Background: Pressure support ventilation (PSV) is the prevalent weaning method. Proportional assist ventilation (PAV) is an assisted ventilation mode, which is recently being applied to wean the patients from mechanical ventilation. Whether PAV or PSV is superior for weaning remains unclear. Methods: Eligible randomized controlled trials published before April 2020 were retrieved from databases. We calculated the risk ratio (RR) and mean difference (MD) with 95% confidence intervals (CIs). Results: Seven articles, involving 634 patients, met the selection criteria. Compared to PSV, PAV was associated with a significantly higher rate of weaning success (fixed-effect RR 1.16; 95% CI 1.07–1.26; I² = 0.0%; trial sequential analysis-adjusted CI 1.03–1.30), and the trial sequential monitoring boundary for benefit was crossed. Compared to PSV, PAV was associated with a lower proportion of patients requiring reintubation (RR 0.49; 95% CI 0.28–0.87; I² = 0%), a shorter ICU length of stay (MD − 1.58 (days), 95% CI − 2.68 to − 0.47; I² = 0%), and a shorter mechanical ventilation duration (MD − 40.26 (hours); 95% CI − 66.67 to − 13.84; I² = 0%). There was no significant difference between PAV and PSV with regard to mortality (RR 0.66; 95% CI 0.42–1.06; I² = 0%) or weaning duration (MD − 0.01 (hours); 95% CI − 1.30–1.28; I² = 0%). Conclusion: The results of the meta-analysis suggest that PAV is superior to PSV in terms of weaning success, and the statistical power is confirmed using trial sequential analysis. Graphical

We aimed to investigate the association between the plasma anion gap (AG) and in-hospital mortality among patients with acute ischemic stroke (AIS). In total, 1236 AIS patients were enrolled using the Medical Information Mart for Intensive Care Database IV. Primary outcome was in-hospital mortality. The patients were divided into four groups according to AG category. The mean age and Charlson comorbidity index increased as the AG category increased. The fourth AG category was most related to the in-hospital mortality (hazards ratio (HR), 95% confidence interval (CI): 2.77, 1.60–4.71), even after adjusting for possible confounding variables (Model 1: HR, 95% CI: 3.37, 1.81–6.09; Model 2: HR, 95% CI: 3.57, 1.91–6.69). Moreover, intensive care unit mortality (p = 0.008) was higher in the highest AG category, but the intracranial hemorrhage (p = 0.071) did not associate with the plasma AG. The plasma AG had a satisfactory predictive ability for in-hospital mortality among AIS patients (areas under the receiver operating characteristic curve: 0.631). The plasma AG is an independent risk factor that can satisfactorily predict the in-hospital mortality among AIS patients.

Background: Endoscopic combined intrarenal surgery (ECIRS) adds ureteroscopic vision to percutaneous nephrolithotomy (PCNL), which can be helpful when dealing with complex renal stones. Yet, there is still no consensus on the superiority of ECIRS. We aimed to critically analyze the available evidence of studies comparing efficacy, safety, bleeding risk, and efficiency of ECIRS and PCNL. Methods: We searched for studies comparing efficacy (initial and final stone-free rate), safety (postoperative fever, overall and severe complications), efficiency (operative time and hospital stay) and bleeding risk between ECIRS and PCNL. Meta-analysis was performed. Results: Seven studies (919 patients) were identified. ECIRS provided a significantly higher initial stone-free rate, higher final stone-free rate, lower overall complications, lower severe complications, and lower rate of requiring blood transfusion. There was no difference between the two groups in terms of postoperative fever, hemoglobin drop, operative time, and hospital stay. In the subgroup analysis, both minimally invasive and conventional ECIRS were associated with a higher stone-free rate and lower complication outcomes. Conclusions: When treating complex renal stones, ECIRS has a better stone-free rate, fewer complications, and requires fewer blood transfusions compared with PCNL. Subgroups either with minimally invasive or conventional intervention showed a consistent trend.

