shoulders were elevated to achieve alignment of the sternal notch and the external auditory meatus; while in the modified-ramped position ( n =  30), the patient shoulders were elevated using a special pillow, and the head was extended to the most possible range. Our primary outcome was the incidence of failed laryngoscopic insertion in the oral cavity (the need for patient repositioning). Other outcomes included time till vocal cord visualization, time till successful endotracheal intubation, difficulty of the mask ventilation, and Cormack-Lehane grade for laryngeal view. Results Fourteen patients (47%) in ramped group required repositioning to facilitate introduction of the laryngoscope in the oral cavity in comparison to one patient (3%) in the modified-ramped position ( p <  0.001). Modified-ramped position showed lower incidence of difficult mask ventilation, shorter time for glottic visualization, and shorter time for endotracheal tube insertion compared to the ramped position. The Cormack-Lehane grade was better in the modified-ramped position. Conclusion Modified-ramped position provided better intubating conditions, improved the laryngeal view, and eliminated the need for repositioning of obese female patients during insertion of the laryngoscope compared to ramped position. Clinical trial registration Identifier: NCT03640442 . Date: August 2018.

The role of long non-coding RNAs (lncRNAs) in Natural Killer (NK) cells is still an ongoing research question. LncRNAs are RNAs with a length of more than 200 nucleotides. While they do not code for functional proteins, they have many regulatory roles from transcriptional to post-translational mechanisms that can affect gene expression. On the other hand, NK cells are large, innate, granular immune cells that exert cytotoxic effects against virus-infected and malignant cells using various mechanisms of actions. In this study, we aimed to perform functional analysis of lncRNAs in NK cells. We focused on five lncRNAs: MALAT1, RMRP, LINC-PINT, GAS5, and LINC00299. Our findings revealed that the expressions of the five lncRNAs were downregulated in cultured NK cells and upon cytokine stimulation. In addition, we observed an upregulation of the PD-1 receptor on the surface of NK cells in response to knocking down RMRP. This suggests that RMRP may have an inhibitory effect on PD-1 expression in NK cells. The proposed inverse relationship between RMRP and PD-1 offers new insights into the regulation of PD-1 expression and its role in NK cell function. Given PD-1’s critical role as an immune checkpoint, by understanding the regulatory relationship between RMRP and PD-1, new strategies can be explored to enhance NK cell efficacy, opening up new possibilities for designing immunotherapies that restore NK cell function by potentially targeting PD-1 regulation.

Background The hemodynamic effects of relatively low-dose epinephrine and phenylephrine infusions during cesarean delivery under spinal anesthesia were compared. Methods This randomized controlled trial included full-term pregnant women who underwent elective cesarean delivery. After spinal anesthesia, participants received either epinephrine (0.03 mcg/kg/min) or phenylephrine (0.4 mcg/kg/min) infusion that continued until 5 min after delivery. The primary outcome was a composite outcome of the occurrence of any of hypotension, hypertension, bradycardia, and/or tachycardia. Neonatal outcomes, including umbilical artery blood gas and Apgar scores, were assessed. Results In total, 98 patients in each group were analyzed, and the number of patients with the composite outcome was comparable between the epinephrine and phenylephrine groups (30/98 [31%] vs. 31/98 [32%], respectively; P  = 0.877). However, the incidence of hypotension was likely lower in the epinephrine group than in the phenylephrine group ( P  = 0.066), and the number of hypotensive episodes per patient was lower in the epinephrine group than in the phenylephrine group. On the other hand, the incidence of tachycardia was higher in the epinephrine group than that in the phenylephrine group. The incidence of hypertension was comparable between the two groups and none of the participants developed bradycardia. Neonatal outcomes were comparable between the two groups. Conclusions Epinephrine and phenylephrine infusion produced comparable maternal hemodynamics and neonatal outcomes. Epinephrine was associated with a higher incidence of maternal tachycardia and likely lower incidence of maternal hypotension than phenylephrine. IRB number: MD-245–2022. Clinical trial registration: This study was registered on May 31, 2023 at clinicaltrials.gov registry, NCT05881915, URL: https://classic.clinicaltrials.gov/ct2/show/NCT05881915term=NCT05881915&draw=2&rank=1

[...]comparison of the two groups might be unfair and should preferably had included multi-variate regression analysis. [...]in the GDFT group, the authors stated that they initiated their algorithm whenever the cardiac index was less than the target value; however, it is not clear whether they provided any intervention if the mean arterial pressure decreased or not. [...]the authors did not mention any details for the hemodynamic management of the patients in the control group.

