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Experimental objective: Hospital air can act as a reservoir of opportunistic and antimicrobial-resistant microorganisms, which may contribute to hospital-acquired infections. However, the composition of airborne bacterial communities and the factors shaping them within hospital environments remain insufficiently characterized. This study investigated airborne bacterial microbiomes across hospital areas and sampling approaches and compared hospitals located in a metropolis versus a smaller city in Thailand. Methods: Air samples were collected from various hospital zones using active air-pump sampling and passive air-grille or high-efficiency particulate air-filter swab approaches at King Chulalongkorn Memorial Hospital in Bangkok and Naresuan University Hospital in Phitsanulok. Microbiota were analyzed using 16S ribosomal RNA gene sequencing, followed by bioinformatic analyses. Results: Bacterial community compositions and alpha-diversity varied significantly along sampling method, hospital area, and geographic location. Passive air-grille swabs captured higher microbial biomass and diversity, consistent with accumulated microbiome deposition over time. Areas with open and semiopen ventilation (e.g., restaurant and outpatient departments) exhibited higher bacterial diversity than filtered areas (e.g., operating rooms). The metropolitan hospital showed higher abundances of Cutibacterium, Acinetobacter, Curtobacterium, and members of Comamonadaceae, whereas the hospital in the smaller city displayed greater overall diversity. High-efficiency particulate air-filter samples showed reduced diversity but enriched in spore-forming taxa. Predicted functional profiles also differed between sampling approaches and hospital locations, including pathways that might be related with human diseases. Conclusion: Hospital air microbiomes were heterogeneous and influenced by environmental conditions and sampling strategy. These findings provide insights for factor correlations and may inform improved air-quality management strategies.

Air ambulance helicopters are a scarce and costly resource in New Zealand. Despite widespread use of the Advanced Medical Priority Dispatch System (AMPDS), no validated framework exists to determine which determinant codes are associated with helicopter tasking. This study aimed to examine whether specific AMPDS codes are associated with an increased likelihood of helicopter arrival at the scene in New Zealand. A retrospective observational study using all AMPDS-coded incidents recorded by the Emergency Ambulance Communications Centre from January 1, 2023, to December 31, 2024, was conducted. Exclusions included interhospital transfers, search and rescue events, direct air desk notifications, and nonpatient incidents. For each code, incident volume and helicopter arrivals at the scene were measured. Codes were classified as high volume (≥ 50 helicopter arrivals) or high yield (arrival ratio, ≤ 1:10). Among 1,161,169 AMPDS-coded incidents, 34,869 (3.0%) were reviewed by an air desk clinician and 7,688 (0.66%) resulted in a helicopter arrival. Thirty-seven codes generated ≥ 50 arrivals, accounting for 59.3% of helicopter responses but representing 440,781 incidents overall. An additional 102 codes had arrival ratios of ≤ 1:10, although most had low absolute volumes. Only 3 traffic-related codes (29D06, 29D02N, 29D02K) met both criteria, accounting for 823 incidents (0.07%) and 192 arrivals (2.5%). In contrast, 791 codes never produced a helicopter arrival, including 133 with > 100 incidents. AMPDS codes alone have limited discriminative capacity for helicopter tasking in New Zealand. A small subset of traffic-related codes demonstrated predictive value and may support more targeted referral pathways. Integrating selected high-yield codes with geospatial thresholds and availability of local critical care resources may streamline clinician review, reduce overtriage, and optimize deployment of scarce aeromedical assets.

