PRISM Rounds: Pulmonary, Critical Care & Sleep Medicine

In this episode of PRISM Rounds, we discuss the AJRCCM 2026 Pickwick Titration Trial, which asked whether automatically adjusted noninvasive ventilation can match manually adjusted NIV titrated in the sleep lab for ambulatory patients with obesity hypoventilation syndrome.The trial found that auto-adjusted NIV produced similar 12-month improvement in daytime PaCO₂ compared with manually adjusted NIV, while reducing cost and potentially decreasing sleep-lab burden. The accompanying editorial highlights the real-world nuance: CPAP remains first-line for many stable OHS patients with severe OSA, but auto-adjusted NIV may be especially useful when NIV is indicated and access to in-lab titration is limited.Article: https://doi.org/10.1093/ajrccm/aamag018Editorial: https://doi.org/10.1093/ajrccm/aamag112This episode is for educational purposes only and is not medical advice. AI-generated voices are used, so occasional mispronunciations may occur.Critical Care, Pulmonary Medicine, Sleep Medicine, Obesity Hypoventilation Syndrome, OHS, Noninvasive Ventilation, NIV, Auto NIV, Auto EPAP, AVAPS, CPAP, PaCO2, Hypercapnia, Sleep Lab, Polysomnography, AJRCCM, Pickwick Titration Trial, PRISM Rounds, Medical Education, Free Open Access Medical Education, FOAMed, AI Generated Medical Education, Research Summary, Journal Club, ICU, Respiratory Therapy, Pulmonary Critical CareTags

In this episode of PRISM Rounds, we discuss the 2026 AJRCCM EITVent randomized clinical trial and its accompanying editorial. The study asked whether electrical impedance tomography, or EIT, could help clinicians individualize PEEP in adults with moderate to severe ARDS compared with the traditional lower PEEP/FIO2 table.The overall trial was neutral: EIT-guided PEEP did not reduce 28-day mortality, ventilator-free days, length of stay, or major safety outcomes. But an important subgroup signal emerged in patients with higher lung recruitability, raising a practical bedside question: should EIT be used selectively to guide precision ventilation rather than as routine daily exhaustive PEEP titration?We discuss the trial design, the “collapse-overdistension crossing point,” the editorial’s caution about repeated recruitment maneuvers and decremental PEEP trials, and how this should influence bedside ventilator thinking in ARDS.Educational only. Not medical advice. AI-generated voices are used and may occasionally mispronounce terms.Trial DOI: https://doi.org/10.1093/ajrccm/aamaf125Editorial DOI: https://doi.org/10.1093/ajrccm/aamag012#PRISMRounds#CriticalCare#PulmonaryCriticalCare#ICU#ARDS#MechanicalVentilation#PEEP#EIT#ElectricalImpedanceTomography#VentilatorManagement#LungProtectiveVentilation#PrecisionVentilation#Recruitability#DrivingPressure#MechanicalPower#PronePositioning#RespiratoryFailure#AJRCCM#EITVent#ClinicalTrials#JournalClub#EvidenceBasedMedicine#FOAMed#MedEd#ICUEducation#AIgeneratedPodcast#FreeOpenAccessMedEdTags

This week on PRISM Rounds, we discuss the April 2026 New England Journal of Medicine PRoMPT BOLUS trial comparing balanced crystalloids with 0.9% saline in children treated for suspected septic shock.The trial enrolled more than 9,000 children across 47 emergency departments and found no significant difference in major adverse kidney events between balanced fluid and saline. Balanced fluids reduced hyperchloremia and hypernatremia, but those biochemical advantages did not translate into better kidney outcomes, mortality, or hospital-free days.Although this is a pediatric trial, it is relevant for adult ICU and ED clinicians because it speaks to a familiar bedside question: when we reach for crystalloid early in sepsis, does fluid type meaningfully change patient-centered outcomes?We connect this trial to adult sepsis resuscitation, prior fluid-choice studies, and the broader lesson that “more physiologic” does not always mean “better outcomes.”Article: Balanced Fluid or 0.9% Saline in Children Treated for Septic ShockDOI: https://doi.org/10.1056/NEJMoa2601969Educational only; not medical advice. This episode uses AI-generated voices. #PRISMRounds#CriticalCare#ICU#EmergencyMedicine#Sepsis#SepticShock#PediatricSepsis#BalancedCrystalloids#NormalSaline#FluidResuscitation#Resuscitation#KidneyOutcomes#MAKE30#NEJM#EvidenceBasedMedicine#MedicalEducation#FOAMed#FOAMcc#PulmonaryCriticalCare#AIgenerated#AIResearchSummary#FreeMedicalEducation#JournalClub#BedsideMedicineTags / Hashtags

In this episode of PRISM Rounds, we review the JAMA FAST randomized clinical trial of rapid antimicrobial susceptibility testing for gram-negative bloodstream infections and the accompanying editorial, “Is FASTer Better?” The trial did not improve the primary DOOR outcome at 30 days, but rapid AST shortened antibiotic modification times and may be most useful when resistant organisms, septic shock, or ineffective empiric therapy are in play. We discuss why faster lab data alone may not improve mortality unless stewardship, drug availability, and bedside action close the loop.Educational only. Not medical advice. https://pubmed.ncbi.nlm.nih.gov/41999287/ Tags:Critical Care, ICU, Sepsis, Gram Negative Bacteremia, Antimicrobial Stewardship, Antibiotic Resistance, Rapid Diagnostics, AST, Bloodstream Infection, Infectious Diseases, JAMA, FAST Trial, FOAMed, FOMEd, Free Open Access Medical Education, Research Summary, Pulmonary Critical Care, Hospital Medicine, Pharmacy, Microbiology

In this episode of PRISM Rounds, we review the NEJM study of MiniDock MTB, a portable near-point-of-care molecular test for pulmonary tuberculosis using sputum and tongue swabs.The study found that MiniDock MTB outperformed smear microscopy, approached Xpert Ultra performance with sputum swabs, and met WHO near-point-of-care diagnostic accuracy targets. We discuss why this matters for resource-limited settings, where delayed TB diagnosis, repeat visits, and limited access to molecular testing remain major barriers to care.We also cover the key limitations: lower sensitivity in paucibacillary disease, smear-negative TB, and people living with HIV, plus the need for reflex drug-resistance testing.Educational use only. AI-generated voices may include occasional mispronunciations.Article: https://doi.org/10.1056/NEJMoa2509761Tuberculosis, TB, pulmonary tuberculosis, MiniDock MTB, point-of-care testing, near-point-of-care diagnostics, molecular diagnostics, tongue swab, sputum swab, Xpert Ultra, smear microscopy, global health, infectious diseases, pulmonary medicine, critical care, resource-limited settings, diagnostic equity, implementation science, public health, NEJM, medical podcast, journal club, evidence-based medicine, FOAMed, FOMEd, Free Open Access Medical Education, PRISM Rounds, AI-generated medical education, AI medical podcast, clinical research summaryTags

Are we treating the monitor or the patient? This episode breaks down the HIT Trial (NEJM Evidence), where 2,173 patients with chronic hyponatremia were randomized to test if intensive sodium correction actually improves clinical outcomes. https://pubmed.ncbi.nlm.nih.gov/41733398/ The ResultsLab Normalization: The targeted algorithm was highly effective at "fixing the number," reaching normal sodium levels in 60.4% of patients compared to 46.2% in standard care. Clinical Outcomes: Despite better labs, there was no reduction in 30-day mortality or rehospitalization (20.5% vs. 21.8%, p=0.45). Safety: While correction was more aggressive in the intervention group, zero cases of osmotic demyelination syndrome occurred. Bedside TakeawayStandard care is likely "good enough" for moderate hyponatremia in the short term. We discuss the "Good Enough" trap and why pushing for perfect laboratory values doesn't always translate to better patient-centered survival.TagsHyponatremia Critical Care Pulmonary ICU Internal Medicine Medical Education Electrolytes HIT Trial NEJM Evidence Evidence Based Medicine Intensivist Physician Education

Is your patient "fighting the vent," or are they trying to tell you something?In this episode of PRISM Rounds, we move beyond the traditional "Lung-Protective" paradigm to explore the integrated frontier of Lung- and Diaphragm-Protective Ventilation (LDPV). We deep-dive into the physiological evidence showing that patient-ventilator asynchrony isn’t just a nuisance—it’s a mortality signal.Join us as we break down 30 years of research, from the foundational 1997 Foti study to the cutting-edge 2025 breakthroughs in non-invasive, real-time monitoring. We’ll teach you how to identify the "Goldilocks Zone" of respiratory effort—avoiding both the atrophy of over-assistance and the myotrauma of under-assistance.The Clinical Stakes: Why "clusters" of ineffective efforts and double-triggering are predictors of poor outcomes (Blanch 2015, Vaporidi 2017, Sousa 2021).The Toolset: How to perform and interpret bedside maneuvers like Delta Pocc, P0.1, and PMI without needing an esophageal balloon.The 2025 Horizon: A first look at N-Pmus—the future of non-invasive, real-time waveform monitoring (Lv 2025, Tonelli 2025).The Protocol: A step-by-step walk-through of the Dianti (2022) titration strategy for sedation, PEEP, and sweep gas flow.Target Audience: ICU Fellows, Residents, Intensivists, and Respiratory Therapists.Featured Research & LiteratureBelow are the pivotal studies discussed in this episode. Search these titles on PubMed or your institutional library for full-text access:Tonelli, R., et al. (2025) – Assessing inspiratory drive and effort in critically ill patients at the bedside. (Critical Care)Lv, Y., et al. (2025) – Respiratory effort monitoring: a novel, bedside, non-invasive, real-time method. (Critical Care)de Vries, H. J., et al. (2023) – Performance of Noninvasive Airway Occlusion Maneuvers to Assess Lung Stress and Diaphragm Effort. (Anesthesiology)Dianti, J., et al. (2022) – Strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure. (Critical Care)Sousa, M., et al. (2021) – Clusters of Double Triggering Impact Clinical Outcomes (EPISYNC Study). (Crit Care Med)Goligher, E. C., et al. (2020) – Lung- and Diaphragm-Protective Ventilation. (AJRCCM)Bertoni, M., et al. (2019) – A novel non-invasive method to detect excessively high respiratory effort ($\Delta P_{occ}$). (Critical Care)Vaporidi, K., et al. (2017) – Clusters of ineffective efforts during mechanical ventilation: impact on outcome. (Intensive Care Med)Blanch, L., et al. (2015) – Asynchronies during mechanical ventilation are associated with mortality. (Intensive Care Med)#CriticalCare #ICU #MechanicalVentilation #LDPV #Pulmonology #MedEd #PRISMRounds #FOAMed #InternalMedicine #FellowshipTraining #VentilatorManagement #DiaphragmProtection

In this episode of PRISM Rounds, we break down a secondary analysis of the CLOVERS trial examining whether crystalloid choice interacts with resuscitation strategy in sepsis.The key finding: balanced crystalloids were associated with lower mortality in a liberal fluid strategy, while normal saline showed lower mortality estimates in a restrictive strategy. This challenges the idea that fluid choice is independent of how we resuscitate.We discuss the physiology, limitations, and what this means for bedside decision-making—especially during early sepsis management.📄 Article: https://doi.org/10.1016/j.chstcc.2025.100226Tags#CriticalCare #ICU #Sepsis #FluidResuscitation #CLOVERS #DAISY #BalancedCrystalloids #NormalSaline #Vasopressors #FOAMed #MedEd #FreeMedEd #MedicalEducation #AIinMedicine #AIResearchSummaries #ClinicalResearch #EvidenceBasedMedicine #PulmCrit #EmergencyMedicine #ICUEducation

In this episode of PRISM Rounds, we break down the CORAL randomized clinical trial published in JAMA evaluating nalbuphine extended-release for chronic cough in idiopathic pulmonary fibrosis (IPF).In this episode, we discuss:The magnitude of cough reduction (~50–60% vs ~17% placebo)Why objective cough monitoring changes trial designDose-response and patient-reported outcomesSafety of a κ-opioid agonist / μ-antagonist strategyWhat this means for pulmonary and critical care practiceThis is one of the first trials to show a strong, clinically meaningful signal for treating IPF-associated cough—an area of major unmet need.📄 PubMed (CORAL Trial):https://pubmed.ncbi.nlm.nih.gov/38265368/📄 JAMA Article:https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2025.26179PRISM Rounds is an audio journal club designed for clinicians who want high-yield, bedside-relevant discussions of new evidence.Tags#FOAMed #CriticalCare #Pulmonary #IPF #InterstitialLungDisease #ILD #ChronicCough #JAMA #RCT #EvidenceBasedMedicine #MedEd #MedicalPodcast #ICU #Respiratory #PulmCrit #JournalClub #Pharmacology #Opioid #Nalbuphine #ClinicalTrials #Healthcare #Medicine #Physicians #MedTwitter #PodcastMedicine #ATS #ERS

In this episode of PRISM Rounds, we break down the 2026 Surviving Sepsis Campaign Guidelines and what they actually mean at the bedside.We focus on the major shifts shaping modern sepsis care: individualized fluid resuscitation, earlier vasopressor use, antimicrobial stewardship, and the move away from rigid protocol-driven management toward precision-informed decision-making.This episode highlights how experienced intensivists are likely to interpret these recommendations in real-world practice and what clinicians should do differently tomorrow.For ICU, ED, and pulmonary/critical care clinicians seeking a high-yield, practical update on sepsis management.Link: https://pubmed.ncbi.nlm.nih.gov/41869847/ Tags#CriticalCare #Sepsis #SepticShock #ICU #FOAMed #PulmCrit #EmergencyMedicine #IntensiveCare #MedEd #MedicalEducation #Guidelines #SurvivingSepsis #SSC #Resuscitation #Shock #Hemodynamics #Fluids #Vasopressors #Antibiotics #Stewardship #Norepinephrine #ICUrounds #JournalClub #PRISMRounds

In this episode of PRISM Rounds, we review the HI-PEITHO trial and its accompanying editorial, both published in The New England Journal of Medicine, and examine their implications for the contemporary management of intermediate-risk pulmonary embolism.The discussion focuses on a clinically consequential subgroup of patients with acute pulmonary embolism who are hemodynamically stable yet demonstrate right ventricular dysfunction, myocardial injury, and signs of physiologic distress. We analyze the trial design, inclusion criteria, primary composite outcome, and safety results, with particular attention to the finding that ultrasound-facilitated catheter-directed thrombolysis was associated with a lower risk of early clinical deterioration, driven largely by a reduction in cardiorespiratory decompensation rather than a demonstrated mortality benefit.We also discuss how these data may influence multidisciplinary Pulmonary Embolism Response Team deliberations, especially when evaluating whether selected patients with intermediate-risk PE may benefit from earlier catheter-based intervention rather than continued observation with anticoagulation alone. The episode places HI-PEITHO in the broader context of prior thrombolysis literature, evolving reperfusion strategies, and the persistent tension between preventing hemodynamic collapse and avoiding bleeding complications.Key topics include patient selection, interpretation of the primary end point, safety considerations, the role of physiologic distress in escalation decisions, and the likely effect of this trial on real-world PERT practice.Primary Article: https://pubmed.ncbi.nlm.nih.gov/41910345/Editorial:https://pubmed.ncbi.nlm.nih.gov/41910345/This episode is intended for educational purposes only and should not be construed as medical advice. Audio is generated using AI voices.Tags#PulmonaryEmbolism #IntermediateRiskPE #VenousThromboembolism #Thrombosis #CriticalCare #IntensiveCare #PulmonaryCriticalCare #EmergencyMedicine #Cardiology #PERT #CatheterDirectedTherapy #Thrombolysis #UltrasoundFacilitatedThrombolysis #EvidenceBasedMedicine #JournalClub #NEJM #MedicalEducation #AcademicMedicine #ClinicalTrials #Resuscitation #AcuteCareMedicine #HospitalMedicine #FOAMed #FOAMcc #PRISMRounds #HI-PEITHO he

Septic shock remains one of the deadliest conditions in intensive care, with mortality near 40% and no widely adopted therapy that directly targets a defined sepsis biology. In this episode of PRISM Rounds, we break down the Tigris trial, the phase 3 randomized study of polymyxin B haemoadsorption in endotoxic septic shock, published in The Lancet Respiratory Medicine on March 23, 2026. We cover the biology of endotoxin-driven shock, the role of the Endotoxin Activity Assay (EAA), why the 0.60–0.89 range mattered so much for treatment selection, and how the investigators used a Bayesian framework informed by prior data from EUPHRATES. We then examine the results, including a 95.3% posterior probability of benefit at 28 days, 99.4% at 90 days, and an estimated number needed to treat of 6.5. Most importantly, we ask the bedside question: does this change practice now, or is it an important signal that still needs confirmation and regulatory follow-through?Full text: https://doi.org/10.1016/S2213-2600(26)00047-0ClinicalTrials.gov: https://clinicaltrials.gov/study/NCT03901807PubMed: https://pubmed.ncbi.nlm.nih.gov/41887242/ Disclosure: Funded by Spectral Medical; conflicts are discussed in the episode. PRISM Rounds is an independent educational podcast and does not provide medical advice.#CriticalCare #Sepsis #SepticShock #IntensiveCare #ICU #PulmonaryCriticalCare #EmergencyMedicine #InternalMedicine #PrecisionMedicine #ClinicalTrials #EvidenceBasedMedicine #MedEd #FOAMed #MedicalPodcast #Healthcare #Medicine #Physician #MedStudent #ResidentLife #Nursing #RespiratoryTherapy

In this episode of PRISM Rounds, we review the NEJM IMPALA-2 trial evaluating inhaled molgramostim for autoimmune pulmonary alveolar proteinosis (PAP).This phase 3 randomized trial showed improved pulmonary gas transfer (DLCO) and quality of life with inhaled GM-CSF compared to placebo, with a favorable safety profile. We break down the pathophysiology, trial design, and what this means for moving beyond whole-lung lavage in PAP.Article:https://pubmed.ncbi.nlm.nih.gov/40834301/Editorial:https://pubmed.ncbi.nlm.nih.gov/40834306/Tags:#CriticalCare #Pulmonary #ICU #FOAMed #MedEd #MedicalPodcast #PRISMRounds #NEJM #ClinicalTrials #EvidenceBasedMedicine #PAP #PulmonaryAlveolarProteinosis #GMCSF #Molgramostim #RareDisease #RespiratoryMedicine #ICUEducation #MedTwitter #HealthcareEducation #JournalClub

In this episode of PRISM Rounds, we review the R2D2 ICU randomized trial (JAMA, March 2026) evaluating restrictive vs liberal physical restraint strategies in mechanically ventilated ICU patients.Bottom line: less restraint did not improve delirium or coma—but it also did not increase harm.We break down the trial design, key results, and the bedside implications for sedation strategy, delirium prevention, patient safety, and ICU culture. This is a practice-challenging study that questions routine restraint use while emphasizing individualized, patient-centered care.Key themes: delirium, sedation, safety vs harm, ICU workflow, ethics, and bedside decision-making.PubMed search links:R2D2 ICU Trial:https://pubmed.ncbi.nlm.nih.gov/41841304/Editorial:https://pubmed.ncbi.nlm.nih.gov/41841296/Tags#FOAMed #FOAMcc #FOAMICU #MedEd #MedTwitter #CriticalCare #ICU #IntensiveCare #PulmCrit #Resus #JournalClub #EvidenceBasedMedicine #EBM #MedicalEducation #ClinicalTrials #JAMA #Delirium #Sedation #MechanicalVentilation #Ventilator #PatientSafety #ICUculture #Restraints #AirwayManagement #ARDS #Sepsis #HospitalMedicine #EmergencyMedicine #EMCrit #ICUrounds #BedsideTeaching #PCCM #PulmonaryCriticalCare #TraineeEducation #MedPodcast #CriticalCareMedicine #Intensivist #NeuroICU #AcuteCare #MedicalPodcast

