Ahmad A Oqlat,1 Ammar A Oglat,2 Mohammad K Alsuleiman,1 Saad A Saidan,1 Anas Isawi31Department of Accident and Emergency Medicine, Jordan University of Science and Technology, Irbid, Jordan; 2Department of Medical Imaging, The Hashemite University, Zarqa, Jordan; 3Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab EmiratesCorrespondence: Ahmad A Oqlat, Email aaoqlat@just.edu.joBackground: Parotitis, inflammation of the parotid gland, is most commonly attributed to infection, salivary duct obstruction, or autoimmune disease; trauma-induced parotitis is uncommon, and blunt-trauma cases are reported less frequently than penetrating injury.Case presentation: We describe a 4-year-old boy who presented to the emergency department with left-sided facial swelling one day after a low-velocity slap to the cheek during play. Examination showed tender left parotid swelling without bruising, pain-limited trismus, and no facial nerve, otologic, oral cavity, or temporomandibular joint abnormalities; a whole-body skin survey and a formal social-work assessment for non-accidental injury were unremarkable. Computed tomography, obtained because the mechanism of injury required clarification and mandibular fracture could not initially be excluded on clinical grounds, showed parotid enlargement with adjacent fat stranding and no fracture. Markedly elevated serum amylase, with normal inflammatory markers and negative viral serology, supported a diagnosis of traumatic parotitis after systematic exclusion of infectious, obstructive, and suppurative causes. The child was managed conservatively and recovered fully within two weeks.Conclusion: This case adds to the limited literature on post-traumatic parotitis by illustrating that even a low-velocity, everyday mechanism such as a slap can produce isolated parotid swelling in children, an association not previously emphasized outside higher-energy blunt trauma. It highlights the value of a structured differential work-up, judicious imaging, and routine safeguarding assessment in this presentation.Keywords: acute parotitis, blunt facial trauma, pediatric patient, facial edema, parotid gland, non-accidental injury
Introduction:Water-related emergencies are a major urban public health concern, particularly along Bangkok's heavily trafficked Chao Phraya River. Between 2019 and 2023, Bangkok reported the third-highest drowning mortality rate in Thailand. Although advanced water-based emergency medical service (EMS) units have operated for more than three decades, their operational characteristics have not been systematically evaluated. Objective:To describe the operational characteristics and system structure of advanced water-based EMS units operating along the Chao Phraya River in Bangkok. Methods:A retrospective descriptive study analyzed operational data from January 1, 2021, to December 31, 2023, using mission report databases from the Bangkok Metropolitan Administration EMS Center and three designated advanced water-based EMS units. Key variables included annual incident notifications, mission characteristics, operational outcomes, and system structure. Results:Descriptive evaluation identified several system limitations across all units, including inadequate docking infrastructure, shortages of specialized medical equipment, and the absence of standardized clinical protocols and performance monitoring. Comprehensive quantitative analysis was not possible for Units 2 and 3 because of incomplete operational records. Unit 1 recorded 28, 71, and 52 incident notifications in 2021, 2022, and 2023, respectively, resulting in 11, 50, and 18 EMS missions. Medical assistance was provided in 1, 11, and 9 cases, