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. [...]

Upper gastrointestinal bleeding (UGIB) frequently presents to the emergency department (ED). Existing scores (Glasgow-Blatchford etc.) may not capture early ED predictors of adverse outcomes. [...]

Laryngeal trauma is an uncommon but potentially life-threatening condition that demands prompt recognition and management, particularly when airway structures are compromised. The larynx, comprising critical components such as the vocal folds, arytenoid cartilages, and surrounding soft tissue, plays a central role in phonation and airway protection (1). Blunt trauma to these structures—especially in anticoagulated patients—can result in rapid haematoma formation, leading to dysphonia, airway obstruction, and ultimately respiratory failure if not promptly addressed (2). [...]

Euglycemic diabetic ketoacidosis (EDKA) is most commonly associated with sodium-glucose cotransporter-2 (SGLT2) inhibitors. However, emerging evidence suggests that glucagon-like peptide-1 (GLP-1) receptor agonists and dual incretin agents such as tirzepatide (Mounjaro) may also precipitate EDKA, though reports remain rare. [...]

Emergency medicine (EM) clerkships are essential in undergraduate medical education, yet the impact of clinical setting—freestanding emergency departments (FSEDs) versus hospital-based emergency departments (HBEDs)—on students’ educational experiences remains understudied. [...]

Large language models (LLMs), such as ChatGPT (cGPT), are increasingly integrated into clinical workflows and medical education. However, concerns persist regarding their susceptibility to bias, especially in high-stakes areas like pain management, where disparities across race, socioeconomic status, and substance use history are well documented. [...]

High-quality bystander CPR is a key element in successful resuscitation from OHCA. However, less than 40% of adults receive bystander-initiated CPR.1 [...]

Procedural sedation and analgesia (PSA) is an essential component of emergency medicine practice. Pre-procedural fasting is recommended to reduce aspiration risk, but compliance with fasting in emergency settings is not necessarily feasible. Gastric ultrasound provides an objective method to assess fasting status. [...]

Previous research has shown that among patients presenting with classic cardiac pain, women receive fewer investigations than men. [...]

The optimal airway management strategy in out-of-hospital cardiac arrest has been controversial. While endotracheal intubation currently represents the gold standard, supraglottic airway securement may provide advantages with respect to handling in out-of-hospital cardiac arrest. [...]

Synthetic cathinones (SC) are a class of psychoactive stimulants structurally similar to amphetamines. Despite a high prevalence of SC detection in emergency department (ED) drug surveillance in Taiwan, detailed reports of SC-related fatalities and their acute clinical course in the emergency medicine literature are limited. This case series describes the presentations, clinical course, and outcomes of four fatal SC-associated intoxications, highlighting critical emergency management insights. [...]

Left ventricular pseudoaneurysm—also referred to as false aneurysm or contained rupture—is a rare complication, with an incidence of approximately 0.5% after acute myocardial infarction; it may also occur following cardiac surgery or trauma.1 The most reported clinical manifestations include chest pain, dyspnea, dysrhythmias, and syncope. Because of the myocardial thinning, there is a potential for rupture and the development of cardiac tamponade.2 We report a 74-year-old man who presented with out-of-hospital cardiac arrest and was found to have a left ventricular pseudoaneurysm during a resuscitative transesophageal echocardiography (TEE). [...]

Impetigo is a condition in which a superficial bacterial skin infection occurs in either normal skin (primary type) or in compromised skin (secondary type, such as in skin trauma, eczema, etc.). Although it is more frequent in younger children, the condition can affect older children and adults (1). Impetigo can be subdivided into 3 different variants: nonbullous impetigo, ecthyma, and bullous impetigo. The variants can be differentiated based on clinical features. This case report will cover the diagnosis and treatment of an 8-year-old patient with a history of atopic dermatitis who presented with bullae and vesicles. [...]

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. [...]

INTRODUCTION Screening for urinary extravasation after high-grade renal trauma using delayed-phase computed tomography (DPCT) has been associated with increased urological intervention rates. We investigated the association of DPCT with urological intervention and major complication rates while analyzing the predictive value of clinical symptoms of urinary extravasation at follow-up DPCT. METHODS This retrospective cohort study analyzed patients aged 18 to 89 years with American Association for the Surgery of Trauma grades III to V renal injuries at a level 1 trauma center from 2013 to 2023. Data were obtained from the institutional trauma registry and electronic medical records. Univariable and multivariable regressions assessed the association of DPCT with major complication and urological intervention rates. In a subgroup analysis of only follow-up DPCT, the sensitivity, specificity, positive predictive value, and negative predictive value of urinary extravasation signs and symptoms (leukocytosis, fever, flank pain, hematuria) were calculated. RESULTS Of 234 patients, 101 (43.2%) underwent DPCT at any point during their hospital course. Baseline characteristics were similar between DPCT versus no DPCT, including injury grade (p = 0.13). Delayed-phase CT patients had higher rates of urological interventions compared with no DPCT (21.8% vs. 2.3%, p < 0.001) but similar complication rates (16.8% vs. 16.5%, p = 0.95). After multivariable regression, DPCT was not associated with major complications (odds ratio, 1.49; p = 0.33) but with increased odds of undergoing urological intervention (odds ratio, 15.22; p < 0.001). The presence of at least one symptom at follow-up DPCT had a sensitivity and NPV of 100% for urinary extravasation (p = 0.019). CONCLUSION Delayed-phase CT was strongly associated with urological interventions for urinary extravasation but not associated with major complications after risk adjusted analyses, and all asymptomatic patients had negative follow-up DPCTs. While our results suggest potential overtreatment regarding urological interventions and follow-up imaging, further confirmative prospective studies are needed given our study's single-center retrospective limitations. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV. [...]

BACKGROUND Quality of Life (QoL) is a core metric for patients with chest wall injury (CWI). No thoracic specific QoL instruments exist and granularity to assess impact of interventions on patients with chest wall injury is lacking. We hypothesized we could develop a valid and reliable CWI specific quality of life (C-QoL) questionnaire. METHODS A systematic review of QoL instruments used in chest wall injury literature was performed and an international group of CWI experts assembled a panel of questions for inclusion. A three-round modified Delphi consensus process was performed using a 70% consensus threshold. A clinical validation study enrolling adults with ≥1 rib fractures(s) was performed. Participants completed the C-QoL and the SF-36 twice, with a week intervening each response. Reliability, construct validity, floor and ceiling effects of the C-QoL (sub)scales were determined using the COnsensus-based Standards for the selection of health Measurement Instruments group guidelines. RESULTS Twenty-two CWI experts participated in the Delphi process resulting in creation of the C-QoL instrument with five domains: pain, physical functioning, general health, socio-economic functioning, and psychological health. Scores ranges from 0 to 100. Median QoL score for the first 154 participants was 34 (P25–P75 25–50). Subscale scores ranged from 29 (P25–P75 14–48) for pain to 55 (P25–P75 37–75) for psychological health. All (sub)scales showed an inverse correlation with injury severity and had adequate reliability (Cronbach alpha between 0.70 and 0.95), construct validity (>75% or correlations with SF-36 (sub)scales are predicted correctly) and had no floor or ceiling effect. CONCLUSION The C-QoL instrument is reliable and valid for measuring CWI specific QoL in patients. A prospective study is needed to externally validate the instrument, and to determine the responsiveness, measurement error, and minimal important change. LEVEL OF EVIDENCE Diagnostic Tests or Criteria; Level II. [...]

No abstract available [...]

No abstract available [...]

INTRODUCTION Limited data exist on the role of sex in coagulation among geriatric trauma patients. This study aimed to assess gender-based differences in thromboelastography (TEG) and conventional coagulation profiles in this population. We hypothesized that older females exhibit faster clot formation and greater clot strength following trauma. METHODS We conducted a 5-year (2018–2023) retrospective review at an American College of Surgeons Level I trauma center. Included were geriatric trauma patients (65 years or older) with Level I activation and a rapid TEG obtained on arrival. Patients with bleeding disorders, on anticoagulants or antiplatelets, or who received blood products or antifibrinolytics prior to TEG were excluded. Patients were stratified by sex. Thromboelastography variables included activated clotting time (ACT), α angle, maximum amplitude (MA), and percent fibrinolysis at 30 minutes (LY30). Conventional profiles (prothrombin time and international normalized ratio [INR]) were also compared. RESULTS A total of 349 patients met the inclusion criteria (63.3% male, 36.7% female). The median Injury Severity Score was 14 (interquartile range, 4–26), and 92% sustained blunt injuries. No significant sex differences were observed in shock index, Glasgow Coma Scale, Injury Severity Score, or time to TEG. Females had significantly shorter ACT (105 vs. 113 seconds, p = 0.037), higher α angle (77 vs. 75 degrees, p < 0.001), and greater MA (68 vs. 65 mm, p < 0.001). Prothrombin time and INR were also lower in females. No differences were found in LY30. After adjusting for confounders, male sex was independently associated with lower α angle (β = −2.08, p = 0.031) and MA (β = −3.28, p = 0.003), but not ACT, LY30, prothrombin time, or INR. CONCLUSION In this single-center study of geriatric trauma patients, females demonstrated faster clot formation and greater clot strength compared with males on TEG. These findings indicate that sex-based hypercoagulability may persist despite age-related hormonal decline. Future prospective, multicenter studies will be essential to validate and expand upon these results and to better define the influence of other factors on the sex-specific differences observed. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV. [...]

