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. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

ABSTRACT Study Objective To characterize opioid and nonopioid drug use in the week following emergency department (ED)-initiated extended-release buprenorphine (XR-BUP) treatment using both self-reported data and urine drug screens (UDS). Methods This study uses data collected during a nonrandomized clinical trial of patients with untreated opioid use disorder (OUD), testing the safety and feasibility of initiating XR-BUP in patients presenting with minimal to mild withdrawal. The study was conducted from July 2020 to May 2023 across four urban academic EDs in the Northeast, Mid-Atlantic, and Pacific regions of the United States. A total of 100 participants, 18 years or older with OUD defined by DSM-5 criteria, a clinical opiate withdrawal scale (COWS [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

ABSTRACT Objective We quantified the magnitude of systolic blood pressure (SBP) adverse effects associated with intravenous furosemide (IVFu), compared to other factors, during treatment for acute decompensated heart failure (ADHF). Methods Continuous BP monitoring (598.2 person-hours, 91,210 observations) before and after IVFu was performed in a prospective multicenter ADHF cohort (n = 253). Multivariable-adjusted mixed effects regression was used to determine the amount of SBP reduction and the risk of hypotension attributable to IVFu administration, as opposed to confounders (e.g., non-IVFu treatments and baseline patient characteristics). Results Median SBP was 124 mmHg (IQR: 105–149) at baseline. Hypotension occurred in 5515 observations (6.0%). The multivariable models explained 79.6% and 58.1% of variance in SBP and risk of hypotension, respectively. Only 1.4% of variance in SBP and 1.7% of hypotension risk were related to IVFu, with the remainder accounted for by confounders. After multivariable adjustment, SBP dropped −11.9 mmHg on average after 80 mg IVFu, reaching a nadir at 147 min (−15.2 mmHg) and partial return to baseline by 6 h (−8.5 mmHg). IVFu-related risk of hypotension after multivariable adjustment depended predominantly on baseline SBP and dose. Risk of hypotension associated with 80 mg IVFu was ≤ 2% with baseline SBP ≥ 120 mmHg. For 40 mg, IVFu-associated hypotensive risk was ≤ 2% with SBPs of 90–100 mmHg, and [...]

I read with great interest the case report by Klokman et al. that described the application of an interfascial plane block for pain relief of shoulder injuries in the emergency department (1). I appreciate the authors for presenting this wonderful case report. I would like to present my clarifications on the regional anesthesia techniques of the shoulder. [...]

I read with great interest the case report by Klokman et al. that described the application of an interfascial plane block for pain relief of shoulder injuries in the emergency department (1). I appreciate the authors for presenting this wonderful case report. I would like to present my clarifications on the regional anesthesia techniques of the shoulder. [...]

We read the recent article by Murk et al., recently published in JEM, with great interest. We appreciate the author's effort in exploring the opioid-sparing strategies in the emergency department (ED) [1]. However, several methodological and reporting concerns warrant clarification before the findings can be confidently interpreted or generalized. [...]

We read the recent article by Murk et al., recently published in JEM, with great interest. We appreciate the author's effort in exploring the opioid-sparing strategies in the emergency department (ED) [1]. However, several methodological and reporting concerns warrant clarification before the findings can be confidently interpreted or generalized. [...]

We commend Lee et al. for their multi-center evaluation of adenosine versus fixed-dose intravenous bolus diltiazem for supraventricular tachycardia (SVT) in the emergency department (ED) (1). The work contributes valuable real-world data on a common clinical scenario. However, several important considerations merit further discussion to contextualize and expand upon their findings. [...]

We commend Lee et al. for their multi-center evaluation of adenosine versus fixed-dose intravenous bolus diltiazem for supraventricular tachycardia (SVT) in the emergency department (ED) (1). The work contributes valuable real-world data on a common clinical scenario. However, several important considerations merit further discussion to contextualize and expand upon their findings. [...]

We read with interest the article published by Dr. Cowan and colleagues describing a pilot randomized clinical trial of HIV pre-exposure prophylaxis (PrEP) initiation among emergency department (ED) patients and we congratulate the authors for taking on such an important, but challenging, topic. (1) Their study randomized 26 patients to immediate PrEP initiation (n = 13) versus outpatient referral for PrEP initiation (n = 13) using dedicated clinical research staff to screen for and enroll into the trial. [...]

We read with interest the article published by Dr. Cowan and colleagues describing a pilot randomized clinical trial of HIV pre-exposure prophylaxis (PrEP) initiation among emergency department (ED) patients and we congratulate the authors for taking on such an important, but challenging, topic. (1) Their study randomized 26 patients to immediate PrEP initiation (n = 13) versus outpatient referral for PrEP initiation (n = 13) using dedicated clinical research staff to screen for and enroll into the trial. [...]

Upper gastrointestinal bleeding (UGIB) is a common and life-threatening emergency with a mortality rate of 2–8%. Although prognostic assessment often relies on the Glasgow-Blatchford Score (GBS) and Rockall Score (RS), their inclusion of multiple parameters limits use in acute settings. The shock index (SI), derived from heart rate and systolic blood pressure, provides a simple and rapid alternative. This study investigates the relationship between the SI and established risk scores (GBS and RS) in patients with UGIB. [...]

Upper gastrointestinal bleeding (UGIB) is a common and life-threatening emergency with a mortality rate of 2–8%. Although prognostic assessment often relies on the Glasgow-Blatchford Score (GBS) and Rockall Score (RS), their inclusion of multiple parameters limits use in acute settings. The shock index (SI), derived from heart rate and systolic blood pressure, provides a simple and rapid alternative. This study investigates the relationship between the SI and established risk scores (GBS and RS) in patients with UGIB. [...]

