Citations

OBJECTIVES: Many PICU admissions start with presentation in the emergency department (ED). However, we do not know whether there are any ED-related factors associated with the subsequent development of pediatric delirium (PD) within 24 hours of PICU admission. DESIGN: Retrospective cohort study. SETTING: Single-center ED and PICU serving a quaternary referral center in the United States. PATIENTS: Children younger than 18 years old presenting to the ED between January 2022 and December 2023 who required direct admission to the PICU, and who had at least one positive delirium screening within 24 hours of the admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The presence of delirium in the PICU was defined as a Cornell Assessment of Pediatric Delirium (CAPD) score of 9 and higher. We identified 138 patients for the final analysis. Overall, 51 of 138 patients (37%) developed PD within 24 hours of admission. The majority of delirium cases were classified as hypoactive (53%, 27/51) and mixed (31%, 16/51) subtypes, while only 16% (8/51) were identified as hyperactive delirium. Factors associated with greater odds (95% CI) of delirium in the PICU in multivariable analysis were use of mechanical ventilation (odds ratio [OR], 3.42 [95% CI, 1.09–10.78]; p = 0.04) and intermittent urinary catheterization (OR, 3.7 [95% CI, 1.21–11.30]; p = 0.02). Initial CAPD score positively correlated with PICU length of stay (LOS; r = 0.32; p < 0.01), Pediatric Index of Mortality 3 (PIM 3) score ( r = 0.26; p < 0.01), and negatively correlated with emergency severity index (ESI) in the ED ( r = –0.35; p < 0.01). CONCLUSIONS: Mechanical ventilation and intermittent urinary catheterization in the ED are associated with greater odds of PD within 24 hours of PICU admission. CAPD at admission positively correlates with PICU LOS, PIM 3 scores, and negatively correlates with ESI in the ED.

ABSTRACT Aims Sarcoid myopathy (SaM) is characterised by granulomatous myositis (GM) and can overlap with inclusion body myositis (IBM), a late‐onset chronic idiopathic inflammatory myopathy with a still enigmatic pathogenesis. As GM can occur in different clinical contexts, we aimed to examine the histomorphologic features and gene expression profiles in cases of definite SaM that may inform diagnostic and therapeutic considerations. Methods We performed a multidimensional characterisation of muscle biopsy specimens from patients with ‘pure SaM’ (n=17), SaM with concomitant IBM (SaM‐IBM) (n=2), including histopathologic and ultrastructural analysis in addition to quantitative real‐time polymerase chain reaction. Additionally, bulk RNA sequencing was performed on 38 muscle biopsy specimens from patients with SaM (including SaM‐IBM) (n=30) and NGI (n=8). Results Histopathological analysis revealed a pattern of endomysial and perimysial granulomatous inflammation frequently extending to the fascia, endomysial fibrosis, muscle fibre atrophy, variation in muscle fibre size and capillary thickening. Findings from immunohistochemical studies established Chitinase 1 as a pure giant cell marker in SaM. On a subcellular level, ‘pure SaM’ was characterised by focal accumulation of large swollen mitochondria with rare cristae but an absence of irregular cristae. Transcriptomic analysis of patients with SaM confirmed markedly elevated expression of both type 1 and type 2 human leukocyte antigen molecules. Macrophage activity markers were highly elevated. Consistent with histologic findings, CHIT1 was specifically overexpressed in SaM samples but not in ‘pure IBM’ muscle biopsy specimens. Conclusions SaM is characterised by a stereotypical appearance at the histopathologic level and disease‐specific immune dysregulation that involves macrophage function and maturation. SaM‐IBM represents a noteworthy overlap syndrome that shares multiple dysregulated immune pathways with ‘pure SaM’.

Wastewater treatment is evolving rapidly with the advent of advanced deep-learning AI, graph-based, and physics-informed approaches. This study integrates graph neural networks, physics-informed neural networks, and multi-agent reinforcement learning within a hybrid digital-twin framework, evaluated on multi-scale real-world datasets. The developed models achieved over 90% dissolved organic carbon removal and reduced aeration energy by up to 22% while maintaining process stability. The results demonstrate that graph–physics synergies not only boost operational efficiency but also reveal critical trade-offs between energy savings and hydraulic performance. Our findings establish a new benchmark for resilient, low-carbon wastewater treatment, highlighting the transformative role of data-driven system design.

