Medicine and Pharmacology

Abstract: Background: Modern warfare has introduced novel mechanisms of injury, particularly drone-induced blast trauma, resulting in complex craniomaxillofacial injuries. These injuries differ substantially from traditional ballistic trauma and require adapted surgical strategies. This study aimed to evaluate the clinical characteristics, management approaches, and long-term outcomes of midfacial blast injuries. Methods: A retrospective analytical study was conducted on 41 patients with drone-induced midfacial blast injuries treated at a tertiary referral center in Armenia following the 2020 Nagorno-Karabakh war. All patients underwent surgical management after initial stabilization and were followed for 5 years. Clinical outcomes, complications, and reconstructive needs were assessed. Results: All patients presented with comminuted midfacial fractures, frequently associated with polytrauma (87.8%). Burns were observed in 82.9% of cases. Surgical management included radical debridement and early definitive osteosynthesis using titanium fixation systems. No cases of postoperative osteomyelitis, bone sequestration, or implant failure were observed during the 5-year follow-up. Patients with extensive soft tissue defects, particularly nasal and lip amputations required multiple reconstructive procedures. Long-term follow-up revealed progressive soft tissue thinning over titanium meshes, especially in the zygomatico-orbital region, necessitating secondary interventions such as lipofilling. Conclusions: Drone-induced midfacial blast injuries represent a distinct and severe form of trauma. Early definitive reconstruction following adequate debridement was associated with favorable outcomes. However, soft tissue reconstruction remains challenging and often requires staged procedures. Long-term follow-up is essential to manage delayed complications and optimize aesthetic outcomes.

Abstract: The use of technology-enhanced training for prehospital mass-casualty incident (MCI) preparedness has grown quickly, but there has been no comprehensive overview of how these technologies operate throughout the training process or how competencies are evaluated. This scoping review, conducted as part of the MCIPHER (Mass-Casualty Incident Prehospital Emergency Response) project, followed the Arksey and O'Malley framework and PRISMA-ScR guidelines. We searched seven databases and additional sources, screened 2,105 records, and included 28 studies published from 2015 to 2025. Virtual reality was the most common method (43%), followed by hybrid approaches (29%) and screen-based simulations (21%). We identified five key analytical constructs. Three were derived from the data: the Technology Function Spectrum revealed that half of the studies used dual-purpose platforms for both training and performance assessment; the Data Capture Architecture linked embedded data collection to advanced learning outcomes (L2+); and the Pedagogical Transparency Gap showed that 75% of studies did not specify a training design framework. Two other constructs — the Immersion-Evaluation Paradox and the Scalability-Rigor Tension — suggest areas for future research. Using a modified Kirkpatrick framework with an L2+ (Applied Learning) sub-level, 56% of completed studies demonstrated applied learning through embedded performance assessments. Overall, these findings suggest that investments in MCI preparedness should focus more on measurement capabilities than immersion, incorporate assessment into training platforms, and work to reduce geographic and resource disparities.

