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Background: Clinical blood resources are scarce and autologous blood transfusion for extracorporeal membrane oxygenation (ECMO) withdrawal is less studied., Objectives: To assess the use of staged autotransfusion during ECMO decannulation., Methods: The study included ECMO withdrawal patients. Patients in the autologous transfusion group underwent staged transfusion during ECMO withdrawal, while those in the control group received 2.0 units of allogeneic packed red blood cells (RBCs) to increase hemoglobin (Hb). Parameters such as Hb, hematocrit (Hct), adverse events, decannulation success rate, volume of allogeneic RBC transfusions, and transfusion costs were compared., Results: A total of 82 Chinese patients were enrolled, with a mean age of 46 years, 27 were female, and the top three primary diagnoses were cardiac arrest, acute myocarditis, and severe pneumonia. There were 41 individuals in the autologous blood transfusion group and 41 in the control group. No significant differences were observed in Hb, Hct, adverse events, and the success rate for decannulation between the two groups (all P > 0.05). Compared with the control group, the volume of allogeneic RBC transfusions [0 (0∼1.50) U vs. 3.5 (1.88∼40) U, P < 0.001] and the total cost [130 (130∼390) Chinese Yuan (CNY) vs. 910 (487.50, 1040) CNY, P = 0.002] were lower in the autologous transfusion group., Conclusion: In comparison with allogeneic RBC transfusion, staged autotransfusion during ECMO decannulation not only effectively maintained Hb levels but also reduced the requirement for allogeneic RBC transfusions. In addition, this approach decreased the associated costs and did not increase the risk of clinical adverse events., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Extracorporeal membrane oxygenation (ECMO) is used for severe cardiopulmonary failure, with veno-arterial ECMO for cardiogenic shock and veno-venous ECMO for acute respiratory failure. ECMO's application has expanded to ICUs, emergency departments, and operating rooms. ECMO patients are at high risk for complications, including acute kidney injury (AKI), often requiring renal replacement therapy (RRT), posing significant management challenges., Methods: From August 2015 to June 2022, 120 patients were cured with veno-venous ECMO (n = 60) or veno-arterial ECMO (VA-ECMO, n = 60) combined with CRRT in our hospital. In the control group (n = 60), the input end (arterial end) of CRRT was connected to the ECMO oxygenator. The reinfusion end (venous end) of CRRT was connected to the oxygenator of ECMO for CRRT + ECMO treatment. In the experimental group (n = 60), the input end (arterial end) of CRRT was connected to the oxygenator of ECMO, and an additional pressure regulating device was installed on the connection of the 2 lines. The observation indexes including clinical therapeutic effect, clinical therapeutic effect, the incidence of complications, and the incidence of complications were compared., Results: There was a notable decrease in serum creatinine, and the differences in blood urea nitrogen, procalcitonin, and C-reactive protein after operation were statistically significant (P < .05). The filter use time in the study group was notably longer (P < .01). There exhibited no remarkable difference in the incidences of bleeding, thrombosis, numbness of hands and feet, metabolic alkalosis, disseminated intravascular coagulation, organ dysfunction syndrome, hyperbilirubinemia, and infection., Conclusion: This study demonstrates that additional pressure regulation devices are installed at the line connection between the CRRT input end and the CRRT return end to ensure that the flow rate of ECMO does not affect the CRRT treatment. ECMO and CRRT provide a safe pressure range so that the ECMO line can be safely connected to the CRRT machine at physiological pressure, reducing the occurrence of complications related to CRRT machine interruption and improving the efficiency of CRRT without affecting the efficiency of ECMO, ensuring patient safety., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Intensive care unit-acquired weakness (ICU-AW) is very common in ICU patients. It is important to understand the status quo of knowledge, attitude and behavior of ICU nurses about ICU-AW. This survey aimed to investigate the knowledge, attitude and behavior of ICU nurses about ICU-AW, to provide useful implications for clinical care., Methods: ICU nurses from two tertiary hospitals in China from October 10 to November 15, 2023 were included. The ICU-AW knowledge, attitude and behavior questionnaire of ICU nurses with 31 items were used for survey. SPSS24.0 statistical software was used for data analysis., Results: A total of 364 ICU nurses were included for survey. The ICU-AW knowledge of ICU nurses was 21.96 ± 5.72 (< 50% of the total knowledge score), the ICU-AW attitude of ICU nurses was 30.24 ± 5.05(< 75% of the total attitude score), the ICU-AW behavior of ICU nurses was 26.77 ± 5.81(< 75% of the total behavior score), the total score was 79.21 ± 12.69(< 75% of the total score). Nurses' ICU-AW knowledge, attitude and behavior were all correlated (all P < 0.05). Multiple linear regression analyses indicated that age, years of ICU work experience, professional ranks and titles, had received the training about the ICU-AW were the influencing factors of knowledge, attitude and behavior of ICU nurses about ICU-AW (all P < 0.05)., Conclusions: The knowledge, attitude and behavior of ICU nurses' ICU-AW needs to be improved, and there are many influencing factors. Hospital nursing administrators should strengthen the training of nurses' ICU-AW knowledge and improve the cognitive and practical ability of ICU nurses on ICU-AW, so as to reduce the occurrence of ICU-AW., (© 2024. The Author(s).)

Objective: To investigate correlation between early net fluid balance and the clinical outcomes of patients receiving extracorporeal cardiopulmonary resuscitation (ECPR)., Methods: Adult patients on ECPR admitted to the Department of Emergency in the First Affiliated Hospital of Nanjing Medical University from May 2015 to December 2020 were included. Net fluid balance for consecutive 4 days after ECPR was recorded. The primary outcome was survival to intensive care unit (ICU) discharge. We used multivariable logistic regression to assess the association between fluid status and clinical outcomes., Results: A total of 72 patients were enrolled and divided into two groups: the survivor group and the non-survivor group. The overall rate of survival to ICU discharge was 44.4%. Daily fluid balance (DFB) in the survivor group was lower than that in the non-survivor group at day 4 (-11.47 (-19.74, 8.7) vs. -5.08 (-12.94, 13.9) mL/kg, P=0.046), as was cumulative fluid balance (CFB) over the first 4 days (-36.03 (-51.45, 19.03) vs. -7.22 (-32.79, 21.02) mL/kg, P=0.009). Both continuous renal replacement therapy (CRRT) and CFB from days 1-4 were significantly correlated with survival to ICU discharge (OR=14.617, 95% CI: 1.344, 48.847, P=0.028; OR=1.261, 95% CI: 1.091, 1.375, P=0.003, respectively). CFB from days 1-4 was determined to have a roughly linear association with the log odds of survival to ICU discharge., Conclusion: Early negative fluid balance maybe associated with survival to ICU discharge in patients receiving ECPR., Competing Interests: None., (AJTR Copyright © 2023.)