In this episode of PRISM Rounds, we break down the new NEJM 2026 COBRRA trial comparing apixaban vs rivaroxaban for acute venous thromboembolism (VTE).Bottom line: in this randomized head-to-head trial, apixaban reduced clinically relevant bleeding compared with rivaroxaban (3.3% vs 7.1%; RR 0.46), including lower major bleeding (0.4% vs 2.4%), with similar observed recurrent symptomatic VTE rates (1.1% vs 1.0%) over 3 months. NEJM trial: Castellucci LA, Chen VM, Kovacs MJ, et al. Bleeding Risk with Apixaban vs. Rivaroxaban in Acute Venous Thromboembolism. N Engl J Med. 2026;394:1051-1060. DOI: 10.1056/NEJMoa2510703. PubMed: https://pubmed.ncbi.nlm.nih.gov/?term=10.1056%2FNEJMoa2510703NEJM editorial: Moores LK. The COBRRA Trial — Ending the Venous Thromboembolism Safety Toss-up. N Engl J Med. 2026. DOI: 10.1056/NEJMe2600525. PubMed: https://pubmed.ncbi.nlm.nih.gov/?term=10.1056%2FNEJMe2600525Tags#PRISMRounds #MedicalPodcast #MedPodcast #JournalClub #FOAMed #MedEd #EvidenceBasedMedicine #NEJM #JAMA #JAMAInternalMedicine #VTE #VenousThromboembolism #DVT #DeepVeinThrombosis #PE #PulmonaryEmbolism #Apixaban #Rivaroxaban #DOAC #DOACs #Anticoagulation #Thrombosis #Bleeding #BleedingRisk #Hematology #ThrombosisResearch #InternalMedicine #HospitalMedicine #CriticalCare #ICU #PulmCrit #EmergencyMedicine #EM #CardiovascularMedicine #Pharmacy #ClinicalResearch #RCT #RandomizedTrial #PragmaticTrial #COBRRA #PulmonaryCriticalCare #Trainees #Residents #Fellows #MedTwitter #ClinicianEducation #PracticeChanging #NEJMArticle #AcuteVTE

We break down the 2026 NEJM SOHO trial: high-flow nasal oxygen did not improve 28-day mortality, but it did modestly reduce intubation in acute hypoxemic respiratory failure. We also unpack the NEJM editorial on why mortality may be the wrong endpoint for this kind of ICU support strategy.Trial: https://pubmed.ncbi.nlm.nih.gov/41841715/Editorial: https://pubmed.ncbi.nlm.nih.gov/41841707/Tags#FOAMed #FOAMcc #CriticalCare #ICU #PulmCCM #EmergencyMedicine #RespiratoryFailure #HFNC #HighFlowNasalCannula #AHRF #ARDS #Intubation #MechanicalVentilation #NEJM #JournalClub #MedEd #EvidenceBasedMedicine #EMCrit #RespiratoryCare #AirwayManagement

In this episode of PRISM Rounds, we break down the March 2026 New England Journal of Medicine trial Inhaled Treprostinil for Idiopathic Pulmonary Fibrosis. We review what the trial showed, what it did not prove, how to interpret the FVC signal, the clinical-worsening endpoint, tolerability, and what this means for intensivists, pulmonologists, fellows, residents, and ILD clinicians.We also place the study in context with the earlier INCREASE trial in pulmonary hypertension due to interstitial lung disease. This episode is built for busy clinicians who want practical bedside translation, key teaching points, and concise evidence-based discussion with light professional banter.Full article linksTETON-2 PubMed: https://pubmed.ncbi.nlm.nih.gov/41812190/TETON-2 NEJM: https://www.nejm.org/doi/full/10.1056/NEJMoa2512911INCREASE PubMed: https://pubmed.ncbi.nlm.nih.gov/33440084/INCREASE NEJM: https://www.nejm.org/doi/full/10.1056/NEJMoa2008470Tags#CriticalCare #ICU #Pulmonary #PulmCrit #SleepMedicine #InternalMedicine #Pulmonology #RespiratoryMedicine #IntensiveCare #MedicalEducation #MedEd #FOAMed #FOAMcc #MedTwitter #JournalClub #EvidenceBasedMedicine #MedicalPodcast #PodcastMedicine #IPF #IdiopathicPulmonaryFibrosis #ILD #InterstitialLungDisease #PulmonaryFibrosis #PulmonaryHypertension #PHILD #Treprostinil #InhaledTreprostinil #NEJM #LungDisease #CriticalCareMedicine #AcademicMedicine #BoardReview #Fellowship #Residency #TeachingRounds #ClinicianEducation #RespiratoryFailure #PulmonaryResearch

In this episode of PRISM Rounds, we review the 2026 Journal of the American Heart Association study by Pedamallu et al., with additional perspective from JAMA Medical News. Using MASALA and MESA cohort data, the study found that South Asian adults in the United States had a higher midlife burden of prediabetes, hypertension, and dyslipidemia, and by age 55 had the highest estimated probability of diabetes among the groups studied.We discuss the clinical implications for earlier cardiovascular risk recognition, the limitations of BMI-based reassurance, and why these findings support more proactive prevention conversations while larger interventional studies are still needed.PubMed linksOriginal study: https://pubmed.ncbi.nlm.nih.gov/41669952/JAMA perspective: https://pubmed.ncbi.nlm.nih.gov/41823955/#PRISMRounds #MedicalPodcast #MedicinePodcast #ClinicalPodcast #AcademicMedicine #FOAMed #MedEd #MedicalEducation #JournalClub #EvidenceBasedMedicine #InternalMedicine #CriticalCare #ICU #PulmonaryCriticalCare #CardiovascularPrevention #CardiometabolicRisk #SouthAsianHealth #PrimaryPrevention #Prediabetes #Hypertension #Dyslipidemia #DiabetesRisk #PopulationHealth #HealthEquity #PreventiveCardiology #MASALA #MESA

In this episode of PRISM Rounds, we revisit the landmark New England Journal of Medicine trial “Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock” from February 28, 2008, along with the accompanying Parrillo editorial. We break down what the VASST trial actually showed, why the overall mortality result was negative, and why the “less severe shock” subgroup still shaped bedside practice for years.Along the way, we discuss why septic shock often does not trigger the same urgency as myocardial infarction, what this trial taught us about vasopressin as an adjunct rather than a rescue pressor, and whether low-dose vasopressin truly increased ischemic complications. This is a practical, teaching-rounds style review for fellows, residents, ICU clinicians, and anyone who wants a clearer bedside translation of one of the classic septic shock papers.PubMed linksVASST trial: https://pubmed.ncbi.nlm.nih.gov/18305265/ Editorial: https://pubmed.ncbi.nlm.nih.gov/18305266/ Tags#CriticalCare #ICU #SepticShock #Sepsis #Vasopressin #Norepinephrine #Pressors #Vasopressor #NEJM #MedicalEducation #FOAMed #PulmCrit #EMCrit #InternalMedicine #PCCM #ResidentEducation #FellowEducation #JournalClub #EvidenceBasedMedicine #PRISMRounds

In this episode of PRISM Rounds, we discuss the ARISS trial: JAMA Network Open (Feb 2026), “Albumin Replacement Therapy in Septic Shock: A Randomized Clinical Trial.” We break down the bedside question: If you replace 20% albumin to maintain serum albumin ≥3.0 g/dL in septic shock, does survival improve?We walk through the study design (multicenter, open-label RCT), the key result (no significant difference in 90-day mortality), what “negative but underpowered” really means, and the practical takeaway for rounds tomorrow: this trial does not support routine albumin replacement just to chase an albumin target—though albumin appeared reasonably safe in this context. PubMed: https://pubmed.ncbi.nlm.nih.gov/41712212/ (Educational content only; not medical advice.)Tags#CriticalCare #ICU #Sepsis #SepticShock #Albumin #Fluids #Resuscitation #Vasopressors #MechanicalVentilation #EvidenceBasedMedicine #JournalClub #FOAMed #JAMANetworkOpen #IntensiveCare #PRISMRounds

