Search Results (152)

Background: The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for control of noncompressible torso hemorrhage remains controversial. We aimed to utilize a novel and transparent/interpretable artificial intelligence (AI) method called Optimal Policy Trees (OPTs) to improve the appropriate use and decrease the misuse of REBOA in hemodynamically unstable blunt trauma patients. Methods: We trained and then validated OPTs that “prescribe” REBOA in a 50:50 split on all hemorrhagic shock blunt trauma patients in the 2010–2019 ACS-TQIP database based on rates of survival. Hemorrhagic shock was defined as a systolic blood pressure ≤90 on arrival or a transfusion requirement of ≥4 units of blood in the first 4 h of presentation. The expected 24 h mortality rate following OPT prescription was compared to the observed 24 h mortality rate in patients who were or were not treated with REBOA. Results: Out of 4.5 million patients, 100,615 were included, and 803 underwent REBOA. REBOA patients had a higher rate of pelvic fracture, femur fracture, hemothorax, pneumothorax, and thoracic aorta injury (p < 0.001). The 24 h mortality rate for the REBOA vs. non-REBOA group was 47% vs. 21%, respectively (p < 0.001). OPTs resulted in an 18% reduction in 24 h mortality for REBOA and a 0.8% reduction in non-REBOA patients. We specifically divert the misuse of REBOA by recommending against REBOA in cases where it leads to worse outcomes. Conclusions: This proof-of-concept study shows that interpretable AI models can improve mortality in unstable blunt trauma patients by optimizing the use and decreasing the misuse of REBOA. To date, these models have been used to predict outcomes, but their groundbreaking use will be in prescribing interventions and changing outcomes. Full article

Acute kidney injury (AKI) is a frequent and severe complication in trauma patients, affecting up to 28% of intensive care unit (ICU) admissions and contributing significantly to morbidity, mortality, and long-term renal impairment. Trauma-related AKI (TRAKI) arises from diverse mechanisms, including hemorrhagic shock, ischemia–reperfusion injury, systemic inflammation, rhabdomyolysis, nephrotoxicity, and complex organ crosstalk involving the brain, lungs, and abdomen. Pathophysiologically, TRAKI involves early disruption of the glomerular filtration barrier, tubular epithelial injury, and renal microvascular dysfunction. Inflammatory cascades, oxidative stress, immune thrombosis, and maladaptive repair mechanisms mediate these injuries. Trauma-related rhabdomyolysis and exposure to contrast agents or nephrotoxic drugs further exacerbate renal stress, particularly in patients with pre-existing comorbidities. Traditional markers such as serum creatinine (sCr) are late indicators of kidney damage and lack specificity. Emerging structural and stress response biomarkers—such as neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule 1 (KIM-1), liver-type fatty acid-binding protein (L-FABP), interleukin-18 (IL-18), C-C motif chemokine ligand 14 (CCL14), Dickkopf-3 (DKK3), and the U.S. Food and Drug Administration (FDA)-approved tissue inhibitor of metalloproteinases-2 × insulin-like growth factor-binding protein 7 (TIMP-2 × IGFBP-7)—allow earlier detection of subclinical AKI and better predict progression and the need for renal replacement therapy. Together, functional indices like urinary sodium and fractional potassium excretion reflect early microcirculatory stress and add clinical value. In parallel, risk stratification tools, including the Renal Angina Index (RAI), the McMahon score, and the Haines model, enable the early identification of high-risk patients and help tailor nephroprotective strategies. Together, these biomarkers and risk models shift from passive AKI recognition to proactive, personalized management. A new paradigm that integrates biomarker-guided diagnostics and dynamic clinical scoring into trauma care promises to reduce AKI burden and improve renal outcomes in this critically ill population. Full article