Objective: The objective of this study was to compare the safety and efficiency of different extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) connection methods., Background: The number of patients receiving ECMO is increasing, and the fields of application are getting wider. However, patients receiving ECMO are prone to acute kidney injury and fluid overload requiring CRRT. There are few comparative studies of two different systems of connecting CRRT device and ECMO from safety and efficacy perspective., Methods: This retrospective observational study included patients receiving ECMO in the extracorporeal life support centre of the First Affiliated Hospital of Nanjing Medical University from June, 2015, to December, 2020. Patients were divided into the parallel system group and integrated system group according to the connecting method between ECMO circuit and CRRT line. The outcomes were discharge survival rate, CRRT therapeutic dose completion rate, CRRT catheterisation time, CRRT initiating time, local bleeding at the CRRT catheter site, mean filter life, ECMO circuit thrombosis, ECMO air leakage, or blood leakage due to CRRT., Results: Thirty patients in the parallel system group and 70 patients in the integrated system group were finally included. The discharge survival rate and CRRT therapeutic dose completion rate were not significantly different between the two groups. The parallel system group had significant longer CRRT initiating time (49.0 ± 12.1 min vs. 14.6 ± 2.1 min, P < 0.001) and shorter filter life (11.5 ± 3.2 h vs. 47.3 ± 14.0 h, P < 0.001) than the integrated system group. The occurrence rate of local bleeding was 93.3% in the parallel system group, and there is no bleeding case in the integrated system group. There was no case of ECMO circuit thrombosis from CRRT as well as ECMO air or blood leakage caused by CRRT in either group. ECMO therapy can be adapted by adjusting the position of the CRRT outlet in the integrated system., Conclusions: Connecting CRRT and ECMO as an integrated system might accelerate CRRT initiation, avoid local bleeding, and prolong filter life compared to the parallel system. The chance of developing CRRT-related ECMO circuit leak and thrombosis is manageable., (Copyright © 2022 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To explore the clinical value of extracorporeal cardiopulmonary resuscitation (ECPR) combined with different targeted temperature management (TTM) for the treatment of cardiac arrest., Methods: From January 2018 to September 2020, ECPR was initiated in patients with cardiac arrest who did not have their spontaneous circulation restored after 20 minutes of traditional cardiopulmonary resuscitation (CPR). A total of 22 patients (observation group) given TTM were treated with Hico-variotherm 550 (HU 550) and 30 patients (control group) not given TTM were treated with a medical water circulation cooling blanket. The Glasgow Coma scale (GCS) score, serum neuron-specific enolase (NSE), survival rate and neurological prognosis after ECMO weaning were compared between the two groups., Results: There was no significant difference between the two groups in GCS score on the third and seventh days after resuscitation and serum NSE on the first and third day after treatment (P>0.05). Compared with the control group, the survival rate (40.91% vs 33.33%) and favorable neurological outcome (36.36% vs 26.67%) of patients in the observation group were slightly higher, but the differences were not statistically significant (all P>0.05). The incidence of shivering and body temperature fluctuation during rewarming in the observation group was lower than that in the control group (P<0.05)., Conclusion: HU550 poikilothermia water cabinet combined with ECMO can better control the targeted temperature of patients in a more accurate range and improve the survival rate; however, it exerts no statistical improvement in the incidence of complications., Competing Interests: None., (AJTR Copyright © 2022.)

Background: Mortality of patients suffering from critical illness has been dramatically improved with advanced technological development of extracorporeal membrane oxygenation (ECMO) therapy. However, the majority of ECMO-supported patients failed to wean from ECMO therapy. As one of several options, cardiopulmonary rehabilitation serves as effective intervention in the improvement of cardiovascular and respiratory function in various major critical illness. Nonetheless, its role in facilitating ECMO weaning has not yet been explored. The purpose of this study is to investigate the effectiveness of cardiopulmonary rehabilitation on rate of ready for ECMO weaning in ECMO-supported patients (CaRe-ECMO). Methods: The CaRe-ECMO trial is a randomized controlled, parallel group, clinical trial. This trial will be performed in a minimum number of 366 ECMO-supported eligible patients. Patients will be randomly assigned to either: (1) the CaRe-ECMO group, which will be treated with usual care including pharmacotherapy, non-pharmacotherapy, and specific nursing for ECMO therapy and the CaRe-ECMO program; or (2) the control group, which will receive usual care only. The CaRe-ECMO program consists of protocolized positioning, passive range of motion (PROM) training, neuromuscular electrical stimulation (NMES), surface electrical phrenic nerve stimulation (SEPNS), and pulmonary rehabilitation. The primary outcome of the CaRe-ECMO trial is the rate of ready for ECMO weaning at CaRe-ECMO day 7 (refers to 7 days after the CaRe-ECMO program initiation). Secondary outcomes include rate of ECMO and mechanical ventilation weaning, total length in day of ready for ECMO weaning, ECMO weaning and mechanical ventilation, all-cause mortality, rate of major post-ECMO complications, ECMO unit length of stay (LOS) and hospital LOS, total cost for hospitalization, cerebral performance category (CPC), activities of daily living (ADL), and health-related quality of life (HRQoL). Discussion: The CaRe-ECMO is designed to answer the question "whether cardiopulmonary rehabilitation can facilitate weaning of ECMO (CaRe-ECMO)." Should the implementation of the CaRe-ECMO program result in superior primary and secondary outcomes as compared to the controls, specifically the add-on effects of cardiopulmonary rehabilitation to the routine ECMO practice for facilitating successful weaning, the CaRe-ECMO trial will offer an innovative treatment option for ECMO-supported patients and meaningfully impact on the standard care in ECMO therapy. Clinical Trial Registration: ClinicalTrials.gov, identifier: NCT05035797., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Zheng, Sun, Mei, Gao, Lv, Pan, Wang, Zhang, Hu, Sun, Li, Zhang, Zhang, Chen, Wang, Zhang, Li, Chen, Zhang and Lu.)

