Emergency Medicine Journals

Background Attempting to improve emergency care (EC) advanced clinical practitioner (ACP) training, Health Education England (HEE) South West (SW) implemented a pilot, whereby emergency departments (ED) were provided with enhanced funding and support to help ED consultants deliver teaching and supervision to EC ACPs to ensure more timely completion of EC ACP training compared with previous cohorts training in the region. We explored the experiences of trainee EC ACPs and consultant EC ACP leads working in EDs, which had implemented the new regional pilot. Methods We used a qualitative design to conduct semi-structured interviews with trainee EC ACPs and consultant EC ACP leads across five EDs that had implemented the HEE SW pilot. Interview data were analysed thematically. Results Twenty-five people were interviewed. We identified four themes: (1) the master’s in advanced practice could be better aligned with the Royal College of Emergency Medicine credentialling e-portfolio; (2) EC ACP training needs some flexibility to reflect the individual—‘one size does not fit all’; (3) supervision and teaching were recognised as important but requires significant staff capacity that is impacted by external pressures and (4) unclear role expectations and responsibilities hinder role transition and impact role identity. It was notable that EC ACPs primarily spoke about the development of their clinical skills both academically and within the workplace, despite there being other skills mentioned in the multiprofessional framework for advanced practice (leadership and management, education and research). Conclusion A clear supervision structure with protected time allocated for teaching and assessment of clinical skills within the ED is essential to facilitate trainee EC ACP progression. However, increasing demands on EDs make this a challenging goal to achieve. Role identity issues continue to persist despite the introduction of new guidance designed to provide more clarity around the ACP role. [...]

Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication. [...]

Background Emergency department (ED) crowding causes increased mortality. Professionals working in crowded departments feel unable to provide high-quality care and are predisposed to burnout. Awareness of the impact on patients, however, is limited to metrics and surveys rather than understanding perspectives. This project investigated patients’ experiences and identified mitigating interventions. Methods A qualitative service evaluation was undertaken in a large UK ED. Adults were recruited during periods of high occupancy or delayed transfers. Semi-structured interviews explored experience during these attendances. Participants shared potential mitigating interventions. Analysis was based on the interpretative phenomenological approach. Verbatim transcripts were read, checked for accuracy, re-read and discussed during interviewer debriefing. Reflections about positionality informed the interpretative process. Results Seven patients and three accompanying partners participated. They were aged 24–87 with characteristics representing the catchment population. Participants’ experiences were characterised by ‘loss of autonomy’, ‘unmet expectations’ and ‘vulnerability’. Potential mitigating interventions centred around information provision and better identification of existing ED facilities for personal needs. Conclusion Participants attending a crowded ED experienced uncertainty, helplessness and discomfort. Recommendations included process and environmental orientation. [...]

Objective Care partners play a vital role in supporting persons living with dementia (PLWD) in using medical services. We conducted a meta-synthesis to explore care partner perspectives of ED care for PLWD, as well as healthcare provider (HCP) perceptions of care partner roles within the ED, to identify care gaps and facilitators across the ED continuum. Methods MEDLINE, PsycINFO and Embase databases were searched from inception to 8 May 2023. Grey literature was also searched. Articles were included if they reported on care partner roles or experiences regarding care delivery for PLWD in the ED, either from the perspective of care partners or HCPs. A charting exercise was used to categorise the primary focus and outcomes of the articles selected for inclusion. A second charting exercise was used to derive overarching themes based on care partner roles in ED care for PLWD, and care partner perspectives surrounding barriers and facilitators to care. Results 16 articles were included. Important barriers and facilitators to care for PLWD were identified and organised according to the timepoint of the visit (pre-ED, during a visit and post-ED). Key care gaps and barriers to care included: gaps in primary care access and care planning, ED environment and organisational processes, deficits in communication regarding patient care, lack of care partner involvement in clinical decisions, and difficulties with discharge transitions and follow-up care. Key facilitators to care included: clinical information provided by care partners, care coordination, and care partner support and engagement. Conclusion These findings can aid in developing dementia-friendly EDs by informing policy and practices, as well as environmental modifications. Future studies should focus on the feasibility and effectiveness of interventions targeted towards EDs and primary care settings. Engagement of care partners in these intervention studies will be critical to their success. [...]

Dementia, the great thief of our times, robs peoples’ memories of who they are and who they were and can break the heart and spirit of those caring for them. Unpaid carers supporting someone with dementia undoubtedly saves health economies billions each year, this does not include the unquantifiable value of carers in the ED setting where they can be enormously helpful, advocating for and providing accurate clinical details of their loved one. The ED can be a very stressful place for patients with dementia as well as their carers and often it is not the right place for them. Research by Alzheimer’s Society UK (2019) found that nearly two-thirds of all emergency admissions of people with dementia were for avoidable illnesses and injuries caused by failures in care.1 To date, there has been little focus on the experiences of family members of being with an older... [...]

Introduction Civilian healthcare workers (HCW) and medical facilities are directly and indirectly impacted by armed conflict. In the Russia-Ukraine war, acute trauma care needs grew, the workforce was destabilised by HCW migrating or shifting roles to meet conflict needs, and facilities faced surge events. Chemical, biological, radiological, nuclear and explosive (CBRNE) exposure risks created unique preparedness needs. In response, an academic and international non-governmental organisation partnership was formed to design, implement and evaluate a locally prioritised training programme in Ukraine. Methods Seven in-person training courses (Advanced Trauma Life Support, Trauma Nursing Fundamentals, Pediatric Trauma Fundamentals, Prehospital Trauma Fundamentals, Stop the Bleed, Mass Casualty Management and CBRNE Preparedness) were adapted, translated, taught and evaluated in seven Ukrainian oblasts (regions; Kyiv, Dnipropetrovsk, Zaporizhzhia, Odesa, Lviv, Chernihiv and Mykolaiv) during the war. Topics were determined by available needs assessments and further adapted based on course participant feedback and evolving logistic and security challenges. Change in participant knowledge and confidence levels was assessed through precourse and postcourse knowledge and self-confidence evaluations and follow-up surveys. Initial courses were taught by international instructors and transitioned to Ukrainian instructors as they were trained. Web-based asynchronous videos in Ukrainian were developed to complement and reinforce in-person training. Results 4368 participants were trained in 164 courses from August 2022 to April 2023. 223 instructors were trained. Aggregate participant knowledge and self-confidence significantly improved in all courses. Interval follow-up responses indicated that the training was useful and 83.3% had used the skills within 8 weeks of training. Twenty-seven training videos were created which, as of April 2023, have been viewed over 1 700 000 times in 500 cities throughout Ukraine. Conclusions Locally prioritised training can be rapidly developed and delivered in an armed conflict setting providing civilians and frontline HCW with the skills and knowledge required to care for patients. Logistics, communication, equipment and security challenges can be overcome through strategic in-country partnerships. Short asynchronous video learning can complement and scale in-person training. [...]

A shortcut review of the literature was conducted to examine the sensitivity and specificity of point-of-care ultrasound (POCUS) in detecting paediatric skull fractures. A total of 162 publications were screened by title and abstract, 13 studies underwent full text review, and after review of bibliographies of meta-analyses and systematic reviews, a total of 6 articles were included. Details about the author, date of publication, country of publication, patient group studied, study type, relevant outcomes (skull fracture), results and study limitations were tabulated. The clinical bottom line is that, in paediatric patients with a minor head injury, POCUS performed by emergency medicine physicians has a sensitivity ranging between 77% and 100% and a specificity between 85% and 100% for skull fracture detection, and its use in clinical decision-making has yet to be validated. [...]

Hidradenitis suppurativa (HS) is a complex, chronic skin disease characterised by painful inflammatory nodules, abscesses, dermal tunnels, sinus tracts and fistulae with a predilection for intertriginous skin. HS carries a substantial disease burden due to its prevalence, associated comorbidities and quality of life impacts and is associated with high healthcare resource utilisation. Clarity regarding the prevalence and pathogenesis of HS has led to improved therapies and more patients seeking care in both outpatient and acute care settings, including the emergency department. Emergency medicine providers play a critical role in HS diagnosis, management of acute flares and connection of HS patients with long-term dermatologic care, which can in turn help manage utilisation of acute care resources. [...]

Emergency medicine (EM) advanced clinical practitioners (ACPs) are an innovative autonomous multiprofessional non-medical practitioner (NMP) workforce in EDs. Historically from nursing and paramedicine backgrounds, regulated by their primary professional regulatory bodies, they already possess considerable clinical experience pre-ACP training. ACP qualification is underpinned by Masters-level education in conjunction with extensive work-based assessments and independent non-medical prescribing which fully maximises role utilisation.1 2 Recognised prospective EM benefits,3 novel governmental enablers, and the 2017 Health Education England multiprofessional framework and definition for ACP in England4 potentiated this new NMP role for current and future UK healthcare delivery.5 Furthermore, the Royal College of Emergency Medicine (RCEM) supports the EM ACP role, including a ‘gold-standard’ credentialing process underpinned through submission of a rigorous portfolio of assessment evidence.2 2018 voluntary RCEM membership data estimated 400 EM ACPs, and a 2022 EM ACP... [...]

