Search Results (58)

Background: Patients in Intensive Care Units (ICUs) often develop non-thyroidal illness syndrome. Potentially, thyroid hormones may be removed during continuous veno-venous hemodiafiltration (CVVHDF), as their molecular size is smaller than the filter pores’ cutoff. The study’s main aim was to assess whether the serum concentration of thyroid hormones changes over time during CVVHDF. Methods: This was a prospective observational trial that included 30 patients treated in an ICU. All patients developed acute kidney injury (AKI) and had clinical indications for implementation of CVVHDF. Blood samples were collected before initiation of CVVHDF and at 1, 2, 3, 6, 9 and 12 days after. The last sample was collected three days after CVVHDF withdrawal. Thyroid function was evaluated by determining the serum concentration of TSH, thyrotropin-releasing hormone (TRH), free triiodothyronine (fT₃), free thyroxine (fT₄), total triiodothyronine (tT₃), total thyroxine (tT₄) and reverse triiodothyronine (rT₃). We additionally calculated the total activity of peripheral deiodinases (G_D) using a mathematical model. Results: TRH and TSH levels remained mostly within normal ranges. fT4 and tT4 were in normal range or slightly below. In contrast, fT3 and tT3 were undetectably low in most patients throughout. Reverse T3 levels remained within normal limits. There were no statistically significant changes in any thyroid hormone levels over the CVVHDF treatment period. The calculated peripheral G_D activity was lower than normal, but importantly, it did not change significantly over time. Conclusions: Thyroid hormones are not lost due to hemodiafiltration. Decreased deiodinases activity is responsible for alterations in serum concentrations of thyroid hormones in patients during CVVHDF. Full article

Background and Objectives: Severe sepsis complicated by refractory shock is associated with high mortality. Adding continuous hemofiltration to venovenous extracorporeal membrane oxygenation (ECMO) may accelerate clearance of inflammatory mediators and improve haemodynamic stability, but evidence remains limited. We analysed 44 consecutive septic-shock patients treated with combined ECMO-hemofiltration (ECMO group) and compared them with 92 septic-shock patients managed without ECMO or renal replacement therapy (non-ECMO group). Methods: This retrospective single-centre study reviewed adults admitted between January 2018 and March 2025. Demographic, haemodynamic, laboratory and outcome data were extracted from electronic records. Primary outcome was 28-day mortality; secondary outcomes included intensive-care-unit (ICU) length-of-stay, vasopressor-free days, and change in Sequential Organ Failure Assessment (SOFA) score at 72 h. Results: Baseline age (49.2 ± 15.3 vs. 52.6 ± 16.1 years; p = 0.28) and APACHE II (27.8 ± 5.7 vs. 26.9 ± 6.0; p = 0.41) were comparable. At 24 h, mean arterial pressure rose from 52.3 ± 7.4 mmHg to 67.8 ± 9.1 mmHg in the ECMO group (mean change [∆] + 15.5 mmHg, p < 0.001). Controls exhibited a modest 4.9 mmHg rise that did not reach statistical significance (p = 0.07). Inflammatory markers decreased more sharply with ECMO (IL-6 ∆ −778 pg mL⁻¹ vs. −248 pg mL⁻¹, p < 0.001). SOFA fell by 3.6 ± 2.2 points with ECMO versus 1.6 ± 2.4 in controls (p = 0.01). Twenty-eight-day mortality did not differ (40.9% vs. 48.9%, p = 0.43), but ICU stay was longer with ECMO (median 12.5 vs. 9.3 days, p = 0.002). ΔIL-6 correlated with ΔSOFA (ρ = 0.46, p = 0.004). Conclusions: ECMO-assisted hemofiltration improved early haemodynamics and organ-failure scores and accelerated cytokine clearance, although crude mortality remained unchanged. Larger prospective trials are warranted to clarify survival benefit and optimal patient selection. Full article