Background and Objectives: The severe systemic response to urinary tract infections known as urosepsis is associated with significant morbidity and mortality rates. The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) are simple blood tests that could be useful in predicting the outcome of sepsis. Materials and Methods: A prospective observational study was conducted at a tertiary care hospital, where our team studied 223 patients with urosepsis. The patients underwent Sepsis-3 criteria-based urosepsis and septic shock stratification followed by survivor and non-survivor classification. Clinical scores (Sequential Organ Failure Assessment-SOFA, National Early Warning Score-NEWS), laboratory markers (NLR, PLR, PCT-procalcitonin), and patient outcomes were then analysed. Results: An admission NLR ≥ 13 was a strong predictor of septic shock (adjusted Odds Ratio (OR) 2.10, 95% Confidence Interval (CI) 1.25–3.54) and in-hospital mortality (adjusted OR 2.45, 95% CI 1.40–4.28). While the prognostic value of the PLR remained moderate, the NLR demonstrated superior predictive power. As easily measurable biomarkers, the NLR and PLR provide valuable information to help clinicians identify at-risk patients during the early stages of urosepsis. Conclusions: The NLR is an independent predictor with high predictive value for both septic shock and mortality, performing as well as established clinical scores. The combination of these parameters with clinical assessments could lead to better early decisions and improved outcomes for patients with urosepsis. Full article

Background/Objectives: Alcoholic acute pancreatitis (AP) is a major cause of hospital admissions in Eastern Europe. However, data from secondary-care centers on the impact of the COVID-19 pandemic are limited. Methods: We retrospectively analyzed all adult AP admissions to a secondary-care hospital between March 2018 and March 2025. Cases were classified by etiology and grouped into pre-pandemic, pandemic, and post-pandemic periods. We compared demographic, clinical, severity, recurrence, outcome, resource use, and cost data between alcoholic and non-alcoholic AP. Results: Among 1096 patients (63.5% male; median age 55 years), alcohol was the leading etiology (40.1%), peaking during the pandemic. Alcoholic AP was more common in men, rural residents, and smokers, and less common in patients with obesity or diabetes. Recurrence was higher in alcoholic AP (21.8% vs. 15.9%; p = 0.015). Severe disease was more frequent in alcoholic than biliary AP (38.4% vs. 22.3%; p = 0.001). Overall mortality was 8.4%, declining after the pandemic (10.4% pre-pandemic vs. 6.5% post-pandemic). In multivariable Cox models, pleural effusion (HR 7.88; 95% CI 3.27–18.99) and age (HR 1.02; 95% CI 1.00–1.03) independently predicted mortality in the overall cohort. In alcoholic AP, pleural effusion was the only independent predictor (HR 13.19; 95% CI 2.48–70.08). In non-alcoholic AP, pleural effusion (HR 6.83; 95% CI 2.40–19.44) and signs of shock (HR 3.49; 95% CI 1.14–10.71) were independent predictors. Conclusions: Alcoholic AP was the most frequent etiology, with higher recurrence and severity than biliary AP, but alcoholic etiology itself did not predict mortality. Mortality drivers differed by etiology: pleural effusion in alcoholic AP, and pleural effusion plus signs of shock in non-alcoholic AP. ICU transfer was associated with death in descriptive analyses but was treated as a downstream mediator and not included in adjusted models. Full article

Introduction: Sepsis, and particularly septic shock, is a life-threatening condition associated with high mortality rates in the emergency department. Timely interventions can significantly reduce these unacceptably high mortality rates. While some studies have demonstrated reduced mortality with early norepinephrine initiation, there is limited research on this intervention specifically within the emergency department setting. The objective of this study was to determine the association between the time to norepinephrine initiation in the emergency department and in-hospital mortality in adult patients diagnosed with septic shock. Methods: This retrospective cohort study included adult patients diagnosed with septic shock in the emergency department. Demographics, paraclinical variables, and the time to norepinephrine initiation were evaluated. In-hospital mortality was defined as the primary outcome. Finally, a multivariate analysis was performed to develop a nomogram for predicting septic shock mortality from the emergency department. Results: A total of 176 patients were included. A significant difference was documented between the time to norepinephrine initiation (in minutes) and survival rates: median (IQR) 12 (2–29) min for survivors versus 104 (68–181) min for non-survivors (p < 0.001). Similarly, when the time to initiation was divided into three groups (<60, 61–179, >179 min), a differential association with mortality was observed: OR 0.16 (95% CI; 0.08–0.32), OR 5.59 (95% CI; 2.67–11.6), and OR 353 (95% CI; 20.8–5978.9), respectively. Additionally, variables associated with mortality included mean arterial pressure, arterial lactate, and creatinine levels. Conclusions: Early initiation of norepinephrine in the emergency department may lower in-hospital mortality from septic shock without raising arrhythmia rates. Further high-quality studies are needed to confirm this and identify the patients who would benefit most. Full article

