Racial disparities disproportionately affect the morbidity and mortality of Black patients with community-acquired pneumonia (CAP). Some scoring systems used in the ICU (eg, Sequential Organ Failure Assessment, APACHE IVa) overpredict mortality in Black patients. However, to our knowledge, the performance of pneumonia severity scoring systems in White and Black adult patients has never been comprehensively evaluated.

Background Post-intubation hypotension (PIH) is a common and clinically significant complication of emergency airway management in critically ill patients and is associated with adverse short-term outcomes. Objective The objective of this study was to determine the incidence, clinical outcomes, and factors associated with post-intubation hypotension among critically ill adults undergoing emergency endotracheal intubation. Methodology This retrospective observational study was conducted at Mayo Hospital, Lahore, Pakistan. Medical records of 234 adult patients who underwent emergency endotracheal intubation between March 2023 to March 2026 were reviewed. PIH was defined as systolic blood pressure <90 mmHg, mean arterial pressure <65 mmHg, or a ≥20% reduction in systolic blood pressure from the pre-intubation baseline within 30 minutes after successful intubation. Multivariable logistic regression was performed to identify factors independently associated with PIH. Results PIH occurred in 68 of 234 patients (29.1%). Patients with PIH were significantly older and had higher Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) score, and Shock Index values than those without PIH. On multivariable analysis, increasing age (adjusted OR (AOR) 1.03, 95% CI 1.01-1.06; p = 0.011), chronic kidney disease (AOR 2.08, 95% CI 1.01-4.29; p = 0.047), sepsis (AOR 2.64, 95% CI 1.38-5.05; p = 0.003), higher APACHE II score (AOR 1.11, 95% CI 1.04-1.18; p = 0.001), elevated Shock Index (AOR 3.42, 95% CI 1.74-6.74; p < 0.001), ketamine use compared with etomidate (AOR 1.89, 95% CI 1.01-3.53; p = 0.045), and difficult airway (AOR 2.27, 95% CI 1.07-4.83; p = 0.033) were independently associated with PIH. PIH was also associated with higher vasopressor requirement, longer mechanical ventilation and ICU and hospital stays, increased AKI, and higher ICU and in-hospital mortality. Conclusion PIH occurred in nearly one-third of critically ill adults undergoing emergency endotracheal intubation and was associated with worse short-term clinical outcomes. Older age, sepsis, chronic kidney disease, higher APACHE II score, elevated Shock Index, ketamine use, and difficult airway were independently associated with PIH. These findings support early recognition of patients at increased risk and warrant prospective multicentre studies to determine whether standardized peri-intubation strategies can reduce PIH and improve outcomes.

Persistent biological injury may remain undetected despite apparent clinical stabilization during critical illness. We evaluated whether serial urinary markers of RNA and DNA oxidation were associated with 90-day mortality, transition from ICU to post-ICU phase, and mortality after ICU discharge, and whether they provided prognostic information beyond baseline illness severity. This single-center longitudinal cohort included 438 critically ill adults who provided 2,516 urine samples during ICU and post-ICU hospitalization. Urinary 8-oxo-7,8-dihydroguanosine (8-oxoGuo) and 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodGuo) were quantified by isotope-dilution ultra-performance liquid chromatography-tandem mass spectrometry and normalized to creatinine. Bayesian joint models were adjusted for age, sex, Charlson Comorbidity Index, and baseline Sequential Organ Failure Assessment (SOFA) score. Each doubling of longitudinal urinary 8-oxoGuo was associated with higher 90-day mortality (hazard ratio [HR], 1.47; 95% credible interval [CrI], 1.17-1.85), higher mortality after ICU discharge (HR, 1.52; 95% CrI, 1.18-1.97), and a lower transition rate to post-ICU care (HR, 0.89; 95% CrI, 0.79-0.99). Associations were similar when APACHE II replaced SOFA, whereas longitudinal 8-oxodGuo showed no consistent associations. Adding baseline 8-oxoGuo to SOFA increased the area under the curve for 90-day mortality from 0.669 to 0.719 (p = 0.046), while incorporating longitudinal trajectory information increased the area under the curve for mortality after ICU discharge from 0.682 to 0.741 (p = 0.029). Overall, these findings indicate that higher longitudinal urinary 8-oxoGuo is associated with adverse outcomes across ICU and post-ICU hospitalization and provides incremental prognostic discrimination beyond baseline SOFA.

