Search Results (491)

Background/Objectives: Low-dose corticosteroids have gained popularity in the treatment of acute respiratory distress syndrome (ARDS); however, the efficacy of high-dose corticosteroids as pulse steroid therapy remains controversial. This study aimed to evaluate the efficacy of pulse steroid therapy in patients with severe ARDS requiring venovenous (V-V) extracorporeal membrane oxygenation (ECMO), where enhanced anti-inflammatory effects may be beneficial. Methods: Using data from the J-CARVE registry, which included patients with severe ARDS managed with V-V ECMO across 24 Japanese hospitals between January 2012 and December 2022, we identified 373 patients treated with corticosteroids. The patients were divided into two groups: pulse steroid therapy and non-pulse steroid therapy. Propensity score matching was performed, and all-cause hospital mortality and ECMO-free days within 28 days were compared between groups. Pulse steroid therapy was defined as methylprednisolone at a dose of 1000 mg/day. Results: After matching, 48 patients were included in each group. The all-cause hospital mortality rates were 41.7% (20/48) in the pulse steroid group and 47.9% (23/48) in the non-pulse steroid group, with no significant difference (odds ratio, 1.28; 95% confidence interval: 0.53–3.12, p = 0.68). The median ECMO-free days were 9.5 (interquartile range [IQR]: 0–17.3) in the pulse steroid group and 3 (IQR: 0–17) in the non-pulse steroid group, showing no significant difference (p = 0.69). Conclusions: Pulse steroid therapy did not improve all-cause hospital mortality or ECMO-free days in patients with severe ARDS who required V-V ECMO. Full article

Extracorporeal cardiopulmonary resuscitation (ECPR) is an established intervention for select patients experiencing refractory cardiac arrest. Among modifiable predictors of survival and neurologic recovery during ECPR implementation, timely restoration of circulation remains critical in the setting of refractory cardiac arrest (CA). The in-hospital cardiac arrest (IHCA) setting is particularly amenable to reducing the low-flow interval through structured system-based design and implementation. Despite increasing utilization of ECPR, the literature remains limited regarding operational standards, quality improvement metrics, and performance evaluation. Establishing operational standards and performance metrics is a critical first step toward systematically reducing low-flow interval duration. In support of this aim, we conducted a comprehensive literature review structured around the Extracorporeal Life Support Organization (ELSO) framework for ECPR implementation. At each step, we synthesized evidence-based best practices and identified operational factors that directly influence time-to-circulation. Our goal is to provide a stepwise evaluation of ECPR initiation to consolidate existing best practices and highlight process components with potential for further study and standardization. We further evaluated the literature surrounding key technical components of ECPR, including cannula selection, placement technique, and positioning. Ongoing research is needed to refine and standardize each stage of the ECPR workflow. Developing optimized, protocol-driven approaches to ensure rapid, high-quality deployment will be essential for improving outcomes with this lifesaving but resource-intensive therapy. 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/Objectives: The objective of this review is to document the modalities to enhance the neuromuscular effects of botulinum toxin (BoNT) injection in spastic patients with multiple sclerosis (MS). Methods: We conducted a literature review focusing on studies involving BoNT administration for MS-related spasticity and the use of adjunctive therapies aimed at reducing dosage and increasing injection intervals. Results: The findings revealed a limited number of studies specific to MS patients, addressing only a few adjunct techniques, including electrical stimulation, vibration therapy, physical exercise, and extracorporeal shock wave therapy. Conclusions: These preliminary findings highlight the need for further research into integrative therapeutic strategies tailored specifically to the MS population. Full article

Background/Objectives: Knee osteoarthritis is one of the most significant diseases globally and in Portugal. Despite the availability of international guidelines, there is a lack of tailored, evidence-based recommendations specifically for Portuguese physiotherapists to manage their knee osteoarthritis patients with non-pharmacological and non-surgical interventions. This study aimed to develop a clinical practice guideline that integrates the latest international evidence with local clinical practice data to enhance patient outcomes. Methods: To achieve the objective, a comprehensive search was conducted in November 2024 across major health-related databases, to identify robust and recent evidence regarding the efficacy of non-pharmacological and non-surgical interventions, as well as their usage in the national context. Two key sources were identified: An umbrella and a mixed-methods study. Data from both sources were independently reviewed and integrated through a comparative analysis to identify interventions with robust scientific support and high local acceptability. Recommendations were then formulated and categorized into gold (strong), silver (moderate), and bronze (weak) levels based on evidence quality and clinical relevance. A decision-making flowchart was developed to support guideline implementation and clinical usage. Results: The integrated analysis identified three gold-level interventions, namely Nutrition/Weight Loss, Resistance Exercise, and Self-care/Education. Five silver-level recommendations were Aerobic Exercise, Balneology/Spa, Extracorporeal Shockwave Therapy, Electrical Stimulation, and Manual Therapy. Similarly, five bronze-level recommendations comprised Kinesio Taping, Stretching, Ultrasound Therapy, Thermal Agents, and Walking Aids. Conclusions: This clinical practice guideline provides a context-specific, evidence-based framework for Portuguese physiotherapists managing knee osteoarthritis. By bridging international evidence with local clinical practice, the guideline aims to facilitate optimal patient care and inform future research and guideline updates. Full article