Stroke alert at 2 a.m. hits different—so in this episode we run “teaching rounds” on the AHA/ASA 2026 Guideline for the Early Management of Acute Ischemic Stroke, published in Stroke. We translate the biggest updates into what you actually do at the bedside: EMS prenotification and destination decisions, rapid imaging workflows (and what not to delay), IV thrombolysis decisions including tenecteplase vs alteplase within the 4.5-hour window, and how to think about disabling vs non-disabling symptoms when NIHSS looks “low.”Then we shift to endovascular therapy: what “expanded eligibility” means in practice, including selected patients with larger ischemic cores, and a clear stance on basilar artery occlusion thrombectomy in the appropriate window. Finally, we cover the underrated stuff that changes outcomes—glucose and blood pressure targets (including what to stop doing out of habit), plus early complications like dysphagia/aspiration risk.PubMed: https://pubmed.ncbi.nlm.nih.gov/41582814/Tags#Stroke #AcuteIschemicStroke #Neurology #EmergencyMedicine #CriticalCare #ICU #FOAMed #AHA #ASA #Guidelines #StrokeAlert #Thrombolysis #Tenecteplase #Alteplase #MechanicalThrombectomy #EndovascularTherapy #BasilarArteryOcclusion #LargeVesselOcclusion #NeurocriticalCare #EMS #Telestroke #CTAngiography #BPManagement #GlucoseControl #Dysphagia

We walk through the 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline for evaluation and management of acute pulmonary embolism in adults (Circulation, 2026). We focus on the guideline’s top take-home messages trainees need on rounds: the new A–E clinical categories for severity/triage, who can be discharged early, who should be hospitalized, when to activate PERT, and how to think about escalation therapies in the sickest patients—plus practical anticoagulation choices (LMWH vs UFH, DOACs vs warfarin) and follow-up to screen for post-PE limitations/CTEPD. Educational use only—not medical advice.Source (guideline): https://www.ahajournals.org/doi/10.1161/CIR.0000000000001415Pubmed: https://pubmed.ncbi.nlm.nih.gov/41712677/Tags#CriticalCare #ICU #PulmonaryEmbolism #PE #VTE #Thrombosis #Anticoagulation #DOAC #Heparin #LMWH #PERT #EmergencyMedicine #HospitalMedicine #Cardiology #PulmonaryMedicine #MedEd #FOAMed #Guidelines #Circulation #ResidentEducation #FellowEducation #RVRstrain #CTPA #D_Dimer #CTEPD

On today’s PRISM Rounds we discuss PreVent 2, the multicenter randomized trial in The Lancet Respiratory Medicine (2025) testing whether a polyurethane cuff + subglottic secretion drainage (PU-EVAC) endotracheal tube improves outcomes after emergency intubation—and what the accompanying editorial argues about the real-world value of subglottic suction devices.We translate the methods and results into what matters on shift: CDC ventilator-associated event metrics (IVAC / possible VAP), workflow realities (cuff pressure checks, suction setup), and why “VAP reduction” only matters if it moves objective outcomes. We also step back to the 2016 AnnalsATS Deem et al. pilot trial as historical context—then return to the core question: should these tubes be routine in emergency intubations, or is it time to move on?Friendly ICU banter included (with love for RTs and nursing). Educational use only.Sources (PubMed):PreVent 2 (Lancet Respir Med, 2025):https://pubmed.ncbi.nlm.nih.gov/41319662/Deem et al. pilot (AnnalsATS, 2016): https://pubmed.ncbi.nlm.nih.gov/26523433/Tags#CriticalCare #ICU #MechanicalVentilation #AirwayManagement #Intubation #VAP #VentilatorAssociatedPneumonia #VentilatorAssociatedEvents #IVAC #SubglotticSuction #EndotrachealTube #RespiratoryTherapy #Nursing #FOAMed #MedEd #JournalClub #EvidenceBasedMedicine #LancetRespiratoryMedicine #AnnalsATS

In this PRISM Rounds episode, we break down the PROMIZING randomized trial in the New England Journal of Medicine (2025) comparing proportional-assist ventilation with load-adjustable gain factors (PAV+) versus pressure-support ventilation (PSV) during weaning. We cover the physiology case for PAV+, the pragmatic reasons the primary outcome was neutral, and the most actionable takeaway for ICU teams: a consistent liberation workflow (readiness checks, SBT quality, timely extubation, and sedation strategy) often matters more than the ventilator mode itself. Education only — not medical advice. PubMed: https://pubmed.ncbi.nlm.nih.gov/40513024/Tags#CriticalCare #ICU #MechanicalVentilation #VentilatorWeaning #RespiratoryTherapy #RT #ARDS #SBT #PAVplus #PSV #NEJM #JournalClub #EvidenceBasedMedicine #FOAMed #Pulmonary #IntensiveCare #Sedation #PatientVentilatorSynchrony

In this episode of PRISM Rounds, Host and Analyst break down the SuDDICU trial from The New England Journal of Medicine (Oct 29, 2025), testing selective digestive decontamination (SDD) in mechanically ventilated ICU patients using a cluster crossover design across 26 ICUs. We cover the headline result—no statistically significant reduction in 90-day in-hospital mortality—then dig into the key microbiology findings (bloodstream infections and resistant organisms) and the unit-level ecological assessment where noninferiority for resistance outcomes was not confirmed. Practical takeaways focus on what this means for ICU policy, stewardship, and surveillance if SDD is being considered or already in use. Educational use only — not medical advice.PubMed link: https://pubmed.ncbi.nlm.nih.gov/41159880/Tags#CriticalCare #ICU #FOAMed #MedEd #EvidenceBasedMedicine #JournalClub #NEJM #SuDDICU #SelectiveDigestiveDecontamination #SDD #MechanicalVentilation #AntibioticStewardship #AntimicrobialResistance #InfectionPrevention #VentilatorAssociatedPneumonia #Bacteremia #Microbiology #ClinicalTrials #ClusterRandomizedTrial #Noninferiority

In this episode of PRISM Rounds, we walk through electrical impedance tomography (EIT)—a bedside, radiation-free tool that provides real-time maps of regional ventilation. Using a 2022 Critical Care Medicine narrative review, we focus on practical ICU applications: PEEP titration (recruitment vs overdistension), tracking physiologic response to prone positioning, and recognizing effort-related regional phenomena such as pendelluft. Educational use only — not medical advice.PubMed: https://pubmed.ncbi.nlm.nih.gov/35607967/Tags#CriticalCare #ICU #Pulmonary #ARDS #MechanicalVentilation #VentilatorManagement #RespiratoryTherapy #EIT #ElectricalImpedanceTomography #PEEP #PronePositioning #LungRecruitment #Overdistension #VentilationDistribution #Physiology #FOAMed #JournalClub #EvidenceBasedMedicine #MedEd #CriticalCareEducation

