Search Results (113)

Background and Objectives: Extracorporeal membrane oxygenation (ECMO) provides temporary respiratory or circulatory support when conventional therapies fail. Some patients do not recover and are not candidates for transplant or durable mechanical support. In these cases, continuing ECMO may no longer align with the patient’s goals. Compassionate ECMO discontinuation (CED) is the planned withdrawal of extracorporeal support with death anticipated. The term “compassionate” refers to the goal of minimizing suffering in the end-of-life process. This review proposes a reliability-oriented framework to standardize CED and reduce preventable distress for patients, families, and clinicians. Materials and Methods: We conducted a targeted narrative review of ethical analyses, consensus guidance, and empirical literature on planned ECMO withdrawal. The results of the narrative review were combined with our existing practical process for CED into this proposed reliability-oriented framework as a guide for clinicians. Recommendations were organized into a four-phase process model that emphasizes operational implementation, anticipatory guidance, and quality improvement. We included modality-specific considerations for veno-arterial (VA), veno-venous (VV) ECMO, and extracorporeal cardiopulmonary resuscitation (ECPR). Results: The framework includes four phases. Phase I, Anticipation and Alignment, emphasizes structured shared decision-making, early expectation setting, time-limited trials, palliative care integration, and predefined pathways for managing disagreement. Phase II, Preparation, includes interdisciplinary role assignment, a pre-withdrawal time out, family coaching on expected physiological changes, and preemptive comfort medications that account for ECMO-altered pharmacokinetics. Phase III, Implementation, prioritizes comfort first, pacing with explicit pause points, environmental controls to reduce alarms and visual distress, and modality-tailored sequencing. Phase VI, Aftercare and Learning Capture, includes bereavement support, standardized documentation, structured team debriefing, and recommended process measures to guide improvement. Conclusions: Viewing CED as a low-frequency, high-stakes clinical process supported by scripts, checklists, and iterative feedback can improve goal-concordant end-of-life (EOL) care, reduce suffering and family trauma, support clinicians, and strengthen ECMO program learning systems. Full article

Drought stress is a significant environmental factor affecting plant growth, fruit quality and distribution. Wild jujube is an important species of eco-economic forest tree. In this study, two wild jujube families, ‘NO. 1’ (tolerant) and ‘NO. 5’ (sensitive), which show significant differences in morphological and physiological indicators in drought treatment, are considered. Compared with the ‘NO. 5’, the ‘NO. 1’ exhibited lower water loss, leaf yellowing and abscission rates, as well as reduced malondialdehyde (MDA) content, while showing higher superoxide dismutase (SOD) activity and elevated levels of soluble sugars (SS), soluble proteins (SP), and proline (Pro). In contrast, the ‘NO. 5’ suffered more severe damage to leaf epidermal cells compared with the ‘NO. 1’, accompanied by a significant decline in net photosynthetic rate (A) and instantaneous water use efficiency (WUEi). Transcriptomic profiles between two wild jujube families with markedly different drought responses (withholding water for 15 days) are shown. The two wild jujube families included 3238 up-regulated and 2675 down-regulated differentially expressed genes (DEGs). Many DEGs enriched in the GO and KEGG pathways are related to antioxidant activity, transmembrane transport, carbohydrate biosynthesis and metabolism, plant hormones, and photosynthesis. The biosynthesis of amino acids, the MAPK signaling pathway, plant hormone signal transduction, and flavonoid and alkaloid biosynthesis were the transcriptome modifications most significantly altered by drought stress. Real-time quantitative polymerase chain reaction (RT-qPCR) was used to verify the precision of the RNA-seq data. ZjJIP23-1, ZjbZIP53, ZjSPS8, ZjCAO, ZjADH1 and ZjERF39 may play important roles in the drought tolerance of the wild jujube. This study provides a solid foundation for further studies on the complex mechanisms and breeding of drought-resistant plants in wild jujube. Full article