No abstract available [...]

INTRODUCTION Traumatic brain injury (TBI) is among the leading causes of death and disability worldwide. Studies have linked peptidylarginine deiminases (PADs) with TBI outcomes. However, nonspecific PAD inhibition makes it difficult to decipher the exact role of specific PAD enzymes in neurotrauma. Since both PAD2 and PAD4 have been linked with neurodegeneration, we sought to clearly establish their roles in TBI. METHODS Male mice (11–14 weeks) were subjected to controlled cortical impact TBI (n = 5/group). Experimental groups included wild-type plus TBI (WT-TBI), PAD2 knockout plus TBI (PAD2-KO–TBI), PAD4 knockout plus TBI (PAD4-KO–TBI), and PAD2/4 double knockout plus TBI (PAD2/4-DKO–TBI). Twenty-four hours post-TBI, frozen brain sections were stained (Nissl and immunofluorescence) to determine lesion size and expression of PAD2 and PAD4. We also assessed the impact of PAD2-KO on neurologic severity scores (1–8 days post-TBI) and visuospatial learning using the Morris water maze test (21–30 days post-TBI). RESULTS Overall, PAD2-KO–TBI and PAD2/4-DKO–TBI animals displayed significantly smaller brain lesion sizes than WT-TBI (p = 0.005 and 0.005, respectively) and PAD4-KO–TBI (p = 0.005 and 0.004, respectively). However, there was no significant difference in lesion size between the PAD4-KO–TBI and WT-TBI (p = 0.880) groups. Analysis of archived snRNA-seq data and immunofluorescence staining 24 hours post-TBI showed upregulation of PAD2 (primarily in astrocytes) in WT-TBI compared with sham (p = 0.048), whereas PAD4 was undetectable. Overall, PAD2-KO–TBI had a significantly lower neurologic severity score on postinjury days 1 to 6 compared with WT-TBI (all p < 0.05) group. Moreover, Morris water maze test demonstrated that the cumulative cued and noncued spatial learning was worse in WT-TBI compared with PAD2-KO–TBI (p < 0.05) animals. CONCLUSION Our results suggest that PAD2, but not PAD4, blockade can improve outcomes following TBI, which justifies its exploration as a potential target for novel neuroprotective therapies. [...]

INTRODUCTION Low Titer Group O Whole Blood (WB) has emerged as a safe and efficient therapeutic agent for hemostatic resuscitation in injured children. The relationship between type of blood product transfused and incidence of organ dysfunction is not well elucidated. We hypothesize that WB transfusion is associated with decreased organ dysfunction compared with component therapy (CT). METHODS This is a retrospective observational study of injured children ages 0 year to 17 years utilizing the TQIP database (2020–2022). Inclusion criteria were receipt of any blood product within 4 hours of ED arrival and survival to 72 hours. Subjects were categorized by receipt of WB. Primary outcome was organ dysfunction, defined as presence of any of the following: mechanical ventilation greater than 6 days, sepsis, acute respiratory distress syndrome, pneumonia, acute kidney injury, urinary tract infection, or myocardial infarction. Data were analyzed using logistic regression, adjusting for age, sex, trauma mechanism, Injury Severity Score, head abbreviated injury score, Glasgow Coma Scale, shock (SIPA score), interfacility transfer, weight-adjusted volume of each blood product (mL/kg) and site. RESULTS Of 6237 subjects analyzed, 907 (14.5%) received WB and 2421 (38.8%) had evidence of organ dysfunction, with respiratory failure being most common (1689 [27%]). In the analysis cohort, the median (IQR) age was 15 years (10–17), 42.7% penetrating mechanism, median (IQR) injury severity score 24 (14–43), median (IQR) total transfusion volume 16.4 mL/kg (8.2–35), and median (IQR) WB transfusion volume 12 mL/kg (7–20). In the adjusted model, WB transfusion was associated with decreased odds of organ dysfunction (odds ratio, 0.78; 95% confidence interval, 0.61–0.98; p = 0.04). Sensitivity analysis including subjects who died within 72-hours did not show a significant difference, suggesting minimal influence of survival bias. CONCLUSION Early WB resuscitation was independently associated with reduced organ dysfunction in injured children. Further large, prospective, and mechanistic studies are needed. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III. [...]

