Abstract Low-altitude unmanned aerial vehicles are increasingly used for intelligent power-grid inspection, where reliable pixel-level perception is a prerequisite for subsequent condition assessment. Power-line segmentation in UAV imagery remains challenging because slender targets are easily fragmented or missed in cluttered scenes with severe class imbalance. We propose HWDiT-Net, an encoder–decoder network integrating hybrid wavelet downsampling (HWD-Down) and a dilated alternating perception mechanism (DAPM). HWD-Down retains high-frequency boundary cues during downsampling, while DAPM alternates neighborhood and dilated attention to enlarge the receptive field progressively and combine local continuity cues with broader context. A systematic loss ablation is further conducted, and the final model adopts a Focal-Dice objective selected from the evaluated loss configurations. On the TTPLA benchmark, the B1 variant achieves 68.81% IoU and 82.93% Recall, improving over MiT-Unet-B1 by 0.98% IoU and 4.11% Recall under the same evaluation protocol. Zero-shot evaluation on WireDataset without fine-tuning yields 68.55% IoU and 81.39% Recall for HWDiT-Net-B1, suggesting improved cross-dataset transferability under the evaluated setting.

This scoping review summarizes the progress of reinforcement learning (RL) in clinical decision-making for sepsis at the intersection of medicine and artificial intelligence (AI). All 72 included studies were retrospective, with the majority using the Medical Information Mart for Intensive Care (MIMIC) database (58 studies [80.6%]), and relatively few employing private datasets (10 studies [13.9%]). Study designs varied widely, especially in state representation, action space, reward definition, and choice of algorithms. Most research focused on vasopressor and intravenous fluid management, while fewer studies addressed antibiotics, corticosteroids, mechanical ventilation, heparin, or vasopressin. Although many studies reported RL-derived policies that outperformed clinicians, the reliability and validity of the evaluation methods remain uncertain. Future research should emphasize clinically guided design of states, actions, and rewards, develop rigorous and widely accepted evaluation tools, and explore a broader range of sepsis treatment strategies. Ultimately, advancing interpretability, generalizability, and safety will be critical to effectively integrating RL into routine clinical practice.

Background High positive end-expiratory pressure (PEEP) may improve ventilation-perfusion (V/Q) mismatch in acute respiratory distress syndrome (ARDS) patients with high recruitability in supine position. However, impacts of PEEP on V/Q mismatch in prone position relative to supine position remain poorly understood. We aimed to compare PEEP effects between positions, and evaluate its relationship with lung recruitability. Methods A total of 50 patients with moderate-to-severe ARDS were consecutively enrolled. Recruitment-to-inflation (R/I) ratio was used to measure baseline lung recruitability. V/Q mismatch, gas exchange, and respiratory mechanics were evaluated at PEEP 5 cm H2O and PEEP 15 cm H2O in supine position, followed by PEEP 5 cm H2O and PEEP 15 cm H2O in prone position. Results Median R/I ratio was 0.60 [0.38, 0.72], separating patients with higher and lower R/I ratio. In patients with higher R/I ratio, PEEP 15 cm H2O (compared to PEEP 5 cm H2O) reduced shunt without significantly increasing dead space in both supine and prone positions, thereby improving V/Q mismatch (supine: 30.7 [28.6, 36.8]% at PEEP 15 cm H2O vs.38.0 [34.9, 45.4]% at PEEP 5 cm H2O, P < 0.001; prone: 25.7 [21.4, 30.4]% at PEEP 15 cm H2O vs. 32.8 [27.5, 36.7]% at PEEP 5 cm H2O, P < 0.001). However, in patients with lower R/I ratio, PEEP 15 cm H2O (compared to PEEP 5 cm H2O) in supine position did not improve V/Q mismatch (37.8 [34.7, 42.1]% at PEEP 15 cm H2O vs. 41.3 [34.8, 45.4]% at PEEP 5 cm H2O, P = 0.078), as the reduction in shunt was accompanied by a significant increase in dead space; in prone position, PEEP 15 cm H2O significantly worsened V/Q mismatch (35.9 [28.3, 43.4]% at PEEP 15 cm H2O vs. 31.7 [24.3, 37.6]% at PEEP 5 cm H2O, P < 0.001), as it failed to reduce shunt while significantly increasing dead space. Conclusions In patients with higher R/I ratio, PEEP 15 cm H2O improved V/Q mismatch in both supine and positions. In patients with lower R/I ratio, PEEP 15 cm H2O did not impact V/Q mismatch in supine position but significantly worsened it in prone position.