In this episode of PRISM Rounds, we revisit the landmark SOAP II randomized trial (New England Journal of Medicine, 2010) at the request of medical students who wanted the “how we got here” story behind modern vasopressor choices. We walk through the trial design and results in 1,679 ICU patients with shock, comparing dopamine vs norepinephrine as first-line vasopressor therapy, then layer in the accompanying NEJM editorial’s critique and clinical framing. We focus on what the data support, what remains inference, and why this study became so practice-shaping—especially around adverse events and bedside tradeoffs. Educational discussion only; not medical advice.Sources: https://www.nejm.org/doi/full/10.1056/NEJMoa0907118https://pubmed.ncbi.nlm.nih.gov/20200382/https://pubmed.ncbi.nlm.nih.gov/20200389/Tags#CriticalCare #ICU #Shock #SepticShock #CardiogenicShock #Vasopressors #Norepinephrine #Dopamine #Arrhythmia #Hemodynamics #RandomizedTrial #NEJM #JournalClub #EvidenceBasedMedicine #MedicalEducation #MedicalHistory #MedEd #Sepsis #Cardiology #FOAMed #SOAP-II #MedicalHistory

In this episode of PRISM Rounds, two hosts break down the American Academy of Sleep Medicine (AASM) 2025 Clinical Practice Guideline on treating central sleep apnea (CSA) in adults—practical bedside takeaways plus a methods-focused look at evidence certainty.We cover CSA phenotypes (heart failure/Cheyne–Stokes, opioid-associated CSA, treatment-emergent CSA, high altitude), what “conditional” recommendations mean, and how to apply options like CPAP, BPAP with backup rate, ASV (with appropriate caution in select heart failure populations), supplemental oxygen, acetazolamide, and transvenous phrenic nerve stimulation.Educational use only; not medical advice.Source (J Clin Sleep Med, 2025): https://doi.org/10.5664/jcsm.11858 Tags#CentralSleepApnea #CSA #SleepMedicine #AASM #ClinicalPracticeGuideline #JournalClub #EvidenceBasedMedicine #CPAP #BPAP #BPAPST #ASV #AdaptiveServoVentilation #CheyneStokes #HeartFailure #Opioids #TreatmentEmergentCSA #HighAltitude #Acetazolamide #PhrenicNerveStimulation #Pulmonology #CriticalCare

In this episode, we break down BICARICU-2, a multicenter open-label randomized clinical trial of 4.2% IV sodium bicarbonate in critically ill adults with severe metabolic acidemia (pH ≤7.20) and moderate-to-severe AKI (KDIGO 2–3). We cover the physiology (why acidemia matters), the trial design (and what open label means for dialysis decisions), and the outcomes that should change bedside behavior. Bottom line: bicarbonate did not improve 90-day all-cause mortality (62.1% vs 61.7%), but it was associated with less kidney replacement therapy by day 28 (35% vs 50%). We close with a practical, conditional approach to when bicarbonate is reasonable as a temporizing strategy—and when it shouldn’t delay needed KRT. Educational use only; not medical advice.JAMA (2025) — “Sodium Bicarbonate for Severe Metabolic Acidemia and Acute Kidney Injury: The BICARICU-2 Randomized Clinical Trial” https://jamanetwork.com/journals/jama/fullarticle/2840824PubMed (2025) — BICARICU-2 trial recordhttps://pubmed.ncbi.nlm.nih.gov/41159812/JAMA (2025) Editorial — “Sodium Bicarbonate in Severe Acidemia and Acute Kidney Injury—Turning the Tide or Chasing a Myth?”https://jamanetwork.com/journals/jama/fullarticle/2840826Tags#CriticalCare #ICU #Nephrology #AcuteKidneyInjury #AKI #MetabolicAcidosis #SevereAcidemia #SodiumBicarbonate #RenalReplacementTherapy #Dialysis #Sepsis #Shock #RandomizedClinicalTrial #EvidenceBasedMedicine #JournalClub #JAMA#IntensiveCare #CriticalCareMedicine #PulmCrit #FOAMed #MedEd #ResidentEducation #FellowEducation #ICUPharmacology #AcidBase #AcidBasePhysiology #Electrolytes #Hemodynamics #SepticShock #Vasopressors #KidneySupport #CRRT #RenalFailure #AKIRecovery #ClinicalTrials #RCT #JAMAPaper #JournalReview #CriticalAppraisal

In this episode of PRISM Rounds, we review a 2025 open-access scoping review and commentary in Sleep Science and Practice examining how hypopnea scoring criteria—4% desaturation-only versus 3% desaturation or EEG arousal—can change the apnea–hypopnea index (AHI) and materially shift obstructive sleep apnea (OSA) diagnosis in women. We walk through what the review found across eight studies, why women are disproportionately affected (phenotype, smaller desaturations, arousal-associated events, and symptom patterns), and what this means for real-world testing pathways (PSG vs HSAT) and access to therapy. Educational use only—this is not medical advice.TagsSleep medicine, Obstructive sleep apnea, OSA, Women’s health, Hypopnea, AHI, Polysomnography, PSG, Home sleep apnea testing, HSAT, AASM scoring, Health equity, Diagnosis, CPAP, Respiratory physiologySource (paper landing page): https://link.springer.com/article/10.1186/s41606-025-00150-x

In this episode of PRISM Rounds, we review “Sotatercept for Pulmonary Arterial Hypertension within the First Year after Diagnosis,” published in the New England Journal of Medicine (published online September 30, 2025; issue October 23, 2025). We break down the phase 3 HYPERION trial in newly diagnosed PAH on background double/triple therapy, focusing on the primary composite endpoint of clinical worsening, the interpretation challenges created by early trial termination, and the safety signals clinicians should anticipate (notably epistaxis and telangiectasia). Educational use only — not medical advice.Article (PubMed): https://pubmed.ncbi.nlm.nih.gov/41025556/NEJM landing page: https://www.nejm.org/doi/full/10.1056/NEJMoa2508170Trial registration: https://clinicaltrials.gov/study/NCT04811092TagsPulmonary Arterial Hypertension, PAH, Pulmonary Hypertension, Critical Care, Pulmonary Medicine, Cardiology, Journal Club, NEJM, Clinical Trials, Randomized Trial, HYPERION, Sotatercept, Right Heart Failure, 6-Minute Walk, NT-proBNP, Risk Stratification, REVEAL Lite 2, COMPERA 2.0, Pharmacotherapy, Evidence-Based Medicine

In this episode of PRISM Rounds, we journal-club ANDROMEDA-SHOCK 2, a multinational randomized clinical trial testing whether a personalized hemodynamic resuscitation protocol targeting capillary refill time (CRT-PHR) improves outcomes in early septic shock compared with usual care. The primary outcome was a 28-day hierarchical composite of mortality, duration of vital support, and hospital length of stay, analyzed using a win ratio approach. We walk through the protocol logic, feasibility at the bedside, and what drove the primary result (including whether effects clustered in mortality vs vital-support duration), then close with practical takeaways for ICU/ED teams. Educational use only — not medical advice. Source (JAMA/DOI): https://doi.org/10.1001/jama.2025.20402. Trial registration: https://clinicaltrials.gov/study/NCT05057611.Tags: Septic shock; Sepsis; Critical care; ICU; Emergency medicine; Hemodynamic resuscitation; Capillary refill time; CRT; Vasopressors; Norepinephrine; Lactate; Fluid resuscitation; Bedside ultrasound; Echocardiography; Clinical trial; Randomized trial; JAMA; Journal club; Evidence-based medicine; PRISM Rounds