No abstract available [...]

No abstract available [...]

No abstract available [...]

No abstract available [...]

Objectives: Venovenous extracorporeal membrane oxygenation (ECMO) represents a standard and well-accepted modality of treating patients with refractory respiratory failure. Nevertheless, some patients might develop refractory hypoxemia, hemodynamic compromise or end-organ perfusion requiring a change. This study analyzed characteristics and outcomes of patients requiring a change from venovenous to a different ECMO configuration. Design: Multicenter, retrospective, observational analysis of the Extracorporeal Life Support Organization Registry (2010–2020) in adult patients (≥ 18 yr old) underwent venovenous ECMO as initial cannulation strategy. Setting and Patients: Comparison of patients who remained on venovenous ECMO vs. those who underwent configuration conversion and multivariable analysis to assess variables associated with configuration change. Interventions: None. Measurements and Main Results: Among 28,888 eligible venovenous ECMO runs, 702 (2.4%) received a change from the original configuration, including 399 (56.8%) conversions to venoarterial and 303 (43.2%) to hybrid ECMO configurations. Variables associated with conversion included: pre-ECMO cardiac conditions, bridge to lung transplant as indication, use of milrinone, epinephrine, sildenafil, bicarbonate, and 24-hour Pao2 value. Conversion occurred at a median of 56 hours (interquartile range, 11.5–210 hr) after ECMO initiation, with earlier conversion to hybrid configuration. Increased rates of cardiovascular, hemorrhagic, vascular, renal, metabolic, infective, and circuit-related complications were reported in converted patients. In-hospital mortality was higher in converted patients (60.8%) overall, and highest for venovenous to venoarterial patients (63.2%). Conclusions: The venovenous patients converted to other ECMO configurations were 2.4% and experienced higher complication and mortality rates. Variables associated with conversion highlight the importance of initial configuration selection and should be considered as part of the risk stratification framework when evaluating a patient for individualized ECMO support mode/configuration. [...]

Objective: Volatile anesthetics (VAs) are gaining renewed interest as a sedation strategy in the intensive care, offering an alternative to traditional IV agents. VAs provide several pharmacologic advantages, including rapid onset and offset, minimal systemic metabolism, and favorable recovery profiles. Advances in delivery systems enabled the safe and practical administration of volatile agents in the ICU. Thus, we aimed to describe the pharmacology and safety aspects of inhaled agents as well as the systems designed to deliver VAs in the ICU. Data Sources: Relevant literature was identified through PubMed and MEDLINE databases. Study Selection: Original research, review articles, commentaries, and guidelines addressing safety, efficacy, and use of VAs in adult ICU patients were included. Data Extraction: Studies were reviewed by the authors, with key findings summarized and organized by pharmacologic properties, delivery systems, and safety domains. Data Synthesis: VAs are halogenated hydrocarbons whose mechanism of action is not fully understood. Although the CNS is the primary site of action, the end-tidal concentration of exhaled anesthetic is used to monitor clinical effects such as immobility to a noxious stimulus. Inhaled agents have unique pharmacokinetics, minimal metabolisms, and distinct recovery. The side effect profile is also unique, with malignant hyperthermia being the most feared, yet rare complication. Two systems for inhalational sedation delivery are available internationally, with one currently under evaluation in the United States. The systems are composed of a miniature vaporizer, delivery controller, and a monitor. The systems have distinct safety considerations, such as tidal volume limits. Conclusions: VAs can be used as sedative agents in the ICU. This article comprehensively reviews the pharmacology of VAs along with their safety profile and describes the structure and function of miniature vaporizers currently available on the world market. [...]

