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Bethany D Pester,1,2,* Jolin B Yamin,2,3,* Maria J Cabrera,2,3 Shivani Mehta,2,3 Jeremy Silverman,2,3 Anne V Grossestreuer,2,3 Patricia Howard,2,3 Robert R Edwards,1,2 Michael W Donnino2,3 1Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA; 2Harvard Medical School, Boston, MA, USA; 3Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA*These authors contributed equally to this workCorrespondence: Michael W Donnino, Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Rosenberg 2, Boston, MA, Boston, USA, +1-617-754-2295, Email mdonnino@bidmc.harvard.eduPurpose: Widely used therapeutic approaches, such as cognitive-behavioral and mindfulness-based therapies, can improve pain and functioning in people with chronic back pain, but the magnitude and duration of their effects are limited. Our team developed a novel 12-week program, psychophysiologic symptom relief therapy (PSRT), to substantially reduce or eliminate pain and disability. This study examined whether PSRT helped more patients achieve large-magnitude (≥ 30%, ≥ 50%, ≥ 75%) reductions in back pain-related disability compared to mindfulness-based stress reduction (MBSR) and usual care (UC), and if the beneficial effects of PSRT were explained by reductions in pain-related anxiety following treatment.Patients and Methods: Data from a three-armed randomized controlled trial were used (N=35 adults with chronic back pain). Change scores (baseline to 4-, 8-, 13-, and 26-weeks post-enrollment) were computed for back pain disability (RDQ) and pain-related anxiety (PASS-20). Fisher’s exact tests and mediation analyses were conducted.Results: Compared to MBSR and UC, PSRT helped significantly more patients achieve ≥ 75% reductions in back pain disability at all timepoints and in pain anxiety at all timepoints except 13-weeks. Change in pain anxiety significantly mediated the relationship between treatment group and change in back pain disability from baseline to 26-weeks.Conclusion: PSRT helped more patients achieve substantial reductions in disability than an established treatment (MBSR) and usual care. Findings indicate reduced pain anxiety may be a mechanism by which PSRT confers long-term benefits on disability. Importantly, this work aims to move the field toward more precise and effective treatment for chronic back pain.Keywords: chronic back pain, mind-body therapies, back pain disability, pain-related anxiety

Background: Many patients require inter-hospital transfer (IHT) to tertiary Emergency Departments (EDs) to access specialty services. The purpose of this study is to determine operational outcomes for patients undergoing IHT to a tertiary academic ED, with an emphasis on timing and specialty consult utilization., Methods: This study was a retrospective observational cohort study at a tertiary academic hospital from 10/1/21-9/30/22. Key operational metrics, including specialty consultations, were queried from the ED Information System (EDIS). Data were analyzed for temporal variation in operational metrics and consulting patterns between transferred and non-transferred patients, stratified by time of day and week., Results: During the study period there were 50,589 ED patient encounters, of which 3196 (6.3 %) were identified as IHTs. Transferred patients made up a larger proportion of patient arrivals in off-hours compared to daytime hours (p < 0.001). Transferred patients were more likely to be admitted to the hospital (76 % vs 35 %, p < 0.001), go directly to a procedure (6 % vs 2 %, p < 0.001), or receive a specialty consult (90 % vs 42 %, p < 0.001), regardless of the day of week or time of day. Relative risk of consults amongst transferred patients varied by service, though was particularly increased amongst surgical sub-specialties., Conclusions: Transferred patients represented a larger proportion of ED volume during evening and overnight hours, received more consults, and had higher likelihood of admission. Consults for transfers were disproportionately surgical subspecialties, though few patients went directly to a procedure. These findings may have operational implications in optimizing availability of specialty services across regionalized health systems., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Diabetic ketoacidosis (DKA) is a potentially life-threatening disorder associated with severe alterations in metabolism and acid-base status. Mitochondrial dysfunction is associated with diabetes and its complications. Thiamine and coenzyme Q10 (CoQ10) are important factors in aerobic metabolism. In this study, we measured cellular oxygen consumption rates (OCRs) and the effects of in vitro administration of thiamine and CoQ10 on OCRs in patients with DKA versus healthy controls., Methods: Blood samples were collected from a prospective cohort of patients with DKA and from controls. Cellular OCRs were measured in peripheral blood mononuclear cells (PBMC) without treatment and after treatment with thiamine, CoQ10, or both. The mitochondrial profile was measured using an XFe96 Extracellular Flux Analyzer and XF Cell Mito Stress Test Kit (Seahorse Bioscience). A linear quantile mixed model was used to compare OCRs and estimate treatment effects., Results: A total of 62 patients with DKA and 48 controls were included in the study. The median basal and maximal OCRs were lower in the DKA group than in the control group (basal: 4.7 [IQR: 3.3, 7.9] vs. 7.9 [5.0, 9.5], p = 0.036; maximal: 16.4 [9.5, 28.1] vs. 31.5 [20.6, 46.0] pmol/min/µg protein, p < 0.001). In DKA samples, basal and maximal OCRs were significantly increased when treated with thiamine, CoQ10, or both. In controls, basal and maximal OCR were significantly increased only with thiamine treatment., Conclusion: Mitochondrial metabolic profiles of patients with DKA demonstrated lower cellular oxygen consumption when compared to healthy controls. Oxygen consumption increased significantly in cells of patients with DKA treated with thiamine or CoQ10. These results suggest that thiamine and CoQ10 could potentially have therapeutic benefits in DKA via their metabolic effects on mitochondrial cellular respiration., (© 2024. The Author(s).)

Introduction: Emergency providers risk encountering firearms in the emergency department, but a minority report familiarity with handling firearms. It may be unsafe if unfamiliar, untrained providers attempt to remove a firearm from the clinical care space. This study assessed the efficacy of an educational intervention training resident physicians in this task., Methods: Five emergency medicine residency programs conducted a prospective, single-blinded randomized controlled trial assessing performance of safely removing a firearm from the clinical care space during a simulated patient encounter. The primary outcome was completion of critical actions previously assessed in a pilot study. Residents viewed a 5-minute educational video developed for this study detailing the principles of safely removing a firearm from the clinical care space. The training video was emailed to prospective participants in the intervention group ahead of the simulation session. Afterward, a debriefing session was held with all participants to review the safe handling of firearms., Results: Sixty-six of 170 prospective participants (38.8%) consented to participate. There were no significant differences in gender, clinical training level, environment of upbringing, confidence in handling firearms, firearm usage frequency, or prior firearm training. Twenty-nine participants handled the firearm during simulation. The intervention group performed significantly better than the control group, completing a median of 7 critical actions (interquartile range, 7-8) versus 6 critical actions (interquartile range, 5-7), P = 0.035. This effect held among participants who handle firearms outside of work and/or have prior firearms training., Conclusions: This study demonstrates how a brief educational intervention was associated with improvement in participants' ability to safely remove a firearm from a simulated clinical care space. This approach can be integrated into existing curricula, and its success suggests broad applicability., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Society for Simulation in Healthcare.)

Aim: Whether changes in oxygen metabolism, as measured by oxygen consumption (VO 2 ), carbon dioxide production (VCO 2 ) and the respiratory exchange ratio (RER), are associated with survival after cardiac arrest is poorly understood. In this prospective observational study, we investigated the association between VO 2 , VCO 2 , and RER in the initial 12 and 24 h after return of spontaneous circulation (ROSC) and survival to hospital discharge., Methods: Adults with ROSC after cardiac arrest, admitted to the intensive care unit, requiring mechanical ventilation and treated with targeted temperature management were included. VO 2 and VCO 2 were measured continuously for 24 h after ROSC, using a noninvasive anesthesia monitor. Area under the curve for VO 2 , VCO 2 & RER was calculated using all available values over 12 and 24 h after ROSC. Using logistic regression, we evaluated the relationship between these metabolic variables and survival to hospital discharge. Analyses were adjusted for temperature, vasopressors, and neuromuscular blockade., Results: Sixty four patients were included. Mean age was 64 ± 16 years, and 59% were women. There was no significant association between the area under the curve of VO 2 or VCO 2 and survival. A higher RER in the initial 12 h was associated with better survival (aOR = 3.97, 95% CI [1.01,15.6], p = 0.048). Survival was lower in those with median RER < 0.7 in the initial 12 h compared with those with a median RER ≥ 0.7 (25% vs 67%, p = 0.011)., Conclusion: Higher RER in the initial 12 h was associated with survival after cardiac arrest. The etiology of unusually low RERs in this patient population remains unclear., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Introduction: Thiamine is a key cofactor for aerobic metabolism, previously shown to improve mortality and neurological outcomes in a mouse model of cardiac arrest. We hypothesized that thiamine would decrease lactate and improve outcomes in post-arrest patients., Methods: Single center, randomized, blinded, placebo-controlled, Phase II trial of thiamine in adults within 4.5 hours of return of spontaneous circulation after out-of-hospital cardiac arrest (OHCA), with coma and lactate ≥ 3 mmol/L. Participants received 500 mg IV thiamine or placebo twice daily for 2 days. Randomization was stratified by lactate > 5 or ≤ 5 mmol/L. The primary outcome of lactate was checked at baseline, 6, 12, and 24 hours, and compared using a linear mixed model to account for repeated measures. Secondary outcomes included SOFA score, pyruvate dehydrogenase, renal injury, neurological outcome, and mortality., Results: Of 93 randomized patients, 76 were enrolled and included in the analysis. There was no difference in lactate over 24 hours (mean difference 0.34 mmol/L (95% CI: -1.82, 2.50), p = 0.43). There was a significant interaction between randomization lactate subgroup and the effect of the intervention on mortality (p = 0.01) such that mortality was higher with thiamine in the lactate > 5 mmol/L group and lower with thiamine in the < 5 mmol/L group. This subgroup difference prompted the Data and Safety Monitoring Board to recommend the study be terminated early. PDH activity increased over 72 hours in the thiamine group. There were no differences in other secondary outcomes., Conclusion: In this single-center randomized trial, thiamine did not affect lactate over 24 hours after OHCA., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Introduction: Elevated lactate is associated with mortality after cardiac arrest. Thiamine, a cofactor of pyruvate dehydrogenase, is necessary for aerobic metabolism. In a mouse model of cardiac arrest, thiamine improved pyruvate dehydrogenase activity, survival and neurologic outcome., Aim: To determine if thiamine would decrease lactate and increase oxygen consumption after in-hospital cardiac arrest., Methods: Randomized, double-blind, placebo-controlled phase II trial. Adult patients with arrest within 12 hours, mechanically ventilated, with lactate ≥ 3 mmol/L were included. Randomization was stratified by lactate > 5 or ≤ 5 mmol/L. Thiamine 500 mg or placebo was administered every 12 hours for 3 days. The primary outcome of lactate was checked at baseline, 6, 12, 24, and 48 hours, and compared using a linear mixed model, accounting for repeated measures. Secondary outcomes included oxygen consumption, pyruvate dehydrogenase, and mortality., Results: Enrollments stopped after 36 patients due Data Safety and Monitoring Board concern about potential harm in an unplanned subgroup analysis. There was no overall difference in lactate (mean difference at 48 hours 1.5 mmol/L [95% CI -3.1-6.1], global p = 0.88) or any secondary outcomes. In those with randomization lactate > 5 mmol/L, mortality was 92% (11/12) with thiamine and 67% (8/12) with placebo (p = 0.32). In those with randomization lactate ≤ 5 mmol/L mortality was 17% (1/6) with thiamine and 67% (4/6) with placebo (p = 0.24). There was a significant interaction between randomization lactate and the effect of thiamine on survival (p = 0.03)., Conclusions: In this single center trial thiamine had no overall effect on lactate after in-hospital cardiac arrest., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: Acute pancreatitis is a common disease which, in its severe form, is associated with significant morbidity and mortality. Currently, there is no specific therapy known to attenuate organ failure in severe pancreatitis and treatment consists primarily of supportive care. Corticosteroids have been shown to be beneficial in disease processes associated with systemic inflammation and could potentially improve outcomes in severe acute pancreatitis., Methods: The Corticosteroids to Reduce Inflammation in Severe Pancreatitis (CRISP) trial is a multi-centre, double-blind, randomized, placebo-controlled clinical trial that aims to determine the impact of corticosteroids versus placebo on organ injury in patients with severe acute pancreatitis. Patients are randomized to receive 100 mg of hydrocortisone parenterally versus matching placebo every 8 h for 3 days. Clinical and laboratory data are collected at the time of study enrollment, at 24, 48 and 72 h. The primary end-point for the trial is the difference in 72-h change in the Sequential Organ Failure Assessment (SOFA) score between hydrocortisone and placebo groups. Additional key secondary outcomes include ventilator free days and 28-day mortality., Discussion: This study will add to the evidence base in the treatment of severe acute pancreatitis. The results will inform clinical practice and future studies in the field. Trial registration number The trial is registered on clinicaltrials.gov (NCT05160506). It was posted on December 16th, 2021. The study protocol was approved by the Beth Israel Deaconess Medical Center Committee on Clinical Investigation (CCI) (protocol 2021 P-000803)., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Diabetic ketoacidosis (DKA) is a potentially life-threatening diabetic complication. Despite the high prevalence of DKA and the substantial associated healthcare burden, limited research on strategies to improve outcomes currently exists.Thiamine (vitamin B1) is a cofactor of pyruvate dehydrogenase, which plays a key role in aerobic glucose metabolism. Thiamine deficiency is common in patients with DKA, resulting in a shift to anaerobic metabolism and hyperlactatemia, which can prolong and complicate recovery. Therefore, we hypothesise that thiamine administration will improve aerobic metabolism and lead to faster resolution of acidemia in patients with DKA., Methods and Analysis: In this single centre, double-blind, randomised, placebo-controlled, parallel group interventional trial, 100 patients admitted to the hospital with DKA will be randomised to receive either intravenous thiamine (200 mg in 50 mL 0.9% saline) or placebo (0.9% saline identical in appearance and volume) two times per day for 2 days. The primary outcome will be the change in bicarbonate level over 24 hours as compared between the two treatment groups. Additional secondary outcomes include the change over time in anion gap, lactate levels, oxygen consumption by circulating mononuclear cells, intensive care unit and hospital length-of-stay and hospital resource usage when comparing the two study arms., Ethics and Dissemination: This trial was approved by the Committee on Clinical Investigations, the institutional review board of Beth Israel Deaconess Medical Center (protocol number 2018P000475). Findings will be disseminated through peer-reviewed publications and professional conference presentations., Trial Registration Number: NCT03717896; clinicaltrials.gov., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: This is a post hoc analysis of combined cohorts from two previous Phase II clinical trials to assess the effect of thiamine administration on kidney protection and mortality in patients with septic shock., Methods: Patient-level data from the Thiamine in Septic Shock Trial (NCT01070810) and the Thiamine for Renal Protection in Septic Shock Trial (NCT03550794) were combined in this analysis. The primary outcome for the current study was survival without the receipt of renal replacement therapy (RRT). Analyses were performed on the overall cohort and the thiamine-deficient cohort (thiamine < 8 nmol/L)., Results: Totally, 158 patients were included. Overall, thiamine administration was associated with higher odds of being alive and RRT-free (adjusted odds ratio [aOR]: 2.05 [95% confidence interval (CI) 1.08-3.90]) and not needing RRT (aOR: 2.59 [95% CI 1.01-6.62]). In the thiamine-deficient group, thiamine administration was associated with higher odds of being alive and RRT-free (aOR: 8.17 [95% CI 1.79-37.22]) and surviving to hospital discharge (aOR: 6.84 [95% CI 1.54-30.36]). There was a significant effect modification by baseline thiamine deficiency for alive and RRT-free (interaction, p = 0.016) and surviving to hospital discharge (p = 0.019)., Conclusion: In the combined analysis of two previous randomized trials, thiamine administration was associated with higher odds of being alive and RRT-free at hospital discharge in patients with septic shock. This signal was stronger in patients with thiamine deficiency., (© 2024. The Author(s).)

Abstract: Introduction: In this study, we assessed whether changes in oxygen consumption (VO 2 ) and other metabolic parameters could be used as an early warning system for detecting clinical deterioration in mechanically ventilated patients. Methods: This was a prospective cohort study of adult patients requiring mechanical ventilation between February 2016 and March 2019. We looked for changes in VO 2 , carbon dioxide production (VCO 2 ), respiratory quotient (RQ), and end-tidal carbon dioxide (EtCO 2 ), occurring prior to clinical deterioration. Clinical deterioration was predefined as a requirement of vasopressor, an increase in serum lactate by 20% where at least one value was above 3 mmol/L, or a decrease in hemoglobin by 20% in the 4 hours prior to clinical deterioration. Results A total of 141 patients were included. There were no detectable changes in VO 2 , VCO 2 , and EtCO 2 within the 4 hours prior to any clinical deterioration. RQ increased significantly within the 4 hours prior to an increase in lactate as compared with no increase in lactate, but there were no detectable changes prior to other clinical deteriorations. Conclusions RQ has the potential to be an early marker of tissue hypoperfusion or mitochondrial dysfunction. However, future studies are necessary to evaluate the use of RQ as a bedside monitor in critical care settings., (Copyright © 2023 by the Shock Society.)

Aim: To evaluate the performance of kidney-specific biomarkers (neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and cystatin-C) in early detection of acute kidney injury (AKI) following cardiac arrest (CA) when compared to serum creatinine., Methods: Adult CA patients who had kidney-specific biomarkers of AKI collected within 12 h of return of spontaneous circulation (ROSC) were included. The association between renal biomarker levels post-ROSC and the development of KDIGO stage III AKI within 7 days of enrollment were assessed as well as their predictive value of future AKI development, neurological outcomes, and survival to discharge., Results: Of 153 patients, 54 (35%) developed stage III AKI within 7 days, and 98 (64%) died prior to hospital discharge. Patients who developed stage III AKI, compared to those who did not, had higher median levels of creatinine, NGAL, and cystatin-C (p < 0.001 for all). There was no statistically significant difference in KIM-1 between groups. No biomarker outperformed creatinine in the ability to predict stage III AKI, neurological outcomes, or survival outcomes (p > 0.05 for all). However, NGAL, cystatin-C, and creatinine all performed better than KIM-1 in their ability to predict AKI development (p < 0.01 for all)., Conclusion: In post-CA patients, creatinine, NGAL, and cystatin-C (but not KIM-1) measured shortly after ROSC were higher in patients who subsequently developed AKI. No biomarker was statistically superior to creatinine on its own for predicting the development of post-arrest AKI., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Rationale: Kidney injury is common and associated with worse outcomes in patients with septic shock. Mitochondrial resuscitation with thiamine (vitamin B1) may attenuate septic kidney injury. Objectives: To assess whether thiamine supplementation attenuates kidney injury in septic shock. Methods: The TRPSS (Thiamine for Renal Protection in Septic Shock) trial was a multicenter, randomized, placebo-controlled trial of thiamine versus placebo in septic shock. The primary outcome was change in serum creatinine between enrollment and 72 hours after enrollment. Measurements and Main Results: Eighty-eight patients were enrolled (42 patients received the intervention, and 46 received placebo). There was no significant between-groups difference in creatinine at 72 hours (mean difference, -0.57 mg/dl; 95% confidence interval, -1.18, 0.04; P  = 0.07). There was no difference in receipt of kidney replacement therapy (14.3% vs. 21.7%, P  = 0.34), acute kidney injury (as defined by stage 3 of the Kidney Disease: Improving Global Outcomes acute kidney injury scale; 54.7% vs. 73.9%, P  = 0.07), or mortality (35.7% vs. 54.3%, P  = 0.14) between the thiamine and placebo groups. Patients who received thiamine had more ICU-free days (median [interquartile range]: 22.5 [0.0-25.0] vs. 0.0 [0.0-23.0], P  < 0.01). In the thiamine-deficient cohort (27.4% of patients), there was no difference in rates of kidney failure (57.1% thiamine vs. 81.5% placebo) or in-hospital mortality (28.6% vs. 68.8%) between groups. Conclusions: In the TRPSS trial, there was no statistically significant difference in the primary outcome of change in creatinine over time. Patients who received thiamine had more ICU-free days, but there was no difference in other secondary outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT03550794).