Abstract: Background: The COVID-19 pandemic profoundly disrupted healthcare utilization patterns at both primary care (PC) and hospital emergency department (ED) levels. This study aimed to assess the impact of the pandemic on referral patterns from PC to a hospital ED and on the resource consumption associated with those referrals. Methods: describe briefly the main methods or treatments applied. Methods: A descriptive, retrospective, longitudinal comparative study was conducted at a first level hospital of Madrid (Spain). All consecutive PC-to-ED referrals received during two observation windows were included: a pre-pandemic period (1 June-31 December 2019; n=946) and a post-pandemic period (1 January-30 June 2022; n=1,797). Sociodemographic characteristics, referral form quality, diagnostic specialty, and in-ED resource utilization variables were collected and compared using χ², Student’s t-test, and Mann–Whitney U tests as appropriate. Results: A total of 2,743 referrals were analyzed. The monthly referral rate increased by approximately 122% between periods (135/month vs 300/month). No significant differences were found in patient age (mean 53.1±18.3 vs 54.9±19.0 years; p=0.015) or sex. Referral form completion improved significantly for clinical history (94.5% vs 98.2%; p<0.001). Orthopedics referrals nearly tripled (5.8% vs 18.4%), while respiratory/COVID-19-related referrals represented 22.0% of the 2022 caseload. ED length of stay between 3 and 6 hours increased from 13.0% to 42.8% (p<0.001), while the need for urgent blood tests fell from 68.9% to 56.0% (p<0.001), hospital admission from 68.4% to 10.9% (p<0.001), and referral to another center from 12.3% to 0.9% (p<0.001). Conclusions: indicate the main conclusions or interpretations. The abstract should be an objective representation of the article, it must not contain results which are not presented and substantiated in the main text and should not exaggerate the main conclusions. After the initial COVID-19 waves, PC-to-ED referrals increased substantially while requiring fewer complementary investigations and generating fewer hospital admissions, suggesting improved coordination and clinical resolution capacity between PC and the ED. These findings have important implications for post-pandemic healthcare planning.

Abstract: Background and Objectives: Slovenia, as many other European nations, have introduced voluntary first responders to enhance survival rates in out-of-hospital cardiac arrests. In currently published research exists no conclusive data on the optimal retraining interval, categorizing recommendations as expert opinion with limited reliability. Materials and Methods: Experimental prospective research was conducted on newly certified (N = 342) and senior (N = 140) licensed first responders (LFRs) in Slovenia, in accordance with national guidelines. LFRs were reassessed for retention of skills and knowledge one year after previous certification. Additionally, each cohort was classified into groups according to the number of interventions they engaged in over the past year, and their retention of skills and knowledge was assessed. Results: In the initial year of service, no statistically significant decline in skills (median 53 [52-54] vs. 53 [50-54]; p = 0.059) and knowledge (median 10 [9-10] vs. 9 [9-10]; p = 0.458) was observed among new LFRs. In contrast, senior LFRs exhibited a marked reduction in skills (median 51 [49-54] vs. 54 [52-55]; p < 0.001) until recertification, although their knowledge (median 9 [8.5-10] vs. 10 [9-10]; p = 0.091) remained stable. The frequency of interventions did not affect the new LFRs; however, there was a significant decrease in skill (median 49 [47-51] vs. 54 [52-55]; p < 0.001) retention among senior LFRs who did not participate in any interventions during the previous certification period. Notably, senior LFRs who engaged in at least one intervention did not demonstrate any decline in skills (median 52 [50-54] vs. 54 [52-55]; p = 0.117). No reduction in knowledge was detected. Conclusions: Initial training for Slovenian LFRs has been found to be adequate. However, senior LFRs experience a decline in skills if they do not participate in interventions during the certification period. A different strategy for recertifying senior LFRs should be adopted, considering the number of interventions they have been involved in during this time.

Abstract: Background: Microcirculatory dysfunction is a key feature of septic shock and contributes to organ failure despite the apparent normalization of systemic hemodynamic parameters. Extracorporeal blood purification (EBP) therapies aim to modulate the dysregulated inflammatory response through removal of endotoxins and cytokines; however, their impact on tissue-level perfusion remains unclear. Direct bedside assessment of microcirculation may provide mechanistic insight into the effects of EBP beyond macrohemodynamic stabilization. Methods: This structured narrative review summarizes current evidence on direct microcirculatory assessment during EBP therapy in sepsis. A literature search of PubMed, Web of Science, and Scopus was performed using combinations of the terms “microcirculation” and “blood purification” or “hemoadsorption.” Studies published between 2015 and 2026 evaluating direct sublingual microcirculation using sidestream dark field (SDF) or incident dark field (IDF) videomicroscopy during EBP were included. Both experimental and clinical studies were considered. Results: Eight studies met the inclusion criteria. Selective endotoxin adsorption with polymyxin B hemoperfusion (PMX-HP) demonstrated improvements in perfused vessel density and small vessel density in both animal and clinical settings. Non-selective cytokine adsorption devices (CytoSorb and HA380) were associated with increases in microvascular flow index (MFI), perfused vessel density (PVD), and proportion of perfused vessels (PPV), although most data derive from small observational studies. Across studies, improvements in microcirculatory parameters were observed during or following hemoadsorption therapy; however, heterogeneity in design, timing, and concomitant treatments limits definitive interpretation. Conclusions: Current evidence suggests that EBP may positively influence microvascular perfusion in septic shock when assessed using direct videomicroscopy. Nevertheless, data remain limited and predominantly observational. Larger randomized controlled trials incorporating predefined microcirculatory endpoints are required to determine whether mediator removal translates into sustained restoration of tissue perfusion and improved clinical outcomes.