Sufficient ventilation during cardiopulmonary resuscitation (CPR) is increasingly recognised as a critical determinant of patient outcomes. The effectiveness of ventilation training, however, likely depends on the anatomical and mechanical fidelity of CPR manikins. While chest compression mechanics of manikins have been studied extensively, ventilation-related anatomy, airflow pathways, and respiratory mechanics have not been evaluated systematically. This study analysed 10 adult CPR manikins from three manufacturers. Airway and lung replicas were documented using photography, video laryngoscopy, and bronchoscopy. Expiratory tidal volume and air leakage were measured during volume-controlled mechanical ventilation via facemask, supraglottic airway devices and endotracheal tube. Mechanics of the respiratory system were described by the peak and plateau airway pressures and respiratory compliance. Manikins differed substantially in airway design and expiratory airflow design. Three distinct expiratory mechanisms were identified, of which only one permitted exhalation through the airway and thus quantification of expiratory tidal volumes. Air leakage varied across manikins and airway devices, including during ventilation via advanced airway devices. Respiratory mechanics showed marked variability, with peak inspiratory pressures ranging from 21 ± 1 to 56 ± 1 mbar and compliances from 7 ± 0 to 51 ± 4 mL/mbar. Several models exhibited substantial leakage via the gastric channel of the i-gel® supraglottic airway. CPR manikins exhibited substantial variability in ventilation-related anatomy, airflow pathways, leakage and respiratory mechanics. None of the assessed manikins consistently approximated human ventilation characteristics across airway devices, underscoring the need for local evaluation of manikin-airway device combinations to optimise ventilation fidelity in CPR training.

Seizures exist on a clinical spectrum, and providers must adopt a nuanced yet assertive treatment approach, as the transition from benign to life-threatening can occur rapidly. Critical care transport teams are moving these patients more frequently as neuro-specialty care continues to concentrate at quaternary centers and rural health facilities face resource challenges. Patients with seizures can have a variety of physical and physiologic symptoms, and transport crews must be aware of the more subtle symptoms as to intervene appropriately. The priority in seizure management is stopping the seizure, starting with benzodiazepine administration and then escalating to second-line anti-epileptics if benzodiazepines are ineffective. The longer seizure activity continues, the more difficult it is to stop, and the risk of permanent neuronal damage increases. Additional priorities include patient safety/positioning and airway management. Critical care transport crews should be prepared to perform advanced airway management in patients who present in status epilepticus and should get the patient to a facility with magnetic resonance imaging, electroencephalography, and neurocritical care resources. The unique environment of air transport makes management and assessment of these patients especially challenging, and we provide updated guidance to consider.

This study reviewed pediatric cases managed by the Aeromedical Evacuation Squadron (AMES) of the Japan Air Self-Defense Force and analyzed patient characteristics. Pediatric transportation cases (n = 34) between 2006 and 2023 were reviewed. Data on patient age, main disease, transportation purpose and distance, and use of mechanical ventilators or extracorporeal membrane oxygenation (ECMO) were obtained by referring to the records. The average (standard deviation) patient age was 5.7 (5.8) years (range: 0-16 years), and 17 patients (50%) were younger than 1 year of age. Furthermore, 10 (58.8%) of these 17 children were younger than 7 months of age and 1 child was under 1 month of age. The most common diseases in the overall patient population were cardiovascular diseases (CVDs, n = 18) and respiratory diseases (RDs, n = 14). The purposes of transportation in cases of 17 patients with CVDs and 3 patients with RDs were the implantation of a ventricular assist device and lung transplantation, respectively. The average transportation distance was 453.7 (218.6) (range: 176.9-962.8) miles or 730.2 (351.8) (range: 284.7-1,549.5) km, and in 8 cases, the transportation distance was > 600 miles. Of the patients, 29 (85.3%) were fitted with a ventilator, of whom 8 received ECMO (6 with CVDs and 2 with RDs). In all cases, physicians from the transporting hospitals were on board. There were no cases of cardiac arrest during the transportation. AMES plays an important role, especially in the long-distance transportation of critically ill children.

Evidence supporting the use of sugammadex as a rescue strategy in prehospital "cannot intubate, cannot oxygenate" (CICO) situations remains sparse and indirect. Although contemporary airway guidelines prioritize front-of-neck access (FONA) as the definitive intervention, discussion of pharmacological reversal persists in prehospital practice, predominantly within gray literature, local protocols, and educational materials. This persistence reflects an ongoing hypothesis in prehospital airway management that warrants critical appraisal. We performed a narrative synthesis of perioperative, emergency department, and prehospital literature, including case reports, expert consensus documents, and contemporary airway guidelines, to assess whether pharmacological reversal can plausibly modify outcomes in airway failure. Across these sources, no outcome-level data support sugammadex as an effective rescue maneuver in established CICO. Perioperative CICO case series further indicate that reversal of neuromuscular blockade does not reliably resolve airway obstruction or obviate the need for surgical airway access. In the prehospital environment, rapid desaturation and limited monitoring further reduce the plausibility of pharmacological rescue once CICO has developed. For helicopter and ground emergency medical service systems, current evidence supports emphasis on early recognition of CICO, structured airway algorithms, and timely performance of FONA, rather than reliance on pharmacological reversal.