Background: Pulseless electrical activity (PEA) and asystole account for 81% of initial in-hospital cardiac arrest (IHCA) rhythms in the U.S.A. These "non-shockable" rhythms are often grouped together in resuscitation research and practice. We hypothesized that PEA and asystole are distinct initial IHCA rhythms with distinguishing features., Methods: This was an observational cohort study using the prospectively collected nationwide Get With The Guidelines®-Resuscitation registry. Adult patients with an index IHCA and an initial rhythm of PEA or asystole between the years of 2006 and 2019 were included. Patients with PEA vs. asystole were compared with respect to pre-arrest characteristics, resuscitation practice, and outcomes., Results: We identified 147,377 (64.9%) PEA and 79,720 (35.1%) asystolic IHCA. Asystole had more arrests in non-telemetry wards (20,530/147,377 [13.9%] PEA vs. 17,618/79,720 [22.1%] asystole). Asystole had 3% lower adjusted odds of ROSC (91,007 [61.8%] PEA vs. 44,957 [56.4%] asystole, aOR 0.97, 95%CI 0.96-0.97, P < 0.01); there was no statistically significant difference in survival to discharge (28,075 [19.1%] PEA vs. 14,891 [18.7%] asystole, aOR 1.00, 95%CI 1.00-1.01, P = 0.63). Duration of resuscitation for those without ROSC were shorter for asystole (29.8 [±22.5] minutes in PEA vs. 26.2 [±21.5] minutes in asystole, adjusted mean difference -3.05 95%CI -3.36--2.74, P < 0.01)., Interpretation: Patients suffering IHCA with an initial PEA rhythm had patient and resuscitation level differences from those with asystole. PEA arrests were more common in monitored settings and received longer resuscitations. Even though PEA was associated with higher rates of ROSC, there was no difference in survival to discharge., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: To determine if psychophysiologic symptom relief therapy (PSRT) will reduce symptom burden in patients suffering from post-acute sequelae of COVID-19 (PASC) who had mild/moderate acute COVID-19 disease without objective evidence of organ injury., Patients and Methods: Twenty-three adults under the age of 60 with PASC for at least 12 weeks following COVID-19 infection were enrolled in an interventional cohort study conducted via virtual platform between May 18, 2021 and August 7, 2022. Participants received PSRT during a 13 week (approximately 44 hour) course. Participants were administered validated questionnaires at baseline and at 4, 8, and 13 weeks. The primary outcome was change in somatic symptoms from baseline, measured using the Somatic Symptom Scale-8 (SSS-8), at 13 weeks., Results: The median duration of symptoms prior to joining the study was 267 days (IQR: 144, 460). The mean SSS-8 score of the cohort decreased from baseline by 8.5 (95% CI: 5.7-11.4), 9.4 (95% CI: 6.9-11.9), and 10.9 (95% CI: 8.3-13.5) at 4, 8, and 13 weeks respectively (all p<.001). Participants also experienced statistically significant improvements across other secondary outcomes including changes in dyspnea, fatigue, and pain (all p<.001)., Conclusion: PSRT may effectively decrease symptom burden in patients suffering from PASC without evidence of organ injury. The study was registered on clinicaltrials.gov (NCT04854772)., (© 2023 Published by Elsevier Inc on behalf of Mayo Foundation for Medical Education and Research.)

Objectives: Despite decades of literature recognizing racial disparities (RDs) in emergency medicine (EM), published curricula dedicated to addressing them are sparse. We present details of our novel RD curriculum for EM clerkships and its educational outcomes., Methods: We created a 30-min interactive didactic module on the topic designed for third- and fourth-year medical students enrolled in our EM clerkships. Through a modified Delphi process, education faculty and content experts in RD developed a 10-question multiple-choice test of knowledge on RD that the students completed immediately prior to and 2 weeks following the activity. Students also completed a Likert-style learner satisfaction survey. Median pre- and posttest scores were compared using a paired Wilcoxon signed-rank test and presented using medians and 95% confidence intervals (CIs). Satisfaction survey responses were dichotomized into favorable and neutral/not favorable., Results: For the 36 students who completed the module, the median pretest score was 40% (95% CI 36%-50%) and the posttest score was 70% (95% CI 60%-70%) with a p-value of <0.001. Thirty-five of the 36 students improved on the posttest with a mean increase of 24.2% (95% CI 20.2-28.2). The satisfaction survey also showed a positive response, with at least 83% of participants responding favorably to all statements (overall mean favorable response 93%, 95% CI 90%-96%).ConclusionsThis EM-based module on RD led to improvement in students' knowledge on the topic and positive reception by participants. This is a feasible option for educating students in EM on the topic of RD., (© 2023 Society for Academic Emergency Medicine.)

