Medicine and Pharmacology

Abstract: Background: Large language models (LLMs) are seeing more use in clinical decision support and medical education, though how well they perform in arterial blood gas (ABG) interpretation is still not fully understood. Few studies have looked at whether model accuracy changes between English and non-English prompts. This study compared ABG interpretation performance of GPT-4o and Gemini 1.5 Pro in English and Turkish. Methods: We conducted a cross-sectional evaluation with 100 open ended questions covering ABG physiology, pathophysiology, and clinical application. Each question was presented to four configurations: GPT-4o and Gemini 1.5 Pro in English and Turkish. Two independent assessors scored responses using a 14-dimension rubric (0–2 points per dimension, maximum 28 points). We used Kruskal-Wallis and Friedman tests with Bonferroni correction for statistical comparisons, and Cohen’s kappa for inter-rater reliability. Hallucination rates and Winter formula accuracy served as secondary outcomes. Results: Mean total scores were: GPT-4o English 22.36 ± 2.11/28 (79.9%); GPT-4o Turkish 21.28 ± 2.54/28 (76.0%); Gemini 1.5 Pro English 19.81 ± 3.52/28 (70.7%); and Gemini 1.5 Pro Turkish 17.52 ± 3.26/28 (62.6%). Kruskal-Wallis H = 109.87, p < 0.001; all six pairwise comparisons remained significant after Bonferroni correction. All four models showed progressive score decline across parts (Friedman p < 0.001 each). English outperformed Turkish within both model families. Cohen’s kappa = 0.91. Hallucination rates were 4%, 7%, 18%, and 25%; Winter formula accuracy was 96%, 88%, 75%, and 63%, respectively. Conclusions: GPT-4o outperformed Gemini 1.5 Pro in both languages, and English prompts yielded higher scores than Turkish prompts. Performance deteriorated with increasing clinical complexity. These findings support continued human oversight for LLM use in ABG-related tasks, particularly in non-English settings and complex cases.

Abstract: Introduction Trauma remains a leading cause of morbidity and mortality in the United States and places a substantial economic burden on the healthcare system. Although simulation-based training has been associated with improved trauma team performance and patient outcomes, whether emergency medicine simulation fellowship programs are associated with differences in trauma mortality remains unknown. This study examined whether counties with emergency medicine simulation fellowship programs differ in trauma mortality rates compared with counties without such programs. Methods County-level trauma mortality data (2021–2023) were obtained from the CDC WONDER Multiple Cause of Death database. The database was queried by county, year, and external cause of death. Trauma-related deaths were identified using ICD-10 external cause-of-death codes corresponding to blunt and penetrating injuries, excluding suicide. Counties with emergency medicine simulation fellowship programs were identified through publicly-available fellowship directories and classified according to the presence or absence of a simulation fellowship program. Trauma mortality rates were calculated by dividing the total number of trauma-related deaths by the cumulative county population for counties with and without simulation fellowship programs. The two mortality rates were compared using the rate ratio, 95% confidence interval, and P value calculated with the MedCalc online statistical calculator. Results Trauma mortality was 8.0 per 100,000 population in counties with emergency medicine simulation fellowship programs compared with 3.3 per 100,000 population in counties without fellowship programs (rate ratio, 2.45; P<0.0001). Conclusion Contrary to our hypothesis, counties with emergency medicine simulation fellowship programs demonstrated higher trauma mortality rates. Because these programs are predominantly located in urban counties, these findings may reflect greater injury severity and higher emergency department volume rather than effects of the fellowship programs themselves. These factors should be considered when interpreting the association between emergency medicine simulation fellowship programs and trauma-related mortality.

Abstract: Background: Undifferentiated chest pain is one of the most common reasons for emergency medical service (EMS) activation, yet its aetiological spectrum remains poorly characterised in the prehospital setting. Furthermore, no clinical prediction model has been specifically developed to identify patients at risk of significant coronary lesions using only information available before hospital arrival. This study aimed to describe the aetiologies of undifferentiated prehospital chest pain and develop a proof-of-concept clinical prediction model. Methods: We conducted a retrospective, single-centre study including 409 consecutive patients managed by the Orléans Mobile Intensive Care Unit (MICU) for undifferentiated chest pain between January and June 2024. Predictors of significant coronary lesions requiring coronary revascularisation were identified using multivariable logistic regression. Model performance was assessed by discrimination and calibration, and internally validated using 1000 bootstrap resamples. Results: Cardiological aetiologies accounted for 19% of cases, including 53 patients (13%) with significant coronary lesions. Four independent predictors were identified: age (OR 6.7–8.9 according to category), male sex (OR 2.2), typical chest pain (OR 6.6), and a positive family history of cardiovascular disease (OR 3.4). These variables were combined to develop the HATS (History, Age, Typical chest pain, Sex) model. The model demonstrated good discrimination (AUC 0.81), excellent calibration (Hosmer–Lemeshow P=0.88), and satisfactory internal validity after bootstrap validation. Conclusions: This study characterises the aetiological spectrum of undifferentiated prehospital chest pain and proposes the HATS model as a proof-of-concept clinical prediction tool. Prospective multicentre external validation is required before routine clinical implementation.

