IMPORTANCE/OBJECTIVE: Neurologic emergencies contribute disproportionately to morbidity and mortality in sub-Saharan Africa, yet structured neurocritical care training remains limited. Emergency Neurologic Life Support (ENLS) standardizes early management of neurologic emergencies, but implementation in resource-limited settings requires contextual adaptation. Limited access to neuroimaging and monitoring compounds diagnostic uncertainty. Portable neuroultrasound (NeuroUS) offers a feasible bedside adjunct. We developed, implemented, and evaluated Tanzania’s first resource-adapted neurocritical care educational program, including hands-on NeuroUS training in a low- and middle-income country (LMIC) setting. DESIGN, SETTING, PARTICIPANTS, MAIN OUTCOMES, AND MEASURES: We conducted a prospective observational study during a 2-day in-person training program (October 2025). Multidisciplinary healthcare professionals caring for neurocritical care patients completed pre- and postcourse assessments evaluating medical knowledge, self-reported knowledge, and confidence across ENLS and NeuroUS domains (5-point Likert scale). Ordinal Likert outcomes were summarized using median and interquartile range (IQR) and compared using two-sided Mann-Whitney U tests. Correct-response proportions were compared using Fisher exact tests. Benjamini-Hochberg false-discovery-rate adjustment was applied within each outcome family. RESULTS: Twenty-two participants completed precourse assessments; 17 completed postcourse assessments. Self-reported medical knowledge improved across 15 of 16 domains. The largest effects were observed for NeuroUS knowledge, which increased from a median of 1.5 (IQR, 1–2) to 4 (IQR, 4–5; rank-biserial, r = 0.85; 95% CI, 0.64–1.00; q < 0.001); Broad-Reaching Acute Interventions in Neurocritical Care, from 3 (IQR, 2–3) to 4 (IQR, 4–5; r = 0.73; 95% CI, 0.48–0.93; q < 0.001); and intracranial hypertension and herniation, from 3 (IQR, 3–4) to 5 (IQR, 4–5; r = 0.70; 95% CI, 0.45–0.89; q < 0.001). Confidence scores were higher in eight of 16 domains after adjustment. Both NeuroUS diagnostic-application items demonstrated large postcourse differences ( q < 0.001). Correct-response proportions increased across all six exploratory knowledge items, but none remained statistically significant after adjustment for multiple comparisons. Ninety-four percent found the program relevant to their practice. CONCLUSIONS AND RELEVANCE: Implementation of resource-limited ENLS integrated with structured neuroultrasound is feasible and significantly improved knowledge and confidence. This hybrid approach represents a scalable education model for LMICs.
OBJECTIVES:. Occlusion pressure at 100 ms after the start of inspiratory effort (P0.1) is a marker of respiratory drive and a predictor of weaning outcomes in mechanically ventilated patients. Some ventilators, like the Hamilton C6 (Hamilton Medical AG, Bonaduz, Switzerland), estimate P0.1 automatically (P0.1vent) without performing an actual airway occlusion, potentially leading to inaccuracies. SETTING:. This prospective clinical and bench study aimed to assess the accuracy of P0.1vent compared with the manual occlusion method (P0.1occ) during spontaneous breathing trials (SBT) and following a reventilation period with varying ventilator settings. DESIGN AND PATIENTS:. The clinical part of the study included patients undergoing SBT on Hamilton C6 (software version 1.2.3) with zero pressure support (PS) and zero end-expiratory pressure (PEEP) and reventilation (PS +8 cm H2O, PEEP +5 cm H2O). P0.1vent and P0.1occ were collected every 15 minutes. Bench part evaluated the P0.1vent and P0.1occ of the Hamilton C6 (software version 1.2.3) connected to a lung simulator (ASL 5000) creating different breathing efforts across different lung mechanics and varying PS and PEEP levels. MEASUREMENT AND MAIN RESULTS:. In patients, P0.1vent values were significantly higher than P0.1occ (median, 11.0 vs. 1.0 cm H2O; p < 0.001), with a mean bias of 8.5 cm H2O. Similar overestimations were observed during the reventilation period (6.0 vs. 1.0 cm H2O; mean difference, 6.5 cm H2O; p < 0.001). Bench results confirmed the variable accuracy of P0.1vent found in the clinical part of the study, with biases ranging from nearly perfect (0.2 cm H2O) under high PS to 2.3 cm H2O under low PS. CONCLUSIONS:. Automatic P0.1 estimation by the Hamilton C6 (software version 1.2.3) is inaccurate during SBTs. Manual occlusion remains essential for reliable P0.1 assessment at the bedside.