Abstract: Lazarus phenomenon (LP), also named auto-resuscitation, may happen after the end of ineffective cardiopulmonary resuscitation (CPR), or after death is confirmed in a person who did not undergo CPR, and heart activity returns spontaneously. The aim of the study was to focus on elder individuals (aged >60) experiencing the Lazarus phenomenon and to analyse distractors that cause the LP. Methods. PubMed, Scopus, and Web of Science electronic databases were searched to find cases of LP from the year 1982 until 31 December 2025. Of the 81 total cases found, 48 pa-tients were elder than 60 years and were included in the study. For the analysis they were divided into two subgroups dependent on age: No 1 (79-60), No 2 (≥80). Results. The causes of cardiac arrest were divided almost equally between cardiac and non-cardiac causes (47.6% and 52.3% respectively). Cardiac arrest occurred equally in the IH and OH, each accounting for 50%. The ECG rhythm during cardiopulmonary resuscitation prior to the onset of LP was as follows: A – 58.7%, PEA – 37% and VF – 4.3% respectively. In 16 out of 37 cases where such data were reported, a return to consciousness was confirmed, representing 43.2%. During statistical analysis of these data no relationship was found. Conclusions. In older people, even those of very advanced age, Lazarus phenomenon may occur following resuscitation or even if resuscitation is not attempted. Based on the analysis of the available data from a literature on LP case reports we have not identified any specific cause for LP in older individuals. The causes of LP probable lie outside the analysed data. Accurate reporting is required, including data such as: CPR time points with details of medication administered during CPR, airway management, quality of ventilation, and laboratory tests (blood gas analysis, electrolyte levels, complete blood count) in order to analyse the suggested causes of LP.

Abstract: One of the most debated scientific topics in recent years is the role of noninvasive respiratory support techniques in the treatment of de novo acute hypoxemic respiratory failure. Until pre-COVID-19, the most accredited guidelines did not make recommendations for or against the use of these techniques in this clinical condition, and the increased risk of adverse events for patients who failed the noninvasive approach was widely reported in the literature. In recent years, in addition to the pandemic experience, we have seen the widespread use of high-flow nasal cannulas (HFNC) in the emergency department, as well as the production of numerous studies comparing them to the more established techniques of noninvasive ventilation and continuous positive airway pressure (NIV, CPAP), as well as to conventional oxygen therapy (COT). The most recent guidelines recommend the use of HFNC as a first-line technique in the treatment of de novo acute hypoxemic respiratory failure to avoid the need for tracheal intubation. However, the strength of these recommendations remains weak, the quality of the underlying evidence is poor, and their usefulness in deciding which technique to apply to an individual patient is questionable. The progressive establishment of the pathophysiological concept of Patient's Self-Inflicted Lung Injury (P-SILI), a potential risk of additional lung damage in spontaneously breathing patients, has highlighted the importance of assessing each patient's risk of developing this complication, individualizing treatment to the patient's specific needs, and monitoring the patient during treatment. This brief narrative review will illustrate the most recent literature on these topics.