Background: Mitochondrial DNA (mtDNA) has strong pro-inflammatory potential and was found to be associated with mortality in critically ill patients. The purine bases from circulating cell-free DNA, including mtDNA, are catabolised into uric acid, contributing to elevated systemic levels. However, the prognostic value of uric acid in unselected critically ill intensive care unit (ICU) patients remains unclear. We aimed to investigate the association between uric acid levels at admission and 30-day mortality, assess its correlation with mtDNA, and examine prognostic relevance based on the primary cause of admission. Methods: This prospective single-centre study included 226 patients admitted to a tertiary care ICU. Uric acid and mtDNA levels were assessed at admission. Survival analyses were performed in the overall cohort and in subgroups stratified by primary diagnosis. Results: Uric acid showed a U-shaped association with 30-day mortality, with both low and high levels linked to reduced survival. In multivariate analysis, the 4th quartile of uric acid remained associated with adverse outcomes, independent of sex, vasopressors, mechanical ventilation, and creatinine (HR 2.549, 95% CI: 1.310–4.958, p = 0.006). A modest correlation was observed between uric acid and mtDNA (r = 0.214, p = 0.020). However, prognostic relevance varied by diagnosis. While uric acid predicted mortality in patients following cardiac arrest (p = 0.017), mtDNA was found to bear prognostic value in cardiogenic shock and decompensated heart failure (p = 0.009). Conclusions: Uric acid was independently associated with mortality in critically ill patients, with both low and high levels carrying prognostic value. Its predictive capabilities differed from mtDNA but showed partial overlap. However, both markers exhibited varying prognostic performance depending on the primary cause of admission. Full article

Background/Objectives: The phase angle (PhA) is an emerging biomarker reflecting the cellular integrity and nutritional status. This study aimed to explore potential associations between the PhA, clinical severity scores, and 60-day survival outcomes following an admission to the Intensive Care Unit (ICU). Methods: This prospective, single-center study included 43 critically ill patients admitted to the ICU at Evangelismos General Hospital between May and November 2024. Patients were stratified by their PhA (≤5.4° vs. >5.4°). The PhA was measured at admission and subsequently on days 5–7, 10–11, 13–14, and until discharge. Severity scores (SOFA and APACHE II) were recorded. Between-group differences were assessed using independent samples t-tests and Mann–Whitney U tests, as appropriate. Survival was analyzed using Kaplan–Meier curves and Cox proportional hazards models. Results: The mean age was 54.6 ± 17 years; 63.6% were male. At ICU admission, patients with a PhA > 5.4° were significantly younger (p < 0.001) and had a higher fat-free mass (p < 0.001), greater calf circumference (p < 0.001), higher extracellular water (p < 0.001), larger mid-upper arm circumference (p = 0.009), and higher resting energy expenditure per kilogram (27.4 vs. 23.1 kcal/kg, p = 0.002). The PhA declined significantly during the ICU stay (p < 0.001). The Kaplan–Meier analysis showed a significantly shorter survival in patients with a PhA ≤ 5.4° (HR: 6.32, p = 0.019), which remained significant after adjusting for sepsis (p = 0.017). In a multivariable Cox regression, both PhA and APACHE II scores independently predicted mortality. Conclusions: While limited by a small sample size and single-center design, these findings support the further exploration of the PhA as a monitoring tool in critical care. Full article

Acute pancreatitis (AP) is primarily caused by inflammation and immunological responses, both of which are regulated by vitamin D. The purpose of this study was to examine the correlation between the severity of AP and vitamin D levels, including its total, free, and bioavailable forms. Eighty individuals with AP were enrolled in this study. Serum levels of free 25(OH)D₃, bioavailable 25(OH)D₃, and total 25-hydroxyvitamin D 25(OH)D₃ were assessed. The severity of the disease course was assessed by scoring systems (Revised Atlanta classification, Ranson score, CTSI). Vitamin D deficiency was common in AP patients, with 31.3% being categorized as deficient (<50 nmol/L) and 27.5% having a severe deficiency (<30 nmol/L). Compared to patients with adequate vitamin D status, those with lower vitamin D levels had a significantly higher risk of developing moderate-to-severe AP (44.7% vs. 14.3%, p = 0.029). Patients with severe vitamin D insufficiency were the only ones who experienced severe AP. Clinical outcomes showed similar correlations: patients with significant vitamin D deficiency had longer hospital stays (mean of 12.1 ± 5.3 days vs. 7.8 ± 3.4 days, p = 0.018) and higher rates of ICU admission (31.8% vs. 8.0%, p = 0.007). Low levels of total, free, and bioavailable vitamin D were significantly associated with the severity of AP and ICU admission. Free, bioavailable, and total vitamin D were correlated with the severity of acute pancreatitis. All severe cases occurred in patients with severe vitamin D deficiency. Given the observational design, these associations require confirmation in interventional or mechanistic studies. Full article