Thoracostomies, and subsequent placements of chest tubes (CTs), are a standard procedure in several domains of medicine. In emergency medicine, thoracostomies are indicated to release a relevant hemothorax or pneumothorax, particularly a life-threatening tension pneumothorax. In many cases, an initial finger-assisted thoracostomy is followed by placement of a CT to ensure continuous decompression of blood and air. CTs prevent the reoccurrence of a hemothorax or pneumothorax, which may otherwise develop by closure of the initial thoracostomy incision. CTs are commercial, purpose-made products; however, in certain settings, those may not be readily available. Triggered by own experience, we review the use of endotracheal tubes as back-up alternatives to commercial CTs. On a structural base, commercial CTs may not be available in economically challenged regions. Furthermore, in settings with restricted capacity for equipment weight and volume, for example, in mountain rescue backpacks, it might not be feasible to carry CTs, even if the care provider is adequately trained. Finally, care providers may run out of stock of commercial CTs, for example, in civil mass casualty (‘MASCAL’) scenarios, natural disasters or on the battlefield with difficult resupply. Literature on this topic is very limited. In this manuscript, we discuss the advantages and disadvantages of standard endotracheal tubes as alternatives in settings, where commercial CTs are not readily available. Although certainly not advocated as standard, the use of endotracheal tubes as CTs may be a suitable alternative or back-up solution in settings where commercial CTs are not readily available. We assume that this technique will be particularly of interest in settings with a high risk for thoracic injuries and limited availability of commercial CTs, for example, in military conflicts. Given the virtual absence of scientific data, more research on risks, benefits and patient outcome is required. [...]

Background Advanced cardiovascular life support (ACLS) for cardiac arrest is a cornerstone of emergency care and yet remains poorly studied in low- and middle-income countries. We characterised the clinical epidemiology and outcomes of cardiac arrest and ACLS in an ED in central Haiti, a lower middle-income country with a nascent emergency care system. Methods We conducted a prospective observational study of adult and paediatric patients who suffered cardiac arrest in an academic hospital ED in central Haiti from January 2019 to August 2020. Patients were identified prospectively at the time of clinical care. Data on demographics, comorbidities, clinical presentation, management with or without ACLS and outcomes were extracted from patient charts using a standardised form and analysed in SAS V.9.4. The primary outcome was survival to 24 hours after arrest. Results We identified 161 patients who suffered cardiac arrest in the ED. The mean age was 45 years; 55.9% were female, and 82.6% were aged >18. Common presenting diagnoses were pneumonia (16.1%), sepsis (14.9%), congestive heart failure/cardiogenic shock (11.2%) and cerebrovascular accident (10.6%). Few patients were on cardiac or oxygen saturation monitors (23.1%; 63.5%) prior to arrest. 43 (27%) patients received ACLS (two patients missing data). Among these, 58.1% had initial rhythm assessed, and 2/25 (8%) patients had shockable rhythms. The median time to arrest was 23.6 hours. Sustained return of spontaneous circulation was achieved in two patients (4.7%). Among patients for whom ACLS was not initiated, the majority were due to poor prognosis (66.4%) or irreversible cause (22.4%) in the setting of available resources. One patient survived to 24 hours; none survived to hospital discharge. Conclusion In this lower middle-income setting, cardiac arrest in the ED was associated with poor survival despite ACLS. Survival may be impacted by limited resources for prearrest monitoring as well as for ongoing critical care. [...]

Objectives Underutilisation of thrombolysis is a major problem in patients with stroke in Bangladesh as patients do not arrive within the therapeutic window due to delays in their way to emergency department. This study aims to assess the time delay from patients’ symptom onset to arrival in the hospital and the factors that are associated with it. Methods This cross-sectional survey of a prospective cohort of stroke patients was conducted between January and March 2023. 448 stroke patients meeting the inclusion criteria were enrolled in the study from five tertiary-level hospitals in Bangladesh. After obtaining informed consent, trained data collectors conducted face-to-face interviews of the patient/patients’ guardians via a pretested structured questionnaire. Stata (V.16) was used to analyse data. Median and IQRs were used to summarise quantitative variables, and qualitative variables were summarised using frequency and relative frequency. Pearson’s 2 test and Mann-Whitney U test were used to explore the bivariate relationship between predictor and outcome variables. Finally, a binary logistic regression model was fit to explore the factors associated with delayed arrival (>4.5 hours) at the hospital. Results The median age of the patients was 61 years (54–70) and 63% were men. The majority hailed from rural (59.6%) areas and had primary (25.89%) education. The patients had an overall median prehospital delay of 14 (8–28) hours, 3 (1–6) hours of decision delay, 1 (0–2) hours of medical contact delay, and 14 (6.5–25.75) hours of referral delay. Patients with master’s education (adjusted OR (AOR): 0.04, p=0.023) and private transport (AOR: 0.26, p=0.029) had a lower chance of late arrival. However, patients having unknown onset, self-medicating, having a previous history of stroke, and being admitted to a private hospital had a significantly higher chance of late arrival. Conclusion Nearly 90% of the patients were late to arrive (>4.5 hours) at hospital and referral delay comprises the majority of the prehospital delay. Therefore, fast symptom recognition and the urgency of seeking healthcare as soon as symptoms appear should be the focus of public awareness efforts. [...]

Academic Emergency Medicine, EarlyView. [...]

Abstract Objective The emergency department (ED) is an essential setting for diagnosis of pregnancy, confirmation of pregnancy location, and management of pregnancy loss and other complications. This health care service delivery is especially important for patients with limited or complicated access into reproductive health care elsewhere. We seek to assess emergency physicians’ knowledge, training, attitudes, and practices related to pregnancy options counseling, reproductive health referrals, and provision of medical- and procedural-induced abortion. Methods We surveyed a sample of emergency physicians in person at a U.S. national medical meeting regarding knowledge, attitudes, and practices related to reproductive health care delivery. Wilcoxon rank sum tests were used to evaluate differences between abortion-restrictive and -permissive states and chi-square tests were used to compare proportions between the two groups and Wilcoxon signed rank was used to compare median scores between questions. Thematic analysis was used to review qualitative responses. Results Of the 295 emergency physicians approached, 252 (85.4%) completed study procedures. The majority (n = 218, 86.5%) practiced in abortion-permissive states. Most (n = 178, 70.6%) supported abortion provision in the ED if legally allowed, though only about half (n = 131, 52.0%) reported ever prescribing medication abortion pills. Despite higher proportions reporting training in services, a small minority responded they could still independently provide pregnancy options counseling (25.1%), direct referrals for abortion (34.9%), medical management for early pregnancy loss (15.1%) or induced abortion (10.7%), or uterine aspiration for any pregnancy indication (1.6%). Training and knowledge were similar, though practice patterns and attitudes differed when comparing abortion-restrictive to -permissive states. Conclusions This national survey demonstrates that, while most emergency physicians support the provision of abortion care in this setting, they do not routinely provide this care due to a variety of factors including lack of knowledge, lack of training, and legal and institutional restrictions. [...]

Academic Emergency Medicine, EarlyView. [...]

Abstract Background Acute intoxication is common in patients evaluated for traumatic brain injury (TBI). However, the effect of elevated blood alcohol levels (BALs) on the diagnostic accuracy of FDA-cleared biomarkers for evaluating traumatic intracranial injury on computed tomography (CT) scan, namely, glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), has not been well studied. Methods We investigated the effect of significantly elevated (>300 mg/dL) and modestly elevated BAL (81–300 mg/dL) at emergency department presentation on the diagnostic accuracy of GFAP and UCH-L1 for predicting a positive CT in patients presenting to 18 U.S. Level I trauma centers within 24 h of TBI as part of the prospective, Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. Plasma GFAP and UCH-L1 were measured using Abbott i-STAT Alinity and ARCHITECT assays. Discrimination was evaluated using the area under the receiver operating characteristic curve (AUC). Results Of 2320 TRACK-TBI participants studied, 54 (2.3%), 332 (14.3%), 1209 (52.1%), and 725 (31.3%) had significantly elevated BAL, modestly elevated BAL, nonelevated BAL (0-80 mg/dL), and no BAL available, respectively; 48.3% of the cohort had a positive brain CT. Those with significantly elevated and modestly elevated BAL were more likely to have positive CT (61.1% and 60.5% vs. 46.9% and 44.0%) and had higher plasma GFAP and UCH-L1 levels than those with nonelevated BAL and no BAL available. The AUC of GFAP and UCH-L1 combined for predicting CT positivity was higher in those with significantly elevated BAL (0.949) than those with modestly elevated BAL (0.858), nonelevated BAL (0.849), and no BAL available (0.883). Conclusions Modestly and significantly elevated BAL does not lower the diagnostic accuracy of GFAP and UCH-L1 for predicting traumatic intracranial injury on CT. These biomarkers may be useful in decreasing avoidable brain CT imaging in persons with acute alcohol intoxication. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Abstract Background Despite the importance of effective communication during verbal de-escalation, research regarding patient primary language during management of agitation symptoms is limited. We evaluated associations between patient primary language and use of physical restraints and intramuscular (IM) sedation in the emergency department (ED). Methods This was a retrospective cohort analysis evaluating physical restraint and IM sedation characteristics using electronic medical records from 13 EDs affiliated with a large regional health care network located in the northeast United States. Data were collected for ED visits from 2013 to 2023 for all adult patients ages 18 and older. We performed logistic regression models using the presence of physical restraint and IM sedation orders as primary outcomes, adjusting for patient primary language, sex assigned at birth, age, race and ethnicity, and chief complaints. Results In our analysis of 3,406,474 visits, 3,086,512 included English speakers, 250,912 included Spanish speakers, 9,057 included Portuguese speakers, 6,616 included Arabic speakers, 6,425 included Italian speakers, 39,303 included other language speakers, and 7,649 included unknown language speakers; 18,546 visits included use of physical restraints and 48,277 visits included use of IM sedation. After demographic and clinical characteristics were adjusted for, visits with Spanish- and Portuguese-speaking patients had a reduced likelihood of physical restraints and IM sedation compared to English speakers, with adjusted odds ratios (95% confidence intervals) of 0.70 (0.65–0.76) and 0.82 (0.79–0.87) for Spanish speakers and 0.39 (0.20–0.68) and 0.84 (0.66–1.05) for Portuguese speakers, respectively. Conclusions ED visits with Spanish- and Portuguese-speaking patients were found to have lower odds of physical restraints and IM sedation, while Arabic, Italian, other, and unknown language–speaking patients were found to have higher odds. Factors contributing to linguistic differences in physical restraint and IM sedation use, such as cultural interpretations of behavior, quality of clinical interactions, and patient–clinician communication strategies, merit further investigation. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, Volume 32, Issue 2, Page 176-178, February 2025. [...]