Aim: Both the arterial and venous systems independently predict mortality in septic shock, yet no bedside tools are able to integrate their assessment. Risk stratification becomes challenging when arterial parameters suggest favourable outcomes while venous parameters indicate poor prognosis, or vice versa. To address this gap, we developed the VTI-VeXUS index and conducted this proof-of-concept study to test its association with mortality. Methods: We conducted a prospective cohort study in two ICUs, enrolling adult patients with septic shock. We calculated the VTI-VeXUS index (VTI/[VeXUS+1]) from ultrasound measurements obtained within 24 h of ICU admission and stratified patients as having a high or low VTI-VeXUS index based on a cutoff of 11. We evaluated the primary outcome of mortality at 30 days using survival analysis. Results: We enrolled 62 patients. Patients with a low VTI-VeXUS index had higher rates of left ventricular dysfunction (32.3% vs. 3.2%, p = 0.006), right ventricular dysfunction (35.5% vs. 0.0%, p < 0.001), lower stroke volume (54.0 mL vs. 62.0 mL, p = 0.005), and increased 30-day mortality (adjusted HR: 3.86, 95% CI 1.23 to 12.14). Conclusions: In this exploratory proof-of-concept study, a low VTI-VeXUS index was associated with ventricular dysfunction and increased mortality. While limited by small sample size and univariate analysis, these findings suggest this novel integrated metric warrants validation in larger prospective studies. Full article

Septic shock is a life-threatening complication of sepsis, particularly in patients with hematologic diseases who are highly susceptible to it due to profound immune dysregulation. Recent advances in artificial intelligence offer promising tools for improving septic shock diagnosis, prognosis, and treatment in this vulnerable population. In detail, these innovative models analyzing electronic health records, immune function, and real-time physiological data have demonstrated superior performance compared to traditional scoring systems such as Sequential Organ Failure Assessment. In patients with hematologic malignancies, machine learning approaches have shown strong accuracy in predicting the sepsis risk using biomarkers like lactate and red cell distribution width, the latter emerging as a powerful, cost-effective predictor of mortality. Deep reinforcement learning has enabled the dynamic modelling of immune responses, facilitating the design of personalized treatment regimens helpful in reducing simulated mortality. Additionally, algorithms driven by artificial intelligence can optimize fluid and vasopressor management, corticosteroid use, and infection risk. However, challenges related to data quality, transparency, and ethical concerns must be addressed to ensure their safe integration into clinical practice. Clinically, AI could enable earlier detection of septic shock, better patient triage, and tailored therapies, potentially lowering mortality and the number of ICU admissions. However, risks like misclassification and bias demand rigorous validation and oversight. A multidisciplinary approach is crucial to ensure that AI tools are implemented responsibly, with patient-centered outcomes and safety as primary goals. Overall, artificial intelligence holds transformative potential in managing septic shock among hematologic patients by enabling timely, individualized interventions, reducing overtreatment, and improving survival in this high-risk group of patients. Full article

Background: Acute kidney injury (AKI) frequently occurs following major liver resection, adversely affecting both short- and long-term outcomes. This study aimed to determine the incidence of AKI post-hepatectomy and identify relevant pre- and intraoperative risk factors. Our secondary objectives were to develop a predictive score for postoperative AKI and assess the associations between AKI, chronic kidney disease (CKD), and 1-year mortality. Methods: This was a retrospective study in a cancer referral center in Marseille, France, from 2018 to 2022. Results: Among 169 patients, 55 (32.5%) experienced AKI. Multivariate analysis revealed several independent risk factors for postoperative AKI, including age, body mass index, the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, time to liver resection, intraoperative shock, and bile duct reconstruction. Neoadjuvant chemotherapy was protective. The AKIMEBO score was developed, with a threshold of ≥15.6, demonstrating a sensitivity of 89.5%, specificity of 76.4%, positive predictive value of 61.8%, and negative predictive value of 94.4%. AKI was associated with increased postoperative morbidity and one-year mortality following major hepatectomy. Conclusion: AKI is a common complication post-hepatectomy. Factors such as time to liver resection and intraoperative shock management present potential clinical intervention points. The AKIMEBO score can provide a valuable tool for postoperative risk stratification. Full article

