Search Results (9,948)

Background and Objectives: Necrotizing fasciitis (NF) is characterized by rapid and aggressive infection of the subcutaneous tissue and fascia, and a high risk of death in case of delay in diagnosis and treatment. Materials and Methods: This 7-year retrospective study (May 2017–May 2024) evaluated 38 patients with upper- and lower-limb NF admitted to the surgery clinic at the County Emergency Hospital in Craiova, Romania. Results: 21.8% of the confirmed NF cases were monomicrobial; Gram-positive strains were predominant, but Gram-negative strains were also involved. The mortality rate was 28.9%; acute kidney injury appears as the only independent risk factor associated with mortality, although in univariate analysis, septic shock and high NLR and INR values were also factors associated with mortality. An increased resistance rate to antibiotics was recorded, with a 32.7% MDR rate; moderate to high resistance to piperacillin + tazobactam, most cephalosporins, most carbapenems (for Gram-negative strains), and quinolones was noted. Conclusions: Multidisciplinary management, comprising intensive medical support, prompt targeted antibiotic therapy, and immediate surgical intervention, was critical for achieving favorable patient outcomes. Increasing antibiotic resistance may alter the prognosis in patients with NF. Full article

Background: The impact of healthcare-related time intervals on outcomes in bone sarcomas remains controversial. We evaluated the impact of clinically defined post-referral, in-hospital care intervals on overall survival (OS) and their variation over two decades, in patients treated at a tertiary sarcoma centre. Methods: We retrospectively analysed 506 patients with localized osteosarcoma (n = 319) or Ewing’s sarcoma (n = 187) treated between 2002 and 2021. We defined three in-hospital time intervals: time to diagnosis (TToD; first specialist evaluation to diagnostic biopsy), time to treatment (TToT; biopsy to treatment initiation), and total post-referral patient journey time (PJT; first specialist evaluation to treatment). Multivariable Cox models adjusted for age, sex, tumour location, and surgical factors evaluated associations with OS. Results: Median PJT was longer in Ewing’s sarcoma than in osteosarcoma (17 vs. 14 days; p < 0.001), mainly because of a longer TToT. Over time, median PJT increased from 12 to 19 days (p < 0.001), driven by longer TToT, while TToD remained stable. Neither PJT nor TToD was associated with OS. Although longer TToT was associated with lower mortality risk, this was not confirmed after stratification by diagnostic period. Worse OS was independently associated with amputation, upper-extremity tumours, and intralesional margins. Conclusions: Within the specialized tertiary centre setting, longer in-hospital care timelines were not associated with poorer overall survival despite increasing over time, a finding that may reflect the growing complexity of multidisciplinary management exclusively during the post-referral phase. Full article

Background/Objectives: Hospital-at-home (HaH) programs have emerged as an alternative model to brick-and-mortar (BaM) hospital management of acute conditions such as heart failure, pneumonia, pyelonephritis, and chronic obstructive pulmonary disease exacerbation among the others. However, the clinical management of acute pancreatitis in the HaH setting has never been described in the literature. The primary objective of this study was to describe the demographic and clinical characteristics of patients with acute pancreatitis managed in a Mayo Clinic Advanced Care at home (ACH) program. The secondary objective was to describe feasibility and short-term clinical outcomes. Methods: This multistate, multicenter, retrospective descriptive study included 40 unique patients with acute pancreatitis managed at ACH between 13 October 2020 and 1 June 2024. Repeat admissions were excluded from the primary analysis. Results: The most common etiologies were idiopathic (42.5%), gallstone-related (22.5%), and alcohol-related (12.5%). Peripancreatic fluid collections occurred in 17.5%, necrotizing pancreatitis in 10.0%, pleural effusion in 12.5%, and infected pancreatitis in 7.5%. Intravenous antiemetics were administered to 22.5%, intravenous fluids to 62.5%, and intravenous opioids to 7.5%. Median total hospital length of stay was 5.0 days (IQR, 3.0–8.25), including a median of 3.0 days (IQR, 2.0–4.0) in ACH. Four patients (10.0%; exact 95% CI, 2.8–23.7%) were transferred from ACH to BaM care. Seven-day and 30-day readmission rates were 10% (95% CI: 2.8%, 23.7%) and 5% (95%CI: 0.6%, 16.9%), respectively. The 30-day emergency department visit was 0%. Although 30-day mortality was 2.5% (95% CI: 0.0%, 13.2%), in-program mortality was 0%. Conclusions: Among a highly selected group of clinically stable patients meeting the program’s eligibility criteria, management of acute pancreatitis in ACH was feasible and was associated with low observed rates of unplanned escalations and short-term adverse outcomes. Full article