We commend Shaw et al. for their retrospective observational study assessing the impact of a clinical decision support system (CDSS) prompting glycated hemoglobin (HbA1c) testing among at-risk emergency department (ED) patients with diabetes (1). Although they were able to identify and target vulnerable patients with suboptimal diabetes control and increase HbA1c testing, the CDSS alert did not translate to a significant decrease in HbA1c on follow-up testing compared with the preintervention group. [...]

We read the article authored by Klokman and Schönberger (1), recently published in your esteemed journal, and it was of great interest to us. The authors had highlighted the role of ultrasound (USG) guided interfacial plane block (IFPB) for anesthesia and analgesia in patients with proximal humerus fractures and dislocation. However, we have some queries regarding the article and suggestions that will be of interest to the readers. [...]

We read the article by Richard et al. recently published in the JEM with great interest (1). We would like to highlight some of the concerns in the manuscript through this correspondence. [...]

We are writing in response to the article titled “Safety of Diltiazem for Acute Management of Atrial Fibrillation (AF) in Patients with Heart Failure and Reduced Ejection Fraction in the Emergency Department” by Schmitt et al (1). The study evaluated the safety of intravenous diltiazem for managing atrial fibrillation with rapid ventricular response (AF RVR) in patients with reduced ejection fraction (EF < 50%). The findings revealed a higher risk of worsening heart failure and mortality in patients with reduced EF, but suggested diltiazem can be used safely in stable patients with isolated AF RVR, emphasizing the need for individualized risk assessment rather than a one-size-fits-all approach. [...]

Chen and Wang add empirical precision to a familiar truth to many clinicians, which is that depression directs disproportionately vulnerable patients into emergency departments (EDs). (1) Their stratified examination compellingly illustrates how depressive symptoms, particularly among poor, elderly, and female patients, are associated with increased ED use. But such a trend is not inevitable. Rather, it is an indication of an overall failure to provide proactive, coordinated care before crises arise. [...]

Thank you for the thoughtful comments on this work. The letter first states, “we disagree with the notion that CVST (cerebral venous sinus thrombosis) is a rare and difficult to diagnose coagulopathic disease,” and that CVST is relatively easy to diagnose when included on a proper differential. In the United States, CVST has a low incidence, varying from 13.9 to 20.2 per million people (1,2). In the context of the emergency department (ED), this diagnosis becomes even more difficult under time pressure, as well as the fact that nonspecific symptoms point to a variety of other more common diagnoses. [...]

We thank the authors of a letter to the editor (1) concerning our review published in The Journal of Emergency Medicine, “Prehospital Cricothyrotomy: A Narrative Review of Technical, Educational, and Operational Considerations for Procedure Optimization” (2). The authors discuss the use of point-of-care ultrasound (POCUS) to visualize the cricothyroid membrane, as studies suggest that identifying the cricothyroid membrane can be challenging, particularly in patients with elevated body mass index and distorted neck anatomy (3–5). [...]

We read with interest the article by Reyes et al. on a cross-sectional questionnaire survey of self-reported COVID-19 positivity rates in the underserved population visiting 14 emergency departments between 12/2020 and 3/2021 (period 1) and 11 emergency departments (EDs) between 2/2022 and 12/2023 (period 2) in California (1). It was found that 16% reported a positive COVID-19 test in period 1, and 46% reported a positive COVID-19 test in period 2 (1). Positivity rates were higher among Hispanics than non-Hispanics in both periods and higher among women than men in period 2 (1). [...]

We read with interest the article by Castleberry et al. about a 26-year-old postpartum woman who presented with a several-day history of right sensorimotor hemisyndrome and odd behavior (1). As she had a history of anxiety disorder, depression, and migraine, and a plain cerebral computed tomography (CCT) scan in the emergency department was normal, her symptoms were assessed as functional and a possible conversion disorder was diagnosed (1). On re-examination the next day due to worsening symptoms, she was found to have venous sinus thrombosis (VST) and was successfully treated with intravenous heparin and dexamethasone (1). [...]

Geriatric hip fractures are a commonly encountered in the emergency department (ED) with significant associated morbidity and mortality. Providing appropriate analgesia has many challenges, and the majority of patients require opioid medications for adequate pain control. Complications of opioids include delirium, respiratory depression, and constipation, among others. Ultrasound (US)-guided nerve blocks for hip fractures have emerged as an additional modality to utilize as part of a multimodal approach to analgesia. [...]

Disparities in emergency care for acute coronary syndrome (ACS) have been reported across sex and race/ethnicity. Evidence-based decision tools may help reduce these gaps if their components are objective. The HEART Score is a validated tool for cardiac risk stratification that may support more equitable care. [...]

The COVID-19 pandemic has turned out to be a huge challenge and a burden for medical services struggling with a huge number of patients and their ailments [1]. Currently in addition to the ever-growing number of COVID-19 cases related to the next wave, our attention should also be paid to patients who will struggle with a number of POST-COVID-19 complications. The implications of COVID-19 infection are continually being studied, both in terms of the frequency with which they occur and the mechanism by which they occur. [...]

This study aimed to examine the usability, feasibility, acceptability, and appropriateness of the information and communication technology for emergency medical services (ICT-EMS) systems to improve the transportation of emergency patients during the COVID-19 pandemic. [...]

The COVID-19 pandemic can exacerbate underlying substance use disorder and has impacted this vulnerable population in a variety of ways. There are limited data regarding how this pandemic has impacted emergency department (ED) patient presentations. [...]

Coronavirus disease 2019 (COVID-19) is primarily a febrile respiratory illness first documented in December 2019 in Wuhan, China that was declared a pandemic by the World Health Organization (WHO) on March 11, 2020 [1]. At the time of this writing COVID 19 infections have impacted 191 counties, and the death toll stands at 1,488,513 [2]. COVID-19 infection is known to cause coagulopathy and an inflammatory state [3], but there are few case reports involving COVID-19 related spontaneous bleeding outside of disseminated intravascular coagulation [3]. [...]

Thank you for sharing your institution's recent data and experience with a case of croup who was seen in your emergency department (ED), admitted on oxygen after dexamethasone treatment, and was found to be co-infected with both SARS-CoV-2 and enterovirus. I am glad your patient had a swift recovery. In our three reported cases of croup associated with SARS-CoV-2 infection over a two-month period, all three patients were positive for a single virus and had a negative viral panel (Biofire® FilmArray Respiratory Panel) (CR) for nineteen other viruses, including the ones most commonly associated with croup [1]. [...]

The efficacy of colchicine administration in patients undergoing percutaneous coronary intervention (PCI) remains controversial. We conduct a systematic review and meta-analysis to explore the influence of colchicine administration versus placebo on treatment efficacy for PCI. [...]

The publisher regrets the below abstract was missed to be included in the article. [...]

Despite the advantages of bone marrow transplantation (BMT), patients receiving this intervention visit the emergency department (ED) frequently and for various reasons. Many of those ED visits result in hospitalization, and the length of stay varies. [...]

A previous population-based study defined a broad set of complications of acute conditions encountered in Pediatric Emergency Departments (PEDs). These conditions represent a spectrum of diagnoses in which optimal PED care seems to reduce the risk of complications [1]. Recent studies on the impact of the severe coronavirus disease 2019 (COVID-19) pandemic found increased rates of appendiceal perforation, and severe diabetic ketoacidosis [2,3]. We investigated the rates of complications of serious acute conditions (CSAC) in PED patients during the COVID-19 pandemic. [...]

To describe the impact of a novel communication and triage pathway called, fast track dialysis (FTD) on the length of stay (LOS), resource utilization, and charges, for unscheduled hemodialysis for end stage renal disease (ESRD) patients presenting, to the emergency department (ED). [...]

We have read the article by Soh et al. reporting two cases of neuroleptic malignant syndrome (NMS) with CoronaVirus 2019 (COVID-19) [1] and we have identified another case by Kajani et al. [2] and the three cases represent NMS with COVID-19, as a part of its neurological complications that was attributed to injury of skeletal muscles and Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) utilizing central nervous system ACE2 receptors. Also, autopsy studies of COVID-19 patients have shown evidence of neuronal degeneration and hyperemic and edematous brain tissue [3]. [...]

Soon after the first patient in New York City (NYC) was diagnosed with the coronavirus disease of 2019 (COVID-19), the number of confirmed cases in New York State (NYS) skyrocketed with NYC being labeled the national epicenter of the pandemic [1]. State and city attempts to harness resources and stem the tide of infections escalated over the initial weeks, including a “NY on PAUSE” order limiting travel, business, and public gatherings. [...]