Sepsis involves dynamic inflammatory and endothelial responses, and the timing of extracorporeal therapies such as therapeutic plasma exchange (TPE) may influence clinical outcomes. However, the optimal timing of TPE remains unclear. This retrospective single-center observational study included adult patients with sepsis or septic shock who underwent TPE in the intensive care unit between January 1, 2017 and August 1, 2025. Patients were categorized as early (≤ 48 hours after diagnosis) or late (> 48 hours). The primary outcome was 28-day mortality. Secondary analyses evaluated longitudinal changes in biomarkers and laboratory parameters. Eighty-eight patients were included (early n = 39; late n = 49). Overall 28-day mortality was 40.9% (36/88). Kaplan-Meier analysis demonstrated no significant difference in 28-day survival between the groups (log-rank P = .91). In multivariable Cox regression adjusted for Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation II, TPE timing was not independently associated with 28-day mortality (hazard ratio 0.90, 95% confidence interval 0.44-1.83, P = .76). Across the overall cohort, significant temporal changes were observed in C-reactive protein and lactate dehydrogenase levels during TPE treatment. Early TPE initiation was not associated with improved 28-day survival. Observed biomarker trajectories should be interpreted cautiously given the retrospective design, limited sample size, and potential residual confounding.

Background and aims: Early phenotyping in the ICU is challenging because severity scores do not capture malnutrition, cellular integrity, or muscle reserve. We assessed whether phase angle (PhA), GLIM-defined malnutrition, and rectus femoris ultrasound were associated with 30-day mortality and whether continuous PhA added prognostic information beyond illness severity. Methods: We analyzed a prospective single-center cohort of adults admitted to a 12-bed ICU. Within 24-48 h, patients underwent bioelectrical impedance analysis, rectus femoris ultrasound, GLIM, mNUTRIC, CONUT, APACHE II, and SOFA assessment. Primary multivariable analyses treated PhA and rectus femoris cross-sectional area (CSA) as continuous variables; ROC-derived cut-offs were considered exploratory. Potential non-linearity was examined with restricted cubic splines, and the continuous PhA model underwent bootstrap internal validation. Results: Among 125 patients (63.2% men; median age 68 [60-76] years), 30-day mortality was 24.0% (30/125). GLIM-defined malnutrition was present in 78.4%, including 12.0% with severe malnutrition. Non-survivors had lower PhA (4.3 [3.6-4.8] vs. 4.8 [4.2-5.5]°; p = 0.008) and smaller rectus femoris CSA (2.6 [1.9-3.4] vs. 3.6 [2.5-5.0] cm[2]; p = 0.007). In the adjusted continuous PhA model, APACHE II (OR 1.23 per point, 95% CI 1.13-1.34; p < 0.001) and severe GLIM-defined malnutrition (OR 5.95, 95% CI 1.45-24.32; p = 0.013) remained independently associated with mortality, whereas lower PhA did not (OR 1.11 per 1° lower, 95% CI 0.74-1.69; p = 0.611). Adding continuous PhA to the reference model changed AUC from 0.868 to 0.867 and did not improve fit (likelihood ratio p = 0.607). Continuous CSA was also not independently associated with mortality (OR 1.17 per 1 cm[2] lower, 95% CI 0.81-1.69; p = 0.412). Conclusions: APACHE II and protocol-defined severe GLIM malnutrition, but not continuous admission PhA or rectus femoris CSA, retained independent associations with 30-day mortality; the GLIM association should be interpreted in light of the protocol-specific morphofunctional operationalization of the muscle criterion. Lower PhA and CSA characterized non-survivors in unadjusted analyses; cohort-derived thresholds should be considered hypothesis-generating and require external validation.

Background and Objectives: Existing severity scores for acute pancreatitis (AP), such as the Ranson, Glasgow-Imrie, APACHE II, BISAP, Balthazar scores, are limited by complexity, delayed availability, or insufficient discriminative accuracy. We aimed to develop a new prognostic score using parameters available at admission in any primary or regional care setting, suitable for early risk stratification and clinical decision-making in AP. Materials and Methods: We conducted a retrospective observational study of 194 patients admitted with acute pancreatitis, classified as mild (MILD, n = 59), moderately severe (n = 82) and severe (n= 53) course, according to the Revised Atlanta Classification. Candidate predictors-including demographic, clinical, inflammatory, nutritional, and radiological variables-were screened using univariable analysis, and independent predictors were identified by backward stepwise logistic regression. Discriminative performance was assessed using receiver operating characteristic (ROC) curve analysis and compared with six established severity scores (Ranson, Glasgow-Imrie, Balthazar, CTSI, BISAP, and HAPS). APACHE II was not included in this comparison because some of its required physiological variables were not consistently available outside the intensive care unit. Results: MODSEV (moderately severe/severe) patients showed significantly higher inflammatory, nutritional, and metabolic derangement at admission than MILD patients. Six variables-admission white blood cell count, blood urea nitrogen (BUN), pleural effusion, admission blood glucose level, platelet-to-lymphocyte ratio (PLR), and serum albumin-were retained in the final logistic regression model (ProbScore2), which demonstrated excellent discriminative ability (AUC = 0.873; 95% CI: 0.819-0.927), showing, within this retrospective cohort, a numerically higher AUC than the Glasgow-Imrie (AUC = 0.832), CTSI (0.775), Balthazar (0.758), BISAP (0.725), Ranson (0.676) and HAPS (0.574). A simplified, unweighted 0-6 point bedside version of the score retained most of this discriminative ability (AUC = 0.852), with an optimal cut-off of ≥3 points yielding a sensitivity of 77.0% and a specificity of 79.7%. Conclusions: ProbScore2, a novel six-variable prognostic score, demonstrated excellent discriminative performance for the early identification of moderately severe/severe acute pancreatitis, with a numerically higher AUC than established severity scoring systems evaluated within this same retrospective, single-center cohort (excluding APACHE II, which could not be calculated for all patients). These comparative findings require confirmation through prospective external validation before any conclusions about generalizable superiority can be drawn. Five of the six components are derived from routine admission blood tests, and the sixth (pleural effusion) requires only a plain chest radiograph rather than cross-sectional imaging. The score and its simplified bedside adaptation can therefore be calculated within hours of admission using resources available even in hospitals without intensive care or advanced, CT-based imaging capabilities. ProbScore2 is not yet ready for routine clinical use; prospective external validation in independent, multicenter cohorts is required before clinical implementation.