The NCCN Guidelines for Biliary Tract Cancers (BTCs) provide recommendations for the evaluation and comprehensive care of patients with gallbladder cancer, intrahepatic cholangiocarcinoma, and extrahepatic cholangiocarcinoma. The multidisciplinary panel of experts is convened at least once annually to review requests from internal and external entities as well as to evaluate new data on current and emerging therapies. This manuscript focuses on the adjuvant chemotherapy and chemoradiation treatment options for BTCs as well as the systemic treatment recommendations for patients with advanced BTCs.

The NCCN Guidelines for Non–Small Cell Lung Cancer (NSCLC) provide recommendations for the treatment of NSCLC. These NCCN Guidelines Insights discuss recent updates to the NCCN Guidelines, with a focus on systemic therapy options for the treatment of patients with nonmetastatic NSCLC and the corresponding molecular testing considerations.

Background and importance Emergency airway management in the emergency department (ED) is a high-risk procedure associated with patient outcomes. First-attempt success is a widely recognized quality metric, as multiple attempts are associated with an increased risk of peri-intubation complications. In Brazil, where emergency medicine is a recently established specialty, many ED are staffed by physicians without formal emergency medicine training. The association between emergency medicine training and intubation outcomes in this setting has not been well characterized. Objective To assess the association of physician specialty with first-attempt success and immediate peri-intubation complications in Brazilian EDs. Design Secondary analysis of a multicenter, prospective cohort study from the Brazilian Airway Registry Cooperation. Setting and participants This study included adult patients who underwent tracheal intubation in EDs between March 2022 and April 2024. Patients were excluded if the intubation occurred outside the ED, during cardiopulmonary resuscitation, or for elective procedures. Intubations performed by medical students were also excluded. Physicians were categorized by specialty as emergency medicine or nonemergency medicine. Outcome measures and analysis The primary outcome was first-attempt success; secondary outcomes included peri-intubation complications (severe hypoxemia, hemodynamic instability, and cardiac arrest). Multivariable logistic regression was used to assess the association between physician specialty and outcomes. Main results Among 2582 patients, 1087 (42.1%) were intubated by emergency physicians and 1495 (57.9%) by other physicians (mainly internal medicine and surgery). Intubations by emergency physicians were associated with a higher rate of first-attempt success [80.4 vs. 70.9%, adjusted odds ratio [aOR]: 1.63, 95% confidence interval (CI): 1.34–1.97]. There was also a higher odds of intubations without major complications (aOR: 1.20, 95% CI: 1.01–1.42). Conclusion In this study, there was a higher rate of first-attempt success in intubations performed by board-certified emergency physicians compared with other physicians working in Brazilian EDs.

Abstract Background This study simulates how assay-specific bias influences the diagnostic performance of 0/1-h accelerated diagnostic protocols (ADPs) for 3 different high-sensitivity cardiac troponin (hs-cTn) assays. Methods We included 1493 patients presenting with chest pain. hs-cTnT (Roche Diagnostics), hs-cTnI from Abbott Diagnostics (hs-cTnI-A), and Siemens Healthineers (hs-cTnI-S) were measured at admission. The absolute total error observed in a state-of-the-art EQA study were added to the admission concentrations, producing 6 new variables being adjusted for maximum possible bias (if analytical variation is 0) (+biasmean, +biasmax95%CI, +biasmin95%CI, −biasmean, −biasmax95%CI, −biasmin95%CI). The influence of this “worst-case scenario” bias was compared after calculating sensitivity, specificity, negative and positive predictive values, and rule-out proportion for 30-day myocardial infarction or death for the observed and bias-adjusted hs-cTn concentrations. Results For 0-h rule-out, hs-cTnI-S and hs-cTnT had a sensitivity of &gt;99.0%, compared to 97.7% for hs-cTnI-A. After adding the bias, sensitivity was unchanged for hs-cTnI-S (99.5%), but lower for hs-cTnT (95.5%), and hs-cTnI-A (96.2%). For the 0-/1-h algorithm, adding bias reduced sensitivity to 95.5% for hs-cTnT, while both hs-cTnI algorithms were unchanged (100.0%). Rule-out proportions for 0 h ranged from 0% to 60.0% for hs-cTnT, 28.2%–62.7% for hs-cTnI-A, and 3.5%–35.5% for hs-cTnI-S. For the 0-/1-h algorithm, ranges were 57.7%–75.8% (hs-cTnT), 52.8%–67.5% (hs-cTnI-A), and 45.7%–61.2% (hs-cTnI-S), Conclusion Analytical bias of hs-cTn assays affects the clinical rule-out rate of the 0/1-h ADPs more than the diagnostic sensitivity. Bias may have a greater influence on the proportion of patients requiring hospital admission and may contribute to the heterogeneity of the reported rule-out rates of current ADPs. ClinicalTrials.gov Registration Number: NCT02620202