Circulation, Ahead of Print. BACKGROUND:Despite current treatment strategies for atherosclerotic vascular disease focusing on lifestyle modification and lowering cholesterol, a significant residual risk of major atherosclerotic complication remains, prompting investigation into lipoprotein(a) (Lp(a)) as a potential predictive biomarker. The objective of this study was to determine the usefulness of Lp(a) in identifying patients at high risk of incident extracoronary atherosclerotic vascular disease and complications.METHODS:Data from 460 544 participants in the UK Biobank with prospectively measured Lp(a) concentrations were included in this analysis. Cox proportional hazards regressions modeled the associations of Lp(a) concentrations with incident peripheral artery disease (PAD) and incident carotid artery stenosis and progression to the first major adverse limb event and the first stroke, respectively.RESULTS:Of the study participants, the median [interquartile range] age at study enrollment was 58 [51–64] years, 54.2% were male, 94.4% were European, 5.5% had diabetes, and 10.5% were smokers. Over a median follow-up time of 13.6 [12.9–14.4] years, 6347 (1.4%) and 1972 (0.43%) developed the first incidence of PAD and carotid stenosis, respectively. Among participants with prevalent PAD and carotid stenosis at enrollment, 196 (2.7%) and 67 (1.9%) progressed to the first incidence of major adverse limb event and stroke, respectively. Median Lp(a) concentrations were significantly different in those without atherosclerotic vascular disease at 19.5 nmol/L [7.6–73.5] compared with incident PAD at 25.3 nmol/L [8.3–107.3], progression to major adverse limb event at 33.3 nmol/L [8.7–158.2], incident carotid stenosis at 29.5 nmol/L [8.5–116.3], and carotid stenosis progression to stroke at 37.8 nmol/L [11.1–158.3]. The risk estimate per 75 nmol/L Lp(a) for incident PAD (hazard ratio [HR], 1.18 [95% CI, 1.15–1.20];P<0.0001) was similar to that for incident carotid stenosis (HR, 1.17 [95% CI, 1.13–1.20];P<0.0001). Among participants with PAD, those with high Lp(a) concentrations had 1.57 times the risk of developing major adverse limb event than participants with normal Lp(a) concentrations (95% CI, 1.14–2.16;P=0.006). Among participants with carotid stenosis, participants had 1.40 times the risk of developing an ischemic stroke with high Lp(a) concentrations, although this was not significant (95% CI, 0.81–2.40;P=0.228).CONCLUSIONS:High concentrations of Lp(a) are associated with both incident extracoronary atherosclerotic vascular disease and progression to major complications. [...]

Circulation, Volume 152, Issue 4, Page e47-e47, July 29, 2025. [...]

Circulation, Volume 152, Issue 4, Page 280-282, July 29, 2025. [...]

Circulation, Volume 152, Issue 4, Page e30-e31, July 29, 2025. [...]

Circulation, Volume 152, Issue 4, Page 230-232, July 29, 2025. [...]

Circulation, Volume 152, Issue 4, Page 283-285, July 29, 2025. [...]

Circulation, Volume 152, Issue 4, Page 213-216, July 29, 2025. [...]

Circulation, Ahead of Print. BACKGROUND:Public health and clinical guidelines identify the importance of sedentary behaviors for cardiovascular diseases, particularly among postmenopausal women. The goal of this trial was to compare the behavioral and physiological impacts of 2 distinct approaches to changing sedentary behaviors.METHODS:Overweight or obese sedentary postmenopausal women (N=407) were randomly assigned to 1 of 3 study conditions for 3 months: (1) healthy living (control), (2) reduce sitting time (sit less), and (3) increase sit-to-stand transitions (STSTs; sit-to-stand). Each study arm received 7 individual health coach sessions across 12 weeks. At baseline and 3 months, participants had fasting blood drawn, had blood pressure measured, and wore thigh (activPal) and hip (ActiGraph) accelerometers for 7 days. Linear mixed models evaluated each intervention arm compared with the control (healthy living) arm.RESULTS:A total of 388 women (95%) completed the 3-month trial. The sit less arm reduced total sitting time by 58 minutes per day more than the healthy living arm (95% CI, –82.9 to –33.6;P<0.001) but did not change STSTs (–1 STST/day [95% CI, –9.4 to 6.5];P=0.72). Conversely, the sit-to-stand arm significantly increased STST by 26 STST per day more than the healthy living arm (95% CI, 17.71 to 33.64;P<0.001) but did not differ in change to sitting time (–10 min/day [95% CI, –34.6 to 14.9];P=0.44). The sit-to-stand arm had significant decreases in diastolic blood pressure compared with the healthy living arm (–2.24 mm Hg [95% CI, –4.08 to –0.40];P=0.02) and similar decreases in systolic blood pressure compared with the healthy living arm (–3.33 mm Hg [95% CI, –6.32 to –0.33];P=0.03), although it did not reach the a priori significance threshold ofP<0.025. There were no significant intervention effects on blood pressure for the sit less arm and no intervention effects for the glucoregulatory outcomes for either arm.CONCLUSIONS:This trial demonstrated the feasibility of changing sedentary behaviors as well as the distinct nature of sitting time and STST. Increasing STST improved blood pressure in overweight and obese postmenopausal women within 3 months. Focusing on increasing STST may be an achievable behavioral target to reduce cardiovascular disease risk in postmenopausal women.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT03473145. [...]

Circulation, Ahead of Print. BACKGROUND:Calcium (Ca2+) homeostasis in cardiac fibroblasts (CFs) plays a critical role in myocardial repair and remodeling after injury. JPH (junctophilin-2; human JPH2 or mouse Jph2) is a structural protein known to regulate intracellular Ca2+signaling and excitation-contraction coupling in cardiomyocytes. However, the role of JPH2 in CF biology remains unexplored.METHODS:Junctophilin expression was assayed in human and mouse CFs using reverse transcription quantitative polymerase chain reaction, Western blotting, and immunofluorescence. To investigate the functional role of Jph2 in CFs, we assessed Ca2+handling with live-cell confocal imaging, conducted RNA sequencing analysis, and assayed TGFβ (transforming growth factor β) responses after adenovirus-mediated gene silencing of Jph2 and fibroblast-specific Jph2 knockout. Jph2 interactions in CFs were identified using immunoprecipitation and proximity biotin ligation assays and confirmed by coimmunoprecipitation and rescue experiments. The in vivo role of Jph2 in CFs was investigated in fibroblast-specific Jph2 knockout mice (Col1a2CreERT/Jph2flox/flox, Jph2fKO) at baseline and after myocardial infarction and evaluated for changes in cardiac function, fibrosis, angiogenesis, CF activation, differentiation, and proliferation.RESULTS:Jph2 was identified as the only junctophilin expressed in CFs and acutely upregulated in response to myocardial infarction. Cellular and RNA sequencing analyses revealed that isolated Jph2-deficient CFs exhibited impaired fibroblast activation, reduced extracellular matrix production, and diminished expression of VEGFA (vascular endothelial growth factor A), VEGFB, and VEGFC after TGFβ treatment. In vivo, Jph2fKOmice displayed exacerbated adverse cardiac remodeling after myocardial infarction, characterized by decreased CF activation/extracellular matrix production, enhanced CF proliferation, worsened systolic dysfunction, enlarged left ventricular dilation, impaired scar maturation, and decreased angiogenesis. Mechanistically, biochemical assays demonstrated that Jph2 interacts directly with the coiled-coil 2 domain of Stim1 (stromal interaction molecule 1) via its joining region. Jph2 knockdown led to Stim1 protein destabilization, defective store-operated Ca2+entry, and a reduction in both canonical and noncanonical TGFβ signaling pathways. Stim1 overexpression partially rescued the sensitivity of Jph2-deficient CFs to TGFβ, as evidenced by increased expression of periostin and fibronectin-1, as well as enhanced Smad3 phosphorylation.CONCLUSIONS:Our results demonstrate that Jph2 is required in CFs to orchestrate Ca2+homeostasis, CF activation, and extracellular matrix production and promotes angiogenesis in the infarcted heart, positioning it as a central regulator of cardiac repair after injury. [...]

Circulation, Ahead of Print. BACKGROUND:Whether cannabis is a risk factor for cardiovascular events is unknown. We examined the association between smoking cannabis and cardiovascular events in a cohort of older veterans (66 to 68 years of age) with coronary artery disease.METHODS:The THC Cohort (Heart and Cannabis) comprised 4285 veterans (mean [SD] age, 67.5 [1.01] years; 2% female) with coronary artery disease who were born in 1950 to 1952. Participants were recruited between April 5, 2018, and March 12, 2020, interviewed about health behaviors, and then classified according to their self-reported cannabis smoking status in the previous 30 days. In a separate analysis, we classified participants according to any form of cannabis use (smoking, vaping, or edible use) versus nonuse in the past 30 days. Data on demographic, behavioral, and clinical characteristics were collected by telephone interview and from national Department of Veterans Affairs and Medicare data sources. The primary outcome included a composite of fatal and nonfatal stroke, fatal and nonfatal acute myocardial infarction, and cardiovascular death. The follow-up period for each patient extended from the date of their initial interview until the end of study (June 14, 2022). All participants were followed until they experienced an outcome or until the end of the follow-up period. Survey nonresponse weights and propensity score–based weights were used to reduce bias and confounding. Hazard ratios were estimated using cause-specific hazard models.RESULTS:The cohort included 1015 veterans with coronary artery disease who reported smoking cannabis in the previous 30 days and 3122 veterans who did not smoke cannabis in the previous 30 days. Mean follow-up was 3.3 years, and 563 events occurred. Compared with veterans who did not smoke cannabis, smoking cannabis (past 30 days) was not associated with the composite outcome of acute myocardial infarction, stroke, and cardiovascular death (adjusted hazard ratio, 0.87 [95% CI, 0.61–1.24]). Similarly, use of any form of cannabis (smoking, vaping, dabbing, edibles) in the past 30 days was not associated with the composite outcome.CONCLUSIONS:In this cohort of older veterans with coronary artery disease, self-reported cannabis use was not independently associated with increased cardiovascular events over a mean of 3.3 years of follow-up. [...]