Background: Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator used as rescue therapy in acute respiratory distress syndrome (ARDS) for transient improvement in oxygenation. Although multiple studies demonstrate improvements in oxygenation parameters, iNO has not consistently shown a mortality benefit or reduced ventilation duration. Methods: A retrospective cohort study was conducted of mechanically ventilated adults with SARS-CoV-2 (COVID-19) admitted to a medical intensive care unit who received iNO. Demographic characteristics, comorbidities, illness severity scores, timing of iNO initiation, and clinical outcomes were analyzed, with comparisons made between survivors and non-survivors. Results: A total of 94 patients were included. The mean age was 52.0 years (Standard Deviation (SD) 14.1), 70.2% were male, and the mean body mass index was 36.5 kg/m[2] (SD 10.0). Hypertension (58.5%) and diabetes (36.2%) were the most common comorbidities. The mean Sequential Organ Failure Assessment (SOFA) score was 4.22 (SD 2.79), and the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 11.69 (SD 6.98). Overall, in-hospital mortality was 85.1% (80/94). The median time from intubation to iNO initiation was 7.6 days (mean 7.7 days). Survivors received iNO significantly earlier than non-survivors (mean 4.14 vs. 8.3 days after intubation, p = 0.024) and had a longer hospital length of stay (mean 37 vs. 23 days, p < 0.01). Duration of iNO therapy did not differ between groups (p = 0.12). Conclusions: In this cohort of critically ill patients with COVID-19 and severe respiratory failure, overall mortality was extremely high. Earlier initiation of inhaled nitric oxide was associated with improved survival, whereas duration of therapy was not. These findings suggest that the timing of iNO administration may be associated with clinical outcomes and warrant further prospective investigation to confirm this association.

Background/Objectives: Elevated intracranial pressure (ICP) drives secondary brain injury and poor outcome. The pressure reactivity index (PRx), the reference marker of cerebral autoregulation, requires high-frequency waveforms unavailable in many centers. We examined whether routinely charted hourly ICP and cerebral perfusion pressure (CPP) can stratify prognosis without the PRx. Methods: In a retrospective cohort of 990 adults with invasive ICP monitoring at a tertiary neurosurgical ICU (a predominantly non-traumatic case mix), we derived from hourly ICP the mean, variability (within-patient standard deviation), and peak burden (time above 22 mmHg), and from CPP the low-perfusion burden (time below 60 mmHg). Each metric (per 1 SD) was related to 28-day mortality and poor neurological outcome (Glasgow Outcome Scale 1-3), adjusted for age, sex, APACHE II, GCS, diagnosis, and mean ICP, with incremental value and sensitivity analyses. Results: In total, 86 of 990 patients died within 28 days. ICP variability was associated with both mortality and poor neurological outcome and, unlike peak burden, remained independent after adjustment for mean ICP. Peak burden lost significance once mean and variability were known. For CPP, hypoperfusion burden, but not CPP variability, was associated with mortality. CPP variability did not survive joint modeling with ICP variability. Excess risk was confined to low CPP, with no harm at high CPP. ICP variability added incremental value beyond a clinical model, robust to sensitivity analyses. Conclusions: Routinely available ICP variability and CPP hypoperfusion burden carry prognostic information beyond mean pressure. ICP variability predicted both outcomes, whereas hypoperfusion burden predicted mortality. These summaries may offer a pragmatic alternative where the PRx is unavailable, pending validation.