Abstract:

Background: Cardiac arrest is the third leading cause of natural death in Europe and thus presents a growing burden on both our society and healthcare system. There has been very little research done on cardiac arrests of non-cardiac origin despite their increasing incidence, as they represent a heterogenous group of patients in which the type and outcome of treatment vary depending on the underlying cause of the cardiac arrest. Aim: The aim of our study is to research how the Slovenian healthcare system has worked and currently works in the field of cardiac arrests of non-cardiac origin. Methods: Our study was descriptive and retrospective. We compared 2 time periods, 2010/2011 and 2022/2023. Our sample included all patients admitted to Centre for Intensive Internal Medicine (CIIM) during these periods after either out-of-hospital or in-hospital cardiac arrest of non-cardiac origin. Results: The incidence of all cardiac arrests of non-cardiac origin was higher in 2022/2023 (Hi-squared test, p=0.021), while the incidence of those that occured in-hospital was lower in 2022/2023 (Hi-squared test, p=0.007). The number of male patients was higher in the second period (Hi-squared test, p=0.013). The age of the patients did not differ significantly between the two periods (Student's t-test, p>0.05). ICU stay was longer in the second period (Mann Whitney U test, p=0.027). The number of tests performed was higher and treatment was more aggressive in the second period than in the first period. Patient survival was higher in the second period in the in-hospital cardiac arrest of non-cardiac origin group (Student's t-test, p=0.048). Conclusion: The incidence of cardiac arrest of non-cardiac origin in Slovenia has been increasing through the years. Better hospital treatment results in better overall survival and a lower incidence of in-hospital cardiac arrests. More patients with out-of-hospital cardiac arrests are nowadays being resuscitated by lay bystanders in the field, so patients' survival to hospital admission is higher. The proportion of male patients is increasing, age is not changing significantly. Despite better diagnosis processes, new treatments and improved knowledge, the survival and neurological outcome of patients have not improved significantly.

Abstract: Wild-boar–related trauma is uncommon but may result in severe injuries that pose di-agnostic and therapeutic challenges, particularly in wilderness or resource-limited en-vironments. Most literature consists of isolated case reports, regional series and foren-sic descriptions; clinical guidance is therefore fragmented. This guideline synthesizes two complementary evidence sources: a structured observational cohort documenting 101 injuries sustained by boar hunters during organized hunts in Germany, and a comprehensive systematic review of all globally published wild-boar– and feral-pig–related human injuries. The observational cohort provided internally consistent epi-demiologic information on who was injured, under what circumstances, how quickly assistance was obtained, and how injuries were treated and ultimately healed. The systematic review added detailed insight into injury morphology and severity across diverse settings, including reports of deep wound tracts, extensive soft-tissue disrup-tion, significant contamination and the risk of hemorrhage, neurovascular compromise or thoracoabdominal penetration. Integrating these sources enabled a field-oriented approach to assessment and management, emphasizing early hemorrhage control, broad-spectrum antibiotic therapy, appropriate use of imaging, thorough surgical ex-ploration when indicated and region-specific tetanus or rabies prophylaxis. Together, these findings support clinicians working in remote or austere environments who may encounter these rare but potentially serious injuries.

Abstract: Background/Objectives: Erythroderma is a rare but potentially life-threatening dermatological emergency characterised by generalised erythema and scaling involving more than 80% of the total body surface area. Erythroderma is associated with significant morbidity and mortality due to systemic complications and diverse underlying aetiologies. Methods: In this narrative review PubMed and Google Scholar were searched up to February 2026. Studies were screened for relevance to emergency physicians, with emphasis on epidemiology, diagnostic approach and acute management. Non-English publications and conference abstracts were excluded. Fifty-seven sources were included in the final synthesis. Results: Erythroderma most commonly results from exacerbation of pre-existing inflammatory dermatoses, drug reactions, infections, or cutaneous T-cell lymphoma. Clinical presentation includes diffuse erythema and scaling affecting ≥80–90% of body surface area, often accompanied by pruritus, systemic symptoms, and signs of organ dysfunction. Systemic complications arise from cutaneous barrier failure and include fluid imbalance, thermoregulatory dysfunction, cardiovascular strain, protein loss, and secondary infection. Initial emergency department management prioritises supportive care, fluid and nutritional optimisation, restoration of skin barrier function, and assessment for organ dysfunction. While definitive aetiological diagnosis is not always immediately required, certain conditions—particularly severe drug reactions and infectious causes such as Staphylococcal Scalded Skin Syndrome—necessitate urgent targeted intervention. Conclusions: Erythroderma represents a syndromic emergency requiring systematic evaluation and early supportive management. Prompt recognition of high-risk aetiologies and timely dermatology referral are essential to optimise outcomes and reduce morbidity and mortality.