BACKGROUND:The best time to perform mobilization in patients after cardiac surgery is still unknown. Specifically, the efficacy and safety of initiating mobilization within the first 24 hours remain unclear. AIM:We evaluated the effect of early mobilization within 24 hours post cardiac surgery on the incidence of delirium. DESIGN:This was a single-centered randomized pilot study. SETTING:Tertiary teaching hospital. POPULATION:Adult post-cardiac surgery patients were randomized to early mobilization group or usual care group. METHODS:In the early mobilization group, sitting down with no support on a wheelchair for more than 30 minutes were implemented within 24 hours of intensive care unit (ICU) admission, then performed every day until day 7. In the usual care group, mobilization was performed after transferred to the cardiac surgery department, then performed every day until day 7. Screening for delirium by Confusion Assessment Method for the ICU (CAM-ICU) was performed on anesthesia recovery period, 8 hours after awakening, on the second day postsurgery, and every morning until 7 days. The primary outcome was the incidence of delirium during the first 7 days after randomization. The secondary outcomes included duration of delirium, mechanical ventilation time, length of ICU stay and in-hospital mortality. RESULTS:Sixty patients were enrolled, 30 assigned to each group. No baseline difference was identified between the early mobilization group and usual care group. The incidence of delirium was 26.7%. In the early mobilization group, a trend toward a lower incidence of delirium on the second day was found, and the duration of delirium was significantly shorter. No severe adverse events were identified during the first mobilization time, which lasted for almost 40 minutes. CONCLUSIONS:Early mobilization might be effective in reducing delirium incidence and duration for post-cardiac surgery patients, despite not significantly reducing its incidence. These preliminary findings should be tested in larger multicenter trials. CLINICAL REHABILITATION IMPACT:Early mobilization within 24 hours post-cardiac surgery might be effective in reducing delirium and is safe for post-cardiac surgery patients, which should be tested in larger multicenter trials.

Lung protective ventilation is crucial for preventing ventilator-induced lung injury in cardiac surgery. The protective role of a low tidal volume (VT) has been established, whereas the added protection afforded by lung recruitment remains uncertain. We investigated whether sigh breaths could provide additional lung protection, when added to protective ventilation with low VT. This randomized, assessor-blinded, phase 2 proof-of-concept trial enrolled 192 patients undergoing elective on-pump cardiac surgery from February to August 2024. Patients were randomly allocated in a 1:1 ratio to receive sigh ventilation (sigh breaths plus protective ventilation with low VT; 96 patients) or conventional ventilation (protective ventilation with low VT; 96 patients). Sigh breaths targeting a plateau pressure of 35 cmH2O (or 40 cmH2O for BMI >35 kg/m2) were delivered once every 6 min. Perioperative respiratory mechanics and gas exchange were monitored. The primary outcome was postoperative oxygenation, a marker of lung injury, as measured by the time-weighted average SpO2/FiO2 ratio during the first postextubation hour. There were 9 predefined secondary outcomes, including the severity of respiratory failure within postextubation day 7. All 192 patients completed the trial (53

BackgroundEnteral nutrition (EN) in septic shock patients is a double-edged sword. The impact of early enteral nutrition (EEN) on mortality in septic shock patients remains uncertain, and whether this association is modified by vasopressor dosage is also unclear.ObjectiveThe study aimed to investigate the association between EEN and 28-day in-hospital mortality in patients with septic shock and to explore whether the association varied across different dosages of vasopressors during the first 24 h.MethodsData were extracted from the Chinese Database in Intensive Care (CDIC). Adult septic patients who received vasopressors within 24 h of intensive care unit (ICU) admission were eligible for inclusion. The primary exposure was whether patients received early nutrition within the first 24 h after ICU admission (the EEN group). The primary outcome was 28-day mortality. Multivariate Cox regression models were employed to assess the association between the EEN group and 28-day mortality in the overall population and in patients receiving different vasopressor dosing intensity (VDI) levels. VDI was defined as the total vasopressor dose expressed in norepinephrine equivalents (NEEs), calculated as the time-weighted average over the first 24 h.ResultsA total of 26,478 patients were screened and, ultimately, 1855 patients met the inclusion criteria. The median Sequential Organ Failure Assessment (SOFA) score was 11 [interquartile range (IQR): 8–14], and the Acute Physiology and Chronic Health Evaluation (APACHE) II score was 20 (IQR: 15–26). The 28-day in-hospital mortality rate was 19.7%. Compared to patients in the EEN group, those in the late enteral nutrition (LEN) group required higher vasopressor doses (8.7 vs. 10.6 ug/min, p<0.001) and had a higher 28-day mortality rate (16.6% vs. 21.1%, p = 0.03). After adjusting for confounding factors, EEN was not significantly associated with a reduction in the risk of 28-day mortality [Hazard ratio (HR) 0.832, 95% confidence interval (CI) (0.654–1.059), p = 0.135]. When stratified by VDI (norepinephrine equivalents), EEN exhibited a trend toward reduced 28-day mortality; however, this difference failed to reach statistical significance in patients with VDI < 15ug/min [HR 0.738, 95% CI (0.523–1.042), p = 0.084]. In contrast, EEN had no discernible impact on 28-day mortality risk in patients with VDI ≥ 15ug/min [HR 0.926, 95% CI (0.660–1.298, p = 0.655)].ConclusionEarly enteral nutrition was not associated with a lower 28-day mortality risk in patients with septic shock, and it only demonstrated a trend in patients receiving low doses of vasopressors.