Background: Renal trauma accounts for approximately 3–5% of all trauma cases, predominantly affecting young males. The most common etiology is blunt trauma, particularly due to road traffic accidents, and it frequently occurs as part of polytrauma involving multiple organ systems. Management strategies are primarily dictated by hemodynamic stability, overall clinical condition, comorbidities, and injury severity graded according to the AAST classification. This study aimed to evaluate the effectiveness of non-operative management (NOM) in high-grade renal trauma (AAST grades III–V), beyond its established role in low-grade injuries (grades I–II). Secondary endpoints included the identification of independent prognostic factors for NOM failure and in-hospital mortality. Methods: We conducted a retrospective observational study including patients diagnosed with blunt renal trauma who presented to the Emergency Department of Policlinico Umberto I in Rome between 1 January 2013 and 30 April 2024. Collected data comprised demographics, trauma mechanism, vital signs, hemodynamic status (shock index), laboratory tests, blood gas analysis, hematuria, number of transfused RBC units in the first 24 h, AAST renal injury grade, ISS, associated injuries, treatment approach, hospital length of stay, and mortality. Statistical analyses, including multivariable logistic regression, were performed using SPSS v28.0. Results: A total of 244 patients were included. Low-grade injuries (AAST I–II) accounted for 43% (n = 105), while high-grade injuries (AAST III–V) represented 57% (n = 139). All patients with low-grade injuries were managed non-operatively. Among high-grade injuries, 124 patients (89%) were treated with NOM, including observation, angiography ± angioembolization, stenting, or nephrostomy. Only 15 patients (11%) required nephrectomy, primarily due to persistent hemodynamic instability. The overall mortality rate was 13.5% (33 patients) and was more closely associated with the overall injury burden than with renal injury severity. Multivariable analysis identified shock index and active bleeding on CT as independent predictors of NOM failure, whereas ISS and age were significant predictors of in-hospital mortality. Notably, AAST grade did not independently predict either outcome. Conclusions: In line with the current international literature, our study confirms that NOM is the treatment of choice not only for low-grade renal injuries but also for carefully selected hemodynamically stable patients with high-grade trauma. Our findings highlight the critical role of physiological parameters and overall ISS in guiding management decisions and underscore the need for individualized assessment to minimize unnecessary nephrectomies and optimize patient outcomes. Full article

Background: Necroptosis, a regulated form of inflammatory cell death, is increasingly recognized as a key driver of sepsis and critical illness. The balance between necroptosis and apoptosis may influence immune responses and outcomes in ICU patients. Objective: To evaluate necroptosis- and apoptosis-related protein expression in critically ill pediatric and adult patients with sepsis/septic shock, trauma/SIRS, or cardiac conditions, and assess their association with clinical outcomes. Methods: In this prospective, observational study, 88 patients admitted to a tertiary ICU were categorized into four groups: sepsis/septic shock, trauma/SIRS, cardiac disease, and healthy controls. Serum levels of RIPK1, RIPK3, MLKL, A20, caspase-8, IL-1β, and IL-18 were measured within 24 h of admission using ELISA. Biomarkers were analyzed by disease group, age, and severity indices. Results: Patients with sepsis—both adults and children—exhibited significantly elevated levels of RIPK1, IL-1β, and IL-18 (p < 0.001) and reduced levels of caspase-8 (p = 0.015), indicating activation of the necroptosis pathway. A20 was significantly upregulated (p < 0.001) and independently associated with lactate levels. RIPK1, IL-1β, and IL-18 were positively correlated with ICU length of stay and illness severity, whereas caspase-8 showed an inverse correlation. ROC analysis demonstrated strong predictive performance for sepsis/septic shock using RIPK1 (AUC = 0.81), IL-18 (AUC = 0.71), and A20 (AUC = 0.71); conversely, caspase-8 was inversely associated with sepsis (AUC = 0.32). Conclusions: Necroptosis appears to play a central role in the pathophysiology of sepsis across age groups. Elevated levels of RIPK1, IL-1β, IL-18, and A20 may serve as biomarkers of disease severity, while reduced caspase-8 supports a shift away from apoptosis toward necroptotic cell death. These findings highlight the potential of necroptosis-related pathways as targets for risk stratification and therapeutic intervention in critically ill patients of all ages. Full article