Objectives: The evidence supporting the use of noninvasive positive pressure ventilation (NPPV) during severe asthma exacerbations is limited. We determined the annual trend in NPPV use, endotracheal intubations, and in-hospital mortality among all hospitalizations for an asthma exacerbation. We additionally evaluated the association between NPPV use and subsequent endotracheal intubation and in-hospital mortality. Design: Retrospective, propensity-score–matched cohort study. Setting: Administrative data from Healthcare Cost and Utilization Project’s State Inpatient Databases for New York and Florida, 2006–2019. Patients: Patients 5–80 years old hospitalized with an asthma exacerbation. Interventions: Receipt of NPPV. Measurements and Main Results: Among 296,788 hospitalizations for an asthma exacerbation between 2006 and 2018, NPPV use for an asthma exacerbation increased from 1.2% to 7.4% (absolute difference, 6.1%; 95% CI, 5.6–6.7%) in adults and from 0.7% to 7.1% (absolute difference, 6.4%; 95% CI, 5.5–7.3%) in pediatric patients. Among 41,902 ICU encounters, we propensity-score matched 1,972 adult and 1,622 pediatric patients who received NPPV with 6,510 adults and 4,766 pediatric patients who did not receive NPPV. NPPV use was associated with a decreased risk of subsequent intubation (risk ratio [RR], 0.48; 95% CI, 0.40–0.57) and improved in-hospital mortality (RR, 0.33; 95% CI, 0.21–0.54) in adults. In pediatric patients, use of NPPV was associated with a decreased risk of intubation (RR, 0.50; 95% CI, 0.29–0.89), but not significant for an improvement in in-hospital mortality (RR, 0.41; 95% CI, 0.15–1.11). Conclusions: NPPV use for asthma exacerbations has increased. In adult and pediatric patients, NPPV use for an asthma exacerbation was associated with a decreased risk of endotracheal intubation. Furthermore, NPPV use for an asthma exacerbation was associated with improved in-hospital mortality in adult patients. [...]

Objectives: Evaluate the predictive and prognostic performance of the Phoenix Sepsis Criteria (PSC) and Phoenix Sepsis Score (PSS) compared with International Pediatric Sepsis Consensus Conference (IPSCC) criteria and other organ dysfunction scores in children admitted to the PICU with suspected infection. Design: Multicenter, prospective cohort study. Setting: Eight PICUs within the Italian Network of PICU Study Group (TIPNet). Patients: Patients younger than 18 years admitted with suspected infection (from February 2022 to April 2024). Interventions: None. Measurements and Main Results: Vital signs, organ dysfunction markers, and organ support requirements were collected during day 1 and day 2 of PICU admission. Sepsis was assessed using IPSCC criteria and PSC. IPSCC Severe Sepsis, PSS, Phoenix-8, Pediatric Logistic Organ Dysfunction-2 (PELOD-2), pediatric Sequential Organ Failure Assessment, and Pediatric Multiple Organ Dysfunction Score were calculated as organ dysfunction scores. Sepsis criteria predictive performance was assessed using sensitivity and positive predictive value (PPV). Organ dysfunction scores prognostic performance was assessed using the area under the precision-recall curve (AUPRC). Primary outcome was PICU mortality. Among 687 patients, PSC showed higher predictive performance than IPSCC sepsis criteria, with improved sensitivity and PPV for mortality on day 1 (PSC: sensitivity, 96.4%; 95% CI, 95.0–97.8%; PPV, 7.6%; 95% CI, 5.6–9.6% and IPSCC: sensitivity, 82.1%; 95% CI, 79.3–85.0%; PPV, 6.2%; 95% CI, 4.4–8.0%) and day 2 (PSC: sensitivity, 100.0%; 95% CI, 100.0–100.0%; PPV, 10.0%; 95% CI, 7.6–12.5% and IPSCC: sensitivity, 75.0%; 95% CI, 71.5–78.5%; PPV, 9.0%; 95% CI, 6.7–11.3%). PELOD-2 exhibited the highest AUPRC for mortality (day 1, 0.45; 95% CI, 0.26–0.63 and day 2, 0.59; 95% CI, 0.38–0.77). IPSCC Severe Sepsis score was outperformed by all other organ dysfunction scores, including PSS and Phoenix-8. All prognostic performances improved from day 1 to day 2. Conclusions: PSC and PSS performed superior to IPSCC criteria in diagnosing and prognosticating pediatric sepsis, with improved performance at day 2 of PICU admission. This study first validated PSC and PSS in a European cohort. [...]

