Purpose: The DIANA study aimed to evaluate how often antimicrobial de-escalation (ADE) of empirical treatment is performed in the intensive care unit (ICU) and to estimate the effect of ADE on clinical cure on day 7 following treatment initiation. Methods: Adult ICU patients receiving empirical antimicrobial therapy for bacterial infection were studied in a prospective observational study from October 2016 until May 2018. ADE was defined as (1) discontinuation of an antimicrobial in case of empirical combination therapy or (2) replacement of an antimicrobial with the intention to narrow the antimicrobial spectrum, within the first 3 days of therapy. Inverse probability (IP) weighting was used to account for time-varying confounding when estimating the effect of ADE on clinical cure. Results: Overall, 1495 patients from 152 ICUs in 28 countries were studied. Combination therapy was prescribed in 50%, and carbapenems were prescribed in 26% of patients. Empirical therapy underwent ADE, no change and change other than ADE within the first 3 days in 16%, 63% and 22%, respectively. Unadjusted mortality at day 28 was 15.8% in the ADE cohort and 19.4% in patients with no change [p = 0.27; RR 0.83 (95% CI 0.60-1.14)]. The IP-weighted relative risk estimate for clinical cure comparing ADE with no-ADE patients (no change or change other than ADE) was 1.37 (95% CI 1.14-1.64). Conclusion: ADE was infrequently applied in critically ill-infected patients. The observational effect estimate on clinical cure suggested no deleterious impact of ADE compared to no-ADE. However, residual confounding is likely.

Appropriate critical care delivery for Coronavirus disease 2019 (COVID-19) is a cornerstone in saving lives. Earlier publications worldwide demonstrate higher mortality among patients receiving mechanical ventilation in intensive care units during “surges” in the number of cases. In contrast, lower mortality outcomes are evident in Japan using CRISIS [CRoss Icu Searchable Information System] data by the national registry, Japan ECMOnet for COVID-19. This highlights the need for scientific analysis of the medical factors contributing to high survival rates and social factors associated with low case “surges,” to gain insight into protective strategies for possible coming waves in the COVID-19 pandemic.

The CAVI is independent of BP and reproducible regardless of the induction of anesthesia and is significantly higher in patients with CAD. The CAVI might be able to predict atherosclerosis and coronary artery stenosis in patients undergoing cardiovascular surgery.

A rapid response system is required in a radiotherapy department for patients experiencing a critical event when access to an emergency department is poor due to geographic location and the patient is immobilised with a fixation device. We, therefore, rebuilt the response system and tested it through onsite simulations. A multidisciplinary core group was created and onsite simulations were conducted using a Plan-Do-Study-Act cycle. We identified the important characteristics of our facility, including its distance from the emergency department; the presence of many staff with little direct contact with patients; the treatment room environment and patient fixation with radiotherapy equipment. We also examined processes in each phase of the emergency response: detecting an emergency, calling the medical emergency team (MET), MET transportation to the site and on-site response and patient transportation to the emergency department. The protocol was modified, and equipment was updated. On-site simulations were held with and without explanation of the protocol and training scenario in advance. The time for the MET to arrive at the site during a 2017 simulation prior to the present project was 7 min, whereas the time to arrive after the first simulation session was shortened to 5 min and was then shortened further to 4 min in the second session, despite no prior explanation of the situation. A multidisciplinary project for emergency response with on-site simulations was conducted at an isolated radiation facility. A carefully planned emergency response is important not only in heavy ion therapy facilities but also in other departments and facilities that do not have easy access to hospital emergency departments.

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