Sodium–glucose cotransporter-2 inhibitors (SGLT2i) are widely prescribed for type 2 diabetes, heart failure, and chronic kidney disease. A rare but dangerous adverse event is SGLT2i-associated diabetic ketoacidosis, often euglycaemic (euDKA), and therefore easy to miss. This narrative review summarizes mechanisms, triggers (fasting, dehydration, infection, perioperative stress), and ketone-centred pathways for diagnosis, treatment, and prevention in acute-care settings. Management priorities are volume resuscitation, blood β-hydroxybutyrate and acid–base testing, insulin infusion with dextrose to suppress ketogenesis, and electrolyte replacement. Prevention relies on “sick-day” rules, perioperative drug withholding, and a low threshold for ketone testing in any patient with high-anion-gap acidosis, despite normal or mildly elevated glucose. Full article

In drip-irrigated maize of arid Xinjiang, seedling hardening (withholding irrigation) is used to induce deep rooting, but the conventional practice of banding phosphorus (P) fertilizer without basal application creates a spatial mismatch—roots are forced downward while P remains trapped in drying topsoil. We hypothesized that co-applying superabsorbent polymer (SAP) with banded P fertilizer can form a localized, persistently hydrated P-enriched patch that synchronizes root–resource distribution. A two-year field experiment (2024–2025) was conducted with three treatments: no P (P0), banded monoammonium phosphate (B-MAP, 120 kg P₂O₅ ha⁻¹), and B-MAP + SAP (15 kg ha⁻¹). Soil properties, root growth, canopy physiology, dry matter accumulation, nutrient uptake, and grain yield were measured. Results: At the V4 stage, B-MAP + SAP increased available P and soil water content in the 0–10 cm layer by 9.4% and 16.1%, respectively, relative to B-MAP. This patch triggered vigorous root proliferation: topsoil root length at V4 rose by 23.9%, and root length density in the 30–40 cm subsoil at V9 and R1 increased by 59.0% and 36.5%. Consequently, B-MAP + SAP sustained the highest leaf area index, net photosynthetic rate, and biomass accumulation. Two-year average grain yield reached 18.2 t ha⁻¹, 9.7% and 20.7% higher than B-MAP and P0. Crucially, P use efficiency (PUE) and water productivity (WP) under B-MAP + SAP improved by 76.2% and 9.8% over B-MAP. Co-applying SAP with banded P fertilizer resolves the spatial mismatch in hardening systems, optimizes root architecture, and synergistically boosts yield, PUE, and WP. This one-time amendment offers a simple, scalable strategy for efficient P management in arid drip-irrigated maize. Full article

Background/Objectives: Neonatal Intensive Care Units (NICUs) constitute a highly complex clinical environment characterized by patient fragility and frequent ethically sensitive decisions. To date, systematic studies investigating how Italian NICUs address these challenges and what forms of ethics support are effectively available are lacking. The aim of this study is therefore to assess how ethical issues are managed in Italian NICUs, with particular attention to the availability, use, and perceived usefulness of clinical ethics support in everyday practice. Methods: A 25-item questionnaire was developed by adapting an existing tool for investigating clinical ethics activities to the neonatal context. Following expert review by the GIBCE (Gruppo Interdisciplinare di Bioetica Clinica e Consulenza Etica in ambito sanitario), the final instrument covered four areas (general data, experience with ethical dilemmas, tools and procedures, opinions and training needs). A manual web search identified all Italian NICUs and their clinical directors, who were asked to disseminate the survey among staff. Participation was voluntary and anonymous. Data collection was conducted via Google Forms and analyzed through qualitative thematic analysis. Results: A total of 217 questionnaires were collected. The most frequent ethical dilemmas concern quality of life with anticipated multiple or severe disabilities (72.4%) and decisions to withdraw or withhold life-sustaining treatments (64.5%). Major challenges include fear of medico-legal repercussions (57.6%) and communication divergences between physicians and nurses (49.8%). More than half of respondents (52.1%) reported no formal training in clinical ethics, and 68.7% had never developed a Shared Care Plan (Shared Document for healthcare ethics planning) as defined by the Italian Law 219/2017. Conclusions: Findings highlight marked fragmentation in ethical practices across Italian NICUs. On this basis, establishing structured and accessible CEC services could help promote consistency, reinforce shared ethical standards, and support transparent and equitable decision-making in critical neonatal care. Full article