Abstract: Background: Procedural sedation and analgesia (PSA) is commonly used for shoulder dislocation reduction in emergency departments (EDs), but it requires monitoring resources and may be associated with sedation-related adverse events. Ultrasound-guided regional anesthesia (UGRA), particularly low-volume superior trunk (ST) block, has emerged as a potential alternative. However, little is known about how this technically demanding technique can be implemented and adopted in routine ED practice. This study aimed to describe the implementation and clinical adoption of low-volume ultrasound-guided ST block for shoulder reduction in a specialized ED over a six-year period. Methods: This retrospective single-center observational cohort study included all consecutive patients undergoing shoulder reduction in a specialized orthopedic ED between February 2018 and February 2024. Patients were managed according to routine clinical practice using either UGRA or PSA, with treatment choice determined by the treating physician. The primary objective was to describe the implementation and clinical adoption of low-volume ST block in routine practice. Additional analyses assessed temporal trends in technique utilization, local anesthetic volume, provider distribution, and ED length of stay. Results: A total of 206 patients were included (124 UGRA; 82 PSA). The use of UGRA increased progressively during the study period, whereas PSA decreased accordingly (p < 0.001). Most UGRA procedures were performed by a small group of experienced physicians, reflecting the gradual adoption of the technique in routine clinical practice. Local anesthetic volumes decreased significantly over time (p < 0.001), with most blocks ultimately performed using approximately 4-5 mL. Successful shoulder reduction was achieved in all patients. No conversion from UGRA to PSA was necessary. No clinically documented respiratory complications related to UGRA were identified in the medical records, although diaphragmatic function was not systematically assessed. Conclusions: This retrospective implementation analysis demonstrates that low-volume ultrasound-guided ST block was increasingly integrated into routine ED practice. The findings primarily describe the implementation and progressive adoption of a technically demanding regional anesthesia technique in a real-world setting. Prospective studies are warranted to further evaluate clinical effectiveness, patient-reported outcomes, and respiratory effects using standardized study protocols.

Abstract: Stress hyperglycaemia affects more than half of critically ill patients within 48 hours of admission and predicts adverse outcomes. The classical mechanistic model attributes this phenomenon entirely to counter-regulatory hormones, inflammatory cytokines, and peripheral insulin resistance. Recent demonstration that red blood cells (RBCs) function as a primary glucose sink under chronic hypoxia, capable of redirecting up to 70% of systemic glucose disposal, demands a re-examination of stress hyperglycaemia mechanisms in patients exposed to the opposite condition: sustained moderate-to-severe hyperoxia delivered routinely in intensive care units. We propose that the band 3-anchored switch between deoxyhaemoglobin-driven glycolysis and oxidative-stress-driven pentose phosphate pathway activation operates symmetrically. ICU hyperoxia—through both acute conformational locking of glycolytic enzymes onto the band 3 N-terminus and chronic generation of oxidant-defensive, low-GLUT1 erythrocyte populations—silences the RBC glucose sink, contributing to systemic hyperglycaemia independent of hormonal and inflammatory pathways. We propose this as the hyperoxia paradox: while short-term hyperbaric oxygen ameliorates insulin resistance through extra-erythrocyte mechanisms, sustained moderate hyperoxia in critical illness imposes an erythrocyte-level metabolic cost not captured by current frameworks. We outline a measurable biomarker panel—the Red Cell Hypoxic Metabolic Index (RHMI)—comprising RBC GLUT1 abundance, ex vivo glucose uptake, intracellular 2,3-diphosphoglycerate, and methaemoglobin fraction, all feasible with existing critical-care laboratory infrastructure. This perspective generates testable predictions: (i) ICU hyperoxia exposure correlates dose-dependently with reduced RHMI; (ii) RHMI correlates inversely with glycaemic variability and insulin requirement; (iii) conservative oxygen targets should preserve erythrocyte glucose disposal capacity. The NIH-sponsored trial NCT04137692, currently testing therapeutic RBC exchange transfusion for GLUT1 deficiency syndrome, validates the broader concept that RBC glucose handling is a tractable therapeutic target. We argue that erythrocyte metabolic phenotyping should be incorporated into the next generation of critical care glycaemic control studies.