Background: Work Relative Value Units (wRVUs) are a component of many compensation models, and a proxy for the effort required to care for a patient. Accurate prediction of wRVUs generated per patient at triage could facilitate real-time load balancing between physicians and provide many practical operational and clinical benefits., Objective: We examined whether deep-learning approaches could predict the wRVUs generated by a patient's visit using data commonly available at triage., Methods: Adult patients presenting to an urban, academic emergency department from July 1, 2016-March 1, 2020 were included. Deidentified triage information included structured data (age, sex, vital signs, Emergency Severity Index score, language, race, standardized chief complaint) and unstructured data (free-text chief complaint) with wRVUs as outcome. Five models were examined: average wRVUs per chief complaint, linear regression, neural network and gradient-boosted tree on structured data, and neural network on unstructured textual data. Models were evaluated using mean absolute error., Results: We analyzed 204,064 visits between July 1, 2016 and March 1, 2020. The median wRVUs were 3.80 (interquartile range 2.56-4.21), with significant effects of age, gender, and race. Models demonstrated lower error as complexity increased. Predictions using averages from chief complaints alone demonstrated a mean error of 2.17 predicted wRVUs per visit (95% confidence interval [CI] 2.07-2.27), the linear regression model: 1.00 wRVUs (95% CI 0.97-1.04), gradient-boosted tree: 0.85 wRVUs (95% CI 0.84-0.86), neural network with structured data: 0.86 wRVUs (95% CI 0.85-0.87), and neural network with unstructured data: 0.78 wRVUs (95% CI 0.76-0.80)., Conclusions: Chief complaints are a poor predictor of the effort needed to evaluate a patient; however, deep-learning techniques show promise. These algorithms have the potential to provide many practical applications, including balancing workloads and compensation between emergency physicians, quantify crowding and mobilizing resources, and reducing bias in the triage process., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To describe trends in critical illness from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children over the course of the COVID-19 pandemic. We hypothesized that PICU admission rates were higher in the Omicron period compared with the original outbreak but that fewer patients needed endotracheal intubation., Design: Retrospective cohort study., Setting: This study took place in nine U.S. PICUs over 3 weeks in January 2022 (Omicron period) compared with 3 weeks in March 2020 (original period)., Patients: Patients less than or equal to 21 years old who screened positive for SARS-CoV-2 infection by polymerase chain reaction or hospital-based rapid antigen test and were admitted to a PICU or intermediate care unit were included., Interventions: None., Measurements and Main Results: A total of 267 patients (239 Omicron and 28 original) were reviewed. Forty-five patients in the Omicron cohort had incidental SARS-CoV-2 and were excluded from analysis. The Omicron cohort patients were younger compared with the original cohort patients (median [interquartile range], 6 yr [1.3-13.3 yr] vs 14 yr [8.3-17.3 yr]; p = 0.001). The Omicron period, compared with the original period, was associated with an average increase in COVID-19-related PICU admissions of 13 patients per institution (95% CI, 6-36; p = 0.008), which represents a seven-fold increase in the absolute number admissions. We failed to identify an association between cohort period (Omicron vs original) and odds of intubation (odds ratio, 0.7; 95% CI, 0.3-1.7). However, we cannot exclude the possibility of up to 70% reduction in intubation., Conclusions: COVID-19-related PICU admissions were seven times higher in the Omicron wave compared with the original outbreak. We could not exclude the possibility of up to 70% reduction in use of intubation in the Omicron versus original epoch, which may represent differences in PICU/hospital admission policy in the later period, or pattern of disease, or possibly the impact of vaccination., Competing Interests: Dr. Ross’ institution received funding from the National Heart, Lung, and Blood Institute (K23HL148312). Drs. Ross and Kleinman received support for article research from the National Institutes of Health (NIH). Drs. Hall’s and Kleinman’s institutions received funding from the NIH. Dr. Hall received funding from AbbVie and Kiadis. Dr. Kleinman’s institution received funding from the U.S. Health Resources Services Administration (HRSA); he disclosed that he is the owner of Quality Matters is a board member of Dartnet Institute of Principal and owns stock in Regeneron, Sanofi, and Amegen; he received support for article research from HRSA (U3DMC32755); and his work is supported in part by National Institute of Child Health and Human Development (1R61HD105619). The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: Differences between adult and pediatric in-hospital cardiac arrest (IHCA) are well-described. Although most adults are cared for on adult services, pediatric services often admit adults, particularly those with chronic conditions. The objective of this study is to describe IHCA in adults admitted to pediatric services., Design: Retrospective cohort analysis from the American Heart Association's Get With The Guidelines-Resuscitation registry of a subpopulation of adults with IHCA while admitted to pediatric services. Multivariable logistic regression was used to evaluate adjusted survival outcomes and compare outcomes between age groups (18-21, 22-25, and ≥26 yr old)., Setting: Hospitals contributing to the Get With The Guidelines-Resuscitation registry., Patients: Adult-aged patients (≥ 18 yr) with an index pulseless IHCA while admitted to a pediatric service from 2000 to 2018., Interventions: None., Measurements and Main Results: A total of 491 adult IHCAs were recorded on pediatric services at 17 sites, during the 19 years of review, and these events represented 0.1% of all adult IHCAs. In total, 221 cases met inclusion criteria with 139 events excluded due to an initial rhythm of bradycardia with poor perfusion. Median patient age was 22 years (interquartile range, 19-28 yr). Ninety-eight percent of patients had at least one pre-existing condition. Return of spontaneous circulation occurred in 63% of events and 30% of the patients survived to discharge. All age groups had similar rates of survival to discharge (range 26-37%; p = 0.37), and survival did not change over the study period (range 26-37%; p = 0.23 for adjusted survival to discharge)., Conclusions: In this cohort of adults with IHCA while admitted to a pediatric service, we failed to find an association between survival outcomes and age. Additional research is needed to better understand resuscitation in this population., Competing Interests: Dr. Ross’ institution received funding from the National Heart, Lung, and Blood Institute (NHLBI). Dr. Ross’s work is supported by NHLBI: K23HL148312. Drs. Ross and Donnino received support for article research from the National Institutes of Health (NIH). Dr. Donnino disclosed that he is a volunteer for the American Heart Association (AHA). Dr. Donnino’s work is funded in part by the NIH grants K24HL127101 and R01HL136705. Dr. Kleinman disclosed that she is the vice chair of the AHA Get with the Guidelines-Resuscitation Pediatric Task Force. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objective: Acute respiratory distress syndrome (ARDS) after out-of-hospital cardiac arrest is common and associated with worse outcomes. In the hospital setting, there are many potential risk factors for post-arrest ARDS, such as aspiration, sepsis, and shock. ARDS after in-hospital cardiac arrest (IHCA) has not been characterized., Methods: We performed a single-center retrospective study of adult patients admitted to the hospital between 2014-2018 who suffered an IHCA, achieved return of spontaneous circulation (ROSC), and were either already intubated at the time of arrest or within 2 hours of ROSC. Post-IHCA ARDS was defined as meeting the Berlin criteria in the first 3 days following ROSC. Outcomes included alive-and-ventilator free days across 28 days, hospital length-of-stay, hospital mortality, and hospital disposition., Results: Of 203 patients included, 146 (71.9%) developed ARDS. In unadjusted analysis, patients with ARDS had fewer alive-and-ventilator-free days over 28 days with a median of 1 (IQR: 0, 21) day, compared to 18 (IQR: 0, 25) days in patients without ARDS (p = 0.03). However, this association was not significant after multivariate adjustment. There was also a non-significant longer hospital length-of-stay (15 [IQR: 7, 26] vs 10 [IQR: 7, 22] days, p = 0.25; median adjusted increase in ARDS patients: 3 [95% CI: -2 to 8] days, p = 0.27) and higher hospital mortality (53% vs 44%, p = 0.26; aOR 1.6 [95% CI: 0.8-2.9], p = 0.17) in the ARDS group., Conclusion: Among IHCA patients, almost three-quarters developed ARDS within 3 days of ROSC. As in out of hospital cardiac arrest, post-IHCA ARDS is common., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Accurate prediction of severity and mortality in diabetic ketoacidosis (DKA) is important for allocation of resources. The APACHE II and SOFA scores are used to predict mortality in critically ill patients, however neither has been tested exclusively in DKA. We sought to determine if these scoring systems can accurately predict mortality in patients with DKA. This was an observational study of patients presenting to an urban tertiary care center with a diagnosis of DKA. Adult patients (age ≥ 18 years) with glucose > 250 mg/dL, bicarbonate ≤ 20 mEg/L, an anion gap ≥ 16 mEg/L, pH ≤ 7.30, and urine ketones were included. Predicted mortality based upon APACHE II and SOFA scores were compared to observed mortality. A total of 50 patients were included. There was no observed mortality in our population. The median APACHE II score was 10 (IQR: 6, 15) which predicted a mortality of 15% and the median SOFA score was 1 (IQR: 0, 2) which predicted a mortality of 0%. In summary, we found the APACHE II illness severity score does not accurately predict mortality in a population of patients with DKA, while the SOFA score appears to predict mortality in the same population.

The relationship between COVID-19 severity and viral load is unknown. Our objective was to assess the association between viral load and disease severity in COVID-19. In this single center observational study of adults with laboratory confirmed SARS-CoV-2, the first positive in-hospital nasopharyngeal swab was used to calculate the log10 copies/ml [log10 copy number (CN)] of SARS-CoV-2. Four categories based on level of care and modified sequential organ failure assessment score (mSOFA) at time of swab were determined. Median log10CN was compared between different levels of care and mSOFA quartiles. Median log10CN was compared in patients who did and did not receive influenza vaccine, and the correlation between log10CN and D-dimer was examined. We found that of 396 patients, 54.3% were male, and 25% had no major comorbidity. Hospital mortality was 15.7%. Median mSOFA was 2 (IQR 0-3). Median log10CN was 5.5 (IQR 3.3-8.0). Median log10CN was highest in non-intubated ICU patients [6.4 (IQR 4.4-8.1)] and lowest in intubated ICU patients [3.6 (IQR 2.6-6.9)] (p value < 0.01). In adjusted analyses, this difference remained significant [mean difference 1.16 (95% CI 0.18-2.14)]. There was no significant difference in log10CN between other groups in the remaining pairwise comparisons. There was no association between median log10CN and mSOFA in either unadjusted or adjusted analyses or between median log10CN in patients with and without influenza immunization. There was no correlation between log10CN and D-dimer. We conclude, in our cohort, we did not find a clear association between viral load and disease severity in COVID-19 patients. Though viral load was higher in non-intubated ICU patients than in intubated ICU patients there were no other significant differences in viral load by disease severity., (© 2021. Società Italiana di Medicina Interna (SIMI).)

Background: This study was conducted to measure the impact of a volunteer "Transition Guide" on patient experience and psychological stress during the transition from ICUs to general medical and surgical wards., Methods: Between July 2017 and February 2020, medical and surgical patients from nine ICUs at a single tertiary care hospital were accompanied by a uniquely trained volunteer Transition Guide to aid them at the time of transfer to general medical/surgical wards, when available. If a Transition Guide was not available, they were transferred without one. The following day, patients were surveyed with a tool assessing overall satisfaction, multiple aspects in the domain of communication, and psychological stress associated with the transition process. When available, family members and ward nurses who admitted patients from the ICU were surveyed., Results: Target enrollment was 300 patients in each group. Due to COVID-19 and institutional restrictions on volunteers, only 264 underwent transfer with a Guide, while 305 transferred without one. Of all patients approached, 95% with a Guide and 96% without a Guide completed the survey. Patients who were accompanied by a Transition Guide reported a better overall transition, better communication, greater understanding, better resolution of concerns, and less stress than those who did not have a Transition Guide (p < 0.05 for all)., Conclusion: Among a cohort of formerly critically ill patients subsequently transferred to general medical and surgical wards, the presence of a volunteer Transition Guide significantly improved patient experience, enhanced patient communication and understanding, and reduced stress associated with the transfer process. Hospitals may consider this expanded and specialized role for volunteerism in the health care setting to improve patient-centered outcomes., (Copyright © 2021 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Thiamine supplementation is recommended for patients with alcohol use disorder (AUD). The authors hypothesize that critically ill patients with AUD are commonly not given thiamine supplementation., Objective: To describe thiamine supplementation incidence in patients with AUD and various critical illnesses (alcohol withdrawal, septic shock, traumatic brain injury [TBI], and diabetic ketoacidosis [DKA]) in the United States., Design: Retrospective observational study., Setting: Cerner Health Facts database., Patients: Adult patients with a diagnosis of AUD who were admitted to the intensive care unit with alcohol withdrawal, septic shock, TBI, or DKA between 2010 and 2017., Measurements: Incidence and predicted probability of thiamine supplementation in alcohol withdrawal and other critical illnesses., Results: The study included 14 998 patients with AUD. Mean age was 52.2 years, 77% of participants were male, and in-hospital mortality was 9%. Overall, 7689 patients (51%) received thiamine supplementation. The incidence of thiamine supplementation was 59% for alcohol withdrawal, 26% for septic shock, 41% for TBI, and 24% for DKA. Most of those receiving thiamine ( n  = 3957 [52%]) received it within 12 hours of presentation in the emergency department. The predominant route of thiamine administration was enteral ( n  = 3119 [41%])., Limitation: Specific dosing and duration were not completely captured., Conclusion: Thiamine supplementation was not provided to almost half of all patients with AUD, raising a quality-of-care issue for this cohort. Supplementation was numerically less frequent in patients with septic shock, DKA, or TBI than in those with alcohol withdrawal. These data will be important for the design of quality improvement studies in critically ill patients with AUD., Primary Funding Source: National Institutes of Health.