Circulation, Volume 152, Issue 3, Page 208-211, July 22, 2025. [...]

Circulation, Volume 152, Issue 3, Page e28-e29, July 22, 2025. [...]

Out-of-hospital cardiac arrest (OHCA) treated by emergency medical services (EMS) in the United States (U.S.) has a neurologically intact survival to hospital discharge rate of 7.2 % with substantial regional variation.1,2 Bystander cardiopulmonary resuscitation (CPR) and high-quality CPR by EMS crews improves neurologically intact survival following OHCA.3–5 However, conventional CPR has limitations which has led investigators to seek novel strategies to optimize CPR and improve patient outcomes [...]

Following cardio-pulmonary resuscitation (CPR) and return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), post-resuscitation management aims to minimise anoxic brain damage1 and high-quality resuscitation care intends to reduce the complexity for care providers.2 To improve patient ventilation without requiring specific skills for endotracheal intubation (ETI), the concept of supraglottic airway management evolved and is guideline-recommended as a first-line, in particular for less skilled rescuers. [...]

Electroencephalography (EEG) is routinely used for prognostication after cardiac arrest (CA).1 Integrated with clinical examination, somatosensory evoked potentials (SSEP), serum neuron specific enolase (NSE), and brain imaging, highly malignant EEG (suppressed or burst-suppressed background with or without periodic discharges2 reliably estimates the likelihood of a poor outcome.1,3 Over the years, increasing attention has been directed towards favorable outcome prediction, forecasted by early continuous, reactive EEG background, along with motor response to stimuli, and low NSE. [...]

The initial rhythm is a known predictor of survival in extracorporeal cardiopulmonary resuscitation (ECPR) patients. However, the effect of the rhythm at hospital admission on outcomes in these patients is less clear. [...]

The incorporation of artificial intelligence (AI) into medical education and evaluation is transforming how clinical skills are assessed, offering new opportunities for efficiency, scalability, and uniformity in testing1–2. A recent study led by Wang et al.3, “Suitability of GPT-4o as an Evaluator of Cardiopulmonary Resuscitation Skills Examinations”, explores the use of GPT-4o4, a large language model, as a tool for evaluating CPR skills among medical students. With AI gradually becoming a fixture in medical examinations5,6, this research highlights its potential to improve both the efficiency and accuracy of practical skills assessments. [...]

The combination of controlled automated head/thorax elevation, active compression-decompression (ACD) cardiopulmonary resuscitation (CPR), and an impedance threshold device (ITD-16), termed AHUP-CPR, lowers intracranial pressure and increases circulation and neurologically-sound survival in pigs versus conventional (C) CPR. This study examined whether AHUP-CPR increased end tidal (ET) CO2, a non-invasive marker of cardiac output and organ perfusion, compared with C-CPR in witnessed out-of-hospital cardiac arrest patients. [...]

To the editor, [...]

The Utstein Out-of-Hospital Cardiac Arrest Resuscitation Registry Template, introduced in 1991 and updated in 2004 and 2015, standardizes data collection to enable research, evaluation, and comparisons of systems of care. The impetus for the current update stemmed from significant advances in the field and insights from registry development and regional comparisons. This 2024 update involved representatives of the International Liaison Committee on Resuscitation and used a modified Delphi process. [...]

The terms ‘heart attack’ and ‘cardiac arrest’ are distinct entities that are regrettably frequently confused, particularly within the media. Complicating the issue further is the fact that the two conditions frequently overlap, with coronary artery disease being the main aetiology of sudden cardiac arrest (SCA) In patients over 25 years of age1. Determining the precise degree of overlap (Figure 1) is of high importance given the heavy medical, societal and economic burden imposed by both conditions2–3. [...]

Despite significant research efforts, the “holy grail” of post-cardiac arrest prognosis remains elusive. Factors related to the arrest, resuscitation care, post-arrest care, and underlying comorbidities all play a role in determining who will survive the arrest beyond admission and who will have a neurological outcome that is meaningful. Much effort has been directed toward understanding hypoxic and ischemic brain injury (HIBI) during the post-arrest phase, especially the dysregulation phase, in which cellular injury to brain tissue progresses1. [...]

In our recent study of emergency ambulance phone calls for out-of-hospital cardiac arrest (OHCA), we identified that callers frequently encounter barriers to performing cardiopulmonary resuscitation (CPR).1 Emergency call-takers have the task of persuading callers to perform CPR as quickly as possible. However, very little has been published about what strategies call-takers use.2,3 We examined whether the “Behavioural Change Technique (BCT) Taxonomy”4 could be useful to classify call-taker strategies. [...]

This study aimed to predict blood pressure during CPR using chest compression waveform information obtained from a CPR feedback device. [...]

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Injury is the leading cause of death and a frequent cause of disability in children and negatively affects physical health, mental health, and quality of life in both the short and long term. The goal of a pediatric trauma system is to optimize the care for children within a state or region encompassing the entire continuum of care regardless of where children live or where traumatic events occur. This continuum includes injury prevention, prehospital care, emergency department care, interfacility transport, acute and critical inpatient care, inpatient and outpatient rehabilitation, and reintegration into the community and primary care medical home. A systems-based approach requires distinct elements of structure and function to perform together in an interrelated and cohesive manner to improve care quality. In this case, it represents a sequential practice of evidence-based evaluation and management along the continuum of care. To improve outcomes after injury, a cohesive system must effectively provide optimal care for the “right child, at the right place, at the right time” across this continuum. LEVEL OF EVIDENCE Consensus/Expert Opinion; Level V. [...]

Injury is the leading cause of death and a cause of disability in children and negatively affects physical health, mental health, and quality of life in both the short- and long-term. The goal of a pediatric trauma system is to optimize the care for children within a state, regional, or national trauma system across the entire continuum of care regardless of where they live or where the traumatic event occurs. This continuum includes injury prevention, prehospital care, interfacility transport between hospitals providing different levels of care, acute and critical inpatient care, inpatient and outpatient rehabilitation, and reintegration into the community and primary care medical home. A systems-based approach, one that requires distinct elements of structure and function to perform together in an interrelated and cohesive manner to improve care quality, is essential. To improve outcomes after injury, a cohesive system must effectively provide optimal care for the “right child, at the right place, at the right time” across this continuum. LEVEL OF EVIDENCE Expert Opinion; Level V. [...]

Prehospital use of tranexamic acid (TXA) has grown substantially over the past decade despite contradictory evidence supporting its widespread use. Since the previous guidance document on the prehospital use of TXA for injured patients was published by the National Association of EMS Physicians, the American College of Surgeons Committee on Trauma, and the American College of Emergency Physicians in 2016, new research has investigated outcomes of patients who receive TXA in the prehospital setting. To provide updated evidence-based guidance on the use of intravenous TXA for injured patients in the emergency medical services (EMS) setting, we performed a structured literature review and developed the following recommendations supported by the evidence summarized in the accompanying resource document. [...]

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The Trauma Quality Improvement Program Mortality Reporting System is an online anonymous case reporting system designed to share experiences from rare events that may have contributed to unanticipated mortality at contributing trauma centers. The Trauma Quality Improvement Program Mortality Reporting System Working group monitors submitted cases and organizes them into emblematic themes. This report summarizes two cases of anticipated mortality that both had opportunity for improvement related to more timely provision of palliative care cases. We present strategies to mitigate these delays locally. [...]

No abstract available [...]

