Explore the vast range of titles available.

In a randomized trial involving 4000 patients in the ICU who required sedation for mechanical ventilation, dexmedetomidine had no benefit on 90-day mortality as compared with usual care and was associated with more adverse events. Additional drugs were required for prescribed sedation levels in the two groups.

Purpose To ascertain the relationship among early (first 48 h) deep sedation, time to extubation, delirium and long-term mortality. Methods We conducted a multicentre prospective longitudinal cohort study in 11 Malaysian hospitals including medical/surgical patients ( n  = 259) who were sedated and ventilated ≥24 h. Patients were followed from ICU admission up to 28 days in ICU with 4-hourly sedation and daily delirium assessments and 180-day mortality. Deep sedation was defined as Richmond Agitation Sedation Score (RASS) ≤−3. Results The cohort had a mean (SD) age of 53.1 (15.9) years and APACHE II score of 21.3 (8.2) with hospital and 180-day mortality of 82 (31.7 %) and 110/237 (46.4 %). Patients were followed for 2,657 ICU days and underwent 13,836 RASS assessments. Midazolam prescription was predominant compared to propofol, given to 241 (93 %) versus 72 (28 %) patients ( P  < 0.0001) for 966 (39.6 %) versus 183 (7.5 %) study days respectively. Deep sedation occurred in (182/257) 71 % patients at first assessment and in 159 (61 %) patients and 1,658 (59 %) of all RASS assessments at 48 h. Multivariable Cox proportional hazard regression analysis adjusting for a priori assigned covariates including sedative agents, diagnosis, age, APACHE II score, operative, elective, vasopressors and dialysis showed that early deep sedation was independently associated with longer time to extubation [hazard ratio (HR) 0.93, 95 % confidence interval (CI) 0.89–0.97, P  = 0.003], hospital death (HR 1.11, 95 % CI 1.05–1.18, P  < 0.001) and 180-day mortality (HR 1.09, 95 % CI 1.04–1.15, P  = 0.002), but not time to delirium (HR 0.98, P  = 0.23). Delirium occurred in 114 (44 %) of patients. Conclusion Irrespective of sedative choice, early deep sedation was independently associated with delayed extubation and higher mortality, and thus was a potentially modifiable risk in interventional trials.

Monitoring anesthetic depth and cerebral oxygenation is particularly important in cardiac anesthesia, where patients are at increased risk of neurological complications and hemodynamic instability. Conventional monitoring approaches based primarily on vital signs and clinical assessment may lack sensitivity for detecting subtle cerebral hypoxia or inadequate anesthetic depth during complex procedures. This narrative review employed a structured literature search of PubMed, Scopus, and Web of Science to identify relevant clinical studies, reviews, and case reports evaluating the use of Bispectral Index (BIS) monitoring and near-infrared spectroscopy (NIRS)–based cerebral oximetry in cardiac anesthesia. The review focuses on the complementary physiological information provided by BIS, which estimates anesthetic depth from electroencephalographic activity, and cerebral oximetry, which enables continuous assessment of regional cerebral oxygenation. Evidence from randomized trials and observational studies suggests that BIS-guided anesthesia is associated with a reduced incidence of intraoperative awareness, shorter extubation times, and decreased intensive care unit length of stay, while defined cerebral oximetry thresholds are consistently linked to postoperative cognitive dysfunction and adverse neurological outcomes. When used together, BIS and NIRS may facilitate earlier recognition of inadequate sedation, cerebral hypoperfusion, and global physiological compromise during cardiopulmonary bypass, with case reports highlighting critical scenarios such as “triple low” states and refractory cerebral desaturation. The review also proposes a conceptual framework and an interim standard operating procedure to guide integrated use of these modalities in clinical practice. Important limitations are discussed, including interindividual pharmacologic variability, sensor-related artifacts, and patient-specific heterogeneity, which contribute to variability in signal interpretation. Emerging directions such as adaptive algorithms, multimodal neuromonitoring platforms, and wireless technologies integrated into Enhanced Recovery After Surgery pathways are also considered. Overall, although BIS and cerebral oximetry each provide incomplete information when applied in isolation, their combined use offers a potentially synergistic neuromonitoring strategy in cardiac anesthesia. The current evidence base, however, remains heterogeneous, underscoring the need for large-scale, methodologically robust studies to clarify outcome benefits and inform standardized implementation.