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. Metabolic and genetic abnormalities have long been noted in cardiovascular diseases, but the contribution of mitochondrial genetic (mitochondrial DNA [mtDNA]) variation is understudied. Mitochondrial genetics is complex in that each mitochondrion contains multiple mtDNA copies that may carry different variants, which is called heteroplasmy. Heteroplasmic variation is dynamic, increases with advancing age, and may contribute to aging-related cardiovascular diseases. Pathogenic variants in mitochondrial genes of the mtDNA or nuclear genome cause mitochondrial diseases, often with cardiac involvement, particularly in patients with adult-onset disease. Population-level studies have identified mtDNA variants associated with cardiovascular risk factors and disease, but evaluation of mtDNA genetic variation is often limited to only a handful of variants and small sample sizes. Studies in animal models have linked several mtDNA variants to cardiac remodeling and dysfunction and suggest a role for mitochondrial–nuclear genetic interactions in disease penetrance. The objective of this scientific statement is to outline the current state of understanding of the role of mitochondrial genetics in cardiovascular pathobiology and highlight important gaps in knowledge. The intended audience of this scientific statement is meant to be broad, spanning clinical, translational, and basic researchers and health care professionals. Despite remaining limitations and barriers, recent advances in genomic sequencing, mtDNA gene editing modalities, and the directed differentiation of stem cells to cardiovascular cell types are creating new opportunities to advance understanding of mitochondrial genetics in cardiovascular pathophysiology. [...]

Circulation, Ahead of Print. BACKGROUND:Oxidized phospholipids on apolipoprotein B-100 (OxPL-apoB) reflect pro-inflammatory properties of Lp(a) (lipoprotein(a)). The effect of OxPL-apoB on major adverse cardiovascular events (MACE) in patients with acute coronary syndrome in recent the era is not known.METHODS:OxPL-apoB levels and Lp(a) were measured in 11 630 participants before and 5185 participants 4 months after randomization to alirocumab or placebo in the ODYSSEY OUTCOMES trial. Proportional hazards models adjusted for baseline covariates evaluated associations between log2-transformed OxPL-apoB and Lp(a) with MACEs. Interactions between the 2 biomarkers and treatment were also evaluated.RESULTS:Participants were followed for a median 2.9 years; the median age was 58 years, and 23.9% were female. Alirocumab reduced median placebo-adjusted OxPL-apoB by 13.0% and Lp(a) by 26.2% (bothP<0.0001). In the placebo group, a doubling of baseline OxPL-apoB was associated with a hazard ratio (HR) of 1.081 (95% CI, 1.026–1.139;P=0.0034) for MACEs. Addition of Lp(a) to the model relegated the relationship of OxPL-apoB insignificant. In the alirocumab group, neither OxPL-apoB nor Lp(a) remained significantly associated with MACEs. A significant 3-way interaction was present among continuous log2OxPL-apoB, Lp(a) stratified at the median, and treatment group on MACEs (Pinteraction=0.0023) so that, in the placebo group, increasing OxPL-apoB was associated with higher risk of MACEs when Lp(a) was below the median concentration but not above. In the alirocumab group, OxPL-apoB was not related to MACE risk irrespective of Lp(a) concentration.CONCLUSIONS:In patients with recent acute coronary syndrome receiving optimized statin treatment, elevated OxPL-apoB levels predicted MACEs, a relationship abrogated by alirocumab. The interaction of OxPL-apoB and Lp(a) in the placebo group indicates that OxPL-apoB independently predicts MACEs when Lp(a) levels are relatively low.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifiers: NCT001747 and NCT01663402. [...]

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Circulation, Ahead of Print. BACKGROUND:Atrial fibrillation and other cardiac arrhythmias pose a major public health burden, but prevention remains difficult. We investigated a genetic variant that we found to act like a natural lifelong cardiac sodium channel blockade.METHODS:We studied the impact of the Finnish-enrichedSCN5Amissense variant (rs45620037 [T220I]) on cardiac arrhythmias, associated mortality, and ECG phenotypes in a multicohort observational study with >1 million individuals across 3 cohorts (FinnGen, UK Biobank, and Health 2000).RESULTS:We identified protective effects of T220I on multiple common cardiac arrhythmias, most notably atrial fibrillation (cause-specific hazard ratio [HR], 0.56 [95% CI, 0.50–0.63];P<0.0001), but also ventricular premature depolarization or ventricular tachycardia, as well as increasing susceptibility to conduction-slowing conditions, such as sick sinus syndrome (mostly in older age groups). Overall, T220I conveyed protection from death resulting from cardiac arrahajournals.org/jouhythmia (HR, 0.65 [95% CI, 0.46–0.92];P=0.015) without a significant effect on overall mortality risk (HR, 0.92;P=0.27). T220I heterozygosity had similar electrophysiological effects as some pharmacological sodium channel blockers, such as significantly shortening QT intervals (−7.49 ms [95% CI, −10.07 to −4.91] ms;P=0.0037; n=3188) in the Health 2000 cohort, which we replicated in the UK Biobank (n=66 616). In addition, T220I protected from (left) heart failure and dilated cardiomyopathy. After myocardial infarction, we found that T220I increased mortality risk, consistent with known sodium channel blocker effects, which, however, normalized to baseline 10 to 15 years after myocardial infarction. We found that T220I could lower a high genetic burden (ie, a high polygenic score) for atrial fibrillation to population average.CONCLUSIONS:TheSCN5AT220I variant, consistent with a previously described weak loss-of-function effect, acted like a genetic proxy for cardiac sodium channel blockade. This enabled us to gain new potentially clinically relevant insights for pharmacological sodium channel blockade, such as after myocardial infarction, which would be too risky to investigate with clinical trials. Our findings may also inspire redesign of cardiac sodium channel blockers. [...]