Abstract: Craniocerebral firearm injuries are associated with high mortality rates which increase in proportion to the damage to the brain and skull produced by the projectile, as a result of the kinetic energy dissipated during the projectile-tissue interaction. Ballistic factors that contribute to the brain injury are related to the ballistic behavior of the bullet (whether it yaws, tumbles, mushrooms or disintegrates following skull penetration) and its effects. While these injuries are complicated by the creation of bone fragments causing further damage to the brain tissue, the pressure waves generated intracranially as a result of the temporary cavitation phenomenon are the landmark of bullet penetration of the head. Because within the skull there is no mechanism of pressure relief as in other parts of the body during cavitation, the largely incompressible brain tissue sustains the pressure built up, transmitting the pressure wave and causing indirect bone fractures. Although cavitation occurs with low-velocity projectiles too, high-velocity projectiles are capable of high energy transfer secondary to bullet tumbling, mushrooming and often fragmentation, resulting in marked cavitation and more widespread tissue damage. The sudden increase in the intracranial pressure and the transient deformation of the brain tissue contributes to the development of diffuse brain edema and the cardiac and respiratory centers of the brainstem when not involved in the path of the bullet can still be affected indirectly by the pressure transmission with catastrophic results. Shotgun injuries to the head at close range cause extensive destruction of the brain involving a different mechanism, as the pellets enter the cranial cavity bunched together, thus acting as a single projectile of large diameter.

Abstract: Background Non-massive hemoptysis is generally considered low-risk and manageable with conservative treatment. However, some patients progress to massive hemoptysis during follow-up. Identifying high-risk patients early in the emergency department matters for calibrating monitoring intensity, guiding timely intervention, and allocating acute care resources. This study aimed to identify clinical, laboratory, and radiological predictors of progression to massive hemoptysis within the first 72 hours in emergency department patients presenting with non-massive hemoptysis who were managed conservatively. Methods This prospective cohort study enrolled patients at a tertiary university hospital emergency department between November 2023 and June 2025. Adult patients presenting with non-massive hemoptysis were enrolled consecutively. The primary outcome was development of massive hemoptysis within 72 hours of admission. Patients were divided into two groups: those who developed massive hemoptysis within 72 hours and those who did not. Demographic, bleeding, laboratory, imaging, and bronchoscopy data were recorded for all patients. Multivariate logistic regression was used to identify independent predictors. Results Of 199 patients, 10.6% developed massive hemoptysis within the first 72 hours. On multivariate analysis, bright red hemoptysis (3.17-fold increase in risk), a cavity or mass on chest CT (7.13-fold increase in risk), and bleeding volume ≥20 mL in a single episode (3.3-fold increase in risk) were independent predictors of massive hemoptysis. Conclusion A meaningful proportion of patients presenting with non-massive hemoptysis go on to develop massive hemoptysis in the early period. Simple clinical and radiological parameters available at admission can support early risk stratification and inform decisions about monitoring intensity and timely intervention.

Abstract: Hemoptysis is a potentially life-threatening clinical emergency requiring rapid identification of the bleeding source to guide appropriate management. CT angiography is the primary imaging modality for evaluating hemoptysis, enabling characterization of underlying parenchymal disease, precise identification of arterial anatomy, and selection of candidates for endovascular intervention. This review describes the comprehensive spectrum of hemoptysis on CT angiography, including parenchymal abnormalities (e.g., tuberculosis and bronchiectasis), bronchial arterial anatomy, non-bronchial systemic and pulmonary arterial sources of hemorrhage, and vascular malformations. Careful evaluation of parenchymal disease, precise arterial source identification, and recognition of vascular pathology is crucial for optimizing diagnosis confirmation, risk stratification, and clinical decision-making. Embolization techniques, contraindications, and indications are also discussed.