Abstract: Introduction: To investigate if specific emergency physician(EP) admission diagnoses and/or neurological signs/symptoms on admission to the Emergency Department(ED) were associated to normal/not-informative emergency-electroencephalogram(emEEG). Methods: Data from consecutive patients admitted to the ED of our tertiary hospital during two-years period (1 Jan 2023-31 Dic 2024) were retrospectively analyzed. We evaluated the correlation between nor-mal/not-specific emEEG and EP admission diagnoses and neurological signs/symptoms on admission. Epileptic EEGs and EEGs showing triphasic morphology sharp-waves were considered as specific patterns. Results: A total of 2,008 patients underwent emEEG during the study-period. EmEEG was considered not-informative in 100% of global amnesia diagnosis, 100% of mild head trauma, 100% of migraine with aura, 98.3% of transient ischaemic attack(TIA), 95.6% of transient loss of consciousness(TLC) when seizure was not the primary suspected diagnosis and 92.7% of falls of unknown dynamics. Epileptic patterns were detected in 4% of patients presenting with TLC and in 2.4% of those with falls of unknown dynamics, with approximately half of these patients having a pre-existing diagnosis of epilepsy. Triphasic waves were detected in 4.9% pa-tients with falls of unknown dynamic, in 1.7% with TIA and in 0.4% with TLC. All these patients showed fe-ver/sepsis or metabolic/electrolyte disorders. Overall, across all clinical scenarios, emEEG was considered not-informative in 385(19.1%) patients who underwent emEEG. Conclusions: emEEG is almost not-informative in the diagnostic pathway of global amnesia, mild head trauma and migraine with aura, while in patients with TIA, TLC, or falls of unknown dynamics, EP can consider to safely avoid emEEG in the absence of previous epilepsy, fever/sepsis, metabolic/electrolyte disturbances or drug abuse.

Abstract: Sepsis is usually described as a dysregulated host response to infection associated with severe organ dysfunction and failure. In 2023 the author proposed that many aspects of sepsis suggested a physiological response and defence to infection that only became “dysregulated” if the infection was overwhelming or there was a deficiency of thiamine and/or intracellular glucose to provide ongoing fuel for the immune response and/or mitochondrial production of adenosine triphosphate (ATP).It was also proposed that during sepsis, the immune system received priority access to available glucose, prompting insulin resistance that minimised glucose utilisation by less essential tissues. Concurrently, mitochondrial ATP production via oxidative phosphorylation (OXPHOS) was deprioritised, with the immune system relying on anaerobic glycolysis for ATP generation. This suppression of OXPHOS was only a temporary measure; mitochondrial ATP production must be resumed for complete recovery. Persistent suppression culminated in critical ATP deficits and cell death.The 2023 paper also reviewed glucose, thiamine and insulin metabolism during sepsis and concluded that administering high-dose insulin alongside mild hyperglycaemia and intravenous thiamine—a pyruvate dehydrogenase kinase (PDK) inhibitor—might help restore physiological mitochondrial ATP production when administered during a crucial window in the sepsis process, potentially improving survival outcomes.The thrust of that hypothesis may have been validated by a recent experiment on sepsis in mice that found superior survival, albeit short-term, following treatment with combined glucose and thiamine compared to antibiotics.