Management of the pediatric airway is a challenging procedure in prehospital emergency medicine. This retrospective study evaluates prehospital airway management in 920 pediatric patients in a German helicopter emergency medical service (HEMS) system from 2012 to 2021. Prehospital pediatric intubation was a rare event (0.2% of all missions). Good visualization of the glottis (Cormack-Lehane I or II) was possible in 96.3% of the intubations. The first-pass intubation success was 86.6%; all children could finally be intubated successfully. The use of muscle relaxants significantly improved first-pass success in prehospital emergency anesthesia (90.1% vs. 83.1%; P = .002). We recognized a low rate of the use of aids such as stylet, bougie, or video laryngoscopy. The use of video laryngoscopy increased over the years, but did not translate into a higher first-attempt success rate. When taking over children with an already managed airway, HEMS teams found tube malplacement in 8.4% of the cases in primary missions. In the analyzed data, pediatric airway management was on a comparable level with adult airway management. Nevertheless, room for improvement and a need for further studies were identified.

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Although recent studies have suggested an association between air pollution and Kawasaki disease (KD), evidence regarding prenatal exposure and subsequent KD risk in children remains limited. This study aimed to evaluate the association between prenatal air pollution exposure and KD incidence in children. We used the Big CHildren's ENvironmental health Study covering mother-child pairs based on the National Health Information Database. We defined KD onset using the tenth revision of the International Classification of Diseases (M30.3) and immunoglobulin prescriptions. We used a multivariate Cox proportional hazards model to evaluate the association between prenatal air pollution exposure (fine particulate matter [PM2.5], particulate matter [PM10], sulfur dioxide [SO2], nitrogen dioxide [NO2], and ozone [O3]) and KD in children. The model was adjusted for maternal age, child sex, income level, maternal occupation, birth season, birth year, and region. Hazard ratios (HRs) and 95% confidence intervals (CIs) were evaluated per interquartile range increase in exposure to PM2.5, PM10, SO2, NO2, and O3. We analyzed 1624,230 mother-child pairs and identified KD onset in 13,126 children (0.8%). Prenatal exposure to PM10, SO2, and NO2 during the second and third trimesters, as well as across the entire pregnancy, was associated with an increased risk of KD, with the strongest associations observed during the third trimester (PM2.5: 1.046, 95% CI: 1.007-1.087; PM10: 1.104, 95% CI: 1.061-1.149; SO2: 1.052, 95% CI:1.117-1.153; NO2: 1.117, 95% CI: 1.082-1.153). We found that exposure to air pollution during pregnancy was positively associated with KD risk in children.

Advanced prehospital care delivered by air ambulance services in the United Kingdom aims to reduce preventable trauma deaths by bringing hospital-level interventions directly to patients. Despite these efforts, a significant proportion of patients still die in the immediate phase, and current learning frameworks focus predominantly on identifying errors rather than examining all fatalities for system-wide improvements. This paper explores the potential of integrating multidisciplinary approaches, particularly clinicopathological correlation (CPC) meetings, into high-performing air ambulance services to enhance learning from every death. By including autopsy pathologists alongside clinicians, CPC meetings provide a robust platform to correlate prehospital findings with definitive postmortem results, improving diagnostic accuracy, clinical reasoning, and professional development. They also foster interprofessional collaboration, support clinician well-being by providing closure, and strengthen patient safety through contextualized learning beyond fault finding. Barriers include limited data sharing, coronial processes, and inconsistent governance across independent air ambulance services. However, the successful implementation of CPC multidisciplinary team meetings demonstrates significant educational and systemic benefits, driving innovation, and quality assurance. We propose that all high-performing air ambulance services should adopt structured, regular CPC meetings with pathologist involvement, thereby embedding learning from every fatality as a cornerstone of governance, resilience, and future improvements in care.