Abstract: Abstract Background: Caffeine toxicity represents a growing public health challenge due to the widespread availability of highly potent formulations. Ingestions of 3–10 grams can be fatal, with serious toxicity occurring at plasma concentrations 15 mg/L or greater. This review provides a framework explaining its diverse clinical consequences. Methods: A comprehensive literature search was conducted across PubMed, Scopus, and Google Scholar using AI-assisted tools, prioritizing clinical, forensic, toxicokinetic, and molecular mechanism studies while excluding chronic moderate consumption. Results: Caffeine toxicity is dose-dependent, progressing from adenosine receptor antagonism to phosphodiesterase inhibition, intracellular calcium release, and GABA-A antagonism. In overdose, these mechanisms interact synergistically to cause severe neurological, cardiovascular, and metabolic complications. Furthermore, the CYP1A2 metabolic system becomes saturated, prolonging the elimination half-life up to 27 hours and causing a disproportionate rise in plasma concentrations. Interactions with drugs like mexiletine drastically reduce clearance. Conclusions: Severe poisoning stems from complex, synergistic molecular interactions. Hypokalemia serves as a promising, actionable clinical biomarker for severity assessment. When massive ingestions saturate endogenous detoxification, hemodialysis becomes essential for survival. Unregulated markets for pure caffeine require stricter regulatory interventions and intensified clinical surveillance.

Abstract: Background: Standard sepsis risk stratification relies on static scores and single time-point biomarkers, failing to capture the temporal complexity of the host response. The dynamic interplay between immune dysregulation and metabolic distress remains poorly integrated into clinical phenotyping. We hypothesized that early longitudinal trajectories of these domains could reveal distinct immunometabolic phenotypes predicting intensive care unit-acquired infection (ICU-AI) and mortality. Methods: This multicenter retrospective study leveraged high-granularity data from the Medical Information Mart for Intensive Care IV (MIMIC-IV) and the eICU Collaborative Research Database (eICU-CRD), enrolling adult patients with a diagnosis of sepsis identified by the International Classification of Diseases (ICD) coding. We employed unsupervised latent class growth modeling (LCGM) to identify phenotypes based on 72-hour serial measurements of core immunometabolic indices, including lymphocyte, neutrophil, and platelet counts, lactate, and the lactate dehydrogenase-to-albumin ratio (LAR). Associations with the primary outcome (ICU-AI) and secondary outcomes (28-day mortality and a composite of ICU-AI/death) were quantified using multivariable Fine-Gray competing-risk models and multivariable logistic regression. We assessed the incremental prognostic value of trajectory phenotypes beyond a baseline model comprising age and sequential organ failure assessment (SOFA) scores. Results: We identified three reproducible immunometabolic trajectory phenotypes, each exhibiting distinct temporal profiles of inflammation and organ function. Trajectory 3 (“Rapid Recovery”) demonstrated swift normalization of biomarkers and favorable outcomes. In contrast, Trajectory 2—characterized by distinct “Immunometabolic Paralysis” (persistent lymphopenia paired with sustained hyperlactatemia and elevated LAR)—conferred the poorest prognosis. Compared to the Rapid Recovery phenotype, Trajectory 2 was associated with a more than two-fold increase in ICU-AI risk and significantly higher 28-day mortality. Integrating trajectory phenotypes into baseline severity models significantly enhanced predictive accuracy and demonstrated superior net benefit in decision curve analysis (DCA). Conclusion: Early 72-hour trajectories of routine biomarkers identify a distinct “Immunometabolic Paralysis” phenotype characterized by sustained metabolic stress and immunosuppression. This dynamic classification outperforms static severity scores in predicting ICU-AI. By distinguishing patients with entrenched dysregulation from those with rapid recovery, this approach offers a scalable framework for risk stratification and predictive enrichment in future trials of immunomodulatory or metabolic therapies.