This study aims to examine the relationship between CSR initiatives (CSRI), CSR-supportive behaviours (CSRSB), brand experience (BE), and consumer brand loyalty (CBL), with brand experience as a mediating variable in four major cities of China. A total of 550 respondents has been surveyed and this paper employed structural equation modeling (SEM) for data analysis. The results indicate that CSRI positively influences both CSRSB and BE. Additionally, both BE and CBL are significantly impacted by CSRSB. The mediation analysis confirms that BE partially mediates the relationship between CSRI and CBL in the present study. This indicates that the important role of brand experience in consumer loyalty. While CSR efforts contribute to consumer commitment, a positive brand experience further strengthens this relationship. The findings provide strategic insights for brand managers, recommending enhanced consumer-brand interactions to maximize the impact of CSR.

The construction industry is known as the most hazardous industry and has always been plagued with accident for a long time. Incidents or accidents that happened at construction sites has caused several drawbacks of project performance, such as delay in project completion, increase project cost, reduce productivity and create negative impressions to the organization. Therefore, it is crucial for employer to ensure safety and health at the workplace is taken care of to avoid accident. This paper presents the review of the factors affecting safety performance of construction project, focusing on project level. Among the most frequently cited factors that affect safety performance of construction project in project level are safety training, implementation of safe working environment and implementation of safe plant and equipment. The outcomes of the paper may serve as a starting point for further research in investigating the main.

Background Septic shock is associated with decreased vasopressor responsiveness. Experimental data suggest that central alpha2-agonists like dexmedetomidine (DEX) increase vasopressor responsiveness and reduce catecholamine requirements in septic shock. However, DEX may also cause hypotension and bradycardia. Thus, it remains unclear whether DEX is hemodynamically safe or helpful in this setting. Methods In this post hoc subgroup analysis of the Sedation Practice in Intensive Care Evaluation (SPICE III) trial, an international randomized trial comparing early sedation with dexmedetomidine to usual care in critically patients receiving mechanical ventilation, we studied patients with septic shock admitted to two tertiary ICUs in Australia and Switzerland. The primary outcome was vasopressor requirements in the first 48 h after randomization, expressed as noradrenaline equivalent dose (NEq [μg/kg/min] = noradrenaline + adrenaline + vasopressin/0.4). Results Between November 2013 and February 2018, 417 patients were recruited into the SPICE III trial at both sites. Eighty-three patients with septic shock were included in this subgroup analysis. Of these, 44 (53%) received DEX and 39 (47%) usual care. Vasopressor requirements in the first 48 h were similar between the two groups. Median NEq dose was 0.03 [0.01, 0.07] μg/kg/min in the DEX group and 0.04 [0.01, 0.16] μg/kg/min in the usual care group ( p  = 0.17). However, patients in the DEX group had a lower NEq/MAP ratio, indicating lower vasopressor requirements to maintain the target MAP. Moreover, on adjusted multivariable analysis, higher dexmedetomidine dose was associated with a lower NEq/MAP ratio. Conclusions In critically ill patients with septic shock, patients in the DEX group received similar vasopressor doses in the first 48 h compared to the usual care group. On multivariable adjusted analysis, dexmedetomidine appeared to be associated with lower vasopressor requirements to maintain the target MAP. Trial registration The SPICE III trial was registered at ClinicalTrials.gov ( NCT01728558 ).

Background Utilising ultrasound technology has resulted in higher success and lower complication rates during regional anaesthesia (RA) procedures. Proper training is necessary to accurately identify structures, optimise images, and improve hand–eye coordination. Simulation training using immersive virtual environments and simulation models has enabled this competency training to be conducted safely before performing on patients. We conducted a study to compare the simulator performance and users’ feedback on a Blue Phantom Regional Anaesthesia Ultrasound Training Block and NeedleTrainer™. Methods Forty-seven participants were recruited via convenient sampling during a RA workshop for novice practitioners. They were divided into the N or B group and then crossover to experience using both Blue Phantom and NeedleTrainer model. Time-to-reach-target, first-pass success rate, and complication rate were assessed, while the learning and confidence scores were rated using six-item and three-item questionnaires, respectively, via a 5-point Likert scale. Results Blue Phantom model has a longer time-to-target as compared to the NeedleTrainer model (16 ± 8 vs 8 ± 3 s, p  < 0.001), higher first- pass success rate (100% vs 80.9%), and lower complication rate (0% vs 19.1%). Higher overall learning satisfaction scores (28 ± 4 vs 25 ± 4, p  = 0.003) and confidence scores after training (13 ± 2 vs 12 ± 2, p  < 0.001) were recorded for the Blue Phantom model. Conclusions We postulated that the artificial intelligence structure recognition software enables NeedleTrainer users to attain shorter time-to-target. That being said, Blue Phantom provides better operator learning satisfaction, improved confidence, higher success and lower complication rates among novice RA practitioners, possibly due to greater tactile feedback during the simulated training.