Triazole fungicides are used to protect tomato yield from fungal infection. However, information regarding triazole residues and dissipation profiles is limited. This study aimed to evaluate the behavior, residue dissipation, and potential risks of penconazole (PCZ, 10% EC, 25 cm³/100 L water) and difenoconazole (DFZ, 25% EC, 50 cm³/100 L water) applied during the fruiting stage of tomatoes over 15 days in Mit Al-Qurashi village, Dakahlia Governorate, Egypt. The study also examined the residue levels of PCZ and DFZ in tomatoes following household preparation methods, as well as the health risks and residue intake associated with these pesticides. Additionally, the impact of PCZ and DFZ residues on macro- and micro-nutrient levels, as well as quality parameters in tomato fruits, was investigated. Our data showed that PCZ and DFZ exhibited dissipation rates recorded at 70.88% and 73.33% after 6 days of application, then increased to 99.74% and 98.25% after 15 days of application, respectively, corresponding to half-lives of 2.08 and 2.78 days. The pre-harvest intervals (PHIs) were determined to be 9 days for DFZ and 12 days for PCZ. Based on risk assessment and Health Risk Index (HRI) calculations, the withholding periods for using treated tomato fruits for human consumption were extended to 15 days for DFZ treatment and reduced to 9 days for PCZ. Notably, tomato fruits treated with PCZ or DFZ could be safely consumed one day after application if processed into paste. However, other forms of processing, including washing with water, acetic acid (5%), and sodium carbonate (5%) for 5 min, significantly reduced the residue levels of the tested fungicides. Moreover, the tested fungicides not only significantly reduced the levels of macro- and micronutrients in tomato fruits but also altered the quality parameters of the tomatoes. These findings could guide the safe and responsible use of PCZ and DFZ in tomatoes, helping to prevent potential health risks to consumers. Full article

Melioidosis is a multisystem disease caused by the sapronotic soil bacterium Burkholderia pseudomallei. Septic arthritis (SA) can occur as either a primary or secondary focus and requires surgical management with prolonged antimicrobial treatment. We used the Darwin Prospective Melioidosis Study to identify patients with melioidosis and SA, filtered by culture confirmation of B. pseudomallei, and subsequently collected synovial fluid analysis, laboratory, clinical, and risk factor data. We identified 68 patients in total with a label of SA, of which 46 patients supplied 69 synovial fluid samples which were culture-positive. These most commonly came from the knee (61%) and ankle (16%), though half (54%) of the specimens were clotted and unable to undergo cell count. We found a median white cell count (WCC) of 63,000 × 10⁶ cells/L in B. pseudomallei culture-positive samples. There was a numerical, but non-significant, difference in median synovial fluid WCC when stratified by preceding antimicrobial use (90,000 × 10⁶ cells/L prior versus 27,800 × 10⁶ cells/L in samples taken post antimicrobial initiation; p = 0.053). One sample was B. pseudomallei culture-positive 32 days following antimicrobial initiation. The presence/absence of contiguous osteomyelitis did not alter synovial fluid white cell counts. These findings suggest that in cases of suspected melioidosis SA, it is not necessary to withhold empirical antimicrobial therapy while awaiting joint aspiration. Further research is needed to define the role of non-culture-based diagnostics in suspected melioidosis SA. Full article