Background Data on the best norepinephrine bolus dose for management of hypotension are limited. The aim of this study was to compare the efficacy and safety of two norepinephrine bolus doses in the rescue management of maternal hypotension during cesarean delivery. Methods This randomized, controlled trial included mothers scheduled for cesarean delivery with spinal anesthesia with a prophylactic norepinephrine infusion. Following spinal anaesthesia administration, a participant was considered hypotensive if systolic blood pressure was ≤80% compared to the baseline reading. Participants were allocated to receive either 6 mcg or 10 mcg norepinephrine bolus for the management of hypotensive episodes. The hemodynamic response after administration of norepinephrine bolus was recorded. The episode was considered successfully managed if systolic blood pressure returned to within 80% from the baseline reading within 2 min after norepinephrine bolus administration, and did not drop again within 6 min after the norepinephrine bolus. The primary outcome was the incidence of successful management of the first hypotensive episode. Other outcomes included systolic blood pressure, heart rate, incidence of maternal bradycardia, and reactive hypertension. Results One hundred and ten mothers developed hypotensive episodes and received norepinephrine boluses for management. The number of successfully managed first hypotensive episodes was 50/57 (88%) in the 6 mcg-treated episodes and 45/53 (85%) in the 10 mcg-treated episodes ( p  = 0.78). Systolic blood pressure was comparable after administration of either bolus dose. Heart rate was lower after administration of 10 mcg bolus compared to 6 mcg bolus, without significant bradycardia requiring atropine administration. The incidence of reactive hypertension was comparable between both groups. Conclusion In mothers undergoing elective cesarean delivery under prophylactic norepinephrine infusion at 0.05 mcg/kg/min, there was no advantage to the use of 10 mcg norepinephrine bolus over 6 mcg norepinephrine bolus for the rescue management of first hypotensive episode. Neither of the 2 bolus doses reached a 100% success rate. The incidences of bradycardia and reactive hypertension were comparable between both norepinephrine doses. Trial registration At clinicaltrial.gov registry system on January 4, 2019 Clinical trial identifier: NCT03792906 .

Background In adults, mini-screw-assisted rapid palatal expansion (MARPE) has proven to be an efficient method for overcoming the drawbacks of conventional expansion methods. In treating adult patients with anteroposterior deficient maxilla, the clinician had to decide between an intrusive surgical approach or a camouflage therapy to mask the Class III malocclusion. However, alternate rapid maxillary expansion and constriction (ALT-RAMEC) is the treatment of choice in younger patients. Methods The 7-week ALT-RAMEC protocol was modified and combined with MARPE to evaluate its efficiency and its sutural and dentoskeletal advantages over conventional MARPE in young adults. Twenty-nine patients with transverse and anteroposterior maxillary deficiency (mean age of 21.3) were randomly assigned to two groups. The conventional group received MARPE with its conventional expansion rate (Control group), while the ALT-RAMEC group was treated with a combination of MARPE and the ALT-RAMEC modified protocol. The efficiency of expansion, circummaxillary sutural displacement, and dentoskeletal effects were assessed. Analysis of the change before and after intervention was examined using paired t-tests while analysis of the parameters comparing the two groups was examined using an independent t-test. For variables that were not normally distributed, the p-value was obtained from Bootstrap for pairwise comparison (BCA). Results The two techniques showed 100% efficiency in producing expansion in both groups. Mid-palatal, frontonasal, and intermaxillary sutures were displaced and increased significantly in width after treatment with both protocols ( p  ≤ 0.001), while the zygomaticomaxillary sutures compressed and showed a significant decrease in width with conventional MARPE, though, expanded and increased significantly in width with the ALT-RAMEC group ( p  < 0.001). The dentoskeletal effects revealed that conventional MARPE produced a buccal molar tipping while ALT-RAMEC showed a more bodily movement of the anchor molars. Conclusion The modified ALT-RAMEC technique is a promising protocol sufficient to expand the maxilla transversely without tipping the anchored teeth in young adult patients. The successful subluxation of circummaxillary sutures might be a sign of hope for maxillary anteroposterior deficient patients if proven to aid in non-surgical maxillary protraction. Trial registration The study protocol was registered in ClinicalTrials.gov public website under the name “New Maxillary Expansion Technique in Adults” with identifier number “NCT04908540”, and registration dates: 25-05-2021 (First submitted) and 01-06-2021 (First posted).

Background This study aimed to evaluate the accuracy of ankle blood pressure measurements in relation to invasive blood pressure in the lateral position. Methods This prospective observational study included adult patients scheduled for elective non-cardiac surgery under general anesthesia in the lateral position. Paired radial artery invasive and ankle noninvasive blood pressure readings were recorded in the lateral position using GE Carescape B650 monitor. The primary outcome was the ability of ankle mean arterial pressure (MAP) to detect hypotension (MAP < 70 mmHg) using area under the receiver operating characteristic curve (AUC) analysis. The secondary outcomes were the ability of ankle systolic blood pressure (SBP) to detect hypertension (SBP > 140 mmHg) as well as bias (invasive measurement – noninvasive measurement), and agreement between the two methods using the Bland-Altman analysis. Results We analyzed 415 paired readings from 30 patients. The AUC (95% confidence interval [CI]) of ankle MAP for detecting hypotension was 0.88 (0.83–0.93). An ankle MAP of ≤ 86 mmHg had negative and positive predictive values (95% CI) of 99 (97–100)% and 21 (15–29)%, respectively, for detecting hypotension. The AUC (95% CI) of ankle SBP to detect hypertension was 0.83 (0.79–0.86) with negative and positive predictive values (95% CI) of 95 (92–97)% and 36 (26–46)%, respectively, at a cutoff value of > 144 mmHg. The mean bias between the two methods was − 12 ± 17, 3 ± 12, and − 1 ± 11 mmHg for the SBP, diastolic blood pressure, and MAP, respectively. Conclusion In patients under general anesthesia in the lateral position, ankle blood pressure measurements are not interchangeable with the corresponding invasive measurements. However, an ankle MAP > 86 mmHg can exclude hypotension with 99% accuracy, and an ankle SBP < 144 mmHg can exclude hypertension with 95% accuracy.

None of our patients developed such a high block nor in any of our previous studies and the comparable data between the groups is expected in a randomized controlled well-powered study [5, 6, 7–8]. [...]we confirm that the results of our study are valid and there is no impact for the level of the block on our findings. Declarations Conflict of interest None. A systematic review of phenylephrine vs. noradrenaline for the management of hypotension associated with neuraxial anaesthesia in women undergoing caesarean section.