Introduction: Time-to-disposition is an important metric for emergency department throughput. We hypothesized that providers view the shift end as a key timepoint and attempt to leave as few dispositions as possible to the oncoming team, thereby making quicker decisions later in the shift. This study evaluates disposition distribution relative to when patients are assigned a provider during the course of a shift., Methods: 50,802 cases were analyzed over the one-year study interval. 31,869 patients were seen in the early half of a shift (hours 1-4) and 18,933 were seen in the later half (hours 5+). We ran a linear mixed model that adjusted for age, gender, emergency severity index score, time of day, weekend arrivals, quarter of arrival and shift type., Results: Median time-to-disposition for the early group was 3.25 h (IQR 1.90-5.04), and 2.62 h (IQR 1.51-4.31) for the late group. From our mixed model, we conclude that in the later parts of the shift, providers take on average 15.1% less time to make a disposition decision than in the earlier parts of the shift., Conclusion: Patients seen during the latter half of a shift were more likely to have a shorter time-to-disposition than similar patients seen in the first half of a shift. This may be influenced by many factors, such as providers spending the early hours of a shift seeing new patients which generate new tasks and delay dispositions, and viewing the end of shift as a landmark with a goal to maximize dispositions prior to sign-out., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Lower oxygen consumption is associated with worse survival in septic shock and in other forms of critical illness. No treatment that increases oxygen extraction, a key determinant of oxygen consumption, has been found. Thiamine is required for aerobic metabolism, and deficiency is common in the critically ill., Objectives: We evaluated the effect of thiamine on oxygen consumption in patients requiring mechanical ventilation for an acute illness., Design: Phase II, randomized, double-blind, and placebo-controlled trial., Setting and Participants: ICUs in a tertiary care hospital in the United States. Patients admitted to the ICU and requiring mechanical ventilation were screened for enrollment., Interventions: After enrollment, baseline measurement of oxygen consumption and baseline laboratories including lactate, central venous oxygen saturation, and pyruvate dehydrogenase, a single dose of 200 mg IV thiamine or placebo was administered. Oxygen consumption was then monitored for 6 additional hours and repeat laboratories were drawn at the end of the protocol., Main Outcomes and Measures: The primary outcome was the change in oxygen consumption. Analysis was done using linear regression with a first-order autoregressive variance-covariance structure to account for repeated measures within subjects. Secondary outcomes included change in lactate, central venous oxygen saturation, and pyruvate dehydrogenase quantity and activity., Results: Sixty-seven patients were enrolled. After excluding 11 patients due to inadequate quantity or quality of oxygen consumption data, 56 patients were included. There was no difference in change in oxygen consumption in the 6 hours after study drug. Results for secondary outcomes were similarly negative. In the prespecified subgroup of 18 thiamine deficient patients, there was a difference in the two oxygen consumption curves ( p = 0.006), although no difference in median oxygen consumption or area under the curve., Conclusions and Relevance: A single dose of IV thiamine did not alter oxygen consumption in patients requiring mechanical ventilation for acute illness., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Although patients in the ICU are closely monitored, some ICU cardiac arrest events may be preventable. In this study, we sought to reduce the rate of cardiac arrests occurring in the ICU through a quality improvement initiative., Design: Prospective, observational study., Setting: ICUs of a single tertiary care center., Patients: Patients hospitalized in the ICUs between August 2017 and November 2019., Interventions: A comprehensive trigger and response tool., Measurement and Main Results: Forty-three patients experienced an ICU cardiac arrest in the preintervention epoch (6.79 arrests per 1,000 discharges), and 59 patients experienced an ICU cardiac arrest in the intervention epoch (7.91 arrests per 1,000 discharges). In the intervention epoch, the clinical trigger and response tool was activated 106 times over a 1-year period, most commonly due to unexpected new/worsening hypotension. There was no step change in arrest rate (2.24 arrests/1,000 patients; 95% CI, -1.82 to 6.28; p = 0.28) or slope change (-0.02 slope of arrest rate; 95% CI, -0.14 to 0.11; p = 0.79) comparing the preintervention and intervention time epochs. Cardiac arrests in the preintervention epoch were more likely to be "potentially preventable" than that in the intervention epoch (25.6% vs 12.3%, respectively; odds ratio, 0.58; 95% CI, 0.20-0.88; p < 0.01)., Conclusions: A novel trigger-and-response tool did not reduce the frequency of ICU cardiac arrest. Additional investigation is needed into the optimal approach for ICU cardiac arrest prevention., Competing Interests: Drs. Moskowitz and Berg are additionally funded through National Institutes of Health grants K23GM128005 and K23 HL128814, respectively. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Introduction: In this study, we investigated whether the Sequential Organ Failure Assessment (SOFA) score performance differs based on the type of infection among patients admitted to the intensive care unit (ICU) with infection., Materials and Methods: Single-center, retrospective study of adult ICU patients admitted with infection between January 2008 and April 2018 at an urban tertiary care center. Patients were uniquely classified into different infection types based on International Classification of Diseases, Ninth Revision ( ICD-9 ) and ICD-10 codes. Infection types included were pneumonia, meningitis, bacteremia, cellulitis, cholangitis/cholecystitis, intestinal and diarrheal disease, endocarditis, urinary tract infection (UTI), and peritonitis. The SOFA score performance and mortality in relation to SOFA score were compared across infection types., Results: A total of 12 283 patients were included. Of these, 50.6% were female and the median age was 70 years (interquartile range: 57-82). The most common infection types were pneumonia (32.2%) and UTI (31.0%). Overall, 1703 (13.9%) patients died prior to hospital discharge. The median baseline SOFA score (within 24 hours of ICU admission) for the cohort was 5 (3-8). Patients with peritonitis had the highest median SOFA score, 7 (4-9), and patients with cellulitis and UTI had the lowest median SOFA score, 4 (2-7). The SOFA score discrimination to predict mortality was highest among patients with endocarditis (area under the receiver operating characteristic [AUC]: 0.79, 95% CI: 0.69-0.90) and lowest for patients with isolated bacteremia (AUC: 0.59, 95% CI: 0.49-0.70). Observed mortality by quartile of SOFA score differed substantially across infection types., Conclusions: Type of infection is an important consideration when interpreting the SOFA score. This is relevant as SOFA emerges as an important tool in the definition and prognostication of sepsis.

Introduction: Chronic back pain is the leading cause of disability in the United States. Based on the hypothesis that nonspecific back pain may be rooted in a psychophysiologic etiology, we propose a new approach to chronic back pain., Objectives: A pilot study was conducted to assess whether psychophysiologic symptom relief therapy (PSRT) can reduce disability and back pain bothersomeness for patients with chronic back pain., Methods: This was a three-armed, randomized trial for adults with nonspecific chronic back pain that compared PSRT with usual care and an active comparator (mindfulness-based stress reduction [MBSR]). Psychophysiologic symptom relief therapy-randomized participants received a 12-week (36 hours) course based on the psychophysiological model of pain. All groups were administered validated questionnaires at baseline and at 4, 8, 13, and 26 weeks. The primary outcome was the reduction in pain disability measured by the Roland-Morris Disability Questionnaire., Results: The mean Roland-Morris Disability Questionnaire score for the PSRT group (n = 11) decreased from 9.5 (±4.3 SDs) to 3.3 (±5.1) after 26 weeks which was statistically significant compared with both MBSR (n = 12) ( P = 0.04) and usual care (n = 12) ( P = 0.03). Pain bothersomeness scores and pain-related anxiety decreased significantly over 26 weeks in PSRT compared with MBSR and usual care (data in manuscript). At 26 weeks, 63.6% of the PSRT arm reported being pain free (0/10 pain) compared with 25.0% and 16.7% in MBSR and usual care arms, respectively. Psychophysiologic symptom relief therapy attendance was 76%, and there was 100% follow-up of all groups., Conclusion: Psychophysiologic symptom relief therapy is a feasible and potentially highly beneficial treatment for patients with nonspecific back pain., Competing Interests: The authors have no conflicts of interest to declare.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The International Association for the Study of Pain.)