Objectives: Patients who have cirrhosis, malignancy, or heart failure frequently accumulate ascitic fluid in their peritoneal cavity. Percutaneous drainage of ascites is a common procedure to provide diagnostic and/or therapeutic benefit to the patient; however, this procedure is associated with a small but life-threatening risk of hemorrhage. Given the avascular nature of the linea alba, it was hypothesized that a midline approach would reduce the risk of hemorrhage. Data Sources: Data were collected from the electronic medical record. This review was authorized by the University of Chicago, Institutional Review Board 20-0083. Study Selection: Using the electronic medical record, 1798 patients were identified using International Classification of Diseases, 9th revision and International Classification of Diseases, 10th revision codes between January 1, 2011, and January 1, 2020. Data Extraction: We conducted a retrospective chart review of 1798 patients who underwent 4563 percutaneous abdominal paracentesis events with ultrasound guidance. Four thousand five hundred thirteen of those procedures had information about procedure location. The location of catheter placement, lateral vs. midline, was recorded in conjunction with occurence rate of post-paracentesis clinically significant hemorrhage, defined as CT imaging with evidence of hemorrhage at the procedural site within 7 days of paracentesis that required either blood transfusion, angiographic intervention, or resulted in death. Baseline characteristics were also collected, including age, sex, body mass index, volume of ascites drained, baseline hemoglobin, platelet count, international normalized ratio, serum sodium, creatinine, bilirubin, albumin, and etiology of ascites. Among paracentesis events for patients with a diagnosis of cirrhosis (n = 2497), 2206 has sufficient data to calculate a Model for End-Stage Liver Disease (MELD) 3.0 score and 2202 had sufficient data to determine Child-Pugh Classification. Data Synthesis: Among patients receiving paracentesis, the overall occurence rate of hemorrhage was 1.3% (60/4563). There was a statistically significant reduction in the occurence rate of hemorrhage among patients who underwent midline percutaneous catheter placement (0/230) compared with lateral percutaneous catheter placement (60/4283; p = 0.03). Among patients with cirrhosis, patients undergoing lateral paracentesis (n = 2086) had a mean MELD 3.0 score of 22 (sd, 8.46) and patients undergoing midline paracentesis (n = 118) had a mean MELD 3.0 score of 25 (sd, 8.13). These groups had a statistically significant difference by Mann-Whitney U test (p ≤ 0.001) with a standardized effect size of 0.071. Logistic regression was performed to identify patient variables that correlated with hemorrhage. Among these, only serum bilirubin nearly approached significance (p = 0.07). No baseline variable had an odds ratio that did not cross 1.0. Conclusions: These data suggest midline paracentesis may reduce the risk of post-procedural hemorrhage among patients undergoing paracentesis. [...]

Objective: There is a lack of comprehensive international data regarding platelet transfusion practices in the ICU. This study aimed to evaluate the current occurrence rate of platelet transfusion in the ICU and provide an overview of platelet transfusion practices including indications for a platelet transfusion, thresholds, (non-)adherence and geo-economic region variations. Design: International prospective cohort study. Setting: Two hundred thirty-three centers in 30 countries worldwide. Patients: All patients 18 years old and older, admitted to the ICU during a single study week, selected by each site from one of the 16 predefined weeks (March 2019 to October 2022), were included. Interventions: None. Measurements and Main Results: Of the 3643 patients, 208 (6%) received a platelet transfusion during their ICU stay and main indications consisted of active bleeding (42%, n = 187/443), prophylaxis (33%, n = 144/443) or an upcoming procedure (12%, n = 51/443). The median platelet count before transfusion was 44 × 109/L (interquartile range [IQR], 20–78) with variation by indication, including a higher median of 60 × 109/L (IQR 31–93) during active bleeding. A threshold for transfusion was stated in 51% (n = 224/443) of the events, with a median threshold platelet count of 50 × 109/L (IQR, 40–100). The advised threshold was not adhered to in 16% (n = 36/224) of cases, with the majority having active bleeding as indication. Contrasts in transfusion practices were observed across different geo-economic regions. Platelet transfusions were administered to 6% (n = 156/2520) of patients in high-income countries, 5% (n = 52/1069) of patients in upper-middle-income countries and in none from lower-middle-income countries (n = 0/54). Non-adherence was higher in the high-income countries (23%, n = 34/149) than upper-middle-income countries (3%, n = 2/75). Conclusions: Platelet transfusions were administered to a small proportion of critically ill patients, and were given to treat active bleeding or as prophylaxis in the majority of cases. Occurence rate, indication and threshold adherence for platelet transfusion widely varied between geo-economic regions. [...]

Objective: To use digital twins constructed based on data from patients with acute respiratory distress syndrome (ARDS) to calculate all key indices of ventilator-induced lung injury (VILI) during airway pressure release ventilation (APRV), and to compare them with corresponding values obtained during pressure-controlled ventilation (PCV). Design: Digital twins were created by matching a high-fidelity cardiopulmonary simulation model to each patient’s data. Setting: Interdisciplinary Collaboration in Systems Medicine Research Network. SUBJECTS: A dataset consisting of pairs of ventilator settings and arterial blood gases for 98 patients with ARDS receiving PCV. INTERVENTIONS: VILI indices were calculated for each recorded PCV datapoint, and for typical APRV settings in fixed and time-controlled adaptive modes, in the same digital twins. Global optimization algorithms evaluated greater than 4.8 million changes to these settings to identify the lowest values of VILI indices that could be achieved in both modes while preserving adequate gas-exchange. Measurements and Mains Results: In digital twins, APRV settings of inspiratory pressure equals to 25 cm H2O, low-pressure setting equals to 0 cm H2O, inspiration time equals to 5 s, and expiration time set to achieve 75% of peak expiratory flow rate (mean 0.5 s), reduced mean mechanical power (MP) by 32% and mean tidal alveolar recruitment/de-recruitment by 34% compared with documented PCV settings, at the cost of moderate hypercapnia (mean PaCO2 58.5 mm Hg, pHa 7.32 vs. PaCO2 45.6 mm Hg, pHa 7.37). Mean driving pressure, tidal volume, and lung stress/strain were similar in both modes. Computational optimization showed that these settings were close to optimal in terms of minimizing both mean MP and mean levels of tidal recruitment/de-recruitment during APRV. Conclusions: Using digital twins we found possible lung-protective conditions and beneficial effects of APRV which need further evaluation in randomized clinical trials. [...]

Objectives: To synthesize the existing use, definitions, and variation in the application of hospital-free days (HFDs) as an outcome measure in randomized controlled trials (RCTs) of critically ill adults. Data Sources: Trial registries (ISRCTN, ClinicalTrials.gov) and electronic databases (CENTRAL, MEDLINE, Embase, and CINAHL PLUS). Study Selection: We included trial registrations, protocols, or articles reporting RCTs that included patients admitted to an adult ICU and had any variation of HFD as a primary or secondary outcome. Data Extraction: Data collected included definition of HFD, statistical analysis, minimal clinically important difference, method of data collection, and loss to follow-up. Risk of bias in the included studies was assessed using the relevant domains of the Cochrane Risk of Bias 2 tool (blinding of outcome assessment, incomplete outcome data, and selective reporting). Data were synthesized quantitatively using frequencies and percentages. Data Synthesis: We identified 110 eligible studies. We found considerable variability in how HFD was defined and reported. Incomplete reporting was common, with 69 studies (62.7%) not reporting all three individual components of HFD. Length of stay was omitted most frequently. Risk of bias related to outcome assessment and measurement was considered low. Fifty-two studies (47.3%) collected HFD data from routine healthcare records. The most common follow-up time points were 28 and 90 days. Over half of all studies (56 [50.9%]) did not report the number of HFD counted if a patient died during follow-up. Conclusions: This systematic review highlights the heterogeneity in the definition, reporting, and analysis of HFD. We propose guidance for the use of HFD and highlight areas for future research to allow standardization in the use and reporting of HFD in critical care research. [...]

Objective: To evaluate if titration of sweep gas oxygen fraction (FDO2) targeting post oxygenator conservative oxygen strategy might decrease organ dysfunction compared with a liberal extracorporeal oxygenation strategy. Design: Pilot multicenter randomized controlled trial. Setting: Four ICUs in three teaching hospitals of the eastern France. Patients: Cardiogenic shock supported by venoarterial extracorporeal membrane oxygenation (VA ECMO). Interventions: FDO2 titration targeting postoxygenator oxygen partial pressure (PPOSTO2) 100–150 mm Hg in the conservative arm, and FDO2 maintained at 100% in the liberal arm. Measurements and Main Results: Primary outcome was mean plasmatic intestinal fatty acid binding protein (IFABP) level at day 2, a marker of gut damage. Secondary outcome were feasibility criteria, biomarkers of hepatic and renal dysfunction, biomarkers of inflammation and antioxidant system. Among the 55 patients analyzed, 29 were assigned to the conservative arm and 26 to the liberal arm. The two arms were well separated over the first 7 days: FDO2 61 (± 7) % vs. 98 (± 5) %, and PPOSTO2 139 (± 40) mm Hg vs. 420 (± 50) mm Hg, in the conservative and liberal arms, respectively. However, in the conservative arm, the mean proportion of time within the targeted window was only 33 (± 20) %. IFABP on day 2 did not differ between conservative and liberal arms (407 [206—549] pg/mL vs. 569 [247—708] pg/mL, p = 0.25). Lactate, vasoactive inotropic score, aspartate aminotransferase, prothrombin time, serum creatinine, need for renal replacement therapy, tumor necrosis factor-α, IL-6 and IL-8 did not differ between the two arms at day 0, 2, and 6 after randomization. Conclusions: In patients supported by VA ECMO for cardiogenic shock, a conservative oxygen target strategy was not easily feasible, as PPOSTO2 could be maintained within the targeted window only 33% of time. However, the conservative and liberal arms were well separated regarding PPOSTO2, and we did not find any difference in biomarkers of organ dysfunction. [...]