Abstract: Background: Sepsis is a heterogeneous syndrome, yet current definitions and management guidelines emphasize standardized, blood pressure–driven interventions. This "one-size-fits-all" approach often obscures physiologically unstable patients who lack overt hypotension. We hypothesized that distinct, reproducible physiological phenotypes of sepsis exist and that some high-risk states remain under-recognized by traditional assessment. Methods: We conducted a retrospective observational study using the PhysioNet 2019 Challenge dataset, comprising high-frequency ICU data from two hospital systems. To ensure independence, we reconstructed unique patient trajectories, yielding 40,217 unique patients. Features included vital signs and markers of perfusion (lactate, creatinine), with engineered variables such as Shock Index (HR/SBP). Unsupervised K-Means clustering was applied to a derivation cohort (70%) to identify phenotypes, with internal validation in the remaining cohort. We assessed the prevalence of algorithmic Sepsis-3 criteria across phenotypes and benchmarked supervised models (logistic regression vs. gradient boosting) to test physiological non-linearity. Findings: Four stable phenotypes were identified: Stable (38.6%, low risk); Hyperdynamic (28.7%, hypertensive/wide pulse pressure); Renal Dysfunction (3.7%, organ-dominant failure); and Cryptic Shock (29.0%). The Cryptic Shock phenotype was characterized by normotension (mean MAP ~75 mmHg) but significant metabolic distress (tachycardia, elevated lactate, high Shock Index). This group demonstrated a significantly higher prevalence of meeting algorithmic sepsis criteria compared with the Stable phenotype (10.2% vs 5.8%; p < 0.001). Gradient boosting significantly outperformed logistic regression (AUC 0.744 vs 0.637), confirming that sepsis risk is driven by non-linear interactions poorly captured by linear scores. Interpretation: We identified a prevalent "Cryptic Shock" phenotype characterized by normotensive metabolic distress that is poorly detected by blood pressure–centric protocols. These findings have direct implications for early risk stratification and trial design, suggesting that blood pressure targets alone are insufficient endpoints for resuscitation in this subgroup.

Abstract: Background: Acute coronary syndrome (ACS) is a cannot miss diagnosis. The gold standard workup for this requires serial troponin biomarker evaluation over a period of hours. Traditionally, many of these patients required telemetry while being evaluated in this fashion, however high-quality literature suggesting that low risk patients do not require ongoing continuous cardiac monitoring. Further to this, it was found locally that over 70% of patients presenting with chest pain to our local high volume urgent care undergoing a cardiac work-up were transferred to the main hospital for this via emergency medical services (EMS). We felt this intersection of patient care and medical services could be streamlined to reduce critical resource utilization. Objective: The aim of this study is to reduce the usage of EMS for transport of chest pain patients from the urgent care to the main hospital by 25% over a 3- month period. Methods: This study was conducted as an uncontrolled before-after interrupted time series design. Comprehensive data drilldown was performed through chart review and structured clinical practise evaluation. This led to the creation of an evidence-based safe-for-self-transport tool to be applied in this patient population. The primary outcome measure was the proportion of patients transported via EMS with main balancing measures being proportion of self-transported patients admitted to hospital and time to troponin blood draw in self-transported patients. Results: The education and the newly developed transport tool resulted in a sustained shift below the previous baseline system mean control limit, indicating a significant reduction in EMS usage for patient transport. The overall reduction in usage was 30%. No change in balancing (safety) measures was identified post implementation. Conclusions: EMS remains a finite resource within many Canadian health regions. The results of this study show that by focusing on a cardinal emergency department presentation like chest pain, adapting evidence-based practise through quality improvement methodologies can result in a significant sustained reduction of EMS utilization.