Background: The final months of the fourth-year of medical school are variable in educational and clinical experience, and the effect on clinical knowledge and preparedness for residency is unclear. Specialty-specific "bootcamps" are a growing trend in medical education aimed at increasing clinical knowledge, procedural skills, and confidence prior to the start of residency., Methods: We developed a 4-week Emergency Medicine (EM) bootcamp offered during the final month of medical school. At the conclusion of the course, participants evaluated its impact. EM residency-matched participants and non-participants were asked to self-evaluate their clinical knowledge, procedural skills and confidence 1 month into the start of residency. Program directors were surveyed to assess participants and non-participants across the same domains. A Fisher's exact test was performed to test whether responses between participants and non-participants were statistically different., Results: From 2015 to 2018, 22 students participated in the bootcamp. The majority reported improved confidence, competence, and procedural skills upon completion of the course. Self-assessed confidence was significantly higher in EM-matched participants 1 month into residency compared to EM-matched non-participants (p = 0.009). Self-assessed clinical knowledge and procedural skill competency was higher in participants than non-participants but did not reach statistical significance. Program directors rated EM-matched participants higher in all domains but this difference was also not statistically significant., Conclusions: Participation in an EM bootcamp increases self-confidence at the start of residency among EM-matched residents. EM bootcamps and other specialty-specific courses at the end of medical school may ease the transition from student to clinician and may improve clinical knowledge and procedural skills., (© 2021. The Author(s).)

Objective: While the judicious use of antibiotics takes past microbiological culture results into consideration, this data's typical format in the electronic health record (EHR) may be unwieldy when incorporated into clinical decision-making. We hypothesize that a visual representation of sensitivities may aid in their comprehension., Materials and Methods: A prospective parallel unblinded randomized controlled trial was undertaken at an academic urban tertiary care center. Providers managing emergency department (ED) patients receiving antibiotics and having previous culture sensitivity testing were included. Providers were randomly selected to use standard EHR functionality or a visual representation of patients' past culture data as they answered questions about previous sensitivities. Concordance between provider responses and past cultures was assessed using the kappa statistic. Providers were surveyed about their decision-making and the usability of the tool using Likert scales., Results: 518 ED encounters were screened from 3/5/2018 to 9/30/18, with providers from 144 visits enrolled and analyzed in the intervention arm and 129 in the control arm. Providers using the visualization tool had a kappa of 0.69 (95% CI: 0.65-0.73) when asked about past culture results while the control group had a kappa of 0.16 (95% CI: 0.12-0.20). Providers using the tool expressed improved understanding of previous cultures and found the tool easy to use (P < .001). Secondary outcomes showed no differences in prescribing practices., Conclusion: A visual representation of culture sensitivities improves comprehension when compared to standard text-based representations., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Communication and interpersonal skills are one of the Accreditation Council for Graduate Medical Education's six core competencies. Validated methods for assessing these among trainees are lacking. Educators have developed various communication assessment tools from both the supervising attending and the patient perspectives. How these different assessment methods and tools compare with each other remains unknown. The goal of this study was to determine the degree of agreement between attending and patient assessment of resident communication skills., Methods: This was a retrospective study of emergency medicine (EM) residents at an academic medical center. From July 2017 to June 2018, residents were assessed on communication skills during their emergency department shifts by both their supervising attending physicians and their patients. The attendings rated residents' communication skills with patients, colleagues, and nursing/ancillary staff using a 1 to 5 Likert scale. Patients completed the modified Communication Assessment Tool (CAT), a 14-item questionnaire based on a 1 to 5 Likert scale. Mean attending ratings and patient CAT scores were calculated for each resident. Means were divided into tertiles due to nonparametric distribution of scores. Agreement between attending and patient ratings of residents were measured using Cohen's kappa for each attending evaluation question. Scores were weighted to assign adjacent tertiles partial agreement., Results: During the study period, 1,097 attending evaluations and 952 patient evaluations were completed for 26 residents. Attending scores and CAT scores of the residents showed slight to fair agreement in the following three domains: patient communication (κ = 0.21), communication with colleagues (κ = 0.21), and communication with nursing/ancillary staff (κ = 0.26)., Conclusions: Attending and patient ratings of EM residents' communication skills show slight to fair agreement. The use of different types of raters may be beneficial in fully assessing trainees' communication skills., Competing Interests: JL, LB, AG, EU, CR, and ND report grant money to Beth Israel Deaconess Medical Center to conduct research conceived and written by Nicole Dubosh from Society for Academic Emergency Medicine Education Research Grant, 2018., (© 2021 by the Society for Academic Emergency Medicine.)

Objective: Proning has been shown to improve oxygenation and mortality in certain populations of intubated patients with acute respiratory distress syndrome. Small observational analyses of COVID-19 patients suggest awake proning may lead to clinical improvement. Data on safety and efficacy is lacking. We sought to describe the effect of proning on oxygenation in nonintubated COVID-19 patients. We also evaluated feasibility, safety, and other physiological and clinical outcomes associated with this intervention., Methods: We conducted a prospective, observational cohort study of nonintubated patients with COVID-19 who underwent proning per an Emergency Department (ED) clinical protocol. Patients with mild to moderate respiratory distress were included. We calculated change in oxygenation by comparing the oxygen saturation to fraction of inspired oxygen ratio (SpO2:FiO2) during the five minutes prior to proning and first 30 min of proning. We also captured data on respiratory rate, duration of proning, need for intubation, intensive care unit admission, survival to discharge., Results: Fifty-two patients were enrolled. Thirty were excluded for not meeting protocol inclusion criteria or missing baseline oxygenation data, leaving 22 for analysis. The SpO2:FiO2 ratio increased by a median of 5 (IQR: 0-15) in the post-proning period compared to the pre-proning period (median: 298 (IQR: 263-352) vs 295 (IQR: 276-350), p = 0.01). Respiratory rate did not change significantly between time periods. No immediate adverse events occurred during proning. Five patients (23%) were intubated within 48 h of admission., Conclusion: Early, awake proning may be feasible in select COVID-19 patients and was associated with improved oxygenation., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier Inc.)

Preliminary data have produced conflicting results regarding whether initial vitamin C levels in patients with severe sepsis correlate with mortality outcomes. We hypothesized that low plasma ascorbic acid or thiamine levels in severe sepsis patients admitted from the Emergency Department (ED) to the Intensive Care Unit (ICU) would be associated with increased mortality and an increased incidence of shock. Retrospective analysis of a prospective database of severe sepsis patients admitted to the ICU at an urban, academic medical center. Ascorbic acid and thiamine levels were analyzed in relation to survivors vs. non-survivors and shock vs. non-shock patients. 235 patients were included; mean age, 59.4 years ± 16.8 years; male, 128 (54.5%); in-hospital mortality, 16.6% (39/235); mean APACHE3 score, 61.8 ± 22.8; mean ascorbic acid level (reference range 0.40-2.10 mg/dL), 0.23 mg/dL (95% CI 0.07-4.02); and the mean thiamine level (reference range 14.6-29.5 nmol/L), 6.0 nmol/L (95% CI 4.0-9.5). When survivors were compared to non-survivors, survivors were more likely to be male (57.7% [113/196] vs. 38.5% [15/39]) and have lower APACHE3 scores (58.2 ± 22.6 vs. 79.9 ± 16.0). For the total cohort of 235 patients, there was no statistically significant relationship between a patient's initial ascorbic acid or thiamine level and either survival or development of shock. In this analysis of early plasma samples from patients with severe sepsis admitted from the ED to the ICU, we found that mean ascorbic acid and thiamine levels were lower than normal range but that there was no relationship between these levels and outcomes, including 28 day mortality and development of shock., (© 2021. The Author(s).)

Novel severe acute respiratory syndrome coronavirus 2 (COVID-19) has become a pandemic of epic proportions, and global response to prepare health systems worldwide is of utmost importance. 2-dimensional (2D) lung ultrasound (LUS) has emerged as a rapid, noninvasive imaging tool for diagnosing COVID-19 infected patients. Concerns surrounding LUS include the disparity of infected patients and healthcare providers, and importantly, the requirement for substantial physical contact between the patient and operator, increasing the risk of transmission. New variants of COVID-19 will continue to emerge; therefore, mitigation of the virus's spread is of paramount importance. A tele-operative robotic ultrasound platform capable of performing LUS in COVID-19 infected patients may be of significant benefit, especially in low- and middle-income countries. The authors address the issues mentioned above surrounding the use of LUS in COVID-19 infected patients and the potential for extension of this technology in a resource-limited environment. Additionally, first-time application, feasibility, and safety were validated in healthy subjects. Preliminary results demonstrate that our platform allows for the successful acquisition and application of robotic LUS in humans.

Introduction: Mitochondrial dysfunction leading to impairment of oxygen extraction, referred to as cytopathic hypoxia, contributes to morbidity in sepsis. Oxygen consumption (VO2) may be a useful measure of the severity of cytopathic hypoxia. We monitored VO2 and carbon dioxide production (VCO2) in septic patients and investigated the association with hospital survival., Methods: We retrospectively identified adult (≥18 years) septic patients from a larger prospective observational cohort of critically ill patients on mechanical ventilation. A gas-exchange monitor recorded continuous VO2 and VCO2 for up to 48 h. We then tested the association of median VO2, VCO2, respiratory quotient (RQ), and the VO2:lactate ratio with survival., Results: A total of 46 septic patients were included in the analysis, of whom 28 (61%) survived. Overall median VO2 was not associated with survival (3.72 mL/kg/min [IQR: 3.39, 4.92] in survivors and 3.42 mL/kg/min [IQR: 2.97, 5.26] in non-survivors, P = 0.12). The overall median VCO2 and RQ were also not associated with survival. Adjusting for age and the presence of shock did not change these results. The VO2:lactate ratio was associated with survival (adjusted OR 2.17 [95% CI 1.12, 4.22] per unit increase in ratio, P = 0.03). The percent change in median VCO2 was 11.6% [IQR: -8.2, 28.7] in survivors compared with -8.3% [IQR: -18.0, 4.7] in non-survivors (P = 0.03). The percent changes in median VO2 and RQ were not different between groups., Conclusion: The VO2:lactate ratio was significantly higher in survivors, while there was no association between median VO2 alone and survival. There was a significant difference in change in VCO2 over time between survivors and non-survivors., Competing Interests: The authors report no other conflicts of interest., (Copyright © 2020 by the Shock Society.)