Key Message: An SVP protein, PhSVP, bound to the CArG-boxes in the promoter regions of FT-like paralogs and repressed their expression, thus affecting the floral transition in Phalaenopsis orchid. Phalaenopsis is an important ornamental flower native to tropical rain forests. It usually reaches vegetative maturity after 4-5 leaves and, after a juvenile stage, forms a flower spike (inflorescence) from the axillary buds. The PEBP gene family encodes a phosphatidyl-ethanolamine-binding protein (PEBP) domain involved in regulating flowering and other aspects of plant development. Here, we identified eight PEBP family genes in Phalaenopsis and detected the expression patterns of seven of them in various organs. Among them, PhFT1 (Phalaenopsis hybrid FLOWERING LOCUS T1), PhFT3, PhFT5, and PhMFT (Phalaenopsis hybrid MOTHER OF FT AND TFL1) promoted flowering in transgenic Arabidopsis, while PhFT6 inhibited flowering. PhSVP (Phalaenopsis hybrid SHORT VEGETATIVE PHASE), an SVP protein that repressed flowering in Arabidopsis, bound to the CArG-boxes in the promoter regions of PhFT3, PhFT6, and PhMFT in a yeast one-hybrid assay. Additionally, dual-luciferase and transient expression assays showed that PhSVP significantly inhibits the expression of both PhFT3 and PhFT6. Together, our work provides a comprehensive understanding of the PhFT-like genes that can promote or repress flowering, and it suggests strategies for regulating the floral transition in Phalaenopsis that exploit the evolutionary versatility of PhFTs to respond to various signals stimuli., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Competing Interests: The authors have no conflicts of interest to disclose.

In order to control nitrogen (N) pollution of Lake Taihu, China, we studied the spatial and temporal distribution characteristics of inorganic N in inflowing rivers polluted by industry, agriculture, and domestic sewage during low, moderate, and high flow periods. The results showed that dissolved total nitrogen (DTN) was the main fraction of total nitrogen (TN) input from these rivers. Inflowing rivers had distinct impacts on TN, DTN, ammonium N (NH 4 + ), and nitrate N (NO 3 - ) concentrations of Lake Taihu during the low flow period. Particulate nitrogen (PN) had an impact on Lake Taihu during the three flow periods and all the three types of rivers would increase PN concentration in the lake. Rivers polluted by agriculture had the greatest impact on Lake Taihu's TN, DTN, NO 3 - , and dissolved inorganic N (DIN) concentrations, while rivers polluted by industry had the greatest impact on NH 4 + concentration. Therefore, agriculture and industry should be key targets for nutrient reductions. The in-lake N concentrations were higher than those of inflowing rivers during moderate and high flow periods.

