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Virtual reality (VR) and augmented reality (AR) are aspiring, new technologies with increasing use in critical care medicine. While VR fully immerses the user into a virtual three-dimensional space, AR adds overlaid virtual elements into a real-world environment. VR and AR offer great potential to improve critical care medicine for patients, relatives and health care providers. VR may help to ameliorate anxiety, stress, fear, and pain for the patient. It may assist patients in mobilisation and rehabilitation and can improve communication between all those involved in the patient’s care. AR can be an effective tool to support continuous education of intensive care medicine providers, and may complement traditional learning methods to acquire key practical competences such as central venous line placement, cardiopulmonary resuscitation, extracorporeal membrane oxygenation device management or endotracheal intubation. Currently, technical, human, and ethical challenges remain. The adaptation and integration of VR/AR modalities into useful clinical applications that can be used routinely on the ICU is challenging. Users may experience unwanted side effects (so-called “cybersickness”) during VR/AR sessions, which may limit its applicability. Furthermore, critically ill patients are one of the most vulnerable patient groups and warrant special ethical considerations if new technologies are to be introduced into their daily care. To date, most studies involving AR/VR in critical care medicine provide only a low level of evidence due to their research design. Here we summarise background information, current developments, and key considerations that should be taken into account for future scientific investigations in this field. Graphical abstract

During infection with positive-strand RNA viruses, viral RNA synthesis associates with modified intracellular membranes that form unique and captivating structures in the cytoplasm of the infected cell. These viral replication organelles (ROs) play a key role in the replicative cycle of important human pathogens like coronaviruses, enteroviruses, or flaviviruses. From their discovery to date, progress in our understanding of viral ROs has closely followed new developments in electron microscopy (EM). This review gives a chronological account of this progress and an introduction to the different EM techniques that enabled it. With an ample repertoire of imaging modalities, EM is nowadays a versatile technique that provides structural and functional information at a wide range of scales. Together with well-established approaches like electron tomography or labeling methods, we examine more recent developments, such as volume scanning electron microscopy (SEM) and in situ cryotomography, which are only beginning to be applied to the study of viral ROs. We also highlight the first cryotomography analyses of viral ROs, which have led to the discovery of macromolecular complexes that may serve as RO channels that control the export of newly-made viral RNA. These studies are key first steps towards elucidating the macromolecular complexity of viral ROs.

BackgroundVirtual reality (VR) and augmented reality (AR) are rapidly developing technologies that offer a wide range of applications and enable users to experience digitally rendered content in both physical and virtual space. Although the number of studies about the different use of VR and AR increases year by year, a systematic overview of the applications of these innovative technologies in intensive care medicine is lacking. The aim of this systematic review was to provide a detailed summary of how VR and AR are currently being used in various areas of intensive care medicine.MethodsWe systematically searched PubMed until 1st March 2023 to identify the currently existing evidence for different applications of VR and AR for both health care providers in the intensive care unit and children or adults, who were in an intensive care unit because of a critical illness.ResultsAfter screening the literature, a total of 59 studies were included. Of note, a substantial number of publications consists of case reports, study plans or are lacking a control group. Furthermore, study designs are seldom comparable. However, there have been a variety of use cases for VR and AR that researchers have explored. They can help intensive care unit (ICU) personnel train, plan, and perform difficult procedures such as cardiopulmonary resuscitation, vascular punctures, endotracheal intubation or percutaneous dilatational tracheostomy. Patients might benefit from VR during invasive interventions and ICU stay by alleviating stress or pain. Furthermore, it enables contact with relatives and can also assist patients in their rehabilitation programs.ConclusionBoth, VR and AR, offer multiple possibilities to improve current care, both from the perspective of the healthcare professional and the patient. It can be assumed that VR and AR will develop further and their application in health care will increase.Graphic Abstract