Background: A comprehensive medical history is fundamental to dental care, supporting accurate diagnosis, personalized treatment, and the prevention of adverse outcomes. Despite its importance, patients may underestimate its relevance or hesitate to disclose information to dental professionals. This study aimed to assess patients’ awareness and willingness to disclose medical histories to dental professionals, as well as the effect of an educational intervention on their knowledge. Methods: A descriptive cross-sectional study was conducted from 1 December 2023 to 30 September 2024 in Riyadh, Saudi Arabia. Data were collected through a structured bilingual questionnaire assessing demographics, awareness of the importance of medical history, willingness to disclose information, and post-intervention knowledge. The questionnaire’s validity and reliability were established through expert evaluation and test–retest reliability, yielding Aiken’s V values greater than 0.90. Internal consistency was confirmed with a Cronbach’s alpha coefficient of 0.8. A convenience sampling technique was used to recruit the study participants. Results: A total of 515 participants completed the survey, with 43.9% withholding medical information from their dentists. Chi-square analysis revealed that disclosure practices were significantly associated with demographic factors, particularly age (p ≤ 0.05). Although 90.7% acknowledged the importance of sharing their medical history, only 67.8% reported disclosing it to dental professionals. The regression analysis revealed that participants under 18 years of age (Odds Ratio (OR) 7.08, Confidence Interval (CI) 3.53–50.90) and those aged 18–29 years (OR 14.36, CI 3.45–25.26), as well as participants with elementary (OR 4.55, CI 2.72–20.57) and middle school education levels (OR 4.55, CI 2.72–20.57), were less likely to disclose any underlying medical condition to their dentist. The younger age group (under 18) respondents were significantly more likely to indicate that it was not essential to inform the dentist about their medical condition (OR 6.60, CI 1.05–41.42). Additionally, a significant number of these respondents (OR 5.77, CI 1.87–17.84) reported being unaware of the reasons why dentists request this information, compared to the older age groups. Conclusions: The findings reveal a significant knowledge gap concerning patient disclosure of medical history in dental care and highlight the importance of patient education. Implementing targeted educational initiatives is recommended to promote patient disclosure, foster interdisciplinary collaboration, and improve overall patient safety and treatment outcomes. Full article

Background/Objectives: Lower respiratory tract infections (LRTIs) are frequent in the intensive care unit (ICU) and drive empiric broad-spectrum antibiotic use. Rapid multiplex PCR assays may improve pathogen detection and stewardship compared with conventional culture. We evaluated the real-world impact of the BioFire^® FilmArray^® Pneumonia Panel Plus (FA-PNEU^®) on antimicrobial management in suspected nosocomial LRTI. Methods: This was a single-centre, prospective observational cohort study conducted in a tertiary ICU (Madrid, Spain) between April 2021 and March 2025. Adult patients with suspected hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), or ventilator-associated tracheobronchitis (VAT) were included if paired respiratory samples underwent FA-PNEU^® and conventional culture (CC). Diagnostic accuracy and prescribing changes were analysed. Results: A total of 344 samples from 236 patients were included. FA-PNEU^® demonstrated high sensitivity (93.4%) and negative predictive value (97.9%) but moderate specificity (65.0%) and low positive predictive value (36.5%). False positives occurred in 85.8% of patients with prior antibiotic therapy targeting the detected organism. Antibiotic management was considered directly influenced by FA-PNEU^® when any prescribing decision (initiation, escalation, de-escalation, or discontinuation) explicitly followed the panel’s results rather than other clinical or microbiological information. Using this definition, FA-PNEU^® directly influenced antibiotic therapy in 57.6% of cases, while in 17.7%, prescribing was instead guided by a suspected alternative infection. In patients without prior antibiotics, treatment initiation or withholding was fully concordant with FA-PNEU^® results, while in those already receiving therapy, 60.8% underwent modification, two-thirds in agreement with the panel. Conclusions: In critically ill patients with suspected nosocomial LRTI, FA-PNEU^® provided rapid, high-sensitivity diagnostics that substantially influenced antimicrobial prescribing. Its greatest value lies in ruling out bacterial infection and guiding stewardship, though results must be interpreted within the full clinical and microbiological context. Full article