Abstract:

Introduction: Pediatric acute appendicitis (PAA) remains challenging to diagnose despite existing diagnostic scores. The BIDIAP index is a three-item diagnostic tool with very high discriminative performance in a derivation cohort. This study aimed to prospectively and externally validate the BIDIAP index in a multicenter pediatric population.Material and Methods: We conducted a prospective, multicenter observational study across four tertiary pediatric centers, enrolling children presenting with suspected PAA. Two groups were analyzed: patients with histopathologically confirmed PAA and patients in whom appendicitis was confidently excluded after diagnostic work-up, classified as non-surgical abdominal pain (NSAP). The BIDIAP index was applied using a predefined cutoff (≥ 4 points), and diagnostic performance was assessed using ROC analysis, calibration metrics, and decision curve analysis (DCA).Results: A total of 644 patients meeting the prespecified analytical criteria were included in the primary analysis. The BIDIAP index demonstrated excellent diagnostic performance, with an area under the ROC curve of 0.93 (95% CI, 0.92–0.95). The calibration slope was 1.00, and the intercept was close to zero, indicating close agreement between predicted and observed risks. At the prespecified cutoff value of ≥ 4 points, the BIDIAP index achieved a sensitivity of 90.5% and a specificity of 81.6%. DCA showed a positive net clinical benefit of the BIDIAP index over treat-all and treat-none strategies across the full range of clinically relevant threshold probabilities. Conclusions: The BIDIAP index demonstrated excellent diagnostic performance for PAA. Its simplicity, based on only three items, and its potential applicability even when the appendix is not visualized on ultrasonography make the BIDIAP index a promising tool for supporting clinical decision-making in routine pediatric emergency practice.

Abstract: The Surviving Sepsis Campaign (SSC) 1-hour bundle has transformed sepsis care in high-income countries. This bundle comprises rapid lactate measurements, blood cultures, broad-spectrum antibiotics, intravenous fluids, and vasopressors. However, in fragile systems such as Turkana County, Kenya, this protocol is largely impractical. This review synthesises current global and regional literature to contextualise the bundle’s limitations and propose evidence-based adaptations. Long travel distances, shortage of essential diagnostics and medicine, limited human resources, and inadequate critical care capacity remain significant systemic barriers. This review advocates for reframing the bundle from a fixed 1-hour metric to an “as soon as possible” (ASAP) framework, emphasising early recognition, timely empirical antibiotics, and pragmatic hemodynamic stabilisation using available resources. Key recommendations include replacing lactate measurements with clinical surrogates (such as capillary refill time), creating locally informed empirical antibiotic protocols, strengthening supply chains, investing in task-sharing and simulation-based training, and embedding community awareness initiatives. These adaptations can achieve meaningful mortality reduction and mitigate antimicrobial resistance.

Abstract:

Hospice and palliative care improve quality of life for patients with advanced illness, yet referrals from emergency departments (EDs) remain limited. This study aimed to establish a baseline rate of ED-initiated referrals from the Northwell’s Long Island Jewish Medical Center to its Health’s Hospice and Palliative Care Program between August and December 2024. Using an institutional database, we reviewed 262 referrals and identified referral sources, documentation of ED goals-of-care (GOC) discussions, and patient disposition. Only 5.3% of all palliative care referrals and 3.0% of actual hospice placement referrals originated from the ED, with a decline in ED GOC discussions over the study period. Nearly all referred patients were admitted or placed in observation rather than discharged home or directly to hospice. Persistent cultural, educational, and workflow barriers may limit integration of palliative care within the ED. Improved interdisciplinary communication, provider training, and structured ED-to-hospice pathways may increase appropriate referrals, reduce unnecessary hospitalizations, and promote goal-concordant end-of-life care. Establishing this baseline provides a foundation for future quality improvement initiatives aimed at enhancing patient-centered outcomes for Northwell patients with advanced illness.