Objective: To determine the predictive values of different critical scoring systems for survival rate after discharge in critically ill patients supported by extracorporeal membrane oxygenation (ECMO)., Methods: The clinical data of 34 critically ill patients supported by ECMO admitted to Department of Emergency of the First Affiliated Hospital of Nanjing Medical University (Jiangsu Provincial People's Hospital) from July 2015 to September 2017 were retrospectively analyzed. The general information and the worst values of vital signs and related pathophysiological indicators within 12 hours before ECMO treatment of patients were collected, and sequential organ failure assessment (SOFA), multiple organs dysfunction score (MODS), simplified acute physiology score II (SAPS II), and acute physiology and chronic health evaluation IV (APACHE IV) scores were calculated. The patients were divided into survival group and non-survival group according to 28-day survival after hospital discharge. General clinical characteristics and aforementioned scores were compared between the two groups. Scoring systems for predicting prognosis were assessed by using the receiver operating characteristic (ROC) curve. The Kaplan-Meier method was used to depict the surviving curve., Results: Thirty-four patients were finally enrolled, 13 of whom were dead at the follow-up period of 28 days after hospital discharge, and 21 survived. Duration of ECMO support in non-survival group was significantly shorter than that in survival group (hours: 101.4±7.8 vs. 134.4±12.6), SOFA, SAPS II, and APACHE IV scores were significantly higher than those of survival group (SOFA score: 10.6±3.6 vs. 8.8±3.3, SAPS II score: 38.7±14.3 vs. 31.8±12.5, APACHE IV score: 46.5±15.5 vs. 38.1±11.3, all P < 0.05). There was no significant difference in gender, age, body mass index (BMI), vital signs or related pathophysiological indicators within 12 hours before ECMO treatment, or MODS score between the two groups. ROC curve analysis showed that the area under ROC curve (AUC) of SAPS II score for predicting 28-day survival rate was the highest, which was significantly higher than that of SOFA, MODS, and APACHE IV score (0.880 vs. 0.694, 0.654, 0.682, all P < 0.05). When the best cut-off value of SAPS II score was 43, the sensitivity was 81.2%, and the specificity was 77.9%. Kaplan-Meier survival analysis showed that 28-day survival rate after hospital discharge in patients with SAPS II score < 43 (n = 18) was significantly higher than that in patients with SAPS II score ≥ 43 (n = 16; χ 2 = 2.444, P = 0.018)., Conclusions: Four critical scoring systems of SOFA, MODS, SAPS II and APACHE IV have been proved to have good prognostic ability to predict 28-day survival after hospital discharge in critically ill patients supported by ECMO. Among them, SAPS II score system has more accurate prediction value.

A surface- and vertical subsurface-flow-constructed wetland were designed to study the response of chlorophyll and antioxidant enzymes to elevated UV radiation in three types of wetland plants (Canna indica, Phragmites austrail, and Typha augustifolia). Results showed that (1) chlorophyll content of C. indica, P. austrail, and T. augustifolia in the constructed wetland was significantly lower where UV radiation was increased by 10 and 20 % above ambient solar level than in treatment with ambient solar UV radiation (p < 0.05). (2) The malondialdehyde (MDA) content, guaiacol peroxidase (POD), superoxide dismutase (SOD), and catalase (CAT) activities of wetland plants increased with elevated UV radiation intensity. (3) The increased rate of MDA, SOD, POD, and CAT activities of C. indica, P. australis, and T. angustifolia by elevated UV radiation of 10 % was higher in vertical subsurface-flow-constructed wetland than in surface-flow-constructed wetland. The sensitivity of MDA, SOD, POD, and CAT activities of C. indica, P. austrail, and T. augustifolia to the elevated UV radiation was lower in surface-flow-constructed wetland than in the vertical subsurface-flow-constructed wetland, which was related to a reduction in UV radiation intensity through the dissolved organic carbon and suspended matter in the water. C. indica had the highest SOD and POD activities, which implied it is more sensitive to enhanced UV radiation. Therefore, different wetland plants had different antioxidant enzymes by elevated UV radiation, which were more sensitive in vertical subsurface-flow-constructed wetland than in surface-flow-constructed wetland.