Circulation, Ahead of Print. Background: Cardiovascular disease caused by atherosclerosis is responsible for 18 million deaths annually, highlighting a significant need for new medical therapies, especially for patients who are not eligible for percutaneous interventions. Atherosclerosis is driven by the accumulation of low-density lipoprotein (LDL) and the formation of foam cells, accompanied by oxidative stress and the accumulation of oxidized LDL (OxLDL), a pro-inflammatory molecule. Lowering LDL is the mainstay of current treatment along with blood pressure control and lifestyle changes, but to date, it has not been feasible to specifically target inflammatory pathways contributing to plaque development without significant systemic side effects. Over the past decade, chimeric antigen receptor (CAR) T cells have been used to treat cancer, resolve cardiac fibrosis, and restore immune balance in autoimmune diseases. In some instances, T regulatory cells endowed with CAR (CAR Tregs) have been developed to treat autoimmunity through antigen-specific immunosuppression.Methods: Using an inducible Treg platform, we created an anti-OxLDL–specific CAR Treg therapy and evaluated cell- and cytokine-mediated immunosuppression to reduce macrophage foam-cell formation in vitro. We then tested murine anti-OxLDL CAR Tregs in immunocompetent mouse models of hyperlipidemia and atherosclerosis.Results: Anti-OxLDL CAR Tregs reduced macrophage foam-cell formation in vitro and significantly inhibited atherosclerotic plaque formation in vivo in immunocompetent mouse models.Conclusions: Anti-OxLDL CAR Tregs mitigate inflammation and plaque deposition associated with oxidized LDL and may offer a new therapeutic option for atherosclerosis. [...]

Rationale: Arterial blood gas analysis is a key component of the initial assessment for patients with cardiac arrest. In accidental hypothermia, temperature effects on gas solubility and hemoglobin-oxygen affinity confound oxygenation status. It remains unclear whether these values can be used to exclude patients from extracorporeal cardiopulmonary resuscitation in hypothermic cardiac arrest. [...]

This study examines the influence of supraglottic airway (SGA) devices versus tracheal intubation (TI) on key ventilation parameters during intra-arrest-ventilation using volume-controlled-ventilation (VCV) in adult out-of-hospital cardiac arrest (OHCA). [...]

Severe coronary artery disease has been suggested as the main cause of out-of-hospital cardiac arrest (OHCA) requiring high number of defibrillations. We investigated the association between an increased degree of treatment refractoriness, defined as an increase in the number of defibrillation attempts, to coronary angiography findings and PCI in OHCA. [...]

Intro – Trauma/Cardiac Arrest Similarities [...]

‘We can only improve what we measure’ has become a widely accepted mantra in the field of resuscitation. For the past decades, measurement efforts have predominantly focused on chest compression quality. This focus recently shifted to intra-arrest ventilation. In this issue of Resuscitation, two studies report on intra-arrest ventilation.[1,2] [...]

Help! [...]

The 12-lead electrocardiogram (ECG) following return of spontaneous circulation (ROSC) after cardiac arrest (CA) is perhaps one of the most high-stakes, high-pressure, and low-fidelity diagnostic tools in acute cardiovascular medicine. Identifying an occlusive myocardial infarction (OMI) is critical, as it triages the patient to emergent coronary angiography (CAG). Yet, this interpretation is confounded by a storm of metabolic derangements, global ischemia, reperfusion injury, and electrical artifacts that can mimic or mask acute coronary occlusion (ACO). [...]

The association between perfusion index (PI) and out-of-hospital cardiac arrest survival outcomes is unknown. The International Liaison Committee on Resuscitation suggested the need to improve the monitoring of cardiopulmonary resuscitation and chest compression quality. We hypothesized that higher event-average perfusion index values are associated with higher probability of return of spontaneous circulation, better survival and neurological outcomes. [...]

To explore the use of filtered Electrocardiogram combined with End-tidal carbon dioxide (fEEt) for the identification of cardiac arrest status without interruption of chest compressions in patients during cardiopulmonary resuscitation. [...]

Sudden cardiac arrest is among the leading causes of death in Europe,1,2 with acute coronary syndrome (ACS) being a major cause of cardiac arrest (CA).3,4 While timely identification of patients with ST-elevation myocardial infarction (STEMI) is essential,5 previous studies demonstrated that in the absence of ST-elevation, further electrocardiogram (ECG)-patterns indicative of occlusive myocardial infarction (OMI) are frequently present,6–12 even after out-of-hospital cardiac arrest (OHCA).13 In addition to the presence of multiple relevant ECG patterns,7 post-arrest metabolic derangement14 such as acidosis, electrolyte shifts, and hypoxia during or after resuscitation may distort the ECG signal and reduce its diagnostic specificity. [...]

To validate whether combining ventricular fibrillation (VF) and defibrillation (DF) waveforms could improve the prediction accuracy of DF outcomes in a retrospective cardiac arrest cohort. [...]

Cardiac arrest in trauma patients can occur from traumatic or non-traumatic aetiologies. Traditionally, trauma has been regarded a contraindication for extracorporeal life support, particularly extracorporeal cardiopulmonary resuscitation (ECPR). [...]

Internal Medicine Journal, Volume 55, Issue S6, Page 4-53, December 2025. [...]

Internal Medicine Journal, Volume 55, Issue S6, Page 4-53, December 2025. [...]

Internal Medicine Journal, Volume 55, Issue S6, Page 54-56, December 2025. [...]