In Norway, helicopter emergency medical services (HEMS) are dispatched for suspected cerebral stroke if intravenous thrombolysis may be administered within 4.5 hours of symptom onset, and it reduces time of transport by ≥30 minutes compared with basic emergency medical services (EMS). However, cerebral stroke presents with heterogeneous symptoms; therefore, identification by emergency dispatchers can be difficult. The primary outcome was the positive predictive value for stroke among patients with suspected stroke for whom HEMS was dispatched. Secondary outcomes included rates of prehospital interventions, quality indicator fulfillment, and rates of selected in-hospital interventions within time limits. We conducted a retrospective cohort study using aggregated prehospital and in-hospital data from an electronic patient journal. It included 161 primary missions from the HEMS base in Trondheim, where HEMS was deployed on the index criterion of cerebral stroke set by the Emergency Medical Coordination Center between 2022 and 2024. Of all primary missions, 14% (n = 162) were because of suspected stroke. A total of 75 patients (47%) were diagnosed with having stroke, whereas 12 (7%) were diagnosed with having transient ischemic attack. In 7% of cases, an advanced intervention that requires a physician was performed. A total of 40 patients (25%) received intravenous thrombolysis and/or endovascular thrombectomy. Stroke was confirmed in 47% of HEMS dispatches for suspected stroke. HEMS likely reduced transport time by ≥30 minutes for most patients, whereas prehospital advanced interventions were rarely performed. Further studies on index use and comparative studies of HEMS and EMS dispatches could help strengthen patient selection and optimize resource utilization.

Numerous in vivo studies have demonstrated beta-2-adrenoceptor (β2AR) -agonism as permissive in the development of allergic lung inflammation, and have implicated the arrestin-dependent signaling arm of the β2AR in mediating this effect. However, the specific cell type(s) mediating β2AR regulation of allergic lung inflammation remain unestablished. To explore the potential contribution of airway epithelia in this phenomenon, we compared the ability of ractopamine (RP), recently identified as a Gs-biased beta-agonist, to that of the unbiased/balanced beta-agonist albuterol (ALB), on IL-13-stimulated mucin and cytokine production in human airway epithelia cultures in air-liquid interface (HAE). ALB, which activates both the β2AR-arrestin and -Gs signaling pathways significantly augmented IL-13-induced mucin production in HAE. RP, which preferentially signals via Gs/PKA, did not. Although IL-13 stimulated production of numerous cytokines, including IL-1α, IL-1RA, MDC, TGF-α, and GROα, ALB-mediated augmentation of these cytokines was highly variable and not statistically significant. Similarly, RP did not augment the induction of cytokines stimulated by IL-13. Moreover, in contrast to previous studies that reported a requirement of concomitant β2AR agonism for IL-13 to stimulate cytokine production, such a requirement was observed only in minority of the (12) cultures examined. These data implicate arrestin-dependent β2AR signaling augmenting airway epithelial mucin production as a contributor to the previously-demonstrated pro-inflammatory effects of β2AR agonism in vivo. Moreover, they suggest that beta-agonist effects on the cytokine profile in the allergen-inflamed lung may be influenced by specific asthmatic endotypes and involve cooperativity among multiple cell types.

Specialized transport systems are used for newborns who require medical care. These complex systems are subjected to vehicle-specific vibration and sound during transport. Prolonged exposure to high levels of sound and vibration can be harmful to humans. This study aimed to quantify the sound and vibration levels experienced within a fixed-wing aircraft (Pilatus PC-12) during neonatal transport. A dedicated flight test was performed in a PC-12. Acceleration and sound data were captured in the cabin at the approximate position of the neonatal patient transport system, were it loaded. Resultant motions of the transport system and patient were estimated using experimentally derived transfer functions. Vertical vibration was most significant, and the average motion of the cabin floor and pilot seat was comparable in the 1 to 80 Hz frequency range. The greatest motion occurred during segments of rough turbulence, when patient levels were estimated to reach the ISO 2631 "very uncomfortable" threshold. Sound levels exceeded the 60 dBA limit recommended by the CSA Group and the European Committee for Standardization across all phases of flight, peaking at 89.3 dBA during a short-field landing. Measured cabin sound exceeded recommended limits, and vertical accelerations reached levels considered uncomfortable under ISO 2631, highlighting the potential risk to this physiologically vulnerable population, compelling further research into vibration mitigation strategies. Aircraft acceleration data have enabled more extensive laboratory testing of the transport system. Establishing neonatal-specific whole-body vibration guidelines remains essential to fully understand and address the clinical implications of these exposures.

