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Obesity appears to be associated with improved health outcomes in patients with sepsis, a phenomenon termed the obesity paradox. However, the potential influence of varying operational definitions of obesity on clinical outcomes within this paradox remains inadequately characterised. This scoping review aimed to identify, analyse, and synthesise the methodological approaches to obesity definition employed in sepsis research. A systematic literature search was conducted in August 2023 across MEDLINE, Embase, CINAHL, and CENTRAL databases. This review included original articles, systematic reviews, and meta-analyses reporting on adult patients with both obesity and sepsis. After removing 60 duplicates, 430 citations were screened, and 68 met the inclusion criteria. Among studies on the obesity paradox, 90.5% supporting and 88.6% refuting it employed body mass index-based definitions, with approximately three-quarters using retrospective designs. Studies supporting the obesity paradox identified patients with obesity as younger, predominantly female, and with higher comorbidity rates. In contrast, studies refuting the paradox reported more diverse age and sex distributions, yet consistently noted elevated chronic disease prevalence in patients with obesity. Both groups found similar or higher illness severity scores among patients with obesity. The lack of methodological rigour in obesity definitions within clinical research may contribute to the obesity paradox. Future studies should critically evaluate measurement methods and definitional variability to clarify their impact on clinical outcomes.

ObjectiveVascular closure devices (VCDs) are frequently employed to achieve hemostasis at the femoral puncture site, offering an alternative to traditional manual compression. However, a rare yet significant complication is common femoral artery (CFA) occlusion caused by suture-mediated VCDs. The optimal management of this complication remains unclear, with open surgical repair traditionally regarded as the standard of care. This paper aims to share our clinical experience in managing CFA occlusions caused by suture-mediated VCDs and to introduce our preferred endovascular treatment strategy.MethodsAt our institution, approximately 250 femoral artery hemostasis procedures using suture-mediated VCDs are performed annually. Over the past 10 years, we encountered 6 cases of CFA occlusion following the use of such devices. This corresponds to an incidence rate of approximately 0.24%. In all cases, endovascular management was selected as the primary treatment modality over open surgical intervention. Our endovascular approach consisted of initial balloon angioplasty, with adjunctive stenting performed when residual stenosis exceeded 50%.ResultsEndovascular treatment was technically successful in all 6 cases, with no major procedural complications. The mean degree of stenosis prior to balloon angioplasty was 91.9%, including 3 cases of long segmental occlusion. Balloon angioplasty alone was sufficient in 4 cases, while the remaining 2 required additional stenting to address significant residual stenosis. Final angiography demonstrated an average residual stenosis of 25.1%. During the follow-up period (mean duration: 37.8 months), no patients reported symptoms of lower extremity ischemia.ConclusionThis case series highlights the feasibility and efficacy of endovascular management as a first-line approach for CFA occlusion caused by suture-mediated VCDs. When diagnosis is delayed, long segmental occlusion with considerable thrombus burden may limit the effectiveness of balloon angioplasty alone, necessitating adjunctive stenting. Therefore, timely diagnosis and intervention are essential to optimize outcomes in these cases.

Objectives: In Italy a recent law was approved for providing patients' wishes regarding end of life issues, commonly referred internationally to as "living wills", (Dichiarazione anticipata di trattamento, DAT). Regardless of this official document, advance care planning (ACP) is often used in a palliative care setting to share the treatments to start, to continue, to withdraw, thus preventing the stress on an acute decision. The aim of this study was to assess DAT and ACP in patients with amyotropic lateral sclerosis admitted to home palliative care. Methods: Patients consecutively admitted to speciliazed home palliative care were prospectively assessed. The presence of DAT or ACP was recorded. Results: Sixty-eight patients were enrolled in the period taken into consideration. No patient had drown up DAT, and only one patient provided his ACP prior to home palliative care admission. Along the course of home palliative care care assistance, 30.9% of patients provided their ACP. Discussion: In Italy DAT resulted scarcely widespread, despite an existing law, as no patient officially provided their indication on end of life issues. In addition, ACP was given only after starting specialized home palliative care in less than 1/3 of patients. Home palliative care seems to be a fundamental resource for improving communication and soliciting expression of patients' wishes regarding end of life issues.