Background: Sepsis and septic shock are major contributors to global morbidity and mortality. The “cytokine storm,” a hyper-inflammatory response, plays a central role in sepsis pathophysiology, leading to multi-organ failure. Extracorporeal cytokine adsorption therapies, such as CytoSorb, Toraymyxin, Oxiris, HA330/380, and Seraph 100 Microbind, aim to mitigate the inflammatory response by removing circulating cytokines and other mediators. Methods: A comprehensive search of Scopus and PubMed was conducted for studies published from January 2020 to May 2025. The search terms included “sepsis,” “septic shock,” and “extracorporeal cytokine adsorption.” Relevant studies, including clinical trials and meta-analyses, were included to assess the efficacy and safety of these therapies. Results: Extracorporeal cytokine adsorption has shown promising results in reducing cytokine levels, improving organ function, and decreasing vasopressor requirements. However, evidence regarding mortality reduction remains inconsistent. Studies have demonstrated benefits in sepsis, ARDS, and cardiogenic shock, improving organ recovery and inflammatory markers. Conclusions: Extracorporeal cytokine adsorption is a potential adjunctive therapy in sepsis management, offering improvements in organ function and inflammatory control. While the mortality benefit remains uncertain, ongoing research and large-scale clinical trials are essential to define its clinical role and optimize its application. Full article

This review highlights recent insights into the pathophysiology and therapeutic strategies for improving biocompatibility in hemodialysis. Hemodialysis activates the innate immune system, particularly the complement cascade and neutrophils, leading to acute microinflammation. Interleukin-8 (IL-8), which increases during dialysis, promotes neutrophil chemotaxis and neutrophil extracellular trap (NET) formation, triggering myeloperoxidase (MPO) release and oxidative stress. Neutrophil accumulation in atherosclerotic plaques exacerbates vascular inflammation through IL-6 upregulation. Elevated levels of IL-8, MPO, and NET-related biomarkers are associated with increased all-cause and cardiovascular mortality in dialysis patients. Strategies to mitigate these effects include the use of advanced membrane materials (e.g., AN69, vitamin E-coated, polymethyl methacrylate), novel dialysis modalities (e.g., high-volume online hemodiafiltration, cool dialysate, hydrogen-enriched dialysate), and citrate-based anticoagulation. These approaches aim to suppress complement activation, reduce oxidative stress, and limit neutrophil-induced damage. Enhancing biocompatibility is crucial for reducing cardiovascular complications and improving outcomes in dialysis patients. Suppressing the innate immune response during dialysis may become a future cornerstone in extracorporeal blood purification therapy. Full article

The case-fatality rate of severe leptospirosis can exceed 50%. This retrospective cohort study examined 111 individuals with laboratory-confirmed leptospirosis admitted to Cairns Hospital, a referral hospital in tropical Australia, between January 2015 and June 2024. We examined the patients’ demographic, clinical, laboratory and imaging findings at presentation and then correlated them with the patients’ subsequent clinical course. Severe disease was defined as the presence of pulmonary haemorrhage or a requirement for intensive care unit (ICU) admission. The patients’ median (interquartile range) age was 38 (24–55) years; 85/111 (77%) were transferred from another health facility. Only 13/111 (12%) had any comorbidities. There were 63/111 (57%) with severe disease, including 56/111 (50%) requiring ICU admission. Overall, 56/111 (50%) required vasopressor support, 18/111 (16%) needed renal replacement therapy, 14/111 (13%) required mechanical ventilation and 2/111 (2%) needed extracorporeal membrane oxygenation. Older age—but not comorbidity—was associated with the presence of severe disease. Hypotension, respiratory involvement, renal involvement and myocardial injury—but not liver involvement—frequently heralded a requirement for ICU care. Every patient in the cohort survived to hospital discharge. Leptospirosis can cause multi-organ failure in otherwise well young people in tropical Australia; however, patient outcomes are usually excellent in the country’s well-resourced health system. Full article