Critical care medicine plays a pivotal role in addressing life-threatening conditions; however, its development in China is hindered by resource scarcity and inequitable distribution. Existing studies have mostly focused on ICU bed numbers or selected regions, and have rarely provided a comprehensive, nationwide assessment of ICU beds, staffing and equipment using standardized methods, nor have they systematically quantified population-based equity of ICU resources. To address this evidence gap and describe the current landscape of critical care capacity in China, we conducted a nationwide survey of critical care resources. The survey aimed to describe the current status of resources, quantify population-based equity, and explore regional and hierarchical disparities that may affect access to critical care. This cross-sectional survey was conducted from January 1, 2021, to December 31, 2023, encompassing public comprehensive hospitals, private hospitals, and specialty hospitals across 31 provinces (including municipalities) in China. A total of 4,744 hospitals with a comprehensive ICU provided valid responses and were included in the analysis; the overall response rate among eligible hospitals invited through provincial health authorities was approximately 89.80

Background: Impaired angiogenesis is the primary driver of refractory diabetic cutaneous wounds, a devastating complication associated with persistently high global rates of amputation and disability. Circulating extracellular vesicles (EVs) and their encapsulated microRNAs (miRNAs) serve as pivotal regulators of angiogenesis and wound healing by mediating intercellular communication. Although the classic traditional Chinese medicine herb pair Astragalus membranaceus (Fisch.) Bunge–Salvia miltiorrhiza Bunge (Huangqi-Danshen, HD) has long been used for diabetic wound repair, its pro-healing mechanisms involving circulating EV-associated miRNAs remain largely unelucidated.Methods: We employed an integrated strategy combining network pharmacology, EV-related miRNA target database analysis, and systematic in vitro and in vivo experiments to explore the underlying mechanisms of HD. Serum EVs were isolated and characterized from HD-treated rats, and their effects on high glucose-injured human umbilical vein endothelial cells (HUVECs) and L929 fibroblasts were evaluated. Furthermore, the therapeutic efficacy of HD was validated in a streptozotocin-induced diabetic wound mouse model. Key targets and pathways were predicted using network pharmacology and molecular docking. Based on published evidence that miR-20b-5p is aberrantly overexpressed in circulating EVs of diabetic patients and closely associated with impaired angiogenesis and delayed wound closure, this miRNA was selected as the candidate molecule for targeted validation in the present study.Results: In vitro, HD-derived serum EVs were efficiently internalized by target cells, significantly reversing high glucose-induced damage by promoting cell proliferation, migration, and angiogenesis while inhibiting apoptosis. In vivo, HD markedly accelerated wound closure, ameliorated dyslipidemia, enhanced dermal regeneration and collagen deposition, and downregulated the levels of pathogenic miR-20b-5p in circulating EVs. Bioinformatic analysis and preliminary in vivo validation suggested that the pro-healing effects of HD may be partially associated with EV-associated miR-20b-5p and its regulatory effect on the AGE-RAGE signaling axis, with STAT3/CCND1/VEGFA as potential downstream targets.Conclusion: The Astragalus membranaceus–Salvia miltiorrhiza herb pair exerts therapeutic effects on diabetic wound healing.The EV-associated miR-20b-5p/AGE-RAGE axis may serve as a potential mechanistic target, providing a preliminary research perspective for subsequent in-depth functional validation.