In this episode of PRISM Rounds (S1E10), we break down a JoVE video-protocol on preoxygenation for tracheal intubation in critically ill adults. We compare oxygen-mask strategies (non-rebreather and bag-valve-mask with a PEEP valve) with noninvasive ventilation (NIV/BPAP or ventilator NIV modes).We keep it practical and bedside-focused:Why it works: physiology, denitrogenation, and “safe apnea time”How to do it: step-by-step setup, key settings, leak control, and troubleshootingHow to choose: a simple approach for picking mask/BVM vs NIV when the patient is already hypoxemic or deterioratingEducational use only — not medical advice. PRISM Rounds reviews one paper per week to support critical appraisal and real-world translation for ICU/ED clinicians, trainees, nurses, respiratory therapists, and pharmacists. Disclosure: one of the authors is from the PRISM research group.Primary article (PubMed): https://pubmed.ncbi.nlm.nih.gov/41428629/DOI: https://doi.org/10.3791/68479JoVE video page: https://www.jove.com/video/68479PRISM Rounds; Critical Care; ICU; Emergency Medicine; Airway Management; Tracheal Intubation; Rapid Sequence Intubation; Preoxygenation; Noninvasive Ventilation; BiPAP; Bag-Valve-Mask; PEEP; Hypoxemia; Respiratory Therapy; Peri-Intubation Complications; Journal Club

Welcome to PRISM Rounds, where we break down one study at a time.This week we review the SONIA trial (a pragmatic randomized clinical trial across Kenyan public hospitals) evaluating whether adjunctive low-dose glucocorticoids added to usual care reduce 30-day mortality in adults hospitalized with community-acquired pneumonia (CAP)—and we pair it with the accompanying NEJM editorial on why context and implementation matter.We discuss: trial design choices in low-resource settings, interpreting absolute vs relative effects, safety/feasibility (especially glucose monitoring), and what ICU/ward teams (physicians, trainees, nurses, pharmacists, and respiratory therapists) can reasonably take back to practice.Educational purpose only. This episode is for education and discussion and is not medical advice.Links:NEJM Trial (SONIA): https://www.nejm.org/doi/abs/10.1056/NEJMoa2507100NEJM Editorial: https://www.nejm.org/doi/abs/10.1056/NEJMe2514533PubMed (Editorial): https://pubmed.ncbi.nlm.nih.gov/41159881/TagsPRISM Rounds, Pulmonary, Critical Care, Hospital Medicine, Infectious Diseases, Community-Acquired Pneumonia, CAP, Sepsis, Global Health, Low-Resource Settings, Pragmatic Trial, Randomized Trial, NEJM, Glucocorticoids, Steroids, Mortality, Evidence-Based Medicine, Journal Club, Clinical Epidemiology, Medical Education

In this episode of PRISM Rounds, we break down the NEJM randomized trial comparing ketamine vs etomidate for induction during emergency tracheal intubation in critically ill adults. We focus on what matters at the bedside: 28-day in-hospital mortality, peri-intubation cardiovascular collapse, and practical workflow implications for ICU/ED physicians, nurses, pharmacists, and respiratory therapists. We also discuss the accompanying editorial (if included in your reading list) and how to translate the trial’s uncertainty into safer airway practice.Read the trial (NEJM): https://www.nejm.org/doi/full/10.1056/NEJMoa2511420PubMed: https://pubmed.ncbi.nlm.nih.gov/41369227/ClinicalTrials.gov: https://clinicaltrials.gov/study/NCT05277896TagsPRISM Rounds, Critical Care, ICU, Emergency Medicine, Airway Management, Rapid Sequence Intubation, Ketamine, Etomidate, NEJM, Randomized Controlled Trial, Hemodynamics, Patient Safety

Confidence: High (study-specific details reflect only the uploaded JAMA RCT + editorial; no added claims.)Spotify Episode DescriptionA ventilator that adjusts support automatically sounds like the future—but does it improve outcomes patients actually feel? In this PRISM Rounds journal club, two hosts break down the ACTiVE randomized clinical trial comparing closed-loop INTELLiVENT-ASV vs protocolized conventional mechanical ventilation across 7 ICUs in the Netherlands and Switzerland. We walk through the study design (including deferred consent and a very strong “best-practice” control arm), the primary endpoint (ventilator-free days at day 28), key secondary outcomes (including mortality), and what the accompanying editorial argues about case mix, generalizability, and whether we’re ready for “autopilot ventilation.”For education only — not medical advice. Always follow your local protocols and clinical judgment.LinksACTiVE Trial (JAMA): https://doi.org/10.1001/jama.2025.24384Editorial (JAMA): https://doi.org/10.1001/jama.2025.24401ClinicalTrials.gov: https://clinicaltrials.gov/study/NCT04593810Tagscritical care, ICU, mechanical ventilation, ventilator management, closed-loop ventilation, INTELLiVENT-ASV, adaptive support ventilation, weaning, spontaneous breathing trial, ventilator-free days, randomized trial, JAMA, journal club, respiratory therapy, sedation, analgosedation, evidence-based medicine, clinical trials, pulmonary critical care, PRISM Rounds

In this PRISM Rounds journal club, we unpack EVERDAC (NEJM)—a multicenter noninferiority randomized trial (n=1,010) asking a deceptively simple ICU question: Do most adults with acute circulatory failure really need an early arterial line, or can we start with cuff-only blood pressure monitoring and “rescue” to an A-line only when safety criteria demand it?We break down the noninferiority design, the prespecified crossover triggers (including the very high vasopressor dose threshold and unit conventions), and what the results mean for real-world ICU workflows—nursing, RT, pharmacy, and trainees included. Bottom line: mortality was similar, while arterial line–site bleeding/hematoma was much lower with a cuff-first strategy—so it’s time to re-think our default threshold for invasive monitoring.Study (NEJM): https://www.nejm.org/doi/10.1056/NEJMoa2502136Editorial (NEJM): https://www.nejm.org/doi/10.1056/NEJMe2512006Norepinephrine-equivalent dosing reference (PubMed): https://pubmed.ncbi.nlm.nih.gov/33220576/Tags: Critical Care; ICU; Shock; Hemodynamics; Arterial Line; Blood Pressure Monitoring; Vasopressors; Norepinephrine; Epinephrine; Noninferiority Trial; Randomized Trial; NEJM; Journal Club; Evidence-Based Medicine; Nursing; Respiratory Therapy; Pharmacy; Fellows; Residents; PRISM Rounds