Myocardial remodelling is a molecular, cellular, and interstitial adaptation of the heart in response to altered environmental demands. The heart undergoes reversible physiological remodelling in response to changes in mechanical loading or irreversible pathological remodelling induced by neurohumoral factors and chronic stress, leading to heart failure. Adenosine triphosphate (ATP) is one of the potent mediators in cardiovascular signalling that act on the ligand-gated (P2X) and G-protein-coupled (P2Y) purinoceptors via the autocrine or paracrine manners. These activations mediate numerous intracellular communications by modulating the production of other messengers, including calcium, growth factors, cytokines, and nitric oxide. ATP is known to play a pleiotropic role in cardiovascular pathophysiology, making it a reliable biomarker for cardiac protection. This review outlines the sources of ATP released under physiological and pathological stress and its cell-specific mechanism of action. We further highlight a series of cardiovascular cell-to-cell communications of extracellular ATP signalling cascades in cardiac remodelling, which can be seen in hypertension, ischemia/reperfusion injury, fibrosis, hypertrophy, and atrophy. Finally, we summarize current pharmacological intervention using the ATP network as a target for cardiac protection. A better understanding of ATP communication in myocardial remodelling could be worthwhile for future drug development and repurposing and the management of cardiovascular diseases.

Myocardial atrophy, characterized by the decreases in size and contractility of cardiomyocytes, is caused by severe malnutrition and/or mechanical unloading. Extracellular adenosine 5′-triphosphate (ATP), known as a danger signal, is recognized to negatively regulate cell volume. However, it is obscure whether extracellular ATP contributes to cardiomyocyte atrophy. Here, we report that ATP induces atrophy of neonatal rat cardiomyocytes (NRCMs) without cell death through P2Y 2 receptors. ATP led to overproduction of reactive oxygen species (ROS) through increased amount of NADPH oxidase (Nox) 2 proteins, due to increased physical interaction between Nox2 and canonical transient receptor potential 3 (TRPC3). This ATP-mediated formation of TRPC3-Nox2 complex was also pathophysiologically involved in nutritional deficiency-induced NRCM atrophy. Strikingly, knockdown of either TRPC3 or Nox2 suppressed nutritional deficiency-induced ATP release, as well as ROS production and NRCM atrophy. Taken together, we propose that TRPC3-Nox2 axis, activated by extracellular ATP, is the key component that mediates nutritional deficiency-induced cardiomyocyte atrophy.

Cardiothoracic surgeries are life-saving procedures but often it results in various complications. Intraoperative cerebral oximetry monitoring used to detect regional cerebral oxygen saturation (rScO2) is a non-invasive method that provides prognostic importance in cardiac surgery. The main aim of the present study was to evaluate the association of intraoperative cerebral oxygen monitoring during cardiac surgery on postoperative complications. This was a case-controlled retrospective study conducted on adult patients, who underwent open-heart surgery in National Heart Institute, Malaysia. The case group comprised patients on protocolized cerebral oximetry monitoring. They were treated using a standardized algorithm to maintain rScO2 not lower than 20% of baseline rScO2. The control group comprised patients with matched demographic background, preoperative risk factors, and type of surgical procedures. Propensity score stratification was utilized to contend with selection bias. Retrospective analysis was performed on 240 patients (case group) while comparing it to 407 patients (control group). The non-availability of cerebral oximetry monitoring during surgery was the prominent predictor for all outcome of complications; stroke (OR: 7.66), renal failure needing dialysis (OR: 5.12) and mortality (OR: 20.51). Postoperative complications revealed that there were significant differences for risk of mortality (p<0.001, OR = 20.51), renal failure that required dialysis (p<0.001, OR = 5.12) and stroke (p <0.05, OR = 7.66). Protocolized cerebral oximetry monitoring during cardiothoracic surgeries was found to be associated with lower incidence of stroke, renal failure requiring dialysis and mortality rate.