Heart failure is a heterogeneous disorder that can lead to cardiogenic shock. Mechanical circulatory support (MCS) devices can replace the cardiac function in an attempt to bridge patients to transplant or they can serve as destination therapy to improve overall patient functionality and in turn quality of life. Currently utilized MCS devices include devices such as Left Ventricular Assist Devices (LVADs), Biventricular Assist Devices (BiVADs), Impella, Total Artificial Hearts (TAHs), and extracorporeal membrane oxygenation (ECMO). This literature review examines a range of studies, case reports, and meta-analyses to present current approaches to mechanical circulatory support (MCS), along with the challenges and limitations of existing devices, common complications, and overall survival and long-term outcomes following MCS therapy. Full article

Background/Objectives: Persistent pulmonary hypertension of the newborn (PPHN) is characterized by increased pulmonary vascular resistance, resulting in severe hypoxemia. This study determined the factors associated with increased risk of mortality and survival rate in infants with PPHN. Methods: This retrospective study was conducted between 2010 and 2023. The risk factors for mortality were assessed by Cox’s proportional hazard models, and the Kaplan–Meier survival curve was used to analyze the survival rates. Results: This study included 233 neonates with PPHN. Gestational age (GA) less than 28 weeks (adjusted hazard ratio [AHR] = 5.46, 95% confidence interval [CI]: 2.25–13.24, p < 0.001), Small for gestational age (SGA) (AHR = 2.93, 95% confidence interval [CI]: 1.24–6.92, p = 0.026), acute kidney injury (AKI) (AHR = 2.48, 95% CI: 1.27–4.84, p = 0.01), pneumothorax (AHR = 3.03, 95% confidence interval [CI]: 1.48–6.21, p = 0.003), vasoactive-inotropic score (VIS) at 24 h of age (AHR = 1.0026, 95% confidence interval [CI]: 1.0004–1.005, p = 0.026), and score for neonatal acute physiology II (SNAP-II) ≥ 43 (AHR = 4.03, 95% CI: 1.66–9.77, p = 0.005) were associated with an increased risk of mortality. The overall survival rate was 82.4%; it rose from 63.8% to 87.1% after inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO) were introduced (p < 0.001). The cumulative survival rates at the end of the 30 days were 62.1% (95% CI: 49.0–78.7) in the Pre-iNO era and 87.5% (95% CI: 82.7–92.6) in the Post-iNO/ECMO era, respectively (p < 0.001). Conclusions: GA less than 28 weeks, SGA, AKI, pneumothorax, high VIS and SNAP-II scores were associated with mortality in infants with PPHN. The improvement in the survival rate was related to the provision of advanced care, including iNO and ECMO therapy. Full article

Background and Clinical Significance: Fulminant pulmonary embolism (PE) leading to an out-of-hospital cardiac arrest (OHCA) is associated with a high mortality rate and cardiopulmonary resuscitation (CPR) frequently failing to achieve return of spontaneous circulation (ROSC). Extracorporeal CPR (eCPR) has emerged as a potential life-saving intervention. Case Presentation: A 66-year-old woman suffered an OHCA due to massive PE, presenting with pulseless electrical activity (PEA). After 90 min of pre- and in-hospital CPR without sustained ROSC, venoarterial extracorporeal membrane oxygenation (va-ECMO) was initiated as eCPR upon arrival at the hospital. Even after implantation of the va-ECMO, there was initially a pronounced acidosis (pH 6.9) with a high elevated lactate level (>30 mmol/L); these factors, together with the prolonged low-flow period, indicated a poor prognosis. Further diagnostic tests revealed intracranial hemorrhage (subdural hematoma), and systemic lysis was not possible. With persistent right heart failure, surgical thrombectomy was performed during hospitalization. Intensive multidisciplinary management finally led to successful therapy and weaning from mechanical ventilation, as well as to complete neurological recovery (CPC-Score 1-2). Conclusions: This case illustrates that eCPR can facilitate survival with good favorable neurological outcomes despite initially poor prognostic predictors. It underscores the importance of refining patient selection criteria and optimizing management strategies for eCPR in refractory cardiac arrest secondary to PE. Full article