The Omicron variant of SARS-CoV-2 has exhibited altered transmissibility and virulence compared with the Wild-type strain. Currently, no research has focused on the differences in organ failure caused by the two strains. Understanding the clinical characteristics and organ failure patterns of Omicron infection is essential to improve management strategies for severe cases. This multicenter retrospective observational study included two cohorts: the Omicron cohort, consisting of 7,000 COVID-19 patients admitted to 10 national research centers in China from December 2022 to January 2023, and the Wild-type cohort, consisting of 733 patients from designated hospitals during the early outbreak in 2020. Demographic, clinical, laboratory, and treatment data were collected and analyzed. We compared the differences in patient characteristics, developments of organ dysfunction and outcomes between the two cohorts. Multivariate logistic regression models were employed to identify risk factors for severe COVID-19 and death. The Omicron cohort included 7000 patients, 1551 (22.2

INTRODUCTION:Epithelial Ovarian Cancer (EOC) is a highly aggressive gynecological malignancy with a high mortality rate primarily due to late-stage diagnosis and metastatic dissemination. Regulatory T cells (Tregs) have emerged as critical mediators of immune evasion, yet the role of Foxp3+ Tregs in modulating Tumor-Associated Macrophage (TAM) polarization and the underlying molecular mechanisms in EOC remains unclear. METHODS:An orthotopic EOC mouse model and in vitro co-culture systems were employed to investigate the effects of Foxp3+ Tregs on TAM polarization. Quantitative Real-Time PCR (qRTPCR), flow cytometry, Western blotting, wound healing, and transwell assays were performed to assess gene expression, immune cell infiltration, and tumor cell migration/invasion. Foxp3 knockdown was achieved using Adeno-Associated Virus (AAV)-mediated delivery to evaluate its effects in vivo. RESULTS:Foxp3+ Tregs induced macrophage polarization toward the M2 phenotype, characterized by downregulation of M1 markers (IL-1β, iNOS) and upregulation of M2 markers (IL-10, Arg-1). Mechanistically, Foxp3+ Tregs activated the Sirt1-ERK1/2-STAT3 signaling pathway while suppressing NF-κB activity. In vitro, Foxp3+ Tregs enhanced the migratory and invasive capacities of ovarian cancer cells, whereas in vivo Foxp3 knockdown significantly reduced tumor growth and M2 macrophage infiltration. DISCUSSION:These findings suggest that Foxp3+ Tregs play a pivotal role in shaping the immunosuppressive tumor microenvironment in EOC by promoting M2 macrophage polarization through Sirt1-ERK1/2-STAT3 signaling and NF-κB suppression, ultimately facilitating tumor progression. CONCLUSION:Foxp3+ Tregs drive immunosuppressive macrophage polarization and ovarian cancer progression, highlighting Foxp3 as a potential therapeutic target for EOC treatment.

Sepsis is a life-threatening syndrome caused by a dysregulated host response to infection and represents a major challenge in critical care medicine due to its high global mortality. Mitochondrial quality control (MQC) denotes the regulatory network essential for maintaining mitochondrial homeostasis, encompassing processes including mitochondrial biogenesis, mitophagy, and mitochondrial dynamics. Impaired MQC leads to the accumulation of damaged mitochondria and constitutes a core pathological mechanism underlying sepsis-induced multiorgan dysfunction. Recent studies have demonstrated that various bioactive components of traditional Chinese medicine (TCM) can facilitate the restoration of the MQC network under septic conditions by modulating distinct signaling pathways, thereby attenuating cytokine storms, mitigating oxidative stress, and preserving organ function. Owing to their multicomponent and multitarget characteristics, TCM interventions offer promising therapeutic potential for sepsis. However, a systematic understanding of how these agents coordinately regulate MQC remains limited. In this review, we aim to elucidate the pharmacological roles and underlying molecular mechanisms of TCM in modulating mitochondrial quality during sepsis, and we also discuss future research directions in this field.

ABSTRACT Sepsis remains a leading cause of mortality worldwide due to its profound biological heterogeneity. While multi‐omics approaches offer promise for precision medicine, existing datasets often lack longitudinal granularity or comprehensive clinical integration. We present the Chinese Multi‐omics Advances In Sepsis (CMAISE) cohort, a prospective, multicenter initiative integrating high‐resolution multi‐omics (transcriptomics, proteomics, metabolomics, and scRNA‐Req) with deep clinical phenotyping. By combining molecular trajectories with continuous vital signs and laboratory data, CMAISE provides an unprecedented resource to decode sepsis complexity. This correspondence outlines the cohort design, data resources, and its potential to accelerate the discovery of treatable traits.