Background/Objectives: Sepsis is a leading cause of mortality. The AST/ALT ratio may serve as a valuable marker for prediction in patients with various diseases. This study analyzed the prognostic value of this ratio in patients with sepsis. Methods: A retrospective analysis was performed on data from a prospective registry of septic shock patients, collected across multiple centers from October 2015 to December 2022. The main outcome of interest was mortality within 28 days. We evaluated the predictive accuracy of 28-day mortality for variables with the Sequential Organ Failure Assessment (SOFA) score, aspartate transaminase (AST) levels, alanine transaminase (ALT) levels, the AST/ALT ratio, and the combination of the SOFA + AST/ALT ratio using the area under the receiver operating characteristics curve (AUROC). A Kaplan–Meier curve was used to compare the 28-day mortality between the AST/ALT subgroups (≥1.84 and <1.84). Stepwise multivariable Cox proportional hazards analyses were performed to determine the association between 28-day mortality and an AST/ALT ratio ≥ 1.84. Results: The AST/ALT ratio had a significantly higher discriminatory ability for predicting 28-day mortality compared to either AST or ALT. In addition, combining the AST/ALT ratio with the SOFA score improved the predictive accuracy compared to the SOFA alone. A multivariable Cox regression analysis demonstrated that an AST/ALT ratio ≥ 1.84 was associated with a higher risk of death within 28 days. Conclusions: The AST/ALT ratio at emergency department admission in sepsis patients is associated with 28-day mortality and, when combined with the SOFA score, provides additional prognostic information with moderate accuracy. Full article

Introduction: Sepsis has a high mortality rate, especially in low-income countries. Improving outcomes depends on the early recognition of patients at risk of death. Therefore, rapid and applicable prediction scores are needed in emergency triage. Objective: This study assessed the effectiveness of the qSOFA, NEWS, and IEWS scales in predicting in-hospital mortality during emergency triage. Additionally, we analyzed the efficacy of the IEWS_L, which integrates the IEWS with arterial lactate levels measured upon admission to the emergency department. Method: This retrospective study included patients who consulted the emergency department with suspected sepsis, where various scoring systems were evaluated for their effectiveness. We evaluated the diagnostic capacity of the tests by measuring the specificity, sensitivity, positive and negative predictive values, as well as the areas under the curve (AUC) of each score to predict mortality. Results: The study included 383 patients who had visited the emergency department. The overall mortality rate was 20.6%, and the mortality rate, precisely due to septic shock, was 35.2%. The AUC values for predicting in-hospital deaths due to sepsis were as follows: qSOFA: 0.68 (95% CI: 0.62–0.74); NEWS: 0.71 (95% CI: 0.64–0.77); IEWS: 0.74 (95% CI: 0.68–0.80); IEWS_L: 0.81 (95% CI: 0.76–0.86). Conclusions: In the emergency department, the IEWS scale demonstrated the best ability to accurately predict in-hospital mortality from sepsis when compared to the qSOFA and NEWS scale. Additionally, incorporating the serum lactate level into the IEWS scale significantly enhances its capacity to predict mortality. Full article

Background: Mitochondrial DNA (mtDNA) has strong pro-inflammatory potential and was found to be associated with mortality in critically ill patients. The purine bases from circulating cell-free DNA, including mtDNA, are catabolised into uric acid, contributing to elevated systemic levels. However, the prognostic value of uric acid in unselected critically ill intensive care unit (ICU) patients remains unclear. We aimed to investigate the association between uric acid levels at admission and 30-day mortality, assess its correlation with mtDNA, and examine prognostic relevance based on the primary cause of admission. Methods: This prospective single-centre study included 226 patients admitted to a tertiary care ICU. Uric acid and mtDNA levels were assessed at admission. Survival analyses were performed in the overall cohort and in subgroups stratified by primary diagnosis. Results: Uric acid showed a U-shaped association with 30-day mortality, with both low and high levels linked to reduced survival. In multivariate analysis, the 4th quartile of uric acid remained associated with adverse outcomes, independent of sex, vasopressors, mechanical ventilation, and creatinine (HR 2.549, 95% CI: 1.310–4.958, p = 0.006). A modest correlation was observed between uric acid and mtDNA (r = 0.214, p = 0.020). However, prognostic relevance varied by diagnosis. While uric acid predicted mortality in patients following cardiac arrest (p = 0.017), mtDNA was found to bear prognostic value in cardiogenic shock and decompensated heart failure (p = 0.009). Conclusions: Uric acid was independently associated with mortality in critically ill patients, with both low and high levels carrying prognostic value. Its predictive capabilities differed from mtDNA but showed partial overlap. However, both markers exhibited varying prognostic performance depending on the primary cause of admission. Full article