Abstract: Background and Objectives: Suspected bacterial infection is one of the leading presentations to the Emergency Department (ED) and is still associated with considerable morbidity and mortality. There is increasing evidence that biological sex may influence host immune responses, disease manifestations, therapeutic requirements, and clinical outcomes in infectious diseases. However, sex-specific differences among patients who present to the ED with suspected infection remain incompletely defined. This study, therefore, aimed to assess demographic characteristics, clinical presentation, and clinical management as well as short-term outcomes related to sex among these patients. Materials and Methods: Our single-center retrospective observational study included consecutive adults patients (n= 213) presented with suspected acute bacterial infection to the Emergency Department between June 2025 and August 2025. Results: Female patients were significantly older than male patients (72.13 ± 15.26 vs. 64.25 ± 13.66 years, p < 0.001). Cardiovascular disease and urinary tract infections were more frequently observed among women, whereas men presented significantly higher diastolic blood pressure values at admission (p = 0.004). Vasopressor therapy was more commonly required in female patients compared to males (26.0% vs. 13.3%, p = 0.019). No significant sex-related differences were identified regarding ICU admission or in-hospital mortality. Conclusions: ED patients with suspected bacterial infection demonstrate sex-related differences in age, comorbidities, infection source, and treatment requirements. Female patients were older and more frequently required vasopressor therapy. On the other hand, male patients had higher diastolic blood pressure and presented more frequently with respiratory infections. Short-term outcomes, including ICU admission and in-hospital mortality, were similar for both sexes. These findings highlight the importance of considering sex-specific characteristics in the early assessment and management of suspected infection in the Emergency Department.

Abstract: Trauma is defined as an injury caused by external mechanical forces ranging from physical, chemical, biochemical, or physchological. The Injury Severity Score (ISS) is established on the Abbreviated Injury Scale (AIS). Advanced Trauma Life Support (ATLS) contains basic procedures for securing the airway, establishing and maintaining hemodynamic stability, and adequately assessing injuries based on diagnostic tests. The damage control strategy is a multidisciplinary approach to the polytraumatized patient, including Damage control resuscitation and Damage control surgery. In the emergency room management of a polytraumatized patient, several critical steps are taken to guarantee comprehensive care: all clothing and jewelry are removed from the patient, monitoring devices are placed, circulatory status is evaluated, blood typing and cross-matching are done, and possibly, the transfusion of blood and blood products is initiated. The Initial Hemorrhage Management Steps are: controlling the bleed source, maintaining permissive hypotension and adequate fluid resuscitation, providing coagulation support and treating/reversing trauma-induced coagulopathy. Supportive perfusion therapy provides maintenance of adequate pH, which, together with maintaining body temperature above 36℃. The shift to directed therapy based on standard coagulation tests and point-of-care methods (viscoelastic haemostatic assays), should be done as soon as possible. Substitution therapy is selected with the aim to correct the identified hemostasis disorder associated with trauma.

Abstract: Accidental foreign body ingestion is a common and often harmless event in childhood, especially among very young children, who naturally explore their surroundings by putting objects in their mouths. However, certain objects whose ingestion carries a risk of complications, sometimes potentially life-threatening. Being aware of these is particularly important, as their removal must be performed as soon as possible in a specialized center. Among these, button batteries, magnets, sharp objects, and coins require special attention. The location of the object is also important in determining the degree of urgency. Since symptoms may be absent initially or are completely nonspecific, the medical history is crucial, as prompt and correct management is particularly important. In the absence of a clear medical history, the diagnosis is often based on a high degree of suspicion. Therefore, this article aims to analyze the situations when a foreign body ingestion constitutes an emergency and to present the appropriate diagnostic and therapeutic approach in specific cases. Preventive measures are important in avoiding these life-threatening situations, and therefore, parents and caregivers must be informed and take steps to keep children from accessing dangerous objects.

Abstract: Background/Objectives: In male trauma patients suspected of having a pelvic fracture with urethral injury (PFUI), repeated urethral catheterization attempts can cause additional injury. Since 2021, our institution has been performing simultaneous percutaneous cystostomy using a guidewire and anterograde urethral Foley catheter insertion during pelvic angiography in patients with suspected PFUI. We aimed to analyze the characteristics and clinical course of this patient group. Methods: We retrospectively analyzed male trauma patients who were admitted to our emergency department between January 2021 and December 2025, and who underwent the aforementioned interventional procedure after standard Foley catheterization failed because of a pelvic fracture-associated urethral injury. The age, mechanism of injury, injury severity score (ISS), abbreviated injury scale, type of pelvic fracture, use of pelvic angiography, time from emergency room arrival to Foley catheterization, and administration of additional urological treatments were investigated. Results: Among 492 male patients with pelvic fractures, 11 underwent the procedure because of PFUI (age: 57.8 ± 13.9 years, ISS: 20.2 ± 9.6). Pelvic crushing was the most common injury mechanism, and pelvic angiography was performed in 81.8% of cases. The mean time from emergency room arrival to interventional Foley catheterization was 283 ± 250 min. Three patients required additional urological treatment after the acute phase, and all underwent endoscopic internal urethrotomy for urethral stricture. Conclusions: In cases in which hemodynamically unstable PFUI is suspected and initial urethral catheterization is difficult, Foley catheter insertion via interventional radiology may represent an alternative to conventional primary endoscopic realignment and suprapubic cystostomy.

