Purpose: Ventilator-associated pneumonia (VAP) is a common ICU complication linked to high morbidity and mortality. Inhaled antibiotics may offer targeted prophylaxis, but their effectiveness has shown mixed results. This study aims to further evaluate whether inhaled antibiotics reduce VAP incidence and ICU mortality through a systematic review and meta-analysis of the most updated available evidence. Methods: A systematic review was conducted following PRISMA 2020 guidelines. Multiple databases were searched for studies published up to November 14, 2024. Ten studies including 2876 patients (1485 intervention; 1391 control) met inclusion criteria. A random-effects meta-analysis was performed to estimate pooled risk ratios (RR) for VAP incidence and ICU mortality. Risk of bias was assessed using ROBINS-I and certainty of evidence via GRADE. Results: Inhaled antibiotics significantly reduced the incidence of VAP compared to controls (RR = 0.67; 95% CI: 0.58–0.77; p < 0.001), but showed no significant effect on ICU mortality (RR = 0.92; 95% CI: 0.79–1.06; p = 0.25). Moderate heterogeneity was observed in VAP outcomes ( I ² = 46.8%), while mortality analysis showed no heterogeneity. Funnel plot analysis suggested minimal publication bias, and GRADE rated the evidence as moderate in certainty. Conclusion: Inhaled antibiotics significantly reduce VAP incidence but show no clear mortality benefit. While promising for prevention, their survival impact remains uncertain. Clinical use should consider patient context and microbial patterns for targeted approach. Future research should identify high-risk subgroups, assess long-term outcomes, and evaluate antibiotic resistance.

Background: The role of cardiopulmonary bypass (CPB) in surgery for tumor thrombi extending into the inferior vena cava (IVC) or right atrium in noncardiac malignancies remains controversial. We systematically compared perioperative mortality and complications between the CPB and non-CPB approaches and summarized findings on surgical techniques and patient selection. Methods: We searched major databases for studies (2015–2025) reporting surgical resection of IVC or right atrial tumor thrombi in noncardiac malignancies stratified by CPB use. Twenty studies were included in the qualitative synthesis, and nine were included in the quantitative meta-analysis. Pooled perioperative mortality and complications were compared via random effects models. Heterogeneity and correlations between CPB use and mortality were assessed. Results: Surgical approaches varied. CPB was typically reserved for extensive thrombus or right atrial involvement. The complication and recurrence rates were heterogeneous. In nine studies (800 patients), the pooled perioperative mortality rate was 9.2% (95% CI: 4.7–17.1%), with no significant difference between the CPB (10.3%) and non-CPB (7.8%) groups. High heterogeneity reflected differences in patient selection, tumor extent, and surgical technique. Qualitative synthesis indicated that CPB increased procedural complexity and risk but was utilized for more advanced disease. Recurrence and long-term outcomes have been inconsistently reported. Most studies were retrospective and at moderate to serious risk of bias. Conclusion: Surgical management with or without CPB results in similar perioperative mortality rates. CPB is generally reserved for extensive thrombi, adding complexity and risk. Individualized, multidisciplinary planning is essential. Prospective studies are needed to refine patient selection and optimize surgical strategies in this challenging setting.

The optimal postaortic valve replacement (AVR) anticoagulation strategy remains poorly defined, particularly when comparing nonvitamin K antagonist oral anticoagulants (NOACs) versus warfarin. This systematic review and meta-analysis aimed to evaluate the safety and efficacy of NOACs compared with warfarin in these patients. Our study was registered on PROSPERO (ID CRD420251028998). A search of the PubMed, EMBASE, and Cochrane databases was conducted on April 9, 2025, for studies published between 2015 and 2025 that compared NOACs to warfarin after aortic bioprosthetic valve replacement. Inclusion criteria included randomized controlled trials (RCTs) and observational studies reporting thromboembolic events, major bleeding, and mortality with at least 6 months of follow-up. Studies on mechanical valves, case reports, and publications that could not be translated into English were excluded. Data extraction was conducted based on study design, patient demographics, clinical outcomes, and effect sizes, expressed as hazard ratios (HRs) with 95% confidence intervals (CIs) using a random effects model. Risk of bias was assessed using the ROBINS-I tool. Seventeen studies (n = 93,510 participants) were included. NOACs were associated with an HR of 0.91 for thromboembolic events (95% CI: 0.76–1.09) and a pooled HR of 1.22 for major bleeding (95% CI: 0.88–1.68). Several studies have suggested a trend toward lower all-cause mortality and major bleeding with NOACs, particularly in patients with lower bleeding risk. In patients undergoing aortic bioprosthetic valve replacement, NOACs show similar efficacy and safety to warfarin for preventing thromboembolic events and major bleeding. However, anticoagulation decisions should be individualized, and larger RCTs are needed to determine the optimal approach. Graphical abstract

Introduction and importance: Mediastinal lymphangiomas are rare benign malformations, comprising less than 1% of adult mediastinal tumors. Idiopathic cases in the anterior mediastinum are exceptional in young adults and often mimic malignancies like lymphoma, posing significant diagnostic challenges. Case presentation: A 24-year-old male presented with chest pain and B-symptoms (fever, night sweats). Imaging revealed a 7.5 cm well-circumscribed anterior mediastinal mass. Biopsy confirmed idiopathic lymphangioma. The patient underwent robotic-assisted thoracoscopic resection. Intraoperative findings showed pericardial involvement and compression of the superior vena cava and pulmonary artery. Complete excision was achieved without complications. Symptoms resolved immediately, and 3-month follow-up showed no recurrence. Clinical discussion: Differentiation from the “four T’s” (thymoma, teratoma, thyroid, lymphoma) requires histopathology. Although benign, these lesions compress vital structures. Robotic surgery offers superior visualization for precise dissection around major vessels compared to open thoracotomy, facilitating complete resection, critical to preventing recurrence (10–50% risk if incomplete). Conclusion: Robotic-assisted surgery is a safe short-term option for resecting rare idiopathic anterior mediastinal lymphangiomas. Early biopsy and complete excision aid in excluding malignancy and lowering recurrence risk, with longer-term follow-up essential.

Background: Acute Respiratory Distress Syndrome is characterized by the sudden onset of hypoxemia, reduced lung compliance, and bilateral pulmonary infiltrates. We investigated patient demographics and clinical predictors of outcomes in adult patients with ARDS. Methods: We conducted a retrospective multi-center intensive care unit database study using the eICU Collaborative Research Database (eICU-CRD). The Analysis included 304 patients with ARDS who met all inclusion criteria, including key demographic variables. We Assessed associations between these variables and outcomes, including mortality and length of stay (LoS). Results: For each year of increased age, odds of mortality decreased by 4.7% (OR = 0.953, p < 0.001). Higher temperatures were associated with reduced mortality (OR=0.470, p=0.003). Gender (p = 0.596) and BMI (p = 0.964) were not significant predictors of mortality. A multiple linear regression model for predicting ICU length of stay was statistically significant at explaining the variance compared to the null model. High temperatures (β = 0.981, p = 0.015) and low temperatures (β = -1.038, p = 0.006) were significant predictors of LoS, while gender and BMI were not. There was significant association between ethnicity and hospital discharge status (χ ² (5) = 13.123, p = 0.022), which suggests disparities in outcomes across ethnic groups. Conclusion: Our study suggests that increasing age and higher temperatures may serve as protective factors, contrary to the popular belief of age-increasing fragility. Analysis also found that gender and BMI do not affect patient LoS nor mortality. These findings suggest clinicians should consider a patient’s age and core body temperature when assessing risk of mortality and prognosis, placing less emphasis on BMI and gender.