Purpose - The purpose of this paper is to suggest a comprehensive framework to elucidate the relationship between personality and networking. Using the Five Factor Model as a framework, the paper aims to argue that traits tapping into social (i.e. extraversion, agreeableness) and informational (i.e. openness to experience) features are relevant in explaining how individual dispositions facilitate networking behaviors. Moreover, it aims to delineate structural and functional differences in networking (i.e. building, maintaining, and using contacts within and outside the organization) and to theorize how these differences yield differential relationships of personality traits with networking dimensions.Design methodology approach - Online surveys were administered to two samples, from Germany and the UK, respectively (n=351). Structural equation modeling is used to test the hypotheses.Findings - Personality traits reflecting social (extraversion) and informational aspects (openness to experience) are broadly related to networking in general. The paper also finds support for differential relationships, for example, agreeableness is related to internal, but not external networking. Both conscientiousness and emotional stability are not related to networking behaviors.Practical implications - The findings help explain why some individuals experience more barriers to networking than others and can be used in networking trainings. Practitioners should also note that there is more than extraversion to accurately predict networking skills in selection assessments.Originality value - The paper provides further insights into determinants of networking, which is an important career self-management strategy. It also offers an integrative framework on the personality-networking relationship as prior research has been fragmentary. Establishing differential relations also furthers understanding on core differences between networking dimensions.

The Emissions Trading System in the European Union was introduced to achieve the climate goal of reducing emissions by around 43% between 1990 and 2030. Accordingly, the costs of emission allowances are part of power generation and, by extension, the price of electricity. Theoretical works thus suggest a positive relationship between the price of emission allowances and electricity. However, this has not been validated empirically for phase III of the Emissions Trading System in the short run as part of the price setting mechanism of electricity producers. Our evidence suggests an opposite effect: According to our empricial results, both European Power Exchange (EPEX) day-ahead and intraday markets are negatively affected during phase III. We further test for a potentially asymmetric influence with the help of quantile regressions. Altogether, the outcome has implications for policy-makers and calls for further attention by academics and policy-makers in the future design of the Emissions Trading System, especially under larger amount of renewables in the electricity system.

Keywords: Virtual reality, ECMO, Cardiohelp, VR, Priming

ObjectivesBempedoic acid (BA) is a novel oral low-density lipoprotein cholesterol lowering drug. This systematic review and meta-analysis aims to assess efficacy and safety for clinical outcomes in high cardiovascular (CV) risk patients.Data sourcesMEDLINE, Cochrane Central Register of Controlled Trials, Google Scholar, Embase, ClinicalTrials.gov, Clinical Trial Results and the American College of Cardiology web site were searched.Study selectionRandomised controlled trials (RCTs) of BA versus placebo in high CV risk patients reporting clinical outcomes were included.Main outcomes and measuresPrimary efficacy outcomes were major adverse cardiovascular events (MACE), all-cause mortality, CV mortality and non-fatal myocardial infarction (MI). Safety outcomes included new onset or worsening of diabetes mellitus (DM), muscular disorders, gout and worsening of renal function.ResultsSix RCTs with a total of 3956 patients and follow-ups of four to 52 weeks were identified. Heterogeneity mainly derived from differing follow-up duration and baseline CV risk. No difference in MACE (OR 0.84; 95% CI 0.61 to 1.15), all-cause mortality (OR 2.37; CI 0.80 to 6.99) and CV mortality (OR 1.66; CI 0.45 to 6.04) for BA versus placebo was observed. BA showed beneficial trends for non-fatal MI (OR 0.57; CI 0.32 to 1.00) and was associated with a lower risk of new-onset or worsening of DM (OR 0.68; CI 0.49 to 0.94), but higher risk of gout (OR 3.29; CI 1.28 to 8.46) and a trend for muscular disorders (OR 2.60; CI 1.15 to 5.91) and worsening of renal function (OR 4.24; CI 0.98 to 18.39).ConclusionBA in high CV risk patients showed no significant effects on major CV outcomes in short-term follow-up. Unfavourable effects on muscular disorders, renal function and gout sound a note of caution. Hence, further studies with longer term follow-up in carefully selected populations are needed to clarify the risk/benefit ratio of this novel therapy.