Objectives: To assess the long-term effects of the early combination of neuromuscular electrical stimulation (NMES) and early mobilization (EM) in critically ill patients. Design: Single-Center, randomized, controlled, and blinded clinical trial Setting: Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo. Patients: Seventy-four patients who had been mechanically ventilated were randomized into two groups within the first 48 hours of ICU admission. Interventions: One group received daily EM starting within first 48 hours of ICU admission (EM group). The other group received the same EM protocol plus NMES, applied 5 days a week, also starting within the first 48 hours of ICU admission until ICU discharge (EM + NMES group). Measurements and Main Results: After hospital discharge, patients were assessed by telephone at 15 days and 6 months, and in person at 30 days and 3 months. Functional status, muscle strength, functional independence, quality of life, and symptoms of post-traumatic stress disorder (PTSD) were assessed. Baseline demographic and clinical characteristics were similar between groups. Patients in the EM + NMES group had significantly higher functional status, independence, and mobility compared with those in the EM group at all time points, as measured by the Barthel Index at 15 and 30 days, and at 3 and 6 months (p < 0.05), and the ICU Mobility Scale at 15 days, and at 3 and 6 months (p < 0.05). Additionally, quality of life was significantly improved in the EM + NMES group compared with the EM group, up to 6 months after hospital discharge (p < 0.05). There was no significant difference in PTSD scores between groups. Conclusions: The application of early NMES in addition to an EM protocol, when initiated within the first 48 hours of ICU admission, resulted in better functional outcomes and quality of life for critically ill patients up to 6 months post-discharge. [...]

Objective: Guidelines recommend implementing early enteral nutrition (EN) (EEN) in critically ill children. The aim of the study was to determine if EEN for critically ill children is associated with improved clinical outcomes compared with delayed enteral nutrition (DEN), prioritizing associations adjusted for severity of illness. PROSPERO (CRD42021286271). Data Sources: MEDLINE, Embase, CINAHL, and CENTRAL databases to October 2024. Study Selection: The population was critically ill children, the intervention was EEN, the comparator was DEN, the outcome was mortality or clinical outcomes, and the study designs included randomized control trials (RCTs), quasi-experimental, observational cohort, or case-control. Data Extraction: Screening, extraction, and risk of bias assessment using the Newcastle-Ottawa Scale and Cochrane Risk of Bias and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment were conducted in duplicate by two reviewers. Eighteen of 8478 screened studies were included. Data Synthesis: Mortality outcomes were pooled and meta-analyzed using random-effects models. Secondary outcomes were described qualitatively, and directions of associations were reported. Thirteen studies (1 RCT, 12 cohort) reported mortality; however, only three adjusted for illness severity. In the adjusted analysis, receiving EEN was associated with reduced mortality (adjusted odds ratio 0.36 (95% CI, 0.14–0.91), I2 = 78.6%, n = 5864). The certainty of evidence, as assessed by GRADE, was very low due to indirectness. In the qualitative review of 18 studies (1 RCT, 17 cohort studies, n = 9829), EEN had an association with reduced length of stay, length of invasive respiratory support, improved nutrition adequacy, reduced maximum pediatric logistic organ dysfunction score, and infection. No harmful effects of EEN were found after adjusting for confounding variables. Conclusions: EEN was associated with beneficial outcomes. However, the inclusion of mostly cohort studies with limited confounding adjustment, the small number of studies, the presence of between-study heterogeneity and residual confounding, and heterogeneity in measured outcomes and assessment methods resulted in very low certainty of evidence. [...]

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Objectives: Sepsis and septic shock require prompt intervention to improve outcomes. A rapid response team (RRT) system facilitates early recognition and management, including transfer to the ICU, but its impact on clinical outcomes remains unclear. This study assessed the association between RRT activation and clinical outcomes in septic patients initially managed in general wards, in a cohort of predominantly tertiary care hospitals in Japan. Design: Secondary analysis of prospectively collected data from the Japanese Intensive Care PAtient Database (JIPAD) for the fiscal years 2017–2022. Setting: A multicenter study using the JIPAD, which includes 324,037 patients across 95 ICUs in Japan. Patients: We identified 3883 adult patients admitted to the ICU with sepsis or septic shock after initial management in a general ward. Interventions: The patients were divided into those in whom the RRT was activated before ICU admission (the RRT group) and those in whom it was not (the control group). Measurements and Main Results: The primary outcome was in-hospital mortality. Secondary outcomes included rate of discharge to home, ICU mortality, length of hospital stay, and length of ICU stay. All outcome analyses were performed after stabilized inverse probability of treatment weighting using generalized estimating equations to account for clustering at the hospital level. There was no statistically significant difference in-hospital mortality between the RRT group (n = 850) and the control group (n = 3033; 38.6% vs. 37.1%; risk difference, 1.4%; 95% CI, –2.8% to 5.6%; p = 0.51). No significant differences were observed in secondary outcomes. Conclusions: In this nationwide study of septic patients requiring ICU admission, RRT activation was not associated with improvement of in-hospital mortality or other clinical outcomes. Despite the widespread implementation of RRTs, their impact on outcomes of sepsis in well-resourced healthcare systems such as Japan remains uncertain. [...]

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Objectives: To determine the temporal evolution of morbidity and mortality across different echocardiographic phenotypes of new-onset myocardial dysfunction in patients with sepsis. Data Sources: PubMed, Embase, Web of Science, MEDLINE, the Cochrane Central Register of Controlled Trials, and Google Scholar were searched up to October 1, 2024. Study Selection: All original studies related to new-onset myocardial dysfunction diagnosed by echocardiography in adult patients with sepsis were included. Data Extraction: Data were collected according to the predefined outcomes. Data Synthesis: This systematic review included 65 studies from 18 regions, involving 17,008 patients with sepsis. The meta-analysis encompassed three echocardiographic phenotypes, namely left ventricular systolic dysfunction (LVSD), left ventricular diastolic dysfunction (LVDD), and right ventricular dysfunction (RVD), as well as four subgroups based on different echocardiographic time points. No patients had cardiac dysfunction at baseline, and the occurrence rate of heart dysfunction declined to a minimal level during the recovery phase. The occurrence rate of LVSD peaked at 33% (95% CI, 27–40%) within 48 hours and declined to 22% (95% CI, 18–25%) within 72 hours. The occurrence rate of LVDD rose to 46% (95% CI, 34–57%) within 48 hours and dropped to 44% (95% CI, 32–56%) within 72 hours. The occurrence rate of RVD peaked at 47% (95% CI, 37–58%) within 48 hours and decreased to 33% (95% CI, 3–75%) within 72 hours. Patients with LVSD, LVDD, or RVD showed a higher risk of death (LVSD: relative risk [RR], 1.57 [95% CI, 1.29–1.91], p < 0.0001; LVDD: RR, 1.36 [95% CI, 1.05–1.75], p = 0.02; and RVD: RR, 1.62 [95% CI, 1.35–1.95], p < 0.0001). Conclusions: This meta-analysis shows a parabolic-like pattern of the occurrence rate of echocardiographic phenotypes (LVSD, LVDD, and RVD) over the time course of sepsis. LVSD, LVDD, and RVD are significant risk factors for mortality in sepsis. [...]

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Ultrasound-guided regional analgesia (UGRA) is a valuable component of a multimodal approach to pain management for children in the emergency department (ED). While widely used in pediatric anesthesiology, its adoption in the pediatric ED setting remains limited despite growing evidence supporting its safety and efficacy. UGRA can provide effective analgesia for pediatric patients with painful conditions while reducing reliance on opioids. However, successful implementation of a pediatric UGRA program requires structured training, multidisciplinary collaboration, and workflow optimization. This review summarizes the evidence base for pediatric UGRA, highlights key pediatric considerations for emergency providers, and outlines strategies for program implementation, including educational resources and system-based approaches to ensure safe and effective use in the pediatric ED setting. [...]

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Malaria is a worldwide problem with significant disease burden in endemic areas, including part of sub-Saharan Africa and several countries in South and Central America. With increasing patterns of global migration, more children with malaria are presenting to nonendemic countries, a phenomenon known as imported malaria. This review summarizes the diagnosis and management of children with imported malaria, with emphasis on key features of the travel history, diagnostic challenges, and management strategies in the acute setting. [...]

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Terminating cardiopulmonary resuscitation (ToR) in pediatric emergency department settings requires complicated clinical and ethical decision-making. This review focuses on providing physicians and advanced practice providers with practical guidance for assessing indicators of prognosis and navigating ethical considerations during the resuscitation of pediatric patients. Clinical indicators such as physical exam findings, arrest etiology, cardiopulmonary resuscitation (CPR) duration, and end-tidal carbon dioxide levels serve as benchmarks to guide resuscitation efforts. Ethical principles, including beneficence and non-maleficence, are critical in balancing the potential benefits of resuscitation with the harms of prolonged CPR, such as dysthanasia, moral distress, and adverse neurological outcomes. Underscored is the importance of compassionate communication with families, the appropriateness of clinician directiveness in ToR decisions, and the role of “slow codes” in the emergency department setting. [...]

Artificial intelligence (AI) has been applied to early recognition and management of rapidly progressive, community-acquired pediatric sepsis, a leading cause of childhood mortality. The broad adoption of electronic health records combined with rapid advances in digital technologies have enabled the federated training of both knowledge-driven AI, known as expert systems, trained by teams of collaborating clinicians, and data-driven AI, known as machine learning (ML), to derive predictive, clustering algorithms trained on “big data.” An important subset of ML is “deep learning,” which includes tools that understand, interpret, and manipulate human imagery and language, such as natural language processing and its subset large language models. We are in an era of rapid deployment of AI/ML-powered tools ranging from real-time electronic health records–embedded decision support tools to continuous wearable vital sign monitors and mobile/conversational virtual assistants/triage apps. These applications have the potential of transforming the timeliness of life-saving sepsis care delivery. This review explores the current and potential AI/ML applications in sepsis care, including tools for screening/early detection, risk stratification/outcome prediction, personalized treatment, and continuous patient monitoring. We highlight successful implementations and ongoing clinical trials, emphasizing the impact on patient outcomes. Finally, we address practical considerations for the future, such as bias mitigation and integration into clinical workflows. [...]