Objectives: The impact of initial emergency room (ER) factors on survival and renal function in critically ill patients undergoing continuous renal replacement therapy (CRRT) remains unclear. This study aimed to evaluate whether these initial factors influence survival and renal recovery in such patients. Methods: This single-center, retrospective study included 190 critically ill patients admitted to the intensive care unit (ICU) via the ER for CRRT between 1 March 2018, and 31 May 2021. Clinical parameters, including urine output, estimated glomerular filtration rate (eGFR), and serum neutrophil gelatinase-associated lipocalin (NGAL), were assessed. The primary outcomes were 30-day and 90-day mortality, while secondary outcomes included 30-day and 90-day RRT-free durations. Results: Patients with low urine output (LUO, defined as the average of <0.5 mL/kg/h over 6 h) were significantly associated with higher 30-day and 90-day mortality rates. Multivariable Cox regression analysis revealed that the LUO group had an increased risk of 30-day and 90-day mortality (hazard ratios: 1.935 and 2.141, respectively) compared to the high urine output (HUO, defined as the average of ≥0.5 mL/kg/h over 6 h) group. No significant association was observed between mortality and initial eGFR or plasma NGAL levels. However, the HUO group and patients with initial eGFR ≥ 30 mL/min/1.73 m² had longer RRT-free durations at 30 and 90 days. Plasma NGAL levels did not significantly correlate with RRT-free durations. Conclusions: Initial 6-h urine output in the ER is a significant predictor of 30-day and 90-day mortality in critically ill patients undergoing CRRT. Full article

Background: The prevalence of malnutrition is high in post-intensive care unit (ICU) coronavirus disease 2019 (COVID-19) patients during hospitalization and after hospital discharge. This paper presents prospective results from the NutriEcoMuscle study, a multicenter observational study. The study aimed to evaluate changes in nutritional and functional status in post-ICU COVID-19 patients following nutritional and physical rehabilitation interventions. Secondary aims included assessing adherence to and tolerance of the oral nutritional supplement (ONS) used in the nutritional intervention. Methods: The study enrolled adults who had been admitted to the ICU due to severe COVID-19. At hospital discharge, the patients underwent a nutritional intervention based on oral nutritional supplements (ONSs) with 100% serum lactoprotein enriched with leucine and vitamin D and a physical rehabilitation program. They were followed up during three months. Performed assessments included Subjective Global Assessment (SGA), Global Leadership Initiative on Malnutrition (GLIM) criteria, Barthel index (BI), handgrip strength and Timed Up and Go test, bioelectrical impedance analysis (BIA), nutritional ultrasound (US), and tolerance and adherence to ONS. Sample size was calculated based on handgrip strength, and parametric and non-parametric tests were used to assess differences between the baseline and three-month outcomes. Results: The study included 96 patients (71.9% male, mean age 58.8 years, mean body mass index (BMI) of 28.8 kg/m², 36.5% obese). A total of 85 patients (62 men and 23 women) completed the 90-day follow-up. The mean weight gain after the intervention was 6.8 (SD 5.2) kg (similar in men and women; p = 0.263). The proportion of patients with malnutrition according to the SGA or GLIM criteria decreased from 100% to 11.8% and 36.4%, respectively (p < 0.00001 in both cases). The proportion of patients with functional limitations by BI decreased from 66.7% to 27.0% (p < 0.0001). Handgrip strength increased more than 40% in both men and women (p < 0.00001). The time to perform the Timed Up and Go (TUG) test decreased more than 40% in both men and women (p < 0.00001). According to BIA, the mean fat mass did not increase significantly in either men or women. The mean fat-free mass index (FFMI) increased significantly in both men and women. There were also significant increases in body cell mass, skeletal muscle mass index, and appendicular skeletal muscle mass index. The phase angle (PhA) increased significantly in both men (26.5%) and women (17.4%). In a multivariate analysis, age and baseline PhA were related to the PhA increase (adjusted R² = 0.5573). The US study showed a significant increase in the mean measurements of muscle area, muscle circumference, X-axis, and Y-axis in the rectus femoris. Regarding abdominal fat, there were no significant increases in total, superficial, or preperitoneal adipose tissue by US. Participants engaged in a median interquartile range (IQR) of 70 (0–120) min/week of strength exercise and 60 (0–120) min/week of moderate physical exercise. The supplement was well tolerated, and poor adherence (less than 50%) was low (4% of the participants). Conclusions: A three-month intervention, including ONS and physical rehabilitation, is associated with a significant improvement in nutritional and functional status. Patients gained weight primarily by increasing their muscle mass. There was no significant increase in fat mass, as measured by BIA or US. The intervention was well tolerated and had good adherence. Full article