Objectives: To summarize knowledge and identify gaps in evidence regarding the effects of vasoactive medications on microvascular perfusion in septic shock. Data Sources: We conducted a comprehensive search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Study Selection: Studies included adult patients with septic shock who received vasoactive therapy with corresponding microcirculatory measurements between 1946 and May 7, 2025. Data Extraction: Data extraction was performed in Covidence by two independent reviewers. Data items included study design, patient population, vasoactive medication, macrohemodynamics, and microcirculation measurements and techniques. Data Synthesis: Thirty-three studies were included evaluating several vasoactive medications and microvascular measurement techniques. Despite heterogeneous study design, studies that recruited patients within 24 hours tended to report more significant microcirculatory changes. Microcirculatory changes and cardiac index only aligned in 39% of cases, highlighting a disconnect between global hemodynamics and microvascular perfusion. Several vasoactives, including norepinephrine, vasopressin, terlipressin, and levosimendan demonstrated context-dependent improvements in peripheral/sublingual microcirculation. Despite limitations in directly monitoring gastric microcirculation, dobutamine may enhance perfusion; however, further studies are needed to support dobutamine and other vasoactive agents’ impacts on clinical outcomes. Conclusions: Despite growing interest in perfusion-guided care, significant challenges remain in understanding how vasoactive agents affect the microcirculation. Clarifying these effects through standardized research and point-of-care perfusion monitoring remains a challenge in advancing outcome-driven resuscitation strategies. [...]

Objectives: To evaluate whether remimazolam besylate could provide noninferior sedation to dexmedetomidine in patients under mechanical ventilation (MV) in the ICU. Design: A multicenter, single-blind, randomized, noninferiority trial. Setting: Fifteen ICUs across China between October 2021 and November 2023. Patients: Adults under endotracheal intubation MV who were expected to require sedation for 8–48 hours. Interventions: Three hundred fourteen patients were randomly assigned at a 1:1 ratio to the remimazolam besylate or dexmedetomidine group. Analgesia was provided via a continuous IV infusion of remifentanil at 1.2–9.0 µg/kg/hr. Remimazolam besylate or dexmedetomidine was administered IV at an initial loading dose of 0.1 mg/kg followed by a maintenance dose of 0.10–0.30 mg/kg/hr or at an initial loading dose of 0.20 µg/kg followed by a maintenance dose of 0.2–0.70 µg/kg/hr to achieve the targeted sedation range on the Richmond Agitation-Sedation Scale of –2 to +1. Measurements and Main Results: Of the 314 patients enrolled, 299 completed the study. The sedation efficacy rates, as the primary endpoint, were 82.6% and 83.2% in remimazolam besylate and dexmedetomidine groups, respectively, in the per-protocol set (PPS), whereas the rate was 72.9% in both groups in the intention-to-treat (ITT) set. The noninferiority margin was set as 10%, and the lower limits of the two-sided 95% CI for the intergroup difference were –3.0% and –2.6% in the PPS and ITT sets, respectively. The dexmedetomidine group had a higher incidence of bradycardia than the remimazolam besylate group (4.7% vs. 0.7%; p = 0.029), whereas no intergroup differences were noted for the remaining secondary endpoints and adverse events. Conclusions: Remimazolam besylate could provide noninferior sedation as dexmedetomidine with a lower risk of bradycardia for 48 hours in mechanically ventilated patients in the ICU. [...]

No abstract available [...]

Objective: The Pao2/Fio2 (PF) ratio is widely used as an assessment of respiratory failure in guiding ventilation strategies and prognostication in critically ill patients. However, given that it mandates invasive arterial access, the Spo2/Fio2 (SF) ratio has been suggested as a noninvasive and readily accessible alternative. What are the best ways to convert SF and PF ratios in critically ill patients, in terms of their diagnostic/prognostic accuracy and clinical utility? Data Sources: We comprehensively searched databases (MEDLINE, Embase, Web of Science, Cochrane library) to identify relevant studies. Study Selection: Any observational studies that compared the SF to PF ratio in critically ill patients. We assessed individual study risk of bias (ROB) using the revised QUADAS II tool. Data Extraction: We included 45 observational studies, ranging from 61 to 141,000 measurements. Data Synthesis: SF to PF imputation was less accurate when the Spo2 was equal to or greater than 97%. Otherwise, all studies were able to establish strong correlational relationships between SF and PF ratios, but there was no clear best equation. Based on ease of use, size, generalizability and methodology, we were able to prioritize four equations (one linear, one logarithmic linear, and two nonlinear). All four equations showed strong correlation between SF and PF ratios, with the linear equation being easiest to apply. The SF ratio also correlated well with clinical outcomes when compared with the PF ratio, both as an individual value and as part of a comprehensive score, with more discriminating performance in some cases. Conclusions: SF and PF ratios demonstrate good correlation, and may have similar prognostic value. Although there is no clear optimal method to convert SF to PF ratios, linear equations show acceptable correlation and are most easily applied at the bedside. [...]