This week on PRISM Rounds, we break down two NEJM trials that reshape decision-making in EGFR-mutated advanced NSCLC—one testing front-line intensification (osimertinib plus platinum–pemetrexed with final overall survival results) and the other addressing post–EGFR-TKI resistance with the Trop-2 antibody–drug conjugate sacituzumab tirumotecan versus platinum–pemetrexed. We then connect the evidence with Roy Herbst’s NEJM editorial to discuss sequencing, tradeoffs (benefit vs toxicity), and practical “Monday morning” takeaways.ArticlesJänne PA, et al. Survival with Osimertinib plus Chemotherapy in EGFR-Mutated Advanced NSCLC. N Engl J Med. DOI: 10.1056/NEJMoa2510308. PMID: 41104938. https://pubmed.ncbi.nlm.nih.gov/41104938/Fang W, et al. Sacituzumab Tirumotecan in EGFR-TKI-Resistant, EGFR-Mutated Advanced NSCLC. N Engl J Med. DOI: 10.1056/NEJMoa2512071. PMID: 41124220. https://pubmed.ncbi.nlm.nih.gov/41124220/Herbst RS. Navigating the Evolving Landscape of EGFR-Mutated NSCLC. N Engl J Med (Editorial). DOI: 10.1056/NEJMe2514042. PMID: 41467655. https://pubmed.ncbi.nlm.nih.gov/41467655/PRISM Rounds; Journal Club; NEJM; Oncology; Lung Cancer; NSCLC; EGFR; Osimertinib; FLAURA2; Platinum Pemetrexed; Antibody Drug Conjugate; Trop-2; Sacituzumab Tirumotecan; Targeted Therapy; Resistance; Progression-Free Survival; Overall Survival; Clinical Trials; Evidence-Based Medicine; Hematology Oncology

Join us as we break down the LIBERATE-D trial, a provocative study questioning the default thrice-weekly dialysis schedule for AKI-D. We explore how a conservative, indications-only strategy (A-E-I-O-U—and sometimes “why”) was linked to higher kidney recovery at discharge in the unadjusted analysis, and why the accompanying editorial urges caution about robustness and real-world generalizability. Finally, we translate the findings into practical bedside decision-making for hemodynamically stable patients—and clarify who this does not apply to.Links (DOI + PubMed)Trial DOI: https://doi.org/10.1001/jama.2025.21530Trial PubMed: https://pubmed.ncbi.nlm.nih.gov/41201895/Editorial DOI: https://doi.org/10.1001/jama.2025.21618Editorial PubMed: https://pubmed.ncbi.nlm.nih.gov/41201902/

This week we review a systematic review and meta-analysis on individual-focused approaches to physician burnout—including mindfulness programs, professional coaching, and peer support. We break down what the authors found, how strong the evidence is, and what practical takeaways ICU clinicians and trainees can apply—while keeping the discussion relevant for the whole ICU team.Article (PubMed): https://pubmed.ncbi.nlm.nih.gov/41597325/

Episode titleTiming Matters in Sepsis: Community-Onset vs Hospital-Onset (Machine Learning Insights)Hospital-onset sepsis (HOS) is often treated as “the same disease” as community-onset sepsis (COS)—but timing changes the phenotype, the treatment timeline, and outcomes. In this episode of PRISM Rounds (S1 E2), we break down a retrospective cohort study (2019–2023) from a large academic medical center comparing COS vs HOS and using random forest modeling to identify which variables matter most for mortality, ICU use, and length of stay.Key findings: HOS was associated with higher in-hospital mortality (38.2% vs 28.5%), longer hospital and ICU stays, higher comorbidity burden, and delayed antibiotic initiation. Timing of onset (HOS vs COS) emerged as an important predictor of mortality and hospital length of stay in machine learning models—supporting “timing-aware” sepsis surveillance and escalation pathways.Article links:PubMed: https://pubmed.ncbi.nlm.nih.gov/41618258/DOI: https://doi.org/10.1186/s12911-026-03353-zVerma R, Elhance A, Marsh TJ, et al. Timing Matters: A Machine Learning–Driven Comparison of Community and Hospital-Onset Sepsis. BMC Medical Informatics and Decision Making (2026).DOI: https://doi.org/10.1186/s12911-026-03353-zHOS is common and clinically distinct, yet many sepsis pathways and predictive models implicitly assume one “sepsis phenotype.”This paper combines clinical comparisons plus ML-based variable-importance to argue for timing-aware detection and management.Retrospective cohort (adults ≥18) hospitalized with sepsis, Jan 2019–Aug 2023.Sepsis identified by linking two sources: institutional Adult Sepsis Events (ASE) surveillance definition + Vizient ICD-10 sepsis dataset.COS vs HOS based on onset timing: COS on/before hospital day 2; HOS on/after hospital day 3 (timing defined by dataset rules).In-hospital mortality, hospital length of stay, ICU days, vasopressor use, mechanical ventilation.Mortality: HOS 38.2% vs COS 28.5%Hospital LOS (median): HOS 24 vs COS 11 daysICU days (median): HOS 7 vs COS 2 daysAntibiotics: COS more likely to receive antibiotics within 24h of sepsis onset (81.7% vs 42.9%); HOS more likely to have been on antibiotics >24h before meeting sepsis criteria (49.3% vs 16.6%).ML insight: COS/HOS status was an important predictor for mortality and especially hospital LOS (ranked 3rd for LOS).HOS may show less dramatic “classic” physiology (e.g., less pronounced abnormalities / lower lactate) yet worse outcomes—so inpatient detection thresholds may need recalibration after hospital day 2.Consider timing-aware decision support: models and screening protocols should treat COS and HOS differently to reduce missed cases and delays.Single-center; dataset linkage may bias retained cases; some clinical confounders unavailable (e.g., infection source, antibiotic appropriateness, full SOFA).Tags: Sepsis, Hospital-Onset Sepsis, Community-Onset Sepsis, Critical Care, ICU, Inpatient Medicine, Clinical Informatics, Machine Learning in Medicine, Random Forest, Early Warning Systems, Antibiotic Timing, Quality Improvement, Patient Safety, Outcomes Research, Evidence-Based Medicine

In this PRISM Rounds episode, we break down the Phase 2b ASTER trial—a multicenter, randomized, placebo-controlled PETAL Network study testing high-dose IV vitamin C (ascorbate) in adults with suspected/confirmed infection plus shock and/or acute hypoxemic respiratory failure. We review trial design, why enrollment stopped early, the primary outcome (days alive and free of respiratory, renal, and circulatory organ support through day 28), and how to interpret secondary signals without over-reading an underpowered study.Original article (free full text): https://www.chestcc.org/article/S2949-7884(25)00041-3/fulltextPubMed: https://pubmed.ncbi.nlm.nih.gov/41574117/DOI: https://doi.org/10.1016/j.chstcc.2025.100168Keywords: sepsis, septic shock, ARDS, acute hypoxemic respiratory failure, vitamin C, ascorbate, PETAL Network, randomized trial, organ support–free days, ICU outcomes, vasopressors, mechanical ventilation, renal replacement therapy, biomarkers, sTNFR1, evidence-based medicine, critical care journal club