Background:Extracorporeal membrane oxygenation (ECMO) has emerged as a promising rescue strategy for patients with refractory cardiogenic shock (CS). However, comprehensive and quantitative insights into the global research landscape of ECMO in CS remain limited. This study aimed to address this gap by systematically mapping the global research landscape of ECMO in CS through bibliometric analysis and knowledge visualization. Methods:A narrative synthesis was used to provide concise summaries of the key findings, highlighting emerging research frontiers and thematic shifts over time. Publications related to ECMO management in CS from 1990 to 2024 were retrieved from the Web of Science Core Collection. CiteSpace and VOSviewer were used to analyze publication patterns, co-authorship networks, keyword clustering, and citation metrics. High-impact authors, institutions, countries, and emerging research frontiers were identified. Results:A total of 701 publications involving 4,433 authors from 1,105 institutions across 55 countries were analyzed. The United States led in both publication volume and citations, followed by Germany and China. Four major thematic clusters were identified: postcardiotomy shock, cardiac arrest, extracorporeal cardiopulmonary resuscitation (ECPR), acute myocardial infarction (AMI)-related mechanical circulatory support, and ECMO bridging to transplantation. Over time, research emphasis has shifted from general survival and mortality to protocol-driven care, predictive modeling, and long-term outcomes. Conclusions:ECMO for CS is a rapidly expanding field, with bibliometric patterns suggesting increasing research consolidation and thematic diversification. Bibliometric analysis revealed a centralized and collaborative academic ecosystem with evolving themes suggestive of a shift toward precision support, multidisciplinary management, and clinical guideline development. These insights provide a roadmap for future research and health policy planning.

Decreased percentage of Foxp3+ regulatory T cells (Tregs) in the lungs results in overwhelming inflammation and delayed recovery of acute lung injury (ALI) caused by acute respiratory distress syndrome (ARDS). Extracellular vesicles (EVs) in the pulmonary microenvironment significantly affect the immune system, but their underlying effects on Tregs are unclear. Here, we demonstrate increased endothelial cell-derived EVs (CD31+ EVs) in lipopolysaccharide (LPS)-induced ALI models by single-EV analysis. EVs from activated pulmonary endothelial cells (ECs) exhibit proinflammatory effects and suppress Treg induction. Exposure of Tregs to these EVs induces massive production of interleukin (IL)-21, which has been proven to reduce Foxp3 expression. Mechanistically, we find that Med1 enriched in these EVs can directly bind to the promoter region of the IL-21 gene thus activating IL-21 transcription in Tregs. Moreover, we confirm that suppressing Med1 accumulation in EVs from activated pulmonary ECs can reverse Treg differentiation, and alleviate lung inflammation. Finally, we observe a significant increase of EVs carrying Med1 in the BALF of patients with ARDS. Taken together, this study identifies that EV-mediated pulmonary endothelium-Treg communication is crucial for Treg suppression in ARDS and may provide potential therapeutic targets for the treatment of this fatal clinical syndrome.

ABSTRACT The heterogeneity of acute respiratory failure (ARF) in non‐intubated patients remains poorly defined. This study aimed to identify novel phenotypes in non‐intubated ARF patients and evaluate their prognostic and predictive ability. We analyzed data from three cohorts: a training cohort from the Chinese Database in Intensive Care, validation cohort A from a randomized controlled trial, and validation cohort B from a multicenter dataset. Latent class analysis and k‐means clustering were applied independently across cohorts to identify phenotypes. A two‐class model demonstrated the optimal fit in the training cohort (n = 706). Compared to Phenotype 1, Phenotype 2 exhibited worse oxygenation, higher lactate concentrations, and more severe coagulation dysfunction, along with significantly higher intubation (56.7 vs. 28.7%, p < 0.001) and mortality rates within 28 days (22.0 vs. 9.7%, p < 0.001). Similar phenotypes were verified in validation cohorts A (n = 409) and B (n = 609). Notably, Phenotype 1 patients benefited most from prolonged awake prone positioning (APP), with a significant interaction observed (p = 0.035; adjusted p = 0.048). Two parsimonious models were further developed for phenotype assignment prediction. The two novel phenotypes with both prognostic and predictive ability may help tailor APP to individual non‐intubated ARF patients.

[This corrects the article DOI: 10.1016/j.jointm.2025.08.011.].

