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The utilization of epidural electrodes in the preoperative evaluation of intractable epilepsy is a valuable but underrepresented tool. In recent years, we have adapted the use of cylindrical epidural 1-contact electrodes (1-CE) instead of Peg electrodes. 1-CEs are more versatile since their explantation is a possible bedside procedure. Here we report our experience with 1-CEs as well as associated technical nuances. This retrospective analysis included 56 patients with intractable epilepsy who underwent epidural electrode placement for presurgical evaluation at the Department of Neurosurgery at the Charité University Hospital from September 2011 to July 2021. The median age at surgery was 36.3 years (range: 18–87), with 30 (53.6%) female and 26 (46.4%) male patients. Overall, 507 electrodes were implanted: 93 Fo electrodes, 33 depth electrodes, and 381 epidural electrodes, with a mean total surgical time of 100.5 ± 38 min and 11.8 ± 5 min per electrode. There was a total number of 24 complications in 21 patients (8 Fo electrode dislocations, 6 CSF leaks, 6 epidural electrode dislocations or malfunction, 3 wound infections, and 2 hemorrhages); 11 of these required revision surgery. The relative electrode complication rates were 3/222 (1.4%) in Peg electrodes and 3/159 (1.9%) in 1-CE. In summary, epidural recording via 1-CE is technically feasible, harbours an acceptable complication rate, and adequately replaces Peg electrodes.

Background Acute respiratory distress syndrome (ARDS) is a heterogeneous condition with varying response to prone positioning. We aimed to identify subphenotypes of ARDS patients undergoing prone positioning using machine learning and assess their association with mortality and response to prone positioning. Methods In this retrospective observational study, we enrolled 353 mechanically ventilated ARDS patients who underwent at least one prone positioning cycle. Unsupervised machine learning was used to identify subphenotypes based on respiratory mechanics, oxygenation parameters, and demographic variables collected in supine position. The primary outcome was 28-day mortality. Secondary outcomes included response to prone positioning in terms of respiratory system compliance, driving pressure, PaO 2 /FiO 2 ratio, ventilatory ratio, and mechanical power. Results Three distinct subphenotypes were identified. Cluster 1 (22.9% of whole cohort) had a higher PaO 2 /FiO 2 ratio and lower Positive End-Expiratory Pressure (PEEP). Cluster 2 (51.3%) had a higher proportion of COVID-19 patients, lower driving pressure, higher PEEP, and higher respiratory system compliance. Cluster 3 (25.8%) had a lower pH, higher PaCO 2 , and higher ventilatory ratio. Mortality differed significantly across clusters (p = 0.03), with Cluster 3 having the highest mortality (56%). There were no significant differences in the proportions of responders to prone positioning for any of the studied parameters. Transpulmonary pressure measurements in a subcohort did not improve subphenotype characterization. Conclusions Distinct ARDS subphenotypes with varying mortality were identified in patients undergoing prone positioning; however, predicting which patients benefited from this intervention based on available data was not possible. These findings underscore the need for continued efforts in phenotyping ARDS through multimodal data to better understand the heterogeneity of this population.

A low dynamic driving pressure during mechanical ventilation for general anesthesia has been associated with a lower risk of postoperative respiratory complications (PRC), a key driver of healthcare costs. It is, however, unclear whether maintaining low driving pressure is clinically relevant to measure and contain costs. We hypothesized that a lower dynamic driving pressure is associated with lower costs. Multicenter retrospective cohort study. Two academic healthcare networks in New York and Massachusetts, USA. 46,715 adult surgical patients undergoing general anesthesia for non-ambulatory (inpatient and same-day admission) surgery between 2016 and 2021. The primary exposure was the median intraoperative dynamic driving pressure. The primary outcome was direct perioperative healthcare-associated costs, which were matched with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP–NIS) to report absolute differences in total costs in United States Dollars (US$). We assessed effect modification by patients' baseline risk of PRC (score for prediction of postoperative respiratory complications [SPORC] ≥ 7) and effect mediation by rates of PRC (including post-extubation saturation < 90%, re-intubation or non-invasive ventilation within 7 days) and other major complications. The median intraoperative dynamic driving pressure was 17.2cmH2O (IQR 14.0–21.3cmH2O). In adjusted analyses, every 5cmH2O reduction in dynamic driving pressure was associated with a decrease of −0.7% in direct perioperative healthcare-associated costs (95%CI −1.3 to −0.1%; p = 0.020). When a dynamic driving pressure below 15cmH2O was maintained, -US$340 lower total perioperative healthcare-associated costs were observed (95%CI −US$546 to −US$132; p = 0.001). This association was limited to patients at high baseline risk of PRC (n = 4059; −US$1755;97.5%CI −US$2495 to −US$986; p < 0.001), where lower risks of PRC and other major complications mediated 10.7% and 7.2% of this association (p < 0.001 and p = 0.015, respectively). Intraoperative mechanical ventilation targeting low dynamic driving pressures could be a relevant measure to reduce perioperative healthcare-associated costs in high-risk patients. •Lower driving pressure is associated with savings in healthcare-associated costs•These observation was made in patients at high risk of respiratory complications.•Postoperative respiratory and other major complications are relevant mediators of the primary association.•Targeting low driving pressure may help reduce healthcare-associated costs for patients at high risk.