Background/Objectives: Gram-negative bloodstream infections (GN-BSIs) in the critically ill carry significant mortality, which is exacerbated by delays in appropriate therapy. To improve the time to effective therapy, aminoglycosides are often recommended as empiric adjunctive antimicrobials. However, there is a paucity of clinical data supporting this practice. This study’s objective was to evaluate the safety and efficacy of adjunctive aminoglycosides compared to β-lactam monotherapy in patients admitted to the intensive care unit (ICU) with GN-BSI. Methods: This was a retrospective, propensity-matched cohort study of critically ill patients with GN-BSI. The primary outcome was 15-day all-cause mortality. The secondary endpoints evaluated included 30-day mortality, ICU-free survival days, 60-day relapse, 30-day readmission, development of acute kidney injury (AKI), and new resistance. Results: A total of 209 propensity-matched patients were included for analysis: 136 received β-lactam monotherapy and 73 received adjunctive aminoglycoside. The primary outcome of 15-day all-cause mortality was not significantly different between groups (17% vs. 21%; p = 0.644). Additional secondary endpoints of 30-day mortality (22% vs. 25%), ICU-free survival (12.1 vs. 12.2 days), 60-day relapse (3.3% vs. 7.4%), and 30-day readmission (23% vs. 18%) did not yield significant differences. The proportion of AKI was higher in the adjunctive aminoglycoside group but was not found to be significantly different (26.5% vs. 37%). Conclusions: The use of adjunctive aminoglycosides for GN-BSI did not affect clinical outcomes in the critically ill. Full article

Background and Objectives: Sepsis is a leading cause of morbidity and mortality worldwide, yet data from Central and Eastern Europe remain scarce. Our study aims to address the scarcity of information regarding the characteristics and mortality rates of patients with sepsis by reporting recent data from one of the largest emergency centers in Romania over an 18-year period (2007–2024). Materials and Methods: A retrospective analysis was conducted on 12,089 adult patients diagnosed with sepsis at the University Emergency Hospital of Bucharest. Patients were identified using International Classification of Diseases (ICD-10) codes and free-text diagnosis. Demographic and clinical data were extracted, including comorbidities, interventions, and mortality outcomes. Associations between comorbidities and in-hospital mortality were assessed using odds ratios (ORs) and 95% confidence intervals (CIs). Results: The study population had a mean age of 68.7 years, with a slight predominance of males (50.9%). In-hospital mortality was 53.9%, and 30-day mortality reached 85.1%. The most common comorbidities were diabetes (27.2%), chronic kidney disease (14.0%), and cancer (12.9%). Pneumonia (OR = 2.08, 95% CI: 1.89–2.28), cirrhosis (OR = 1.69, 95% CI: 1.40–2.03), and chronic obstructive pulmonary disease (OR = 1.50, 95% CI: 1.27–1.77) were strong predictors of mortality, while diabetes was associated with a slightly lower risk (OR = 0.90, 95% CI: 0.83–0.97). Conclusions: Sepsis-related mortality in Romania is higher than reported in Western Europe and North America, resembling trends in resource-limited settings. Targeted early recognition, antimicrobial stewardship, and improved intensive care units (ICU) resource allocation are crucial for reducing mortality. Multicenter studies and microbiological analyses are needed to further understand sepsis outcomes in this region. Full article