Background Few studies address the care of critically ill non-traumatic patients in the emergency department (ED). The aim of this study was to assess the epidemiology, management, and outcome of these patients. Methods In this retrospective study, we identified and analyzed data from all consecutive adult critically ill non-traumatic ED patients treated from March 2018 to February 2019. Patient characteristics, major complaint leading to admission, out-of-hospital, and in-hospital interventions and 30-day mortality were extracted from medical records of the electronic patient data management system. Results During the study period, we analyzed 40,764 patients admitted to the ED. Of these, 621 (1.5%) critically ill non-traumatic patients were admitted for life-threatening emergencies to the resuscitation room (age: 70 ± 16 years, 52% male). Leading problem on admission was disability/unconsciousness (D), shock (C), respiratory failure (B), airway obstruction (A), and environment problems (E) in 41%, 31%, 25%, 2%, and 1%, respectively. Out-of-hospital and in-hospital measures included: intravenous access (61% vs. 99%), 12-lead ECG (55% vs. 87%), invasive airway management (21% vs. 34%) invasive ventilation (21% vs. 34%), catecholamines (9% vs. 30%), arterial access (0% vs. 52%), and cardiopulmonary resuscitation (11% vs. 6%). The underlying diagnoses were mainly neurological (29%), followed by cardiological (28%), and pulmonological (20%) emergencies. The mean length of stay (LOS) in the resuscitation room and ED was 123 ± 122 and 415 ± 479 min, respectively. The 30-day mortality was 18.5%. Conclusion The data describe the care of critically ill non-traumatic patients in the resuscitation room. Based on these data, algorithms for the structured care of critically ill non-traumatic patients need to be developed.

BackgroundThis large-scale analysis pools individual data about the Clinical Frailty Scale (CFS) to predict outcome in the intensive care unit (ICU).MethodsA systematic search identified all clinical trials that used the CFS in the ICU (PubMed searched until 24th June 2020). All patients who were electively admitted were excluded. The primary outcome was ICU mortality. Regression models were estimated on the complete data set, and for missing data, multiple imputations were utilised. Cox models were adjusted for age, sex, and illness acuity score (SOFA, SAPS II or APACHE II).Results12 studies from 30 countries with anonymised individualised patient data were included (n = 23,989 patients). In the univariate analysis for all patients, being frail (CFS ≥ 5) was associated with an increased risk of ICU mortality, but not after adjustment. In older patients (≥ 65 years) there was an independent association with ICU mortality both in the complete case analysis (HR 1.34 (95% CI 1.25–1.44), p < 0.0001) and in the multiple imputation analysis (HR 1.35 (95% CI 1.26–1.45), p < 0.0001, adjusted for SOFA). In older patients, being vulnerable (CFS 4) alone did not significantly differ from being frail. After adjustment, a CFS of 4–5, 6, and ≥ 7 was associated with a significantly worse outcome compared to CFS of 1–3.ConclusionsBeing frail is associated with a significantly increased risk for ICU mortality in older patients, while being vulnerable alone did not significantly differ. New Frailty categories might reflect its “continuum” better and predict ICU outcome more accurately.Trial registration: Open Science Framework (OSF: https://osf.io/8buwk/).

Background The reduction of myocardial infarction (MI) and narrowing the gap between the populations with and without diabetes are important goals of diabetes care. We analyzed time trends for sex-specific incidence rates (IR) of first MI (both non-fatal MI and fatal MI) as well as separately for first non-fatal MI and fatal MI in the population with and without diabetes. Methods Using data from the KORA myocardial infarction registry (Augsburg, Germany), we estimated age-adjusted IR in people with and without diabetes, corresponding relative risks (RR), and time trends from 1985 to 2016 using Poisson regression. Results There were 19,683 people with first MI (34% fatal MI, 71% men, 30% with diabetes) between 1985 and 2016. In the entire study population, the IR of first MI decreased from 359 (95% CI: 345–374) to 236 (226–245) per 100,000 person years. In men with diabetes, IR decreased only in 2013–2016. This was due to first non-fatal MI, where IR in men with diabetes increased until 2009–2012, and slightly decreased in 2013–2016. Overall, fatal MI declined stronger than first non-fatal MI corresponding to IRs. The RR of first MI substantially increased among men from 1.40 (1.22–1.61) in 1985–1988 to 2.60 (2.26–2.99) in 1997–2000 and moderately decreased in 2013–2016: RR: 1.75 (1.47–2.09). Among women no consistent time trend for RR was observed. Time trends for RR were similar regarding first non-fatal MI and fatal MI. Conclusions Over the study period, we found a decreased incidence of first MI and fatal MI in the entire study population. The initial increase of first non-fatal MI in men with diabetes needs further research. The gap between populations with and without diabetes remained.