IntroductionHypernatraemia, defined as a plasma sodium concentration >145 mmol/L, is a frequent complication in critically ill patients treated in the intensive care unit (ICU) (= ICU-acquired hypernatraemia), with reported prevalence ranging from 4% to 26%. Hypernatraemia adversely affects various physiological functions and is associated with delirium, prolonged length of stay and increased ICU and post-discharge mortality. The sodium load from intravenous drug diluents significantly contributes to ICU-acquired hypernatraemia, with drug infusions comprising about 30% of the daily fluid volume of an average ICU patient. This study aims to investigate if using glucose 5% solution as the default drug diluent, instead of sodium chloride 0.9%, can reduce the prevalence of ICU-acquired hypernatraemia and improve patient outcomes.Methods and analysisTo test the effectiveness of glucose 5% solution as the default drug diluent, we will conduct a multicentre, pragmatic, embedded, open-label, stepped-wedge, cluster-randomised trial. The study will include twelve clusters (ICUs and one intermediate care unit) across six hospitals in Germany, with a projected total sample size of 4485 patients. In line with the stepped-wedge cluster-randomised design, one ICU will transition every 4 weeks, in a randomised sequence, from using sodium chloride 0.9% as the default drug diluent to glucose 5%.The primary endpoint is the prevalence of hypernatraemia >150 mmol/L through day 28. The number of days alive and free of the ICU through day 28 will be tested hierarchically as a key secondary endpoint. Other exploratory endpoints include ICU mortality, ICU-free days, hospital-free days and other clinical outcomes. The primary endpoint will be analysed using a logistic mixed-effects model.Ethics and disseminationThe trial was approved by the Charité—Universitätsmedizin Berlin Ethics Board and by the ethics board of each enrolled hospital. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.Trial registration numberThe trial protocol was registered with the German Clinical Trials Register on 21 June 2024 prior to initiation of patient enrolment (DRKS00033397).

PurposeLatent class analysis (LCA) has identified hyper- and non-hyper-inflammatory subphenotypes in patients with acute respiratory distress syndrome (ARDS). It is unknown how early inflammatory subphenotypes can be identified in patients at risk of ARDS. We aimed to test for inflammatory subphenotypes upon presentation to the emergency department.MethodsLIPS-A was a trial of aspirin to prevent ARDS in at-risk patients presenting to the emergency department. In this secondary analysis, we performed LCA using clinical, blood test, and biomarker variables.ResultsAmong 376 (96.4%) patients from the LIPS-A trial, two classes were identified upon presentation to the emergency department (day 0): 72 (19.1%) patients demonstrated characteristics of a hyper-inflammatory and 304 (80.9%) of a non-hyper-inflammatory subphenotype. 15.3% of patients in the hyper- and 8.2% in the non-hyper-inflammatory class developed ARDS (p = 0.07). Patients in the hyper-inflammatory class had fewer ventilator-free days (median [interquartile range, IQR] 28[23–28] versus 28[27–28]; p = 0.010), longer intensive care unit (3[2–6] versus 0[0–3] days; p < 0.001) and hospital (9[6–18] versus 5[3–9] days; p < 0.001) length of stay, and higher 1-year mortality (34.7% versus 20%; p = 0.008). Subphenotypes were identified on day 1 and 4 in a subgroup with available data (n = 244). 77.9% of patients remained in their baseline class throughout day 4. Patients with a hyper-inflammatory subphenotype throughout the study period (n = 22) were at higher risk of ARDS (36.4% versus 10.4%; p = 0.003).ConclusionHyper- and non-hyper-inflammatory subphenotypes may precede ARDS development, remain identifiable over time, and can be identified upon presentation to the emergency department. A hyper-inflammatory subphenotype predicts worse outcomes.