Objectives: To examine how accurately ICU clinicians perceived family-reported prognostic expectations (FPEs) for patients with prolonged mechanical ventilation (PMV). Design: A cross-sectional, exploratory design using secondary analysis. Setting: Thirteen ICUs across five hospitals in the United States. Subjects: Family members of patients with PMV and ICU clinicians, including physicians and nurses. Interventions: None. Measurements and Main Results: Latent profile analysis was used to identify profiles of accuracy in clinician perception of FPE, followed by bivariate analyses and multinomial logistic regression to examine associations between patient, family, and clinician characteristics and profile membership. A total of 554 participants (239 family members, 150 physicians, and 165 nurses) were included. Five distinct latent profiles of accuracy in clinician perception of FPE were identified: 1) clinician underestimation of FPE; 2) clinician overestimation of FPE; 3) accurate perception: low prognosis; 4) accurate perception: moderate prognosis; and 5) accurate perception: high prognosis. Families in profile 1 (clinician underestimation of FPE) were more likely to be spouses/partners of patients and reported higher levels of hope and optimism, whereas those in profile 2 (clinician overestimation of FPE) reported lower levels. Patient characteristics, including age, employment status, admission to medical ICU, and pulmonary-related hospital diagnosis, were statistically significantly associated with the profile membership. Conclusions: Understanding how accurately clinicians perceive FPE is vital to improving shared decision-making and developing goal-concordant care for patients with PMV. Further research examining strategies for clinicians to accurately perceive what families believe about prognosis is needed to identify potential misalignment, initiate timely and empathetic conversations, and build toward shared decision-making and goal-concordant care. [...]

Objectives: We sought to determine trends in use of IV vitamin C for hospitalized patients with sepsis in the context of evolving evidence, including a single-center before-after study in late 2016 and several trials in 2019–2021. Design: Retrospective cohort study. Setting: One thousand one hundred fifteen U.S. hospitals contributing to the Premier Healthcare Database, 2008–2021. Patients: Eleven million three hundred seventy-five thousand three hundred twenty-six adult inpatients with sepsis. Interventions: IV vitamin C, at any point of the hospital stay. Measurements and Main Results: Patients had a median (interquartile range [IQR]) age of 71 years (59–81 yr) and a median (IQR) of 5 comorbidities (4–7 comorbidities); 53.0% were female; on hospital day 1, 6.9% were mechanically ventilated and 7.5% received a vasopressor. Overall, 32,131 patients (0.3%) received IV vitamin C at any point during hospitalization. During the study period, administration fell from 2008, quarter 1 (0.5%) through 2017, quarter 1 (< 0.1%), then rose and peaked in 2020, quarter 1 (0.6%), and fell through 2021, quarter 4 (0.1%). Examining three time periods defined by predetermined cutpoints (2015 quarter 4, when International Classification of Diseases coding for sepsis changed, and 2020 quarter 1, when the COVID-19 pandemic began), vitamin C use also varied (p < 0.001): 0.2% (2008 quarter 1 to 2015 quarter 3); 0.3% (2015 quarter 4 to 2019 quarter 4); and 0.3% (2020–2021). Temporal trends were similar in sicker subcohorts defined by early mechanical ventilation, early vasopressor use, and diagnosis of COVID-19 (2020–2021). A multilevel logistic regression model with data from 91 hospitals that contributed at least 1 sepsis case per quarter showed a similar utilization pattern, with substantial between-hospital variability (median odds ratio, 7.78; 95% CI, 5.45–11.58). Conclusions: IV vitamin C prescription for hospitalized patients with sepsis in the United States was overall infrequent over the 14-year study period, rising after the publication of a before-after study and declining in the COVID-19 pandemic as clinical trial results emerged. [...]