Background/Objectives: The role of double-lumen endotracheal tube (DLT) versus single-lumen endotracheal tube (SLT) use during lung transplantation (LTx) and its effects on postoperative dysphagia have not yet been studied. It has been shown that new-onset oropharyngeal dysphagia (OPD) is common after various thoracic surgeries including lung transplantation and that OPD is associated with increased postoperative complications. Methods: A single-center, retrospective cohort study was performed using a data exploration tool in the electronic medical record. Data included demographic characteristics, medical history, postoperative dysphagia measured by Functional Oral Intake Scale (FOIS) via modified barium swallow study (MBSS) within 5 days of surgery, and other secondary outcomes. Results: In univariate analysis, participants who had a DLT (49 patients) had significantly higher FOIS scores (indicating better swallowing function) as compared to those with an SLT (21 patients) (p = 0.035). Lumen type remained significant in a multivariable model, with use of a DLT showing more than a 5-fold increase in the odds of a higher FOIS score after controlling for other factors (p = 0.004; cumulative OR (95% CI): 5.2 (1.7–15.9)). Participants who had a DLT had shorter hospital length of stay (LOS) (p = 0.017; single 18 days (IQR = 13), double 14 days (IQR 7)). Those who had a DLT experienced significantly greater ventilator-free time at postoperative day 30 compared to those who received an SLT (p = 0.018). ICU LOS was similar between those who received a DLT vs. SLT. Conclusions: Overall, DLT seems to confer reduced new-onset OPD after lung transplantation surgery when compared with SLT. The use of DLT instead of SLT for lung isolation for LTx may have the potential to reduce morbidity and mortality in this population. Full article

Introduction: Postreperfusion syndrome (PRS) is associated with complications following liver transplantation (LT). Mannitol may play a role in attenuating PRS as a free radical scavenger. This study aimed to evaluate the association between intraoperative mannitol administration and the incidence of PRS and postoperative acute kidney injury (AKI) in LT. Methods: A retrospective analysis of adult liver-only transplantation between August 2019 and January 2023 at the Mount Sinai Hospital was performed. Patients in the mannitol group received 25G of the drug intravenously prior to reperfusion. Any recipients with pre-existing renal diagnoses were excluded. Demographic, laboratory, intraoperative, and hospital course data were extracted from an institutional data warehouse. Multivariable logistic regressions were used to evaluate the association between mannitol administration and PRS, AKI, early allograft dysfunction, and postoperative cardiac complications. Negative binomial regression was used to evaluate the association with postoperative length of stay (LOS) and ICU LOS. Results: 495 LT cases were included. A total of 81 patients received mannitol before graft reperfusion, while 414 patients did not. The incidence of PRS in patients who received mannitol was 13% and 17% for those who did not receive mannitol (p = 0.53). Additionally, 79% of patients who received mannitol experienced AKI at 7 days, compared to 73% in those who did not receive mannitol (p = 0.48). In the multivariable regression models, mannitol administration was not associated with decreased incidence of PRS or postoperative AKI. It was, however, associated with increased postoperative cardiac complications (risk-adjusted odds ratio 2.70, 95% confidence interval 1.15–6.14, p = 0.02). Conclusions: Mannitol administration during LT was not an effective therapy for reducing PRS or postoperative AKI. Full article

(1) Background: Suspicious adnexal masses should be referred to gynecological oncology units. However, when surgery waiting lists are prolonged, these patients usually suffer from a delay in surgery. This could have a negative impact on their prognosis when the final diagnosis is ovarian cancer (OC). The primary aim of this study was to investigate the impact of surgery delay on the oncological results of early-stage ovarian cancer patients. (2) Methods: We retrospectively reviewed the records of early-stage OC patients who underwent surgery in the 1st Department of Obstetrics and Gynecology from 2012 to 2019. Time to surgery was defined as the time interval from the day of first examination to the day of surgery. (3) Results: A total of 72 patients were categorized into two groups, with a cut-off point of 5 weeks: 32 were treated ≤ 5 weeks (group A), and 40 > 5 weeks (group B). Concerning age, BMI or comorbidities, no differences were found between the two groups. Furthermore, no differences were presented in the post-operative complications rate, hospital stay, ICU admittance, or in disease-free (p = 0.48) and overall survival rates (p = 0.703). (4) Conclusions: Suspicious adnexal masses should undergo careful differential diagnosis to avoid delays in the “wait and see” period when the final diagnosis is positive for malignancy. However, the time to surgery for early-stage OC over 5 weeks seems to be relatively safe, with no impact on the mortality, morbidity, or recurrence rate. Full article