OBJECTIVES: To determine the diagnostic accuracy of the Radiographic Assessment of Lung Edema (RALE) score for acute respiratory distress syndrome (ARDS) and its interobserver reliability. DESIGN: Post hoc analysis of a prospective observational cohort study. SETTING: ICUs at Vanderbilt University Medical Center participating in the Validating Acute Lung Injury Biomarkers for Diagnosis study. PATIENTS: Adult patients receiving invasive ventilation for at least two consecutive days, with chest radiographs available on the first 2 ICU days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Chest radiographs from the first 2 ICU days were scored independently by at least two experienced raters; scores were averaged per radiograph, and the highest averaged score from ICU day 1 or 2 was selected for analysis. The primary outcome was ARDS according to the Berlin definition during the first 2 ICU days. Of 236 patients, 92 (39%) had ARDS. The median RALE score was higher in patients with ARDS than in those without (29.5 [22.2–34.5] vs. 12.2 [7.5–17.8]; p < 0.01). The area under the receiver operating characteristic curve was 0.93 (95% CI, 0.90–0.96). At the optimal cutoff of 20, sensitivity was 85%, specificity 83%, positive predictive value 76%, and negative predictive value 90%. Interobserver reliability was high, with pairwise intraclass correlation coefficients ranging from 0.81 to 0.87. CONCLUSIONS: In patients invasively ventilated for at least 2 days, the RALE score demonstrated excellent diagnostic accuracy for ARDS at a cutoff of 20, together with high interobserver reliability, supporting its potential role as a standardized radiographic tool in the diagnosis of ARDS.
OBJECTIVES: Heterogeneity of treatment effect is thought to drive conflicting results for the benefits of corticosteroids in sepsis. Proenkephalin A (PENK) is a biomarker of renal function. Given the kidney’s role in sepsis pathophysiology and corticosteroid metabolism, we hypothesized that baseline renal function, assessed using PENK, would be associated with hydrocortisone efficacy. DESIGN: A post hoc analysis of a double-blind, randomized clinical trial in septic shock (Effect of Early Vasopressin vs. Norepinephrine on Kidney Failure in Patients with Septic Shock [VANISH]). SETTING: ICUs across the United Kingdom. PATIENTS: One hundred seventy-three patients admitted to ICU with septic shock. INTERVENTIONS: Norepinephrine vs. vasopressin and hydrocortisone vs. placebo. MEASUREMENTS AND MAIN RESULTS: PENK was measured in plasma, and patients were dichotomized using a PENK concentration above 89 pmol/L. PENK greater than or equal to 89 pmol/L was associated with 28-day mortality (odds ratio, 3.24; 95% CI, 1.62–6.74). We found no interaction between PENK and randomization to vasopressin or norepinephrine on outcome. However, there was a significant interaction between the PENK groups and hydrocortisone or placebo use in those patients who reached the maximum vasopressor threshold ( n = 111) for kidney failure-free days (high PENK [≥ 89 pmol/L] placebo 26 [13–28], hydrocortisone 11 [0–26] and low PENK placebo 28 [15–28], hydrocortisone 28 [28–28]; p = 0.01). Patients with high PENK receiving hydrocortisone had the fewest kidney failure-free days. Although we found no significant interaction for 28-day mortality ( p = 0.14), the patients with high PENK who received hydrocortisone had the highest mortality (high PENK hydrocortisone 50%, placebo 32% and low PENK hydrocortisone 14%, placebo 24%). CONCLUSIONS: This exploratory analysis identified a possible interaction between baseline PENK and hydrocortisone treatment on kidney failure-free days. These findings require validation in independent and prospective studies.
BACKGROUND: Cardiotoxic ingestions of calcium-channel blockers and beta-adrenergic antagonists are highly lethal, often causing refractory vasoplegic shock and noncardiogenic pulmonary edema. While venoarterial extracorporeal membrane oxygenation (ECMO) is a recognized rescue therapy for cardiogenic shock, the roles of venovenous ECMO and albumin dialysis—specifically the molecular adsorbent recirculating system (MARS)—as well as the effectiveness of linking patients to therapy through a coordinated referral process remain underexplored. CASE SUMMARY: We describe five consecutive patients with severe cardiotoxic ingestions managed via a regionally triggered transfer pathway. Patients presented with profound hypotension and respiratory failure despite standard therapies. All five patients received MARS for drug clearance and vasoplegia management; two required venovenous ECMO for refractory hypoxemia. One patient died due to profound myocardial poisoning; four survived to discharge. Complications included continuous renal replacement therapy filter clotting and catheter-associated thrombosis. CONCLUSIONS: A coordinated regional protocol enabling early access to ECMO and MARS is feasible in massive cardiotoxic ingestions.