Internal Medicine Journal, Volume 55, Issue S6, Page 54-56, December 2025. [...]

Internal Medicine Journal, Volume 55, Issue S6, Page 1-3, December 2025. [...]

Internal Medicine Journal, Volume 55, Issue S6, Page 1-3, December 2025. [...]

No abstract available [...]

No abstract available [...]

Trauma registries are a critical component of mature trauma systems that have enabled robust outcomes measurement and quality improvement initiatives. In low- and middle-income countries (LMICs) where trauma mortality is disproportionately high, however, trauma registries have faced challenges in implementation and sustainability. This scoping review characterized recent LMIC trauma registry implementation efforts, synthesizing facilitators and barriers to inform best practices for future establishment and maintenance of trauma registries in resource-limited settings. We used the preferred reporting items for systematic reviews and meta-analyses - scoping review framework to conduct a scoping review of PubMed, Embase, and MEDLINE for articles published after 2017 that reported on trauma registry implementation efforts in LMICs. Data were extracted including duration of registry implementation, number of institutions, country, barriers and facilitators cited, and funding sources. Barriers and facilitators were thematically classified according to health systems building blocks and synthesized to create best practices recommendations based on pooled experience. Of 873 articles searched, 29 met the inclusion criteria. Information management was the most common barrier (22 articles, 76%) and the most common facilitator (18 articles, 62%). Other barriers and facilitators included workforce, infrastructure, financing, and organizational support. Fifteen studies (52%) reported multiple barriers to implementation, and 14 (48%) reported multiple facilitators. Average length of registry implementation was 20.2 months. Trauma registries in LMICs often face multiple barriers to implementation, most commonly in information management. However, previous implementers have overcome these barriers through best practices including standardized data collection, technological safeguards, engaging local stakeholders, dedicated data coordinators, and sustainable funding across multisite implementation projects. [...]

BACKGROUND Incidence of hypocalcemia in trauma patients has been reported as 23% to 56% in small studies with strict inclusion criteria. We aim to describe the incidence of hypocalcemia in a larger set of patients with an ionized calcium level drawn in the trauma bay. We also aim to corroborate the association of calcium levels with mortality, blood product administration, emergent procedural intervention, and coagulopathy by thromboelastography (TEG). METHODS We performed a retrospective review of patients 15 years or older who presented as a trauma activation over 1 year. We describe the incidence of hypocalcemia and compare normal (ionized calcium, >4.0 mg/dL) versus low (3.0–4.0 mg/dL) versus very low ( [...]

10.1542/6377133537112Video AbstractPEDS-VA_2025-0723496377133537112Bereaved caregivers are at risk of poor mental and physical health outcomes following the death of their child. However, their voices are often excluded from the very end-of-life and bereavement research aimed at improving outcomes during this vulnerable time. In this article, we highlight the importance of involving bereaved caregivers in research by sharing personal insights as well as data on bereavement outcomes and caregivers’ experiences with research participation. We then present strategies for effectively engaging bereaved caregivers throughout the research process, including evidence-based recommendations and practical approaches. Patient-engaged research helps (1) tailor interventions to the population of interest and (2) facilitate recruitment and retention (3) with results interpretation and (4) dissemination, among other benefits; all of which could benefit bereaved caregivers. Despite concerns that bereaved caregivers participating in research is overly burdensome, research shows that bereaved caregivers often find benefit in research participation and appreciate the opportunity to be involved, even when participation is emotionally challenging. Although distress during research participation is occasionally reported, it rarely reaches a level requiring professional assistance. Conducting high-quality bereaved caregiver research requires a thoughtful approach, ideally with bereaved-caregiver partners guiding the efforts. We describe best practices and considerations for identifying bereaved-caregiver research participants, timing of approach, recruitment, renumeration and appreciation, distress monitoring, and providing psychosocial support, as well as data collection, analysis, interpretation, and dissemination for studies. We must ensure that bereaved caregivers are meaningfully and appropriately engaged in bereaved caregiver research, which is an essential step in improving bereaved-caregiver outcomes. [...]

10.1542/6377133537112Video AbstractPEDS-VA_2025-0723496377133537112Bereaved caregivers are at risk of poor mental and physical health outcomes following the death of their child. However, their voices are often excluded from the very end-of-life and bereavement research aimed at improving outcomes during this vulnerable time. In this article, we highlight the importance of involving bereaved caregivers in research by sharing personal insights as well as data on bereavement outcomes and caregivers’ experiences with research participation. We then present strategies for effectively engaging bereaved caregivers throughout the research process, including evidence-based recommendations and practical approaches. Patient-engaged research helps (1) tailor interventions to the population of interest and (2) facilitate recruitment and retention (3) with results interpretation and (4) dissemination, among other benefits; all of which could benefit bereaved caregivers. Despite concerns that bereaved caregivers participating in research is overly burdensome, research shows that bereaved caregivers often find benefit in research participation and appreciate the opportunity to be involved, even when participation is emotionally challenging. Although distress during research participation is occasionally reported, it rarely reaches a level requiring professional assistance. Conducting high-quality bereaved caregiver research requires a thoughtful approach, ideally with bereaved-caregiver partners guiding the efforts. We describe best practices and considerations for identifying bereaved-caregiver research participants, timing of approach, recruitment, renumeration and appreciation, distress monitoring, and providing psychosocial support, as well as data collection, analysis, interpretation, and dissemination for studies. We must ensure that bereaved caregivers are meaningfully and appropriately engaged in bereaved caregiver research, which is an essential step in improving bereaved-caregiver outcomes. [...]