Delirium is a complex neuropsychiatric syndrome with multifactorial pathophysiology, encompassing a wide range of neuropsychiatric symptoms, and its management remains a significant challenge in critical care. Although often managed with antipsychotics, like haloperidol, current research has predominantly focused on dopamine dysregulation as the primary driver of delirium, overlooking its broader neuroanatomical and neurochemical underpinnings. This has led to a majority of research focusing on haloperidol as a treatment for intensive care unit (ICU) delirium. Our review critically evaluates the role of haloperidol in ICU delirium management, particularly in light of recent large-scale randomized controlled trials (RCTs) that have primarily focused on delirium-free days and mortality as the primary endpoints. These studies highlight an limited understanding of the true nature of delirium treatment, which requires a broader, neuropsychiatric approach. We argue that future research should shift focus to neuropsychiatric symptoms such as agitation and psychosis and explore the clinical and functional benefits of reducing these distressing symptoms. Additionally, the stratification of delirium by subtypes and etiology, the enhancement of detection tools, and the adoption of multi-intervention and multi-disciplinary care approaches should be prioritized. Despite the methodological flaws in these studies, the findings support the safety of haloperidol in the ICU setting, with minimal risk of adverse events, particularly cardiac and neuropsychiatric. Moving forward, delirium research must integrate modern neuroscientific understanding and adopt more multi-disciplinary input and nuanced, patient-centered approaches to truly advance clinical care and outcomes. Full article

Background: Treatment with veno-venous extracorporeal membrane oxygenation (VV ECMO) has become a frequently considered rescue therapy in patients with severe acute respiratory distress syndrome (ARDS). Hemolysis is a common complication in patients treated with ECMO. Currently, it is unclear whether increased ECMO blood flow (Q̇_EC) contributes to mortality and might be associated with increased hemolysis. Methods: A total of 441 patients with ARDS and VV ECMO, treated in a tertiary ARDS center, were included. The Q̇_EC value for a significant increase in ICU mortality was determined by binary recursive partitioning. Linear regression analysis was performed to analyze a correlation between mean Q̇_EC and mean plasma concentrations of cell-free hemoglobin (CFH). Results: A Q̇_EC of 4 L/min divided the cohort into two groups with significantly different ICU mortality (Q̇_EC ≤ 4 L/min: 39.3% (n = 300) versus Q̇_EC > 4 L/min: 71.6% (n = 141), p < 0.001). Patients with Q̇_EC > 4 L/min had a higher 28-day mortality. Furthermore, a higher mean Q̇_EC was associated with increased CFH and decreased haptoglobin plasma concentrations. Conclusion: In patients with ARDS and VV ECMO, a mean Q̇_EC > 4 L/min is associated with increased mortality, increased CFH and decreased haptoglobin plasma concentrations. Whether increased hemolysis determines the poorer outcome associated with higher Q̇_EC should be the subject of future research. Full article

Objective: To investigate the effects of prophylactic use of stimulant laxatives and/or docusate on the clinical outcomes in critically ill patients who required mechanical ventilation (MV). Methods: A single-center, retrospective, cohort study was conducted. Patients who received MV in the first 24 h after intensive care unit (ICU) admission were enrolled and divided into four groups: non-laxative, stimulant laxatives, docusate, and stimulant laxatives–docusate combination. The primary outcome was in-hospital mortality. The major secondary outcomes included ICU-free days and ventilator-free days at 28 days; the other outcomes were ventilation-associated pneumonia (VAP), enterobacterial infection, diarrhea, and electrolyte disturbances. Inverse probability treatment weighting (IPTW) was used to adjust for confounders. Results: A total of 2129 patients were included in this study, 263 of whom received stimulant laxatives, 253 received docusate, 368 received a combination, and 1245 did not receive any laxative. The prophylactic use of docusate was associated with a decreased risk of in-hospital mortality (OR: 0.59, 95% CI 0.42 to 0.83, p = 0.002) and VAP (OR: 0.62, 95% CI 0.47 to 0.81, p = 0.001). It was also associated with an increase in ICU-free days at 28 days (β: 0.89, 95% CI 0.83 to 0.95, p < 0.001). Importantly, laxatives prophylaxis was not associated with increased risks of diarrhea, electrolyte disturbances, and enterobacterial infections. Conclusions: Prophylactic use of docusate may improve certain prognoses and does not demonstrate any adverse events. However, further research is necessary to determine the optimal regimen and dosage of prophylactic laxatives in this specific population. Full article