The standard size of bougie for laparoscopic sleeve gastrectomy (LSG) is not yet established. Therefore, a systematic review and network meta-analysis were conducted to assess the weight loss effects and associated complications of LSG for patients with morbid obesity, based on different bougie sizes. A total of 15 studies were reviewed in this systemic review and network meta-analysis (2,848 participants), including RCTs and retrospective studies in PubMed, and Embase until September 1, 2020. The effectiveness of different bougie calibration sizes was assessed based on excess weight loss (EWL), total complications, and staple line leak. Within this network meta-analysis, S-sized (≤ 32 Fr.) and M-sized (33–36 Fr.) bougies had similar effects and were associated with the highest EWL improvement among all different bougie sizes (S-sized: standardized mean difference [SMD], 10.52; 95% confidence interval [CI] − 5.59 to − 26.63, surface under the cumulative ranking curve [SUCRA], 0.78; and M-sized: SMD, 10.16; 95% CI − 3.04–23.37; SUCRA, 0.75). M-sized bougie was associated with the lowest incidence of total complications (M-sized: odds ratio, 0.43; 95% CI, 0.16–1.11; SUCRA, 0.92). Based on our network meta-analysis, using M-sized bougie (33–36 Fr.) is an optimal choice to balance the effectiveness and perioperative safety of LSG in the clinical practice.

We conducted a systematic review and meta-analysis to assess the clinical efficacy of high-flow nasal cannula (HFNC) therapy as apneic oxygenation in critically ill patients who require endotracheal intubation in the intensive care unit (ICU). This systematic review and meta-analysis included six randomized controlled trials and a prospective study identified in PubMed, Embase, Cochrane Library, and the Web of Science until August 18, 2019. In this meta-analysis including 956 participants, HFNC was noninferior to standard of care during endotracheal intubation regarding incidence of severe hypoxemia, mean lowest oxygen saturation, and in-hospital mortality. HFNC significantly shortened the ICU stay by a mean of 1.8 days. In linear meta-regression interaction analysis, the risk ratio of severe hypoxemia decreased with increasing baseline partial oxygen pressure (PaO₂) to fraction of inspired oxygen (FiO₂) ratio. In subgroup analysis, HFNC significantly reduced the incidence of severe hypoxemia during endotracheal intubation in patients with mild hypoxemia (PaO₂/FiO₂> 200 mmHg; risk difference, −0.06; 95% confidence interval, −0.12 to −0.01; number needed to treat = 16.7). In conclusion, HFNC was noninferior to standard of care for oxygen delivery during endotracheal intubation and was associated with a significantly shorter ICU stay. The beneficial effect of HFNC in reducing the incidence of severe hypoxemia was observed in patients with mild hypoxemia.

Background: Early identification of impending in-hospital cardiac arrest (IHCA) improves clinical outcomes but remains elusive for practicing clinicians. Objective: We aimed to develop a multimodal machine learning algorithm based on ensemble techniques to predict the occurrence of IHCA. Methods: Our model was developed by the Multiparameter Intelligent Monitoring of Intensive Care (MIMIC)–IV database and validated in the Electronic Intensive Care Unit Collaborative Research Database (eICU-CRD). Baseline features consisting of patient demographics, presenting illness, and comorbidities were collected to train a random forest model. Next, vital signs were extracted to train a long short-term memory model. A support vector machine algorithm then stacked the results to form the final prediction model. Results: Of 23,909 patients in the MIMIC-IV database and 10,049 patients in the eICU-CRD database, 452 and 85 patients, respectively, had IHCA. At 13 hours in advance of an IHCA event, our algorithm had already demonstrated an area under the receiver operating characteristic curve of 0.85 (95% CI 0.815‐0.885) in the MIMIC-IV database. External validation with the eICU-CRD and National Taiwan University Hospital databases also presented satisfactory results, showing area under the receiver operating characteristic curve values of 0.81 (95% CI 0.763-0.851) and 0.945 (95% CI 0.934-0.956), respectively. Conclusions: Using only vital signs and information available in the electronic medical record, our model demonstrates it is possible to detect a trajectory of clinical deterioration up to 13 hours in advance. This predictive tool, which has undergone external validation, could forewarn and help clinicians identify patients in need of assessment to improve their overall prognosis.