Abstract: Background/Objectives: Prolonged stays in the emergency department (ED) may contribute to an increase in the rate of healthcare-associated infections (HAIs) with an increased risk of mortality. Early identification of the risk profile of these patients could reduce both complications and adverse outcomes. The study aimed to verify whether the development of an HAI was associated with mortality. Design, settings and participants: This prospective multicentre study involved all subjects, who required urgent admission to an acute care hospital from the ED, between 2023 and 2024. Outcome measures: The primary endpoint was 30-day mortality. A Cox proportional hazards model was used to test the hypothesis. Results: Of the 27,516 patients included in the analysis, with a mean age of 79 [20] years (median [IQR]), 1,575 (7.8%) died. The main features, in order of importance, selected for predicting mortality were: diagnosis of neoplasm; older age; NEWS; diagnosis of infectious diseases; HAIs; diagnosis of respiratory diseases; CCI; priority level on arrival; and male gender, yielding an accuracy of 0.804 ± 0.012. The development of a nosocomial infection was associated with a mortality risk ratio of 1.518 (95% confidence interval (CI): 1.338–1.721; p < 0.001), particularly high for bloodstream infections (2.54; 2.12–3.06) and pneumonia (1.44; 1.20–1.73). Conclusion: In patients admitted to acute care hospital from the ED, the development of HAIs is associated with an increased risk of mortality. This risk is particularly elevated in cases of bloodstream infections and pneumonia.

Abstract: Background: In-hospital immobilization of the spine is a critical component of major trauma care, particularly to prevent secondary neurological injury of the cervical spine (C-spine). While prehospital recommendations are relatively consensual, evidence-based, standardized procedures for the in-hospital transition phase are lacking. Objective: To experimentally and quantitatively assess C-spine motion reduction under in-hospital conditions with four commonly used whole-body immobilization devices (long spine board, soft positioning mattress, TraumaMattress, vacuum mattress) and to investigate the effect of a stabilization pillow on a soft positioning mattress. Methods: In a standardized trauma-room scenario, C-spine movements (flexion/extension, rotation, lateral flexion) were recorded using inertial sensors (IMUs; Xsens® MTi 10) during transport and transfers and analyzed as motion scores for each axis and as total composite. An ancillary experiment tested the effect of a stabilization pillow on the soft positioning mattress. Results: The devices differed markedly in motion reduction. The total motion score was lowest for the spine board (122.0), followed by the TraumaMattress (138.7). The soft positioning mattress (238.7) and vacuum mattress (276.3) showed higher motion values. On the soft positioning mattress, the stabilization pillow primarily reduced rotation, with minimal increases in flexion/extension and lateral flexion; the overall effect remained small. Conclusions: Under experimental in-hospital conditions, the spine board and the TraumaMattress achieved the greatest reduction in C-spine motion. For clinical protocols, a standardized, patient-centered positioning strategy with reliable fixation appears reasonable; prospective clinical studies involving trauma patients are required for external validation.

Abstract: Background and objectives: The purpose of this study was to investigate whether high ethmoid sinus volume (ESV) constitutes a risk factor for the formation of orbital blowout fractures (OBF) after craniofacial trauma and whether it affects the fracture pattern. Materials and Methods: This is a retrospective case-control study involving subjects over 15 years of age who presented to the emergency department with craniofacial trauma. The case group included subjects with OBF, while the control group included subjects without any facial fractures. The case group was divided into subgroups according to the fracture location. We performed volumetric measurements on computed tomography images of the ethmoid sinuses of subjects in the case and control groups using the fully automated 3D Slicer application. The mean ESV values of the groups were compared using the necessary statistical methods. P-values below 0.05 were considered significant. Results: The case group consisted of 108 (median age: 41.5 years; 76 males, 69%), and the control group consisted of 122 (median age: 38 years; 84 males, 69%) subjects. OBFs were more frequent in males (69%), most commonly detected in the orbital floor (68.2%), and were bilateral in two (1.8%) subjects. The mean ESV in the case group (3.91 ± 1.39 cm³) was significantly higher than that in the control group (2.82 ± 0.94 cm³) (p< 0.001). Unlike the cases with medial wall fractures and those with orbital floor fractures, there was no significant difference in mean ESV between the cases with medial wall and orbital floor fractures and the control group (p= 0.562). Conclusions: A large ethmoid sinus not only increases the risk of orbital blowout fracture but also has an impact on the fracture pattern. Based on the data obtained from our study, we identified a large ethmoid sinus as a predictive risk factor for orbital blowout fracture.