Abstract: Most children presenting with a life-threatening cardiopulmonary catastrophe will have a final diagnosis of a benign, self-limited, or low-risk condition. The emergency physician must be able to recognize the pattern of normal development and not mistake it for a life-threatening condition. There are 5 pediatric presentations that commonly prompt the emergency physician to consider a cardiac or respiratory emergency. These are briefly discussed as they relate to the emergency physician and are resolved as BRUE, breath-holding spells, syncope of reflex and vasovagal origin, chest pain of benign origin, and innocent heart murmur or irregularity. Common pathophysiologic themes underlying these clinical presentations are (1) transient autonomic instability, (2) exaggerated physiologic response to pain or emotional stress, (3) benign pain of musculoskeletal or chest wall origin, and (4) cardiac flow or rhythm abnormalities with normal structural and functional cardiopulmonary findings. A framework for the evaluation of a child with an acute presentation and concern for a life-threatening condition is (1) determine if the child is currently unstable, (2) recreate the event and identify red flags for conditions such as seizure, sepsis, myocarditis, arrhythmia, critical congenital heart disease, or pulmonary embolic disease, (3) selective ordering of diagnostic tests rather than reflexive testing, and (4) disposition based on (a) whether the child's symptoms are recurrent, (b) abnormal physical examination, (c) abnormal electrocardiogram, (d) the child's history placing them at high risk for serious illness, and (e) the child failing to return to a normal baseline after observation. Each of these points will be elaborated upon and the step-by-step actions that are taken at the bedside and an explanation of what to do, how to do it, and why will be provided. Children with BRUE should have a focus placed on risk stratification as opposed to ordering a battery of diagnostic tests. Children with breath-holding spells require safe positioning of the child on their back and recognition of the 2 phenotypes of breath-holding (cyanotic and pallid) and their relationship to iron deficiency. Children with syncope of reflex or vasovagal origin can typically be distinguished from those with ominous causes based on history, particularly an orthostatic component, and ECG screening is indicated. Children with chest pain of benign origin can typically have a distinction made between musculoskeletal origin or precordial catch and exertional, inflammatory, or even ischemic origin of their chest pain. Children with an innocent heart murmur and isolated cardiac ectopy are 2 of the most common outpatient and emergency department concerns for which children and their families are referred for urgent imaging. The majority of children with these presentations will have a completely normal physical examination and can be managed as an outpatient. A pathophysiology-based, clinically concrete approach to the evaluation of children with acute presentations will lead to decreased overtesting and improved accurate disposition of children with concerns for life-threatening illness while maintaining sensitivity for detecting dangerous cardiopulmonary disease.

Abstract: Objectives: To evaluate the impact of Point-of-Care Ultrasound (POCUS) performed by family physicians on the management of abdominal pain in the emergency department, assessing its effect on length of stay, performance of complementary diagnostic tests, diagnostic concordance, and patient satisfaction. Methods: Quasi-experimental pilot study with a control group conducted in a hospital emergency department. A total of 222 adult patients with abdominal pain were included and allocated according to the attending professional (with or without ultrasound training). Clinical, care-related, and patient-satisfaction variables (SERVPERF questionnaire) were analyzed. Non-parametric statistical tests were used, and multiple linear regression analyses were performed. Results: The POCUS group showed a shorter length of stay (3.46 vs. 4.41 hours; p=0.022) and a lower number of plain radiographies (16.8% vs. 69.9%; p<0.001) and CT scans (p=0.034). Diagnostic concordance was significantly higher in the experimental group (99.2% vs. 75.7%; p<0.001). Overall satisfaction with received care was also higher in the intervention group (p<0.001), with significant differences observed across all evaluated dimensions. The multivariate model explained 26.6% of the variability, with patient satisfaction emerging as a positive predictor. Conclusions: POCUS improves the quality of care in emergency departments by reducing length of stay and the use of complementary diagnostic tests while increasing diagnostic accuracy and patient satisfaction. Its implementation can be considered an effective and potentially cost-effective strategy; however, further studies with greater methodological robustness are required to validate the development of standardized composite indexes.

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.