Background: Widespread reports suggest the characteristics and disease course of coronavirus disease 2019 (COVID-19) and influenza differ, yet detailed comparisons of their clinical manifestations are lacking., Objective: Comparison of the epidemiology and clinical characteristics of COVID-19 patients during the pandemic with those of influenza patients in previous influenza seasons at the same hospital DESIGN: Admission rates, clinical measurements, and clinical outcomes from confirmed COVID-19 cases between March 1 and April 30, 2020, were compared with those from confirmed influenza cases in the previous five influenza seasons (8 months each) beginning September 1, 2014., Setting: Large tertiary care teaching hospital in Boston, MA PARTICIPANTS: Laboratory-confirmed COVID-19 and influenza inpatients MEASUREMENTS: Patient demographics and medical history, mortality, incidence and duration of mechanical ventilation, incidences of vasopressor support and renal replacement therapy, and hospital and intensive care admissions., Results: Data was abstracted from medical records of 1052 influenza patients and 582 COVID-19 patients. An average of 210 hospital admissions for influenza occurred per 8-month season compared to 582 COVID-19 admissions over 2 months. The median weekly number of COVID-19 patients requiring mechanical ventilation was 17 (IQR: 4, 34) compared to a weekly median of 1 (IQR: 0, 2) influenza patient (p=0.001). COVID-19 patients were significantly more likely to require mechanical ventilation (31% vs 8%) and had significantly higher mortality (20% vs. 3%; p<0.001 for all). Relatively more COVID-19 patients on mechanical ventilation lacked pre-existing conditions compared with mechanically ventilated influenza patients (25% vs 4%, p<0.001). Pneumonia/ARDS secondary to the virus was the predominant cause of mechanical ventilation in COVID-19 patients (94%) as opposed to influenza (56%)., Limitation: This is a single-center study which could limit generalization., Conclusion: COVID-19 resulted in more weekly hospitalizations, higher morbidity, and higher mortality than influenza at the same hospital.

Introduction: Ubiquinol (reduced coenzyme Q10) is essential for adequate aerobic metabolism. The objective of this trial was to determine whether ubiquinol administration in patients resuscitated from cardiac arrest could increase physiological coenzyme Q10 levels, improve oxygen consumption, and reduce neurological biomarkers of injury., Materials and Methods: This was a randomized, double-blind, placebo-controlled trial in patients successfully resuscitated from cardiac arrest. Patients were randomized to receive enteral ubiquinol (300 mg) or placebo every 12 h for up to 7 days. The primary endpoint was total coenzyme Q10 plasma levels at 24 h after enrollment. Secondary endpoints included neuron specific enolase, S100B, lactate, cellular and global oxygen consumption, neurological status, and in-hospital mortality., Results: Forty-three patients were included in the modified intention-to-treat analysis. Median coenzyme Q10 levels were significantly higher in the ubiquinol group as compared to the placebo group at 24 h (441 [IQR, 215-510] ηg/mL vs. 113 [IQR, 94-208] ηg/mL, P < 0.001). Similar results were observed at 48 and 72 h. There were no differences between the two groups in any of the secondary endpoints. Median neuron specific enolase levels were not different between the two groups at 24 h (16.8 [IQR, 9.5-19.8] ηg/mL vs. 8.2 [IQR, 4.3-19.1] ηg/mL, P = 0.61)., Conclusions: Administration of enteral ubiquinol increased plasma coenzyme Q10 levels in post-cardiac arrest patients as compared to placebo. There were no differences in neurological biomarkers and oxygen consumption between the two groups., (Copyright © 2021. Published by Elsevier B.V.)

Objective: Evaluate the relationship between heat generation during rewarming in post-cardiac arrest patients receiving targeted temperature management (TTM) as a surrogate of thermoregulatory ability and clinical outcomes., Methods: This is a prospective observational single-centre study conducted at an urban tertiary-care hospital. We included post-cardiac arrest adults who received TTM via surface cooling device between April 2018 and June 2019., Results: Patient heat generation was calculated by multiplying the inverse of the average machine water temperature with time to rewarm to 37 °C and standardized in two ways to account for target temperature variation: (1) divided by number of degrees between target temperature and 37 °C, and (2) limited to when patient was rewarmed from 36 °C to 37 °C. The primary outcome was poor neurologic status, defined as Cerebral Performance Category (CPC) score 3-5, and the secondary outcome was 30-day survival. Sixty-six patients were included: 45 (68%) had a CPC-score of 3-5 and 23 (35%) were alive at 30 days. Besides initial rhythm and arrest downtime, baseline characteristics were similar between outcomes. Heat generation was not associated with poor neurological outcome (CPC 3-5: 6.6 [IQR: 6.1, 7.4] versus CPC 1-2: 6.6 [IQR: 5.7, 7.6], p = 0.89) or survival at 30 days (non-survivors: 6.6 [IQR: 6.6, 7.4] vs. survivors: 6.6 [IQR: 5.7, 8.0, p = 0.78])., Conclusion: Heat generation during rewarming was not associated with neurologic outcomes. However, there was a relationship between poor neurological outcome and higher median water temperatures. Time to rewarm was prolonged in patients with poor neurological outcome., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Aims: To describe trends in pediatric in-hospital cardiac arrest drug administration and to assess temporal associations of the Pediatric Advanced Life Support (PALS) guideline changes with drug usage., Methods: Pediatric patients <18 years old with in-hospital cardiac arrest recorded in the American Heart Association Get With The Guidelines-Resuscitation database between 2002 and 2018 were included. The annual adjusted odds of receiving each intra-arrest medication was determined. The association between changes in the PALS Guidelines and medication use over time was assessed interrupted time series analyses., Results: A total of 6107 patients were analyzed. The adjusted odds of receiving lidocaine (0.33; 95% CI, 0.18, 0.61; p < 0.001), atropine (0.19; 95% CI 0.12, 0.30; p < 0.001) and bicarbonate (0.54; 95% CI 0.35, 0.86; p = 0.009) were lower in 2018 compared to 2002. For lidocaine, there were no significant changes in the step (-2.1%; 95% CI, -5.9%, 1.6%; p = 0.27) after the 2010 or 2015 (Step: -1.5%; 95% CI, -8.0%, 5.0; p = 0.65) guideline releases. There were no significant changes in the step for bicarbonate (-2.3%; 95% CI, -7.6%, 3.0%; p = 0.39) after the 2010 updates. For atropine, there was a downward step change after the 2010 guideline release (-5.9%; 95% CI, -10.5%, -1.3%; p = 0.01)., Conclusions: Changes to the PALS guidelines for lidocaine and bicarbonate were not temporally associated with acute changes in the use of these medications; however, better alignment with these updates was observed over time. A minor update to the language surrounding atropine in the PALS text was associated with a modest acute change in the observed use of atropine. Future studies exploring other factors that influence prescribers in pediatric IHCA are needed., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Aim: Guidance on post-cardiac arrest prognostication is largely based on data from out-of-hospital cardiac arrest (OHCA), despite clear differences between the OHCA and in-hospital cardiac arrest (IHCA) populations. Early prediction of mortality after IHCA would be useful to help make decisions about post-arrest care. We evaluated the ability of lactate and need for vasopressors after IHCA to predict hospital mortality., Methods: Single center retrospective observational study of adult IHCA patients who achieved sustained return of spontaneous circulation (ROSC), required mechanical ventilation peri-arrest and had a lactate checked within 2 h after ROSC. We evaluated the association of post-ROSC lactate and need for vasopressors with mortality using multivariate logistic regression., Results: A total of 364 patients were included. Patients who received vasopressors within 3 h after ROSC had significantly higher mortality compared to patients who did not receive vasopressors (58% vs. 43%, p = 0.03). Elevated lactate level was associated with mortality (44% if lactate <5 mmol/L, 58% if lactate 5-10 mmol/L, and 73% if lactate >10 mmol/L, p < 0.01). A multivariable model with lactate group and post-ROSC vasopressor use as predictors demonstrated moderate discrimination (AUC 0.64 [95%CI:0.59-0.70]). Including other variables, the most parsimonious model included lactate, age, body mass index, race, and history of arrhythmia, cancer and/or liver disease (AUC 0.70 [95% CI: 0.64-0.75])., Conclusion: Post-ROSC lactate and need for vasopressors may be helpful in stratifying mortality risk in patients requiring mechanical ventilation after IHCA., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Patients who experience sepsis often have long-term effects that may impact health-related quality of life. This study aimed to investigate whether the combination of ascorbic acid, corticosteroids, and thiamine compared with placebo improves health-related quality of life in patients with septic shock., Design: Secondary analysis of the Ascorbic Acid, Corticosteroids, and Thiamine in Sepsis randomized controlled trial (NCT03389555)., Setting: Thirteen tertiary-care hospitals in the United States., Patients: Patients who were enrolled in Ascorbic Acid, Corticosteroids, and Thiamine in Sepsis, survived to 90 days post enrollment and were able to be contacted by telephone., Interventions: Patients were randomly assigned to parenteral ascorbic acid (1,500 mg), hydrocortisone (50 mg), and thiamine (100 mg) every 6 hours for 4 days or placebo., Measurements and Main Results: One hundred seventeen patients (59%) survived to 90 days and were administered the Short Form 36 questionnaire; of these, 72 (62%) completed the Short Form 36 (38 [53%] in the intervention group, 34 [47%] in placebo). Sixty-six (92%) completed all survey questions (36 [95%] in the intervention group, 30 [88%] in placebo). There was no significant difference in overall Short Form 36 score between intervention and placebo group (median score: 39.4 [interquartile range, 31.2-45.4] vs 43.2 [37.0-46.7], respectively, p = 0.18). We found no statistically significant difference between the two groups in any of the other health-related quality of life domains used., Conclusions: We found no difference in the health-related quality of life in patients with septic shock treated with a combination of ascorbic acid, corticosteroids, and thiamine compared to placebo., Competing Interests: Dr. Grossestreuer reported receipt of grants from Harvard Catalyst Medical Research Investigator Training. Drs. Donnino, Moskowitz, and Berg reported receipt of grants from the National Institutes of Health. The remaining authors have not disclosed any potential conflicts of interest., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: The Sequential Organ Failure Assessment (SOFA) score is a commonly used severity-of-illness score in cardiac arrest research. Due to its nature, the SOFA score often has missing data. How much data is missing and how that missing data is handled is unknown., Objectives: We conducted a scoping review on cardiac arrest studies using SOFA, focusing on missing data., Data Sources: PubMed, Embase, and Web of Science., Study Selection: All English-language peer-reviewed studies of cardiac arrest with SOFA as an outcome or exposure were included., Data Extraction: For each study, quantity of missing SOFA data, analytic strategy to handle missing SOFA variables, whether/to what degree mortality influenced the amount of missing SOFA scores), SOFA score modifications, and number of SOFA measurements was extracted., Data Synthesis: We included 66 studies published between 2006-2019. Five studies were randomized controlled trials, 26 were prospective cohort studies, and 25 were retrospective cohort studies. SOFA was used as an outcome in 36 (55%) and a primary outcome in 10 (15%). Nine studies (14%) mentioned the quantity of missing SOFA data, which ranged from 0 to 76% (median: 10% [IQR: 6%, 42%]). Twenty-seven (41%) studies reported a method to handle missing SOFA. The most common method used excluded subjects with missing data (81%). In the 50 studies using serial SOFA scores, 11 (22%) documented mortality prior to SOFA measurement; which ranged from 3% to 76% (median: 12% [IQR: 6%-35%])., Conclusions: Missing data is common in cardiac arrest research using SOFA scores. Variability exists in reporting and handling missing SOFA variables., (© 2020 The Authors.)