Emergency resuscitative thoracotomy (ERT) is a crucial intervention employed in prehospital settings to address life-threatening conditions, such as cardiac tamponade, hemorrhage, and air embolism. Despite its critical nature, the efficacy of prehospital ERT in enhancing survival rates compared with in-hospital procedures remains controversial. This retrospective analysis was conducted using data from the Japanese Society for Aeromedical Services Registry between January 2020 and December 2022. After excluding nontraumatic cases, non-ERT cases, and records with missing data, 143 prehospital ERT cases were identified. The cohort was categorized into survivors (n = 3) and nonsurvivors (n = 140) based on patient outcomes. Comparative analyses were conducted on variables such as age, injury severity, time intervals, and transportation modalities using the Wilcoxon rank-sum test and Pearson's chi-square test, with the statistical significance set at P < .05. The overall survival rate after prehospital ERT was 2.1% (3 of 143). Only a few variables, such as hospital length of stay, showed statistically significant differences between the groups; most patient characteristics and prehospital time intervals did not. The patients who experienced cardiac arrest at the time of contact with the emergency medical service (EMS) contact had a survival rate of 0%, whereas those who arrived at the hospital with vital signs had the highest survival rate (11.1%). The presence of vital signs upon hospital arrival and the rapid initiation of intervention were identified as key factors influencing survival. These findings suggest that prehospital ERT provides limited survival benefits, with a 0% survival rate in cases of cardiac arrest at EMS contact. Therefore, further research is essential to refine the patient selection criteria and optimize ERT deployment to improve prehospital patient outcomes.

Decreased time to cardiac catheterization improves survival and limits cardiac tissue damage in ST Elevation myocardial infarction (STEMI). Emergency medical services delays account for half of treatment delays in STEMI. Helicopter air ambulance (HAA) can reduce the time to percutaneous intervention (PCI), and therefore may reduce mortality. The impact of physical distance between the PCI hospital helipad and the PCI laboratory on the door-to-door-to-balloon time (DDBT) for cardiac intervention in STEMI patients transported through HAA from remote community hospitals to PCI facilities was assessed. This was a retrospective chart review of interfacility STEMI patients where HAA was activated to reduce DDBT from January 1, 2020, to January 1, 2023. The HAA agency under review transports STEMI patients to 2 PCI centers. There is a significant difference in the distance between the helipad and the PCI laboratory at the 2 hospitals. Descriptive statistics were used to compare DDBT as well as the time from HAA arrival at the PCI hospital helipad to the cardiac catheterization laboratory. Data were available for 91 STEMI cases. The median time for DDBT was 89.9 minutes with a median time of 10.5 minutes from helipad arrival to catheterization laboratory (Table 1). Of the 91 cases, 69 (76%) were from hospital A and 22 (24%) were from hospital B. There was no detectable difference in the distribution of DDBT times between hospitals (P = .47). Helipad arrival times to cardiac catheterization laboratory were significantly longer for hospital A than hospital B (P < .001). The median time for hospital A was 11.0 minutes (interquartile range, 9.2-14.0) compared with hospital B, which had a median of 5.4 minutes (5.0-7.3). The physical distance a PCI laboratory is located from the helipad can be a significant addition to ischemic time for STEMI patients.