Abstract The prevalence of immune-mediated inflammatory diseases (IMIDs) is rising, associated with increasing disease burden and healthcare expenditure. Medical therapy is the major driver of healthcare costs associated with IMIDs, owing to the need for lifelong therapy. However, many patients exhaust medical options, highlighting the need for new therapies with novel mechanisms of action. Recently, a highly effective class of medical therapy gained registration for use in Australia for IMIDs but was unsuccessful in attaining Pharmaceutical Benefits Scheme reimbursement. There is a growing need to reevaluate the reimbursement process for medicines in Australia, aiming to balance access to new therapies with prudent health-economic policy. [...]

Abstract The prevalence of immune-mediated inflammatory diseases (IMIDs) is rising, associated with increasing disease burden and healthcare expenditure. Medical therapy is the major driver of healthcare costs associated with IMIDs, owing to the need for lifelong therapy. However, many patients exhaust medical options, highlighting the need for new therapies with novel mechanisms of action. Recently, a highly effective class of medical therapy gained registration for use in Australia for IMIDs but was unsuccessful in attaining Pharmaceutical Benefits Scheme reimbursement. There is a growing need to reevaluate the reimbursement process for medicines in Australia, aiming to balance access to new therapies with prudent health-economic policy. [...]

Abstract Background Individuals with psoriasis have a high prevalence of metabolic dysfunction–associated steatotic liver disease (MASLD), yet the association between MASLD as a cardiometabolic risk factor and cardiac manifestations in this population remains unclear. Objectives We aimed to evaluate associations between MASLD, cardiometabolic risk factors, and cardiac structure and function in adults with psoriasis. Methods We performed a cross-sectional analysis of 255 adults with psoriasis prospectively enrolled. Participants underwent transthoracic echocardiography and transient elastography. MASLD was defined by hepatic steatosis with a controlled attenuation parameter of ≥250 dB/m and the presence of ≥1 cardiometabolic risk factor(s), excluding other liver disease causes. Cardiac structure and function were compared between individuals with psoriasis and MASLD and those without MASLD. Associations between MASLD and myocardial dysfunction were assessed in uni- and multivariable regression models. Results MASLD was present in 92 participants (36.1%), of whom 5 (5.4%) had evidence of increased liver stiffness. Those with MASLD exhibited higher blood pressure, body mass index (BMI), and more adverse cardiometabolic profiles. MASLD was associated with cardiac structural changes and worse diastolic and systolic function. After adjusting for age, sex, and BMI, most associations were attenuated. In fully adjusted models, higher BMI and diabetes, but not MASLD, were independently associated with myocardial dysfunction. Conclusions In adults with psoriasis, the association between MASLD and cardiac structural and functional changes was attenuated after adjusting for BMI and cardiometabolic risk factors, underscoring the importance of cardiometabolic risk factor control, in particular of obesity and diabetes, in psoriasis with concomitant MASLD. [...]

Abstract Background Individuals with psoriasis have a high prevalence of metabolic dysfunction–associated steatotic liver disease (MASLD), yet the association between MASLD as a cardiometabolic risk factor and cardiac manifestations in this population remains unclear. Objectives We aimed to evaluate associations between MASLD, cardiometabolic risk factors, and cardiac structure and function in adults with psoriasis. Methods We performed a cross-sectional analysis of 255 adults with psoriasis prospectively enrolled. Participants underwent transthoracic echocardiography and transient elastography. MASLD was defined by hepatic steatosis with a controlled attenuation parameter of ≥250 dB/m and the presence of ≥1 cardiometabolic risk factor(s), excluding other liver disease causes. Cardiac structure and function were compared between individuals with psoriasis and MASLD and those without MASLD. Associations between MASLD and myocardial dysfunction were assessed in uni- and multivariable regression models. Results MASLD was present in 92 participants (36.1%), of whom 5 (5.4%) had evidence of increased liver stiffness. Those with MASLD exhibited higher blood pressure, body mass index (BMI), and more adverse cardiometabolic profiles. MASLD was associated with cardiac structural changes and worse diastolic and systolic function. After adjusting for age, sex, and BMI, most associations were attenuated. In fully adjusted models, higher BMI and diabetes, but not MASLD, were independently associated with myocardial dysfunction. Conclusions In adults with psoriasis, the association between MASLD and cardiac structural and functional changes was attenuated after adjusting for BMI and cardiometabolic risk factors, underscoring the importance of cardiometabolic risk factor control, in particular of obesity and diabetes, in psoriasis with concomitant MASLD. [...]

Abstract Background The long-term risk across severity strata of people infected with SARS-CoV-2 has not yet been comprehensively described. Methods Using nationwide registries, all COVID-19 cases in Sweden with [...]

Abstract Background The long-term risk across severity strata of people infected with SARS-CoV-2 has not yet been comprehensively described. Methods Using nationwide registries, all COVID-19 cases in Sweden with [...]