Objectives: To evaluate the feasibility of randomizing children on extracorporeal membrane oxygenation (ECMO) to one of two prophylactic platelet transfusion thresholds. Design: Randomized controlled trial. Setting: Ten ECMO centers (nine in United States, one in Israel). Patients: Critically ill children (0 to younger than 18 yr), supported on ECMO, with no or minimal bleeding within 24 hours of cannulation. Interventions: Children were randomized to a higher platelet threshold (transfused when platelet count < 90 × 109/L) or a lower platelet threshold (transfused when platelet count < 50 × 109/L). Primary feasibility outcome was pre-transfusion platelet count to test for a difference between strategies. Primary safety outcome was progression to severe bleeding, severe clotting, and/or all-cause mortality. Measurements and Main Results: Of 159 patients screened for eligibility, 77% (123/159) met eligibility criteria. Sixty-five percent (80/123) of caregivers were approached for consent. Consent was obtained in 63% (50/80). Enrolled children had a median age of 0.2 years (interquartile range 0.0; 1.7) and 88% (44/50) were supported by veno-arterial (V-A) ECMO. The model-adjusted mean difference in pre-transfusion platelet count between the groups was 32 × 109/L (p < 0.001). Compliance with assigned transfusion threshold was 99.2%. Eleven (22%) children experienced the primary safety outcome. Progression to severe bleeding occurred in 14% (7/50) of patients, whereas progression to severe clotting was observed in 4% (2/50). Conclusions: Non-bleeding children on ECMO can be screened, enrolled and randomized to different platelet transfusion strategies within 24 hours of cannulation. Compliance with the protocol was excellent with significant separation in pre-transfusion platelet counts between the arms. Severe bleeding and severe clotting occurred at similar rates in both thresholds. A larger, definitive trial is feasible and needed. [...]

Objectives: High-flow nasal cannula is increasingly used in patients with acute hypoxemic respiratory failure. However, its impact on diaphragmatic function remains poorly understood. Design: Observational crossover pilot study. Setting: Single-center ICU. Patients: Twenty-eight adult ICU patients with a Pao2/Fio2 ratio less than or equal to 300 mm Hg were enrolled. Interventions: Patients underwent sequential 60-minute phases of noninvasive respiratory support using a Venturi mask, high-flow nasal cannula (40 L/min), and helmet continuous positive airway pressure (CPAP). Measurements and Main Results: Diaphragmatic function was assessed using ultrasound, while inspiratory effort was evaluated through esophageal pressure swings. Arterial blood gases were also collected. High-flow nasal cannula significantly improved the diaphragmatic thickening fraction compared with the Venturi mask (27% ± 9.9% vs. 20% ± 6%; p = 0.0013). Conversely, diaphragmatic excursion was lower with high-flow nasal cannula than with both the Venturi mask and CPAP (1.1 ± 0.63 cm vs. 1.5 ± 0.95 cm and 1.4 ± 0.59 cm, respectively; p = 0.0002). High-flow nasal cannula also reduced inspiratory effort compared with the Venturi mask. In patients with diaphragmatic dysfunction index greater than 100, both high-flow nasal cannula and CPAP enhanced diaphragmatic thickening and decreased esophageal pressure swings relative to the Venturi mask. Conclusions: This study shows that high-flow nasal cannula improves diaphragmatic function compared with Venturi mask oxygen therapy. Larger studies are needed to confirm these findings. [...]

Background: Sepsis is one of the leading causes of death among children worldwide. The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force developed and validated the Phoenix sepsis criteria, new clinical criteria for pediatric sepsis and septic shock based on organ dysfunction. Although this represents a significant advancement in standardizing sepsis and septic shock definitions, its applicability in emergency department (ED) settings remains unexplored. Importance: Given that EDs are often the first point of contact for critically ill children, we must examine the use of the Phoenix criteria in these settings and across varying resource levels. In this CME review article, we explore the evolution of pediatric sepsis definitions to the Phoenix sepsis criteria, and its utility, strengths, and limitations in emergency care in both high-resource and low-resource ED settings. [...]

Measles is a highly contagious viral infection that resulted in significant morbidity and mortality before widespread vaccination efforts began in the 1960s. In 2000, measles was declared eliminated in the United States; however, continued global circulation combined with rising vaccine hesitancy has resulted in recent outbreaks of increasing severity. This review article highlights relevant epidemiology and prepares clinicians to differentiate measles infection from similar febrile exanthems of childhood. We review available diagnostics and the management of patients with or exposed to measles infection in an era of unfamiliarity with the condition. [...]

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 [...]

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. [...]

No abstract available [...]

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. [...]

No abstract available [...]

No abstract available [...]

No abstract available [...]

No abstract available [...]

No abstract available [...]

No abstract available [...]

No abstract available [...]

No abstract available [...]

No abstract available [...]

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). [...]