Optimal oxygen targets for mechanically ventilated adults remain uncertain. Prior meta-analyses included both ventilated and non-ventilated patients, limiting applicability to invasive ventilation. We performed a PRISMA-compliant systematic review and meta-analysis of randomized trials exclusively enrolling mechanically ventilated adults or reporting extractable IMV-specific data, comparing conservative (lower SpO2/PaO2 targets) versus liberal (higher targets) oxygen therapy. The primary outcome was mortality at longest follow-up; secondary outcomes included 28/30-day, 90-day, ICU mortality and predefined adverse-event composites. Risk of bias was assessed with RoB 2 and certainty with GRADE. Trial sequential analysis (TSA) evaluated information size and robustness. Fourteen trials enrolling 22,930 mechanically ventilated adults were included. For the primary outcome of mortality at longest follow-up, data from all 14 trials (n = 17,858 patients; 77.9

Background:​ Sepsis-associated acute kidney injury (SA-AKI) confers a high mortality risk. Although Xuebijing injection (XBJ) reduced mortality in a general sepsis population, its effect heterogeneity in the high-risk SA-AKI subgroup remains unclear, posing a challenge for personalised treatment. Methods:​ This was a post-hoc analysis of the EXIT-SEP trial, a multicentre, randomised, double-blind, placebo-controlled trial conducted at 45 intensive care units in China. A total of 1750 enrolled sepsis patients were stratified by the presence of AKI at enrolment. The primary outcome was 28-day all-cause mortality. Within the AKI cohort, we assessed heterogeneity of treatment effects (HTE) using risk stratification, causal forest machine learning for individualised treatment effect (ITE) estimation, and Shapley Additive Explanations (SHAP) analysis to identify key predictors. Model performance was evaluated in an independent external validation cohort. Findings: ​Of 1750 patients, 388 had AKI. XBJ was not associated with significantly reduced mortality in the overall AKI cohort (HR 0.75, 0.53–1.07, P=0.114). However, significant heterogeneity of treatment effect was present within the AKI population. In the predicted beneficiary subgroup, XBJ treatment lowered mortality from 39.3% to 21.7% (Absolute risk difference [ARD]: -17.6%). This subgroup was characterized by younger age, lower illness severity, and distinct laboratory profiles. The model's ability to pinpoint this responsive subgroup was confirmed in an independent external validation cohort. Interpretation: ​The treatment effect of XBJ on sepsis mortality is substantially influenced by AKI status and exhibits significant heterogeneity within the SA-AKI population. These findings underscore that SA-AKI is not a single entity in terms of treatment response. A precision medicine approach, incorporating risk and response stratification, is needed to identify patients with SA-AKI who are most likely to benefit from XBJ treatment.

RATIONALE:Physiological studies showed benefits for bedside setting of personalized positive end-expiratory pressure (PEEP) by electrical impedance tomography (EIT), balancing lung overdistension and collapse. OBJECTIVES:To evaluate whether EIT-guided PEEP improves the clinical outcomes of patients with acute respiratory distress syndrome (ARDS) compared to the lower PEEP/FiO2 table strategy. METHODS:This randomized trial enrolled adult patients with moderate to severe ARDS across five sites in China from February 2022 to June 2023. Participants were randomly assigned to EIT-guided PEEP (collapse-overdistension crossing point value by decremental PEEP trial) or the classical lower PEEP/FiO2 table. The primary outcome was 28-day mortality. MEASUREMENTS AND MAIN RESULTS:The trial was terminated early for futility, based on a pre-planned interim analysis. A total of 190 patients were included and completed follow-up. PEEP levels didn't differ between groups during the first 7 days (difference in marginal means 0.2 [SE 0.1]; P = .187). At 28 days, mortality was 52 patients (55.9%) in the EIT-guided PEEP group and 51 patients (52.6%) in the lower PEEP/FiO2 table group (hazard ratio [HR] 0.96 [95% CI, 0.65-1.41]; P = .821). Ventilator-free days and other secondary clinical and safety outcomes did not differ, either. However, EIT-guided PEEP assigned higher PEEP and decreased mortality in patients with higher lung recruitability, as assessed by the recruitment-inflation ratio method (16 [35.6%] of 45 patients vs 27 [60.0%] of 45 patients; HR 0.49 [95% CI, 0.26-0.91]; P = .024). CONCLUSIONS:In patients with moderate to severe ARDS, EIT-guided PEEP did not significantly reduce 28-day mortality compared with the lower PEEP/FiO2 table strategy. Due to early termination, the study may have been underpowered to detect a clinically important difference. TRIAL REGISTRATION:clinicaltrials.gov NCT05207202.