Objectives: To identify the impact of early hypothermic temperature control (HTC) initiation and achievement on neurologic outcomes after cardiac arrest. Secondary endpoints assessed: 1) overall survival, 2) body temperature at hospital admission, 3) time taken to reach targeted temperature, and 4) adverse events. Subgroup analyses assessed: 1) HTC induction method, 2) presenting rhythms (shockable vs. nonshockable), and 3) timing of HTC initiation (during cardiopulmonary resuscitation [CPR] vs. post-return of spontaneous circulation [ROSC]). Data Sources: PubMed, Cochrane Library, U.S. National Library of Medicine, MedRxiv, BioRxiv. Study Selection: Prospective randomized controlled trials enrolling comatose adult cardiac arrest patients that assessed the efficacy of early cooling (defined by initiation of HTC within 30 min of ROSC) against late cooling. Data Extraction: Two reviewers independently conducted study selection, data extraction, and assessment of evidence quality. Full texts were jointly reviewed, with discrepancies resolved by a third reviewer through discussion and consensus. Data Synthesis: Of 7269 citations, 11 met the inclusion criteria. Early cooling did not improve neurologic outcomes (risk ratio [RR], 1.01; 95% CI, 0.94–1.14) nor survival (RR, 1.01; 95% CI, 0.92–1.11). Nasal evaporative cooling initiated during resuscitation may benefit patients with shockable rhythms (RR, 1.40; 95% CI, 1.00–1.96), while administering cold fluid during CPR was associated with a higher risk of rearrest. Cooling was initiated in the prehospital phase in ten studies, nine of which failed to achieve target temperature (32–34°C) by hospital admission. The median time to reach target temperature ranged from 38 to 360 minutes. Conclusions: Early HTC showed no neurologic nor survival benefit in cardiac arrest survivors. Nasal evaporative cooling during CPR may benefit those with shockable rhythms. Delays in reaching the target temperature may underlie the failure of HTC. Future studies should evaluate whether achieving target temperature, for example, within 30 minutes, rapidly improves outcomes. [...]

Objective: Hyperthermia is common in brain-injured patients and is considered a systemic secondary brain injury. Paracetamol is most often administered as first-line treatment, although its efficacy in controlling cerebral temperature (CT) has never been evaluated, which is the aim of this study. Design: Pharmacodynamic prospective randomized double-blind placebo-controlled study. Setting: Neuro-ICU. Patients: Brain-injured patients who were febrile (CT ≥ 38.5°C for > 30 min) and monitored with an intracerebral pressure sensor including a thermal probe. Interventions: Patients received paracetamol or placebo (only one IV administration). CT and systemic temperature (ST) were recorded every 10 minutes over 6 hours. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the difference in mean CT over 6 hours after treatment. The primary endpoint was the difference in mean CT over6 hours after treatment. We included 99 patients (mean age 55 ± 13 yr, 24% female): 49 in the paracetamol group and 50 in the placebo group. Mean CT during the 6-hour follow-up was significantly lower in the paracetamol than placebo group: 38.4 ± 0.5 vs. 39.0 ± 0.5°C (p < 0.001). In both groups, mean CT was always higher than mean ST: 38.7 ± 0.6 vs. 38.4 ± 0.6°C (p < 0.001). Median time with CT less than 38.5°C was 215 minutes (interquartile range 0–290) in the paracetamol group vs. 0 minutes (0–5) in the placebo group (p < 0.001). One-third (30%) of patients in the paracetamol group did not respond to treatment. In the responder group paracetamol lowered the mean CT by 1°C. The paracetamol group exhibited a moderate decrease in systolic arterial pressure and heart rate, without any other significant effect. Conclusions: Paracetamol significantly reduced CT in febrile brain-injured patients (overall mean reduction of 0.6°C), maintaining temperatures less than 38.5°C for a median of 3.6 hours. The gradient between CT and ST was consistently about 0.3°C in both groups. [...]

Objectives: Cardiogenic shock is a time-critical emergency requiring aggressive therapeutic interventions, yet prognostication remains challenging with no consensus on the comparative applicabilities of risk scores. Our study aims to evaluate the capacities of existing risk scores for efficient, effective, and generalizable prognostication of mortality across various patient demographic cohorts. Data Sources: We searched MEDLINE, Embase, and Scopus databases up to June 15, 2024. Study Selection: We included articles developing, redeveloping, or validating a multivariable model predicting all-cause mortality in adults with cardiogenic shock. Data Extraction: We pooled area under the curve (AUC) statistics and observed: expected (O:E) ratios as an assessment of discrimination and calibration, respectively. We conducted random-effects inverse-variance weighted meta-analyses on prespecified prediction models (Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock [IABP-SHOCK II], CardShock, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and Survival After Venoarterial Extracorporeal Membrane Oxygenation) to derive pooled estimates of AUCs and aggregate O:Es for each model. Subgroup analyses were conducted to identify sources of heterogeneity. Data Synthesis: We included 102 studies comprising 126 study cohorts in our final analysis (89,546 patients), with 40 unique prediction models identified. There were no significant differences between the performances of all included scores. However, in terms of absolute pooled values, CardShock score had the highest pooled discrimination (AUC, 0.73 [95% CI, 0.70–0.76]) and best calibration (O:E, 1.06 [95% CI, 0.79–1.41]) among other widely used scores. Subgroup analyses were highly variable between studies and again did not reveal a superior prediction model. Unique prediction models developed by authors were found to be superior to existing prediction models, yet lacked generalizability. Conclusions: Meta-analysis of six included scores revealed no clear “gold standard” prediction model, although the CardShock score had the highest discrimination and most accurate calibration. The degree of variability between studies precluded in-depth assessment of subgroup analysis. Further research into novel risk scores can be conducted to better inform clinicians on their utility. [...]