In this study, we aimed to evaluate physiological and agronomic traits in 120 sugarcane genotypes under early drought stress conditions in a field trial across various soil types. The experiment used a split-plot arrangement, with a randomized complete block design and two replications. Two different water regimes were assigned to the main plot: (1) non-water stress (CT) and (2) drought (DT) at the early growth stage, during which sugarcane was subjected to drought stress by withholding water for 4 months. The subplot consisted of 120 sugarcane genotypes. The stalk height, stalk diameter, number of stalks, photosynthetic traits including SPAD chlorophyll meter reading (SCMR) and maximum quantum efficiency of photosystem II photochemistry (Fv/Fm), and normalized difference vegetation index (NDVI) were measured at 3, 6, and 9 months after planting (MAP). Yield and yield component parameters were measured at 12 MAP. Drought treatments lead to significant changes in various physiological traits in the sugarcane. Clustering analysis classified 36 sugarcane varieties grown in sandy loam soil and 15 genotypes in loam soil into two main clusters. In sandy loam soils, Biotec4 and CO1287 exhibited outstanding performance in drought conditions, delivering high cane yields. Meanwhile, in loam soil, MPT13-118, MPT07-1, Q47, F174, MPT14-1-902, and UT1 exhibited the best drought tolerance. Under drought conditions, cluster 1 showed higher values for SCMR, NDVI, height growth rate (HGR), cane yield, and drought tolerance index compared to cluster 2. These findings suggest that breeders can utilize these genotypes to enhance drought resistance, and the identified physiological traits can assist in selecting stronger candidates for drought tolerance. Full article

Soybean (Glycine max (L.) Merrill) is highly sensitive to water deficit, particularly during the vegetative phase, when morphological and metabolic plasticity support continued growth and photosynthetic efficiency. We applied eleven water regimes, from full irrigation (W100) to total water withholding (W0), to plants grown under controlled conditions. After 14 days, we quantified morphophysiological, biochemical, leaf optical, gas exchange, and chlorophyll a fluorescence traits. Drought induces significant reductions in leaf area, biomass, pigment pools, and photosynthetic rates (A, g_s, ΦPSII) while increasing the levels of oxidative stress markers (electrolyte leakage, ROS) and proline accumulation. OJIP transients and JIP test metrics revealed reduced electron-transport efficiency and increased energy dissipation for many parameters under severe stress. Principal component analysis (PCA) clearly separated those treatments. PC1 captured growth and water status variation, whereas PC2 reflected photoprotective adjustments. These data show that progressive drought limits carbon assimilation via coordinated diffusive and biochemical constraints and that the accumulation of proline, phenolics, and lignin is associated with osmotic adjustment, antioxidant buffering, and cell wall reinforcement under stress. The combined use of hyperspectral sensors, gas exchange, chlorophyll fluorescence, and multivariate analyses for phenotyping offers a rapid, nondestructive diagnostic tool for assessing drought severity and the possibility of selecting drought-resistant genotypes and phenotypes in a changing stress environment. Full article

Background/Objectives: Iron deficiency (ID) is a common nutritional deficiency in infancy and early childhood associated with increased risk of infection and increased likelihood of receiving antibiotic intervention. In the context of ID, antibiotics have been shown to exaggerate the growth impairments and negative impacts on metabolic health of ID itself. The objective of this research was to assess the tissue-level impact of antibiotics when provided during ID. Methods: ID was induced in piglets by withholding an iron dextran shot shortly after birth, and iron deficiency was maintained after weaning by providing an iron-deficient diet starting on postnatal day (PD) 25. Half of the ID piglets received a 3-day antibiotic course (ID + Abx) consisting of spectinomycin and gentamicin from PD34-36. The kidney, liver, skeletal muscle, and hippocampal metabolomes, as well as activity of proteins in the mTOR signaling pathway, were assessed on PD43. Results: While ID had minimal impacts on the liver, kidney, and skeletal muscle metabolomes, ID + Abx impaired energy metabolism and increased ketosis and oxidative stress in peripheral tissues. Hippocampal metabolites involved in neurotransmitter synthesis pathways were affected by ID and ID + Abx to a greater extent. Additionally, the activities of several proteins in the mTOR pathway were upregulated in the hippocampi of ID + Abx piglets compared to both ID and control piglets. Abx provided to iron-sufficient piglets had minimal effects on tissue metabolomes and did not alter the activity of proteins in the mTOR pathway. Conclusions: These results highlight that antibiotic treatment in ID alters metabolism in peripheral tissues and the developing hippocampus beyond those induced by ID alone. Considering that infants and children are develop rapidly, the combination of ID and antibiotics may have lasting impacts on neurodevelopment and cognition. Full article