Background Neuromuscular blockade (NMB) agents are often administered to control shivering during targeted temperature management following cardiac arrest. In this study, we hypothesized that early, continuous NMB would result in a greater reduction in serum lactate levels among comatose patients after cardiac arrest. Methods and Results Randomized trial of continuous NMB for 24 hours versus usual care following cardiac arrest conducted at 5 urban centers in the United States. Adult patients who achieved return of spontaneous circulation, remained unresponsive, and underwent targeted temperature management after cardiac arrest were included. The primary outcome was change in lactate over 24 hours. A total of 83 patients were randomized, and 80 were analyzed (37 and 43 in the NMB and usual care arms, respectively). There was no significant interaction between time and treatment group with respect to change in lactate over 24 hours (median lactate change from 4.2 to 2.0 mmol/L [-2.2 mmol/L] in the NMB arm versus 4.0 to 1.7 mmol/L [-2.3 mmol/L] in the usual care arm; geometric mean difference, 1.3 [95% CI, 1.0-1.8]; P =0.07 for the interaction term). There was no difference in hospital survival (38% [NMB] versus 33% [usual care]; P =0.63) or survival with good functional outcome (30% [NMB] versus 21% [usual care]; P =0.35). There were no adverse events in either arm attributed to study interventions. Conclusions Continuous NMB compared with usual care did not reduce lactate over the first 24 hours after enrollment compared with usual care. There was no difference in overall hospital survival, hospital survival with good neurologic outcome, or adverse events. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02260258.

Study Objective: Triage quickly identifies critically ill patients, facilitating timely interventions. Many emergency departments (EDs) use emergency severity index (ESI) or abnormal vital sign triggers to guide triage. However, both use fixed thresholds, and false activations are costly. Prior approaches using machinelearning have relied on information that is often unavailable during the triage process. We examined whether deep-learning approaches could identify critically ill patients only using data immediately available at triage., Methods: We conducted a retrospective, cross-sectional study at an urban tertiary care center, from January 1, 2012-January 1, 2020. De-identified triage information included structured (age, sex, initial vital signs) and textual (chief complaint) data, with critical illness (mortality or ICU admission within 24 hours) as the outcome. Four progressively complex deep-learning models were trained and applied to triage information from all patients. We compared the accuracy of the models against ESI as the standard diagnostic test, using area under the receiver-operator curve (AUC)., Results: A total of 445,925 patients were included, with 60,901 (13.7%) critically ill. Vital sign thresholds identified critically ill patients with AUC 0.521 (95% confidence interval [CI] = 0.519-0.522), and ESI <3 demonstrated AUC 0.672 (95% CI = 0.671-0.674), logistic regression classified patients with AUC 0.803 (95% CI = 0.802-0.804), 2-layer neural network with structured data with AUC 0.811 (95% CI = 0.807-0.815), gradient tree boosting with AUC 0.820 (95% CI = 0.818-0.821), and the neural network model with textual data with AUC 0.851 (95% CI = 0.849-0.852). All successive increases in AUC were statistically significant., Conclusion: Deep-learning techniques represent a promising method of augmenting triage, even with limited information. Further research is needed to determine if improved predictions yield clinical and operational benefits., Competing Interests: Risk Management Foundation of the Harvard Medical Institutions Incorporated, was not involved in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation and review of the manuscript. CRICO did not approve the manuscript and had no input in the decision to submit the manuscript for publication. No publication restrictions apply. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard University and its affiliated academic healthcare centers., (© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.)

Importance: The combination of ascorbic acid, corticosteroids, and thiamine has been identified as a potential therapy for septic shock., Objective: To determine whether the combination of ascorbic acid, corticosteroids, and thiamine attenuates organ injury in patients with septic shock., Design, Setting, and Participants: Randomized, blinded, multicenter clinical trial of ascorbic acid, corticosteroids, and thiamine vs placebo for adult patients with septic shock. Two hundred five patients were enrolled between February 9, 2018, and October 27, 2019, at 14 centers in the United States. Follow-up continued until November 26, 2019., Interventions: Patients were randomly assigned to receive parenteral ascorbic acid (1500 mg), hydrocortisone (50 mg), and thiamine (100 mg) every 6 hours for 4 days (n = 103) or placebo in matching volumes at the same time points (n = 102)., Main Outcomes and Measures: The primary outcome was change in the Sequential Organ Failure Assessment (SOFA) score (range, 0-24; 0 = best) between enrollment and 72 hours. Key secondary outcomes included kidney failure and 30-day mortality. Patients who received at least 1 dose of study drug were included in analyses., Results: Among 205 randomized patients (mean age, 68 [SD, 15] years; 90 [44%] women), 200 (98%) received at least 1 dose of study drug, completed the trial, and were included in the analyses (101 with intervention and 99 with placebo group). Overall, there was no statistically significant interaction between time and treatment group with regard to SOFA score over the 72 hours after enrollment (mean SOFA score change from 9.1 to 4.4 [-4.7] points with intervention vs 9.2 to 5.1 [-4.1] points with placebo; adjusted mean difference, -0.8; 95% CI, -1.7 to 0.2; P = .12 for interaction). There was no statistically significant difference in the incidence of kidney failure (31.7% with intervention vs 27.3% with placebo; adjusted risk difference, 0.03; 95% CI, -0.1 to 0.2; P = .58) or in 30-day mortality (34.7% vs 29.3%, respectively; hazard ratio, 1.3; 95% CI, 0.8-2.2; P = .26). The most common serious adverse events were hyperglycemia (12 patients with intervention and 7 patients with placebo), hypernatremia (11 and 7 patients, respectively), and new hospital-acquired infection (13 and 12 patients, respectively)., Conclusions and Relevance: In patients with septic shock, the combination of ascorbic acid, corticosteroids, and thiamine, compared with placebo, did not result in a statistically significant reduction in SOFA score during the first 72 hours after enrollment. These data do not support routine use of this combination therapy for patients with septic shock., Trial Registration: ClinicalTrials.gov Identifier: NCT03389555.

Ubiquinol is a fundamental component of cellular metabolism. Low ubiquinol levels have been associated with mortality. This was a substudy of a randomized trial in patients undergoing coronary artery bypass grafting. We drew blood before and after surgery. Ubiquinol or placebo was added to peripheral blood mononuclear cells for oxygen consumption (OCR) measurements. In vivo ubiquinol levels were lower postsurgery compared to presurgery (0.16 μmol/L [quartiles: 0.02-0.39], P = .01), although the difference disappeared when adjusting for hemoglobin levels ( P = .30). There was no difference in presurgical basal (1.0 mL/min/mg [95% confidence interval [CI]: -0.9 to 2.2], P = .08) and maximal (0.5 mL/min/mg [95% CI: -4.3 to 7.3], P = .56) OCR in cells receiving ubiquinol or placebo. There was a difference in postsurgical basal (1.1 mL/min/mg [95% CI: 0.9-1.6], P < .001) and maximal (4.2 mL/min/mg [95% CI: 0.3-7.0], P = .01) OCR between the groups. We found no association between ubiquinol and OCR levels (all P > .05).