Caregiver intimate partner violence (IPV) is common, with an estimated one in 4 children exposed to family violence during their lifetime. This often leads to poor physical, emotional, and cognitive outcomes for these children. Pediatric emergency departments (EDs) are critical touchpoints for addressing caregiver IPV, as these caregivers frequently seek care for their children. This CME article explores the prevalence of caregiver IPV and identifies best practices around identification, trauma-informed care, documentation, and resource provision within pediatric EDs. We highlight universal education—an approach endorsed by the American Academy of Pediatrics—which involves providing IPV-related resources to all caregivers to normalize conversations and expand access to support. Ongoing efforts to enhance caregiver IPV identification and intervention in the pediatric ED setting are crucial for addressing this widespread public health concern. [...]

Point-of-care ultrasound (POCUS) has been useful in describing soft tissue infections, such as cellulitis and abscesses. There has been limited use of ultrasound to describe findings of intracranial infections, such as Pott's puffy tumor, in cases of forehead prominence and signs of infection. In this case series we present POCUS findings in 2 cases of intracranial infections and one case of soft tissue edema without intracranial involvement from a single pediatric tertiary care center. Ultrasound findings revealed subgaleal fluid collections with associated periosteal lifting of the frontal bone in cases of Pott's Puffy tumor and intracranial infection, but no bony disruption or periosteal lifting in the patient with traumatic soft tissue edema. As pediatric intracranial infections may continue to have uncharacteristic seasonal peaks, POCUS may be considered as a first-line imaging technique for patients presenting with forehead swelling for differentiating infectious and traumatic etiologies as well as judging the need for further imaging techniques such as computed tomography and magnetic resonance imaging. [...]

Objectives: According to the ideation-to-action framework of suicidality, suicidal ideation and suicidal action arise via distinct trajectories. Studying suicidality under this framework requires accurate identification of both ideation and action. We sought to assess the accuracy of International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes for suicidal ideation and action in emergency department encounters. Methods: Accuracy of ICD-10-CM coding for suicidality was assessed through chart review of clinical notes for 205 emergency department encounters among patients 6–18 years old at a large academic pediatric hospital between June 1, 2016 and June 1, 2022. Physician notes were reviewed for documentation of past or present suicidal ideation, suicidal action, or both. The study cohort consisted of 103 randomly selected “cases,” or encounters assigned at least 1 ICD-10-CM code for suicidality, and 102 propensity-matched “noncases” lacking ICD-10-CM codes. Accuracy of ICD-10-CM codes was assessed using sensitivity, specificity, positive predictive value, and negative predictive value. Results: Against a gold standard chart review, the positive predictive value for ICD-10-CM suicidality codes was 86.9% (95% confidence interval [CI]: 84.5%–89.3%), and the negative predictive value was 76.2% (95% CI: 73.2%–79.2%). Nearly half of encounters involving suicidality were not captured by ICD-10-CM coding (sensitivity = 53.4%; 95% CI: 49.9%–56.9%). Sensitivity was higher for ideation-present (82.4%, 95% CI: 77.7%–87.1%) than for action-present (33.7%, 95% CI: 27.9%–39.5%) or action-past (20.4%, 95% CI: 15.5%–25.3%). Conclusions: Many cases of suicidality may be missed by relying on only ICD-10-CM codes. Accuracy of ICD-10-CM codes is high for suicidal ideation but low for action. To scale the ideation-to-action model for use in large populations, better data sources are needed to identify cases of suicidal action. [...]

Cannabis remains one of the most frequently misused substances among adolescents. As recreational cannabis has proliferated across the United States, cannabis-related emergency department visits have increased. Cannabis hyperemesis syndrome, a variant of cyclic vomiting syndrome, has emerged as a recognized but poorly understood complication of chronic cannabis use among a subset of individuals. Cannabis hyperemesis syndrome is characterized by repeated cycles of abdominal pain, nausea, and vomiting refractory to standard antiemetics, with users reporting the compulsive use of hot showers to mitigate symptoms. Treatment modalities include intravenous fluid and electrolyte repletion, topical application of capsaicin, and the use of antidopaminergics (eg, droperidol, haloperidol). [...]

Objective: Entrustment describes the balance of supervision and autonomy between resident and preceptor to complete doctoring tasks like procedures. Entrustment alignment between resident and preceptor facilitates safe, successful outcomes, and promotes learning. Study objectives describe procedural entrustment alignment between senior pediatric residents and their preceptors and report the impact of a simulation-based formative assessment (SFA) on entrustment alignment. Methods: This prospective observational study enrolled a convenience sample of senior pediatric residents in 2023. The SFA was videoed, consisted of obtaining informed consent and performing simulated procedures (laceration [LAC] and lumbar puncture [LP]). Residents self-assessed their entrustability pre/post-SFA. A PEM preceptor panel individually rated videos of the residents. PEM panel's scores were compared to residents' scores on both an 8-point scale and the dichotomized variable of needing “in versus out” of the room entrustment. Results: Twenty-four residents' SFAs were rated by 9 panelists. Before the SFA, entrustment alignments on the 8-point scale were as follows: resident LAC 4.08 vs PEM panel 4.97 (P  [...]

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OBJECTIVES: To evaluate the feasibility of conducting a large international electronic health record-enabled randomized controlled trial (RCT) designed to compare two strategies for RBC transfusion (RBCT) in almost all anemic critically ill children, and the ability to support data abstraction from electronic medical data monitoring systems (eMDMSs). DESIGN: Two-arm parallel design pilot RCT. SETTING: Four university-affiliated PICUs in Canada, France, and United Kingdom. PATIENTS: Non-cyanotic critically ill children with hemoglobin (Hb) less than or equal to 9.5 g/dL. INTERVENTIONS: Participants were randomly allocated to a restrictive strategy (no RBCT if Hb ≥ 7.0 g/dL) or to usual care (clinician discretion for RBCT). MEASUREMENTS AND MAIN RESULTS: Feasibility outcomes were recruitment, adherence, separation of pre-RBCT Hb, and electronic data extraction from eMDMS. The proportion of patients with Hb less than or equal to 9.5 g/dL who were eligible for consent to participate in Pilot-Optimizing Transfusion Therapy in Critically Ill Children With Anemia (P-OpTTICCA) was 83% (feasibility criterion: ≥ 80%). We enrolled 120 patients, 63 in the restrictive and 57 in the usual care arms. We reached the planned recruitment rate (≥ 2 participants/wk in sites with > 800 admissions/yr, ≥ 1 in other sites). The pre-RBCT Hb concentration was 6.6 ± 7 and 6.7 ± 1.3 g/dL in the restrictive and usual care arms, respectively (separation = 0.1 g/dL; desired difference ≥ 1.0 g/dL). The pre-transfusion Hb concentration was greater than or equal to 7.0 g/dL for 6 of 20 RBCT (30%) given to patients allocated to the restrictive arm (success criterion for protocol adherence: < 20%). There were two protocol deviations, but no protocol violation. Using eMDMS, 87.7% of the 390 data elements in the case report form were extracted and/or calculated electronically (success criterion: > 80%). CONCLUSIONS: P-OpTTICCA demonstrated the feasibility of recruitment, adherence, and electronic data extraction, but we did not get a good separation of pre-RBCT Hb. Future trials need to clearly define transfusion Hb thresholds in both trial arms (NCT03871244). [...]

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OBJECTIVES: To investigate plasma nucleosome, histone H3 (H3), and citrullinated histone H3 (CitH3) levels in PICU patients with viral or bacterial pneumonia, and the associations with pediatric acute respiratory distress syndrome (PARDS) and sepsis. DESIGN: Single-center observational study of plasma nucleosome, H3, and CitH3 levels collected within 24 hours of PICU admission in patients with pneumonia requiring respiratory support. SETTING: A children’s hospital PICU in Yunnan, China. PATIENTS: Pneumonia patients and healthy controls seen during 2022–2024. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 152 children (0.3–12 years old) with severe pneumonia were enrolled and, post hoc, 47 met the 2024 Phoenix criteria for sepsis, and 45 met the 2023 criteria for PARDS. Pneumonia in comparison with 22 controls was associated with higher levels of all three markers (nucleosome, p = 0.0006; H3, p = 0.003; and CitH3, p = 0.029). In comparison with non-sepsis and non-PARDS cases, the sepsis and PARDS categories were associated with higher levels of all three markers (sepsis, p < 0.0001, p = 0.015, p < 0.0001; PARDS, p = 0.003, p < 0.0001, p = 0.0002). The area under the receiver operating characteristic curve (AUROC) analysis with nucleosome level using the sepsis endpoint was 0.79 (95% CI, 0.71–0.87), p < 0.0001. The relationship between H3 and PARDS vs. non-ARDS patients was AUROC 0.83 (95% CI, 0.75–0.91), p < 0.0001; and there was a negative correlation with Pao2 to Fio2 of r –0.63 (p < 0.0001). Regarding, the association between bacterial vs. viral etiology of pneumonia, the combination of plasma CitH3 and C-reactive protein showed AUROC of 0.84 (95% CI, 0.76–0.92), p < 0.0001. CONCLUSIONS: In PICU patients with pneumonia requiring respiratory support, we detected significant plasma of nucleosome, H3, and CitH3 within the first 24 hours of admission. Furthermore, categorization as PARDS or sepsis was associated with higher levels of these biomarkers. [...]

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