Recent developments in 3D bioprinting offer innovative alternative solutions to classical treatments for head and neck defects. Soft tissues in an anatomical area as diverse in composition as the head and neck are complex in terms of structure and function. Understanding how cellular interaction underlies functionality has led to the development of bioinks capable of mimicking the natural morphology and roles of different human parts. Moreover, from the multitude of recently developed materials, there are now many options for building scaffolds that potentiate the activity of these cells. The fidelity and accuracy of the utilized techniques ensure maximum precision in terms of model construction. Emerging technologies will allow for improved control of the scaffold, facilitating optimal results in the treatment of various pathologies, without concerns about the availability of donors, immunological response, or any other side effects that traditional treatments withhold. This paper explores the current landscape of bioprinted scaffolds and their applications in the head and neck region, with a focus on the properties and use of natural and synthetic bioinks in the attempt to replicate the biomechanical features of native tissues. Customization capabilities that support anatomical precision and biofunctionality are also addressed. Moreover, regulatory requirements, as well as current challenges related to biocompatibility, immune response, and vascularization, are critically discussed in order to provide a comprehensive overview of the pathway to clinical application. Full article

Olive trees are generally considered a species well-adapted to drought, but the impact of water shortage is of critical importance on olive production. For this reason, developing tolerant cultivars could be an effective strategy to mitigate the impact of drought in the future. Characterizing drought stress tolerance in olive is a complex task due to the numerous traits involved in this response. In this study, plant growth, pressure–volume curves, gas-exchange and chlorophyll fluorescence traits, and stomata characteristics were monitored in nine cultivars to assess the effects of mild and severe drought stress conditions induced by withholding water for 7 and 21 days, respectively, and were compared to a well-watered control treatment. The plant materials evaluated included traditional cultivars, as well as new developed cultivars suited for high-density hedgerow olive orchards or resistant to verticillium wilt. Significant differences between cultivars were observed for most evaluated traits, with more pronounced differences under severe drought conditions. A multivariate analysis of the complete dataset recorded throughout the evaluation period allowed for the identification of promising cultivars under stress conditions (‘Sikitita’, ‘Sikitita-2’, and ‘Martina’) as well as highly discriminative traits that could serve as key selection parameters in future breeding programs. Full article

Transcranial pulse stimulation (TPS) is a non-invasive neuromodulation method that uses, high-intensity acoustic shockwaves to deliver focused mechanical stimulation to neural tissue with minimal thermal effects. The mechanism of action includes but is not limited to promotion of blood flow and angiogenesis through mechanotransduction. Clinical data to date are limited and preliminary. In Alzheimer’s disease (AD), TPS has demonstrated cognitive and mood improvements in pilot studies and secondary endpoint analysis in first randomized trials. The enhancement of gamma-band oscillations and network connectivity has been reported. Clinical observations in Parkinson’s disease (PD) suggest TPS as a hypothesis-generating approach to address non-motor symptoms—such as depression, cognitive decline, and the freezing of gait—through theoretical modulation of basal ganglia–cortical circuits. TPS is CE-marked in Europe for AD and shows a favorable safety profile; however, ethical considerations arise from the limited evidence base, potential impairment of patient autonomy and judgment in dementia, and the risk of withholding established treatments. TPS should only be offered under structured scientific protocols or within patient registries to ensure rigorous oversight. Ensuring that consent processes account for cognitive capacity, and that TPS is applied as adjunct rather than replacement therapy, is paramount. Future research must include large-scale randomized controlled trials (RCTs), standardize stimulation protocols, deepen mechanistic insight, and embed robust ethical frameworks. Full article