The Commission on Accreditation of Medical Transport Systems has used patients being admitted for less than 24 hours at the receiving facility as a surrogate marker for improper helicopter emergency medical services (HEMS) utilization, therefore triggering a review to determine proper HEMS utilization. Recent guidelines modified this to use discharge directly from the emergency department (ED) after transfer as a marker for inappropriate HEMS utilization. This study aimed to evaluate which metric is associated with better adherence to Wisconsin (WI) HEMS utilization criteria in adult trauma patients transported to the ED. This was a retrospective chart review of 1,520 transports by a midwestern HEMS service to a level 1 adult trauma center between January 1, 2013, and December 31, 2022. Charts with a disposition of discharge home, admission of less than 24 hours, or death in the ED were evaluated for adherence to WI HEMS utilization guideline criteria. A total of 287 patients met the inclusion criteria. Most patients were transported directly from the scene; 53% of transports met utilization criteria. Interfacility transports were more likely to meet utilization criteria than scene transports. Patients admitted for less than 24 hours were more likely to meet utilization criteria than patients discharged directly from the ED. This significance occurred for both scene and interfacility transports. Patients transported after a motor vehicle crash were less likely to have met utilization criteria. Patients admitted for less than 24 hours were more likely to have met WI HEMS utilization guidelines than patients discharged from the ED. The relatively low adherence rate to the WI HEMS utilization guidelines suggests that stricter guidelines may be necessary to reduce overtriaging in HEMS transport.

Helicopter Emergency Medical Services (HEMS) play a crucial role in providing timely emergency care, leading to improved patient outcomes. This study aimed to analyze HEMS time intervals in Iran through a systematic review and meta-analysis. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in various databases up to August 2025. Ten studies were included for quality assessment and meta-analysis using a random-effects model. Data analysis was performed using STATA 14 software. The meta-analysis revealed that the mean response time, on-scene time, and transport time for HEMS in Iran were 19.55 minutes, 10.46 minutes, and 14.63 minutes, respectively. The overall mean HEMS time was reported as 50.59 minutes. Meta-regression analysis revealed a decreasing trend in response and on-scene times over the years, whereas transport time and overall HEMS time exhibited an increasing trend. HEMS in Iran demonstrate acceptable operational times, but improvements in triage, fleet enhancement, and the establishment of a national HEMS registry are needed to enhance efficiency and evidence-based decision-making.

A 3-year-old male passenger developed acute respiratory distress approximately 30 minutes after takeoff during an international flight from the United States to Addis Ababa. Despite multiple rounds of nebulized albuterol and escalating oxygen therapy, his respiratory status progressively deteriorated. A multidisciplinary team of onboard physicians administered epinephrine and hydrocortisone from the emergency medical kit while coordinating with ground medical control. The aircraft was subsequently diverted to Athens, Greece, where the child was handed over to emergency services and later stabilized. This case highlights the challenges of managing pediatric respiratory distress in-flight and the critical importance of prompt coordination, adequate medical supplies, and crew preparedness.

Peri-implantitis remains a challenging biofilm-associated condition, and the comparative effectiveness of adjunctive nonsurgical decontamination approaches is still unclear. This randomized, assessor-blinded, multi-arm clinical trial evaluated the clinical performance of different local submarginal decontamination protocols used alone or in combination with mechanical instrumentation in the management of early peri-implantitis lesions. Eighty implants from 26 patients were allocated to five treatment groups: mechanical instrumentation alone, mechanical instrumentation combined with chlorhexidine irrigation, ozone application, or glycine powder air abrasion, and glycine powder air abrasion as monotherapy. Clinical parameters, including probing pocket depth, bleeding on probing, and modified plaque index, were assessed at baseline, 3&#xa0;months, and 6&#xa0;months, and analyzed using linear mixed-effects models accounting for clustering at the patient level. All treatment modalities resulted in significant clinical improvements over 6&#xa0;months. The greatest numerical reductions in probing depth, bleeding on probing, and plaque index were observed when mechanical instrumentation was combined with glycine powder air abrasion; however, no statistically significant differences were detected among treatment groups. These findings suggest that nonsurgical mechanical instrumentation, with or without adjunctive approaches, can provide meaningful short-term improvements in early peri-implantitis, while adjunctive glycine powder air abrasion may offer additional clinical benefits without demonstrating clear overall superiority.