Objectives: Cardiogenic shock is a time-critical emergency requiring aggressive therapeutic interventions, yet prognostication remains challenging with no consensus on the comparative applicabilities of risk scores. Our study aims to evaluate the capacities of existing risk scores for efficient, effective, and generalizable prognostication of mortality across various patient demographic cohorts. Data Sources: We searched MEDLINE, Embase, and Scopus databases up to June 15, 2024. Study Selection: We included articles developing, redeveloping, or validating a multivariable model predicting all-cause mortality in adults with cardiogenic shock. Data Extraction: We pooled area under the curve (AUC) statistics and observed: expected (O:E) ratios as an assessment of discrimination and calibration, respectively. We conducted random-effects inverse-variance weighted meta-analyses on prespecified prediction models (Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock [IABP-SHOCK II], CardShock, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and Survival After Venoarterial Extracorporeal Membrane Oxygenation) to derive pooled estimates of AUCs and aggregate O:Es for each model. Subgroup analyses were conducted to identify sources of heterogeneity. Data Synthesis: We included 102 studies comprising 126 study cohorts in our final analysis (89,546 patients), with 40 unique prediction models identified. There were no significant differences between the performances of all included scores. However, in terms of absolute pooled values, CardShock score had the highest pooled discrimination (AUC, 0.73 [95% CI, 0.70–0.76]) and best calibration (O:E, 1.06 [95% CI, 0.79–1.41]) among other widely used scores. Subgroup analyses were highly variable between studies and again did not reveal a superior prediction model. Unique prediction models developed by authors were found to be superior to existing prediction models, yet lacked generalizability. Conclusions: Meta-analysis of six included scores revealed no clear “gold standard” prediction model, although the CardShock score had the highest discrimination and most accurate calibration. The degree of variability between studies precluded in-depth assessment of subgroup analysis. Further research into novel risk scores can be conducted to better inform clinicians on their utility. [...]

Objectives: To describe the epidemiology of methylene blue (MB) use in septic shock and explore the association between MB dose and hospital outcomes. Design: Retrospective cohort study. Setting: United States. Patients: Eight hundred fifty-nine thousand eight hundred sixty-eight adult (≥ 18 yr) patients from 1100 centers with a diagnosis of septic shock (sepsis with vasopressor administration), discharged from Premier Healthcare Database hospitals in the United States from 2008 to 2021. Interventions: None. Measurements and Main Results: We included patients who received MB at any point during hospitalization (to describe utilization), then separately focused on those who received MB within the first 3 hospital days (to examine association of dose with outcomes). The primary outcome was hospital mortality. We used mixed-effects multivariable regression models to evaluate the MB use and the association between MB dose (modeled as a five-knot restricted cubic spline) and outcomes. Among patients with septic shock, 4082 patients (0.5%) from 663 hospitals received at least one dose of MB. Patients receiving MB tended to be younger and received major surgery. Hospitals in which MB was administered were larger urban teaching hospitals. After multivariable adjustment, use of MB was lower in 2016–2020 than in 2008. Of 2507 patients (61.4%) who received MB within the first 3 days of hospitalization, 375 (15.0%) died in hospital. Our spline analysis suggests a nonlinear association between MB dosing and outcomes among patients receiving MB early in their hospitalization. Conclusions: Use of MB in septic shock is rare in the United States, but with substantial inter-hospital variability and decreased use over time through 2020. Randomized evidence is required to evaluate the efficacy and safety of MB. [...]

No abstract available [...]

Internal Medicine Journal, EarlyView. [...]

Internal Medicine Journal, EarlyView. [...]

Clonidine is being increasingly prescribed in pediatric populations for behavioral conditions such as attention-deficit/hyperactivity disorder (ADHD), contributing to a rise in pediatric exposures and toxic ingestions. This article reviews the toxicokinetics, clinical presentation, and management of pediatric clonidine toxicity. Children under 5 years old account for the highest proportion of clonidine exposures, most of which are unintentional. Clonidine toxicity mimics an opioid toxidrome, often presenting with CNS depression, miosis, bradycardia, and hypotension. Diagnosis is primarily clinical. While supportive care remains the core component of treatment, naloxone may be beneficial in reversing CNS depression, though higher-than-standard doses are often required. Given the potential for delayed and prolonged toxicity, particularly with ingestion of transdermal patches, early recognition and intervention are critical. This review equips clinicians to understand, diagnose, and manage pediatric clonidine toxicity, emphasizing the importance of supportive care and consideration of naloxone for severe cases. [...]

No abstract available [...]

Objectives: Cardiogenic shock is a time-critical emergency requiring aggressive therapeutic interventions, yet prognostication remains challenging with no consensus on the comparative applicabilities of risk scores. Our study aims to evaluate the capacities of existing risk scores for efficient, effective, and generalizable prognostication of mortality across various patient demographic cohorts. Data Sources: We searched MEDLINE, Embase, and Scopus databases up to June 15, 2024. Study Selection: We included articles developing, redeveloping, or validating a multivariable model predicting all-cause mortality in adults with cardiogenic shock. Data Extraction: We pooled area under the curve (AUC) statistics and observed: expected (O:E) ratios as an assessment of discrimination and calibration, respectively. We conducted random-effects inverse-variance weighted meta-analyses on prespecified prediction models (Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock [IABP-SHOCK II], CardShock, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and Survival After Venoarterial Extracorporeal Membrane Oxygenation) to derive pooled estimates of AUCs and aggregate O:Es for each model. Subgroup analyses were conducted to identify sources of heterogeneity. Data Synthesis: We included 102 studies comprising 126 study cohorts in our final analysis (89,546 patients), with 40 unique prediction models identified. There were no significant differences between the performances of all included scores. However, in terms of absolute pooled values, CardShock score had the highest pooled discrimination (AUC, 0.73 [95% CI, 0.70–0.76]) and best calibration (O:E, 1.06 [95% CI, 0.79–1.41]) among other widely used scores. Subgroup analyses were highly variable between studies and again did not reveal a superior prediction model. Unique prediction models developed by authors were found to be superior to existing prediction models, yet lacked generalizability. Conclusions: Meta-analysis of six included scores revealed no clear “gold standard” prediction model, although the CardShock score had the highest discrimination and most accurate calibration. The degree of variability between studies precluded in-depth assessment of subgroup analysis. Further research into novel risk scores can be conducted to better inform clinicians on their utility. [...]