Background: Septic shock is a heterogeneous syndrome with diverse clinical presentations and pathophysiology, yet current management guidelines largely treat it as a homogenous entity. Early risk stratification relies on lactate and different predictive scoring systems, which may not capture the underlying heterogeneity in host responses. Aim: To identify discrete subphenotypes of septic shock using admission demographics and laboratory parameters, and to evaluate their relationship with in-hospital outcomes. Methods: We conducted a retrospective multicenter cohort study of 10,462 adult patients with ICD-10-defined septic shock admitted to intensive care units between 2014 and 2015. We used Two-Step Cluster Analysis using log-likelihood distance and the Bayesian Information Criterion to identify two distinct phenotypes. We compared clusters on baseline characteristics, in-hospital outcomes including mortality, days on mechanical ventilation, vasopressor use, acute kidney injury (AKI), AKI requiring renal replacement therapy (RRT), and ICU and hospital lengths of stay. Results: We identified two clusters (Cluster 1, n = 5355 and Cluster 2, n = 5107) in our study. Cluster 1 showed greater biochemical severity at presentation, including higher median lactate (2.40 vs. 2.20 mmol L⁻¹; p < 0.001), serum creatinine (1.39 vs. 1.20 mg dL⁻¹; p < 0.001), blood urea nitrogen (28 vs. 25 mg dL⁻¹; p < 0.001), and neutrophil-to-lymphocyte ratio (11.12 vs. 10.38; p < 0.001), and a higher mean SOFA score (7.05 ± 3.85 vs. 6.76 ± 3.87; p < 0.001). Despite this, Cluster 1 required mechanical ventilation more frequently (46.1% vs. 42.2%; p < 0.001) and had a higher incidence of AKI (58.1% vs. 55.6%; p = 0.009), including more stage 3 AKI (17.2% vs. 15.2%; p < 0.001) and dialysis (6.6% vs. 5.2%; p = 0.005), yet experienced similar in-hospital mortality (15.4% vs. 15.8%; p = 0.615) and comparable ICU (2.18 vs. 2.26 days; p = 0.254) and hospital lengths of stay (6.63 vs. 6.80 days; p = 0.251). Conclusions: Two septic shock phenotypes were identified, one with marked early organ dysfunction (Cluster 1) and another with milder initial derangements (Cluster 2), yet both showed convergent short-term mortality and lengths of stay despite divergent support needs. These results challenge reliance on single-parameter severity markers and underscore the need for phenotype-guided risk stratification and personalized management strategies in septic shock. Full article

Background and Objectives: Assessing risk is essential for optimal care in acute pulmonary embolism (PE). The present research seeks to evaluate the value of admission blood cellular indices as predictors of in-hospital outcome in acute PE and their utility in conjunction with validated risk tools such as the Pulmonary Embolism Severity Index (PESI) score and the European Society of Cardiology (ESC) risk stratification. Materials and Methods: A total of 1058 individuals hospitalized at Bihor County Emergency Hospital, Oradea, Romania, with a diagnosis of acute PE confirmed by contrast-enhanced computed tomographic pulmonary angiography were retrospectively evaluated. Results: A total of 165 patients (18.2%) experienced adverse outcomes, including in-hospital mortality, cardiac arrest, cardiogenic shock, or persistent hypotension, and required rescue thrombolytic therapy. The neutrophil-to-lymphocyte ratio (NLR) was an independent predictor for in-hospital adverse outcome OR = 1.071 (95% CI 1.01–1.137), p < 0.001. NLR as a predictor of adverse outcome had an AUC of 0.712 (95% CI 0.661–0.742), p < 0.001, sensitivity of 72.56%, and specificity of 64.19% for a cutoff value of >5.493. In a combined model with PESI or with ESC risk classification, NLR is leading to a significant improvement in their AUC (p < 0.001). Conclusions: Among hematological markers, NLR holds the greatest relevance for stratifying risk in acute pulmonary embolism and serves as an independent indicator of unfavorable in-hospital prognosis. NLR had an acceptable discriminative power to predict short-term complications and can increase the predictive value of the PESI score and of ESC risk classification. Full article