Objectives: Anticipatory grief is associated with post-bereavement grief; however, reports on the influence of pre-loss depression are limited. Therefore, we investigated the association between the anticipatory grief of family members and post-loss and post-depression grief adjusted for pre-loss depression. Methods: This cohort study included the family members of dying patients with cancer. Questionnaires were distributed to them during hospitalization in four inpatient palliative care units from 2016 to 2017. We also administered follow-up questionnaires after their bereavement in 2018. The pre-bereavement questionnaire consisted of three items from the Anticipatory Grief Scale for Families Caring for a Terminally Ill Person for assessing anticipated grief and the Patient Health Questionnaire 9 for assessing depression. The Brief Grief Questionnaire was used to assess post-loss grief. Results: We distributed 181 pre-bereavement questionnaires to the family members; 112 (62%) responded to the pre-bereavement survey, out of which 71 (63%) responded to the post-bereavement survey. Anticipatory grief was significantly associated with pre-loss (ρ = 0.37, ρ < 0.001) and post-loss (ρ = 0.24, P = 0.009) depression and marginally associated with post-loss grief (ρ = 0.15, P = 0.10). Pre-loss depression was also significantly associated with post-loss depression (ρ = 0.50, P < 0.001) and post-loss grief (ρ = 0.41, P < 0.001). However, anticipatory grief was not significantly associated with post-loss depression (P = 0.35) and post-loss grief (P = 0.65) after adjusting for pre-loss depression. Significance of Results: Bereaved families who experienced anticipatory grief had worse post-bereavement depression. However, this association was not statistically significant after adjusting for pre-bereavement depression. Post-bereavement depression may be in a continuum with pre-loss depression, and anticipatory grief does not independently affect post-loss reactions.

Background: Antipsychotics and benzodiazepines are prescribed for hyperactive delirium despite their side effects and lack of supportive evidence. Valproic Acid (VPA) improves agitation without QTc prolongation, excessive sedation, and parkinsonism. However, high quality evidence for this is lacking in delirium. Methods: This retrospective study involved hospitalized patients seen by Palliative medicine from 10/1/2019 to 4/17/2020 who received VPA for at least 24 hours for hyperactive delirium. Patients were excluded if VPA was used for seizures or bipolar disorder. We hypothesized that VPA improves agitation and thus reduces the use of opioids, antipsychotics, and benzodiazepines. Results: Twenty patients, 50% women, and a median age of 81.5 years were treated. Nine had cancer, five dementia and two had strokes. The median daily VPA dose was 831.6 mg (IQR 671.4 -1016.4). Due to the small numbers, we did not find a statistically significant differences in benzodiazepine, opioid, or antipsychotic use on days 1, 2, or 3. VPA was used as monotherapy in 10 patients, with no additional antipsychotic or benzodiazepines needed. Eleven patients were on comfort care measures at the time of VPA initiation. Ten died in the hospital. Three were discharged home, and seven transferred to a skilled nursing facility. Discussion: This study explored the use of VPA in palliative care. VPA may be effective in treating aggitation. Randomized controlled trials are needed to validate VPA benefits in treating agitated delirium.

IntroductionBlunt trauma to the external iliac artery (EIA) is rare but potentially fatal. Endovascular stent-graft placement is used to control hemorrhage and restore limb perfusion. However, the safety profile and potential complications associated with stent-graft treatment are not well documented. We report a case of EIA injury following blunt trauma complicated by stent-graft deployment into a false lumen, successfully managed with an endovascular rescue technique.Case ReportAn 88-year-old man sustained blunt pelvic trauma with active extravasation from the left EIA. Initially, a covered stent-graft was deployed, which inadvertently caused arterial occlusion due to placement within a false lumen. A rescue procedure was performed using an endovascular approach, where a guidewire was advanced through the perigraft space and snared to establish a pull-through technique. Over this, a second stent-graft was deployed within the perigraft space, restoring flow through the true lumen. Follow-up computed tomography images confirmed successful recanalization and persistent exclusion of the false lumen.ConclusionThis case highlights the potential for stent-graft misplacement in EIA trauma and the importance of ensuring access to the true lumen. Accessing the perigraft space and placing an additional stent-graft represents a new therapeutic approach to achieve recanalization in similar complex vascular injuries.