Objectives: Cardiogenic shock is a time-critical emergency requiring aggressive therapeutic interventions, yet prognostication remains challenging with no consensus on the comparative applicabilities of risk scores. Our study aims to evaluate the capacities of existing risk scores for efficient, effective, and generalizable prognostication of mortality across various patient demographic cohorts. Data Sources: We searched MEDLINE, Embase, and Scopus databases up to June 15, 2024. Study Selection: We included articles developing, redeveloping, or validating a multivariable model predicting all-cause mortality in adults with cardiogenic shock. Data Extraction: We pooled area under the curve (AUC) statistics and observed: expected (O:E) ratios as an assessment of discrimination and calibration, respectively. We conducted random-effects inverse-variance weighted meta-analyses on prespecified prediction models (Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock [IABP-SHOCK II], CardShock, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and Survival After Venoarterial Extracorporeal Membrane Oxygenation) to derive pooled estimates of AUCs and aggregate O:Es for each model. Subgroup analyses were conducted to identify sources of heterogeneity. Data Synthesis: We included 102 studies comprising 126 study cohorts in our final analysis (89,546 patients), with 40 unique prediction models identified. There were no significant differences between the performances of all included scores. However, in terms of absolute pooled values, CardShock score had the highest pooled discrimination (AUC, 0.73 [95% CI, 0.70–0.76]) and best calibration (O:E, 1.06 [95% CI, 0.79–1.41]) among other widely used scores. Subgroup analyses were highly variable between studies and again did not reveal a superior prediction model. Unique prediction models developed by authors were found to be superior to existing prediction models, yet lacked generalizability. Conclusions: Meta-analysis of six included scores revealed no clear “gold standard” prediction model, although the CardShock score had the highest discrimination and most accurate calibration. The degree of variability between studies precluded in-depth assessment of subgroup analysis. Further research into novel risk scores can be conducted to better inform clinicians on their utility. [...]

Spondylolysis is a defect of the pars interarticularis resulting from developmental or acquired stress. It is a common injury in children, and while most patients are asymptomatic, spondylolysis may also lead to significant back pain. There should be an index of clinical suspicion for patients presenting to the emergency department with back pain, and various radiographic modalities can be used for diagnosis, with referral to ongoing and definitive treatment. [...]

No abstract available [...]

No abstract available [...]

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. [...]

No abstract available [...]

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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OBJECTIVES: In children with sepsis, thrombocytopenia is linked to poor outcomes, including longer hospital length of stay, increased bleeding risk, and higher mortality. However, the clinical significance of changes in platelet counts over time remain poorly characterized. We have examined dynamic platelet patterns and their association with mortality and patient-illness factors. DESIGN: Single-center retrospective cohort study. SETTING: Hospital pediatrics and PICU at Guangdong Women and Children Hospital, China. PATIENTS: Children with sepsis between January 2015 and December 2023. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Group-based trajectory analysis was used to examine the trend in platelet count during the first 7 days of hospital admission. A regression model was developed to investigate possible associations between patient characteristics with platelet count trajectory. Additionally, a multivariable Cox proportional hazards model, adjusted for age, sex, comorbidities, and site/source of infection, was constructed to evaluate the association between platelet count trajectories and 28-day mortality. Among 1010 children with sepsis, we identified three platelet count trajectories with distinct characteristics. Age, fibrinogen level, activated partial thromboplastin time, and lactic acid were each associated with platelet count trajectories. The overall 28-day mortality for the cohort was 5.4%, varying across groups: 1.2% in group 3 with persistently high platelet count; 2.2% in group 2 with high-normal platelet count; and 12.6% in group 1 with low platelet count. In the multivariable Cox proportional hazards model, compared with group 1, both groups 2 and 3 were independently associated with reduced hazard of death at 28 days (hazard ratio, 0.26; p < 0.001 for group 2 and hazard ratio, 0.18; p = 0.021 for group 3). CONCLUSIONS: We have identified three distinct and clinically relevant platelet count trajectories in children with sepsis, which serve as robust associations with survival in this patient population. [...]

OBJECTIVES: To use a multidimensional outcomes portfolio to assess neurodevelopmental sequelae among PICU survivors during the first 3 years after hospital discharge. DESIGN: Prospective study of a cohort recruited 2017–2018, with interval follow-up for 3 years. SETTING: PICU at an urban academic tertiary care center. PATIENTS: Children 0–17 years admitted to the PICU with anticipated discharge home. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We evaluated outcomes using a PICU Outcomes Portfolio (POP) survey, which combined a study-specific Healthcare and Neurodevelopmental Profile and the Family Impact Survey and standardized measurement tools, including the Pediatric Quality of Life Inventory, the Strengths and Difficulties Questionnaire, and the National Institute for Children’s Health Quality Vanderbilt Assessment Scales, to identify various components of post-PICU challenges. Our POP survey identified a sustained impact of child health on family finances and parental employment. Our multidimensional outcomes assessment flagged more at-risk children than individual measures of neurodevelopmental functioning. CONCLUSIONS: Children and families face diverse challenges during recovery from critical illness. Parent-reported outcomes and a multidimensional outcomes portfolio identify the broad impact of critical illness on family well-being as well as the long-term outcomes among PICU survivors. Future mixed-methods studies incorporating parental input regarding post-discharge needs are needed to enrich the evaluation of post-PICU outcomes using standardized measures and guide the development of post-PICU follow-up programs. [...]

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). [...]

No abstract available [...]

No abstract available [...]