Extracorporeal membrane oxygenation (ECMO) is a crucial life support therapy for patients with severe cardiac and respiratory failure. However, the complications associated with venoarterial ECMO (VA-ECMO), including thrombus formation, bleeding, and hemolysis, remain significant challenges that impact patient outcomes and healthcare costs. These complications primarily arise from blood–material interactions within the ECMO circuit, necessitating the development of biocompatible materials to optimize hemocompatibility. This review provides an updated overview of the latest advancements in VA-ECMO materials, focusing on cannula, oxygenators, and centrifugal pumps. Various surface modifications, such as heparin coatings, nitric oxide-releasing polymers, phosphorylcholine (PC)-based coatings, and emerging omniphobic surfaces, have been explored to mitigate thrombosis and bleeding risks. Additionally, novel oxygenator membrane technologies, including zwitterionic polymers and endothelial-mimicking coatings, offer promising strategies to enhance biocompatibility and reduce inflammatory responses. In centrifugal pumps, magnetic levitation systems and hybrid polymer-composite impellers have been introduced to minimize shear stress and thrombogenicity. Despite these advancements, no single material has fully addressed all complications, and further research is needed to refine surface engineering strategies. This review highlights the current progress in ECMO biomaterials and discusses future directions in developing more effective and durable solutions to improve patient safety and clinical outcomes. Full article

Sepsis is a life-threatening syndrome characterized by a dysregulated immune response to infection, frequently leading to multiorgan failure and high mortality. Inflammasomes—cytosolic multiprotein complexes of the innate immune system—serve as critical platforms for sensing pathogen- and damage-associated molecular patterns (PAMPs and DAMPs). Key sensors such as NLRP3, AIM2, and IFI16 initiate caspase-1 activation, IL-1β and IL-18 maturation, and gasdermin D–mediated pyroptosis. In sepsis, excessive inflammasome activation drives oxidative stress, endothelial dysfunction, immunothrombosis, and immune exhaustion. This maladaptive cascade is further aggravated by the release of DAMPs and procoagulant factors, compromising vascular integrity and immune homeostasis. Prolonged activation contributes to immunoparalysis, lymphopenia, and increased susceptibility to secondary infections. Inflammasome signaling also intersects with necroptosis and ferroptosis, amplifying systemic inflammation and tissue injury. Additionally, various pathogens exploit immune evasion strategies to modulate inflammasome responses and enhance virulence. Therapeutic interventions under investigation include selective NLRP3 inhibitors, IL-1 blockers, gasdermin D antagonists, and extracorporeal cytokine hemoadsorption. Emerging approaches emphasize biomarker-guided immunomodulation to achieve personalized therapy. While preclinical studies have shown promising results, clinical translation remains limited. Targeting inflammasomes may offer a path toward precision immunotherapy in sepsis, with potential to reduce organ dysfunction and improve survival. Full article

This review provides an in-depth analysis of argatroban as an alternative anticoagulant in cardiac surgery, with a focus on its use in patients with heparin-induced thrombocytopenia (HIT). We examine argatroban’s pharmacokinetics and dosing regimens and the challenges associated with cosnventional monitoring methods—such as activated clotting time (ACT) and activated partial thromboplastin time (aPTT)—to evaluate its safety and effectiveness in high-risk surgical settings. Drawing on data from multiple case reports and series, our review highlights both the potential benefits and limitations of argatroban, including complications such as clot formation in extracorporeal circulation systems and prolonged postoperative coagulopathy. In addition to the literature review, we present a detailed clinical case of urgent HeartMate 3 left ventricular assist device implantation in a patient with advanced heart failure and active HIT. In this case, despite targeting an ACT above 400 s, intraoperative complications such as clot formation in the heart–lung machine and difficulty achieving hemostasis highlight the need for improved monitoring and dosing protocols. Our findings call for refined anticoagulation strategies and advanced monitoring techniques to optimize argatroban use in cardiac surgery, offering valuable insights for clinicians managing complex scenarios where conventional heparin therapy is contraindicated. Full article

Radial extracorporeal shockwave therapy (rESWT) is used in the rehabilitation of patients with shoulder periarthritis (SP) to promote tendon regeneration. This quasi-experimental non-randomized comparative study included 36 cases of SP, divided into two groups, and aimed to comparatively investigate the analgesic and functional effects of two different rESWT protocols. In Group One, the protocol involved an energy level of 210 J/session, a frequency of 10 Hz, and 2500 impulses per session. In Group Two, the protocol used an energy level of 190 J/session, a frequency of 10–15 Hz, and 2000 impulses per session. Treatments were administered over three sessions in Group One and five sessions in Group Two, with one-week intervals between sessions. Both rESWT protocols were combined with a physical therapy program consisting of ten daily sessions of analgesic physiotherapy and kinesiotherapy. Before and after the rehabilitation program, patients were assessed for pain intensity using the visual analog scale (VAS) and shoulder function using range of motion (ROM) measurements (via goniometry) and the Shoulder Pain and Disability Index (SPADI). Significantly better outcomes were observed in Group One (p < 0.001), particularly in terms of pain reduction and improvements in shoulder functionality, especially external rotation. These results support the effectiveness of the rESWT protocol used in Group One, which combined lower energy and frequency levels with a higher number of impulses over fewer sessions. Full article