Purpose of the review: Perioperative pain management continues to evolve as we see the pendulum of opioid use swinging back from highly restrictive administration towards more balanced intraoperative dosing strategies. Striking the optimal balance between nonopioid multimodal pain regimens and thoughtful opioid use has been at the forefront of cardiac surgical enhanced recovery protocols for several years. Herein, we review the history of methadone as a long-acting opioid and its resurgence with pleiotropic benefits in cardiac surgery patients.

Recent findings: Despite barriers to use and potential adverse effects, methadone is a proven agent for long-lasting analgesia, potentially reducing both short- and long-term opioid consumption. Multiple studies have demonstrated safety and efficacy in cardiac surgery. Dosing (0.1-0.3 mg/kg) and timing vary slightly in published studies and protocols; however, through standardization and clinical judgement regarding patient selection, methadone can safely be used to reduce opioid use and improve analgesia for cardiac surgery.

Summary: Further studies are needed to explore the mechanisms and ideal protocols for incorporating methadone into routine use as part of existing enhanced recover protocols. Long-term treatment effects extending beyond the immediate postoperative period, outcomes when included with adjuncts, and broader dose-response analysis are needed to guide future implementation.

Body mass index (BMI) on its own is a poor diagnostic and staging tool for obesity because it does not measure health status. The newly published Lancet Clinical Obesity Criteria (LCOC) for defining clinical obesity distinguish preclinical and clinical obesity based on organ or tissue dysfunction. The King's Obesity Staging System (KOSS) goes further and incorporates biomedical, psychosocial, and economic factors while offering a practical, holistic, and health domain-specific assessment of obesity's impact. This paper compares and maps the LCOC against the KOSS to highlight their complementary aspects, strengths, and potential for integration. By combining the LCOC philosophical framework with the practical patient-centred approach of the KOSS, we propose a unified model that enhances diagnostic ability and allows the clinician to track the impact of any obesity treatment. This integrated framework advances obesity management, addressing both medical, functional, and broader psychosocial challenges.

Orthodox Jewish patients with terminal illnesses have unique goals and desires, often driven by halakha (Jewish law and ethics) and cultural norms. We conducted a quality improvement project investigating the baseline perceptions and experiences of medical professionals who care for Orthodox Jewish patients with terminal illnesses. The survey included health care professionals who cared for Orthodox Jewish patients as part of Intensive Care Unit (ICU), Oncology, or Palliative Care and Hospice teams. The three main elements of the survey included respondent demographics, multiple choice selections, and a free-text section. A total of 73 medical professionals responded to the survey. Several important findings were noted. Compared to the general population, Orthodox Jewish patients with terminal illnesses are more likely to request aggressive measures at end-of-life and are less likely to have completed advanced directives and health care power of attorney documentation. They also do not always have a rabbinic authority involved in decision-making. Health care professionals highlighted strong religious and community support as positive elements of caring for this population and recommend that medical teams establish early and direct communication with rabbinic authorities for those patients for whom a rabbi's involvement is desired. These data inform ongoing next steps to improve the quality of care for these patients and their families.

There is an emerging need to provide high-quality pediatric palliative care and end-of-life care to children, adolescents, and young adults with life-limiting illnesses. Currently, there are no standardized quality measures supporting pediatric palliative care and end-of-life care patient outcomes. The aim of this literature review was to explore current quality measures utilized in pediatric palliative care and end-of-life care among pediatric patients with life-limiting illnesses within the conceptual framework of Comfort Theory. A comprehensive review of relevant articles resulted in 15 articles that met criteria and were evaluated. Included studies focused on pediatric patients with life-limiting illnesses receiving palliative care or end-of-life care. Articles related to children with acute illness, trauma, or accidental death were excluded. Emergent themes among quality measures were categorized into 7 domains: (a) Alleviation of distressing symptoms, (b) Structures and processes of care, (c) Health care utilization, (d) Location of death and bereavement care, (e) Patient and family experiences, (f) Psychological and spiritual care, and (g) Cultural, ethical, and legal considerations. These domains support the physical, psychospiritual, sociocultural, and environmental contexts of Comfort Theory. Quality measure research, development, and standardization should focus within the 7 domains identified for the promotion of comfort, equity, and accessible care.