Previous studies proposed comorbidity-based prediction tools to facilitate patient-level assessment of mortality risk, which are essential for confounder adjustment in epidemiologic studies. We compared established comorbidity indices using real-world administrative data of a broad surgical population. Adult patients undergoing surgical or interventional procedures between January 2005 and June 2020 at a tertiary academic medical center in Massachusetts, USA, were included. The Elixhauser Comorbidity Index (van Walraven modification), Combined Comorbidity Score, and Charlson Comorbidity Index were compared regarding the prediction of 30-day mortality. Age and sex were included in all models. Discriminative ability was quantified by the area under the receiver operating characteristic curve (AUROC), and calibration was assessed using the Brier score and reliability plots. A total of 514,282 patients were included, of which 5849 (1.1%) died within 30 days. A model including age and sex alone had an AUROC of 0.73 (95% CI 0.72-0.74). The Elixhauser Comorbidity Index–based model showed the best discriminative ability with an AUROC of 0.86 (95% CI 0.86-0.87) compared to models, including the Combined Comorbidity Score (AUROC, 0.85 [95% CI 0.84-0.85]) and the Charlson Comorbidity Index (AUROC, 0.82 [95% CI 0.81-0.83], P < .001, respectively). The Brier score was 0.011 for all scores. Overall, score performances were similar or improved after the implementation of the 10th Revision International Classification of Diseases (Clinical Modification) coding system. The primary findings were confirmed for in-hospital, 7-day, 90-day, 180-day, and 1-year mortality and when including score comorbidities as separate indicator variables (P < .001, respectively). Patient and procedural characteristics were predictive of mortality (AUROC, 0.91 [95% CI 0.91-0.91]), with confirmatory findings and slightly improved performances when adding comorbidity scores (AUROC, 0.93 [95% CI 0.93-0.93] for the Elixhauser Comorbidity Index; AUROC, 0.93 [95% CI 0.93-0.93] for the Combined Comorbidity Score; AUROC, 0.92 [95% CI 0.92-0.93] for the Charlson Comorbidity Index, P < .001, respectively). All 3 comorbidity indices predicted mortality with excellent discrimination; however, they showed only slightly improved performance when incorporated into a model including patient and procedural characteristics. When surgical data are unavailable and in surgical setting–specific subgroups, the Elixhauser Comorbidity Index consistently performed best. [Display omitted] •Comorbidity-based prediction tools enable patient-level assessment of mortality risk.•We compared established prediction tools using electronic health records.•Among 514,282 surgical patients, the Elixhauser Comorbidity Index performed best.•The Elixhauser Comorbidity Index may be used preferably for mortality prediction in broad surgical populations.

The role of antithrombotic therapy in the prevention of ischemic stroke after non-cardiac surgery is unclear. In this study, we tested the hypothesis that the association of new-onset postoperative atrial fibrillation (POAF) on ischemic stroke can be mitigated by postoperative oral anticoagulation therapy. Of 251,837 adult patients (155,111 female (61.6%) and 96,726 male (38.4%)) who underwent non-cardiac surgical procedures at two sites, POAF was detected in 4,538 (1.8%) patients. The occurrence of POAF was associated with increased 1-year ischemic stroke risk (3.6% versus 2.3%; adjusted risk ratio (RRadj) = 1.60 (95% confidence interval (CI): 1.37–1.87), P  < 0.001). In patients with POAF, the risk of developing stroke attributable to POAF was 1.81 (95% CI: 1.44–2.28; P  < 0.001) without oral anticoagulation, whereas, in patients treated with anticoagulation, no significant association was observed between POAF and stroke (RRadj = 1.04 (95% CI: 0.71–1.51), P  = 0.847, P for interaction = 0.013). Furthermore, we derived and validated a computational model for the prediction of POAF after non-cardiac surgery based on demographics, comorbidities and procedural risk. These findings suggest that POAF is predictable and associated with an increased risk of postoperative ischemic stroke in patients who do not receive postoperative anticoagulation. In a large cohort of patients who underwent non-cardiac surgery, postoperative prescription of oral anticoagulation medication decreased the risk of stroke in patients with postoperative atrial fibrillation (POAF), especially for patients deemed to be at high risk for POAF based on a newly developed risk score.