Background and Objectives: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a major cause of stroke, heart failure, and death. Evidence on AF in Latin American and Andean tertiary-care settings remains limited. The objective was to describe the demographic and clinical profile, documented thromboembolic and bleeding risk, in-hospital management, and outcomes of adults with AF treated at a tertiary hospital located at 2850 m above sea level. Materials and Methods: We retrospectively reviewed unique adult patient records from January 2021 through December 2023 identified by ICD-10 code I48 and explicit clinician documentation of AF. Independent electrocardiographic adjudication was not performed. Demographics, comorbidities, chart-recorded AF category, risk scores, echocardiographic findings, in-hospital treatments, and outcomes were summarized descriptively. Results: Among 238 patients, mean age was 77.9 ± 13.3 years, 55.0% were male, and 97.1% were recorded as mestizo. Hypertension (58.0%) and heart failure (22.7%) were the most frequent comorbidities. CHA₂DS₂-VASc and HAS-BLED scores were documented for 199 patients (83.6%); their respective means were 3.3 ± 1.4 and 2.3 ± 1.1. Any anticoagulant was administered during hospitalization to 195 patients (81.9%), but previous and discharge therapy, indications, contraindications, dosing, and temporary interruptions were not consistently available. Five patients died in hospital (2.1%). Secondary exploratory comparisons by survival status were hypothesis-generating, and none remained significant after false-discovery-rate correction. Conclusions: This cohort describes an older, comorbid population treated at a hospital situated at high altitude. The study does not establish an altitude-related AF phenotype, the appropriateness of chronic anticoagulation, or prognostic factors for mortality. Prospective multicentre studies with adjudicated AF, individual altitude exposure, oxygenation and haematologic measures, and longitudinal treatment data are warranted. Full article

Background: Heart failure (HF) and substance use disorder (SUD) are independently associated with morbidity and mortality. How SUD influences HF outcomes has not been described longitudinally in a national cohort. Methods: Retrospective study of adult patients with a primary diagnosis of HF enrolled in the Optum Clinformatics Data Mart (2010–2020), stratified by history of SUD (any time; prior or current use; substance type) compared to no SUD history. Logistic regression analyses were conducted in propensity score 1:1 matched (PSM) cohorts. Outcomes were 30-day, 180-day, and 1-year hospital readmission and mortality. Results: Study included 194,020 patients, 11,611 (6.0%) with documented SUD at any time. Prior to matching, patients with SUD were younger, more often male, and with fewer comorbidities compared to no history of SUD. In the PSM analysis, SUD was associated with greater 30-day [21.1% vs. 15.0%, p < 0.001], 180-day [54.7% vs. 41.9%, p < 0.001], and 1-year [67.9% vs. 55.4%, p < 0.001] hospital readmission. Thirty-day [1.6% vs. 1.0%, p < 0.001], 180-day [5.9% vs. 4.2%, p < 0.001] and 1-year [15.4% vs. 12.5%, p < 0.001] mortality was also higher in patients with SUD. In multivariable analyses, SUD remained independently associated with higher odds of poorer outcomes. Risk was retained when SUD was restricted to use prior to or at time of index hospitalization. Methamphetamine and other stimulant use were associated with an increased risk of hospital readmission across all time points, and an increased risk of mortality at one year. Conclusions: In patients with HF, SUD was independently associated with an increased risk of hospital readmissions and mortality. Full article

The treatment of infective endocarditis (IE) in patients who inject drugs (PWID) is complex and challenging. These patients face stigma in the healthcare system, as well as higher mortality, longer length of hospital stay, higher rates of recurrent infections, and lower likelihood of antibiotic completion. Standard treatment for IE involves several weeks of antibiotics. For PWID, these prolonged courses often mean intravenous antibiotics administered in the inpatient setting for at least 4 to 6 weeks, which increases both healthcare costs and the risk of patient-directed discharge against medical advice. Effective treatment of IE in PWID involves a combination of addiction management and appropriate antibiotic therapy. To promote rational use of healthcare resources and optimize antibiotic stewardship, novel approaches to antibiotic therapy must be utilized. This review discusses evidence supporting treatment strategies outside of the inpatient hospital setting, including outpatient parenteral antibiotic therapy (OPAT), long-acting lipoglycopeptides, and oral antibiotic therapy for the treatment of endocarditis. Optimal treatment of IE in PWID involves support from a multidisciplinary healthcare team, management of substance use disorder, and effective antibiotic therapy. Full article

Background and Objectives: Acute chest syndrome (ACS) is the leading cause of sickle cell disease (SCD)-related mortality (~25% of deaths). A subset of patients develops severe respiratory compromise requiring intensive care unit (ICU) admission or mechanical ventilation (MV), a high-risk group with widely variable reported mortality. This review aimed to determine the mortality rates, ICU/hospital length of stay, and reported complications among adult SCD patients with ACS admitted to the ICU or placed on MV. Materials and Methods: This PRISMA 2020-compliant systematic review was prospectively registered on PROSPERO (CRD420261295111). Cochrane Library, PubMed, Web of Science, ScienceDirect, EBSCOhost, and Scopus were searched without date restriction. Due to substantial clinical and methodological heterogeneity, the pre-specified meta-analysis was replaced by a narrative synthesis. Methodological quality was assessed using the Newcastle–Ottawa Scale. Results: Eight studies were included (one multicenter prospective cohort, two national database studies, three single-center cohorts, and one before–after antimicrobial stewardship study). In-hospital mortality ranged from 0.95% to 3.8%; overall mortality including follow-up reached 12.9% in a dedicated ICU cohort, a distinct endpoint from in-hospital death. Mechanical ventilation was the strongest indicator of mortality, with odds ratios of 67.53 (MV < 96 h) and 8.73 (MV ≥ 96 h) in the largest national cohort. Tricuspid regurgitant jet velocity ≥3 m/second was associated with cor pulmonale, invasive ventilation, and all immediate hospital deaths in one severe cohort. Documented bacterial infection was uncommon (10–20% of episodes), despite frequent antibiotic use, and procalcitonin-guided discontinuation safely reduced antibiotic exposure. All eight included studies were rated high quality on the Newcastle–Ottawa Scale (score ≥ 7/9). Conclusions: Mechanical ventilation, pulmonary hypertension/cor pulmonale, and comorbidity burden are the most consistent markers of poor outcome in ACS. The findings support early recognition, severity-based respiratory support, and antimicrobial stewardship, but should be interpreted cautiously given the substitution of narrative synthesis for meta-analysis, heterogeneous populations, and the geographic concentration of the included studies. Full article

Background: Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection in mechanically ventilated preterm infants and is increasingly caused by multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative organisms. Tigecycline, a glycylcycline with broad activity against many such pathogens, is not approved below 18 years of age and carries a boxed warning for excess mortality that is most pronounced in hospital-acquired and ventilator-associated pneumonia. Its role, if any, in preterm infants with VAP is undefined. Objectives: To systematically identify and appraise all human evidence on the efficacy (clinical cure, microbiological eradication, survival) and safety (adverse events, mortality) of tigecycline used to treat VAP or nosocomial pneumonia during mechanical ventilation in preterm infants and neonates. Methods: A PRISMA 2020 structured search of PubMed/MEDLINE, Cochrane CENTRAL, Scopus, trial registries, regulatory documents, Google Scholar and reference lists was designed without language or date restrictions. Eligible reports described tigecycline treatment of pneumonia/VAP in neonates or young infants; pediatric case series and syntheses were retained as contextual evidence. Because only case reports and small non-comparative series were anticipated, a narrative synthesis was pre-specified; JBI tools and GRADE were planned for appraisal and certainty. Results: No randomized controlled trial, controlled observational study, or study dedicated to tigecycline for VAP in preterm infants was identified. Direct evidence meeting the full eligibility criteria (preterm neonate, VAP specifically, separately extractable outcomes) was limited to two case reports of extremely preterm neonates with VAP successfully weaned after tigecycline-based salvage combination therapy. Six further neonatal/young-infant reports initially considered were, on full-text re-review, reclassified as contextual (not index) evidence because they described non-VAP infections (sepsis, or CNS infections such as ventriculitis/meningitis), non-preterm ages, or mixed-infection series without separable VAP data. Reported outcomes were generally favorable in published cases but are subject to severe selection and publication bias; thrombocytopenia, hypofibrinogenemia and hepatic enzyme elevation were the principal adverse signals, against a class-level mortality signal concentrated in VAP. Quantitative pooling was not appropriate. The overall certainty of evidence was very low. Conclusions: There is no direct, credible efficacy or safety evidence supporting tigecycline for VAP in preterm infants. Available data neither establish benefit nor exclude harm. Based on this very-low-certainty evidence and on regulatory/class-level safety data rather than on demonstrated efficacy, tigecycline warrants consideration only as a last-resort, combination salvage option for culture-confirmed pan- or extensively drug-resistant pathogens when no safer alternative exists, with intensive monitoring and, ideally, within a registry or trial. Adequately designed neonatal pharmacokinetic and comparative safety studies are urgently needed. Registration: PROSPERO CRD420261450972 (registered 14 July 2026). Full article

Background: PADS combines two neural networks predicting ICU mortality and discharge within 48 h, placing critically ill patients into one of four clinically meaningful states. Developed on MIMIC-IV alone, it left open whether it generalizes to other ICUs, whether its models transfer across hospitals, and whether its predictions can be explained at the bedside. Methods: We evaluated PADS on four ICU databases from different hospitals and countries (MIMIC-IV, AmsterdamUMCdb, eICU-CRD, and HiRID), using the same routinely collected variables. Mortality is scored on the final 48-h window (terminal-window, not early-warning, discrimination). For each external database, we compared the MIMIC model used as-is, retrained from scratch, and retrained from the MIMIC weights, and added an explainability layer. Results: For mortality, reusing and retraining the MIMIC model gave the highest discrimination on every database (AUROC 0.955–0.986; terminal-window (near-outcome) discrimination) and stabilized training; used as-is, it ranged from chance (Amsterdam) to good (eICU, HiRID). For discharge, training fresh on local data matched or beat reusing MIMIC on every external database, consistent with discharge timing depending on local organization rather than physiology. The explainability layer produced clinically coherent, cross-checked explanations. Conclusions: Transportability was task-dependent: mortality transferred between hospitals, discharge did not. PADS demonstrated promising external transportability across heterogeneous ICU databases, particularly after local adaptation. Reusing and adapting the MIMIC-IV mortality model across hospitals improves accuracy. This approach also stabilizes training, providing a basis for potential federated deployment, whereas discharge is better trained locally. The mortality results reported here are terminal-window discrimination and do not support use of the framework as an early-warning model. A transparent explainability layer provides an interpretable representation of model predictions, addressing a key barrier to clinical adoption. Full article

Background: Community-acquired pneumonia (CAP) remains a leading cause of morbidity and mortality worldwide and a major driver of hospital admissions. Older adults are disproportionately affected, owing to immune senescence and a higher prevalence of chronic comorbidities. This study examined two decades (2000–2019) of adult hospital admissions for CAP in mainland Portugal. Methods: We analyzed adult CAP hospitalizations between 2000 and 2019 from the Portuguese Mainland Hospital Diagnosis National Database. We assessed all hospitalizations attributable to CAP over the 20 years, stratified by age group, and examined seasonal variation. Trends in hospital length of stay and in-hospital case fatality were evaluated. Results: Between 2000 and 2019, the adult CAP hospitalization rate in Portugal rose from 3.61 to 5.28 per 1000 persons-year. This was fostered by patients older than 80 years, who grew from 30.4% to 53.1% of CAP admissions. The mean age increased over time, from 70.1 ± 17.0 years to 77.7 ± 14.1 years. Hospitalization episodes of patients older than 85 years admitted for CAP increased fourfold. CAP-associated case fatality increased slightly, driven by patients older than 80 years. A modest decline was noted from 2016 to 2019 (from 23.1% to 21.8%). This was strongly correlated with mean age. Invasive mechanical ventilation was offered in a growing number of hospitalization episodes of CAP (from 3.1% in 2000 to 7.5% in 2019) but with significant age imbalance. Admissions peaked in January, whereas case fatality was highest during the summer months. Conclusions: These findings underscore the growing burden of CAP on healthcare systems, driven by an aging population and rising life expectancy. This has implications for both resource allocation and preventive strategies. Full article

Severe dengue remains an important cause of pediatric hospitalization, morbidity, and mortality in tropical and subtropical regions, particularly where rapid triage and pediatric critical-care capacity are limited. This structured narrative review synthesizes evidence on the epidemiology, pathogenesis, early recognition, diagnosis, management, and prevention of severe dengue in children. Severe disease reflects interactions among viral factors, pre-existing immunity, dysregulated host responses, and microvascular endothelial injury. Antibody-dependent enhancement, inflammatory mediators, dengue nonstructural protein 1, and endothelial glycocalyx disruption contribute to vascular hyperpermeability, plasma leakage, shock, severe bleeding, and organ impairment. Because deterioration often occurs abruptly around defervescence, serial clinical assessment, hematocrit trends, urine-output monitoring, and timely recognition of warning signs are central to risk stratification. Molecular assays and NS1 antigen testing are most useful during the early febrile phase, although diagnostic performance varies with illness timing and immune status. Carefully titrated isotonic crystalloid therapy remains the cornerstone of treatment; both delayed resuscitation and excessive fluid administration may worsen outcomes. Reducing mortality requires integrated clinical and public-health strategies combining standardized pediatric management, accessible diagnostics, effective referral systems, vaccination where appropriate, surveillance, and vector control. Full article

Background: Adults who undergo blood-culture sampling in the emergency department (ED) may be discharged before results are finalized and later found bacteremic. Factors identifying which patients require readmission are not well defined. We sought predictors of return and hospitalization available at the index ED visit. Methods: In this retrospective study at a 1000-bed university-affiliated hospital (September 2021–March 2026), we included adults discharged from the ED with a positive blood culture identified post-discharge. The primary outcome was ED return with hospitalization within 30 days. Multivariable logistic regression was restricted to variables available at the index ED visit. Results: Of 197 eligible patients, 16 were excluded, leaving 181 analyzed: 78 (43.1%) were managed as outpatients, 36 (19.9%) returned and were re-discharged, and 67 (37.0%) returned and were hospitalized. Median age was 73 (IQR 61–83) years and 105 (58.0%) were male. Index-visit vital signs and laboratory values did not differ across trajectories. The only independent predictor of return and hospitalization was a non-UTI working discharge diagnosis (aOR 2.53, 95% CI 1.3–5.0). Creatinine ≥ 2 mg/dL (aOR 2.65, 95% CI 0.9–7.5) and previous hospitalization within 6 months (aOR 1.82, 95% CI 0.8–4.1) were significant per univariate analysis but attenuated after adjustment, and age was not predictive. Enterobacterales predominated (n = 111, 61.3%). All nine endovascular-infection cases were hospitalized. Overall mortality was 1.1% (2/181). Conclusions: Post-discharge bacteremia carried low mortality but frequent ED return and hospitalization. A non-UTI working diagnosis independently identified a higher-risk minority; renal impairment and recent hospitalization were supportive but non-independent markers. Full article

Cardiovascular diseases remain the leading cause of global mortality, yet conventional diagnostics are episodic and clinic-centered, missing the dynamic physiological events that unfold between encounters. Wearable devices offer continuous, real-world monitoring and, together with artificial intelligence, digital biomarkers, and telecardiology, increasingly support a shift toward predictive, preventive, personalized, and participatory (P4) cardiovascular care. This narrative review synthesizes the contemporary evidence base for wearable cardiovascular technology and organizes it around the four pillars of P4 medicine, with the explicit aim of distinguishing what is clinically proven from what remains aspirational. The wearable ecosystem now spans consumer smartwatches, medical-grade ECG patches, smart textiles, and emerging soft bioelectronics, generating an expanding repertoire of digital biomarkers. Evidence is strongest where validation is most mature: atrial fibrillation screening, supported by large-scale studies, and structured heart-failure telemonitoring, associated with reductions in heart-failure hospitalization of 18–32% in structured programs. For acute coronary syndrome triage, cuffless blood pressure, cardiac rehabilitation, and AI-derived prognostic markers, the supporting evidence is growing but rests largely on analytical and early clinical validation rather than on demonstrated improvements in hard cardiovascular outcomes. Across all four pillars, translation is constrained by accuracy variability across demographic subgroups, regulatory fragmentation, data privacy concerns, interoperability deficits, and inequitable access for elderly, low-income, and low- and middle-income populations. Realizing the P4 promise will require harmonized validation standards, demographic-stratified accuracy reporting, equitable access strategies, and a clinical infrastructure capable of converting continuous wearable data into actionable decisions. Full article

Ralstonia pickettii is an opportunistic Gram-negative bacterium associated with healthcare-associated infections, particularly in premature infants and other immunocompromised or critically ill patients. This study aimed to investigate a neonatal intensive care unit outbreak of Ralstonia pickettii bacteremia by describing the clinical characteristics of affected infants, identifying the environmental source, and evaluating the genetic relatedness between clinical and environmental isolates. Hospital records from January 2023 through November 2025 were reviewed; the nine included cases occurred between February 2024 and October 2025. Demographic, clinical, and laboratory data were reviewed. Environmental sampling was performed to identify the source of contamination. Genetic relatedness between clinical and environmental isolates was evaluated using arbitrarily primed polymerase chain reaction (AP-PCR), and the molecular findings were interpreted together with microbiological and epidemiological data. This study was initially designed as a retrospective clinical review and was subsequently expanded to include an outbreak investigation after three temporally clustered cases were identified in October 2025. The outbreak involved nine neonates with Ralstonia pickettii bacteremia. Environmental investigation identified Ralstonia pickettii in both opened and unopened sterile distilled water samples. Clinical and environmental isolates demonstrated highly similar AP-PCR banding patterns, supporting genetic relatedness when interpreted together with microbiological and epidemiological findings. Following removal of the contaminated source and implementation of infection control measures, no additional R. pickettii bacteremia cases were identified. Overall mortality was 44.4%, whereas only one death (11.1%) was considered attributable to Ralstonia pickettii bacteremia. Ralstonia pickettii can cause healthcare-associated outbreaks in neonatal intensive care units. Integration of microbiological, environmental, epidemiological, and molecular findings may facilitate timely outbreak source identification and implementation of effective infection control measures. Full article

Background/Objectives: Carbapenem overuse contributes to antimicrobial resistance, but pragmatic stewardship models for high-complexity Internal Medicine wards remain underreported. We evaluated the feasibility and stewardship impact of a carbapenem-sparing intervention based on time-limited named-patient dispensing, pharmacist-supported reassessment, and mandatory infectious diseases reassessment for continuation beyond seven days, while assessing short-term clinical outcomes as exploratory safety signals. Methods: We conducted a prospective quasi-experimental before-and-after pilot implementation study in two Internal Medicine wards of a university hospital. Consecutive adult inpatients receiving a carbapenem or fluoroquinolone were enrolled during a 2-month control phase (standard care, n = 40) and a subsequent 2-month intervention phase (n = 38). Initial prescription remained at the discretion of the treating physician; targeted antibiotics were dispensed on a named-patient basis for a maximum initial duration of seven days, with pharmacist-supported reassessment on days 3 and 5 and mandatory infectious diseases reassessment for continuation beyond seven days. Results: Antibiotic therapy duration was shorter in the intervention group (median approximately 6 vs. 9 days, p = 0.0001), and antibiotic discontinuation by day 7 was more frequent than in controls (81.6% vs. 45.0%, p = 0.001). Total targeted antibiotic exposure decreased by approximately 40% (mean 5.9 vs. 10.0 Defined Daily Doses (DDD) per patient, p < 0.001), mainly driven by reduced meropenem use. No significant differences were observed in biomarker trajectories, clinical status at day 7, 30-day readmission or relapse, or 90-day mortality. Conclusions: A time-limited dispensing and reassessment model was feasible in Internal Medicine and was associated with lower carbapenem and targeted restricted-antibiotic exposure. No apparent short-term signal of clinical worsening was identified, although the study was not powered to establish safety, clinical non-inferiority, or equivalence. Larger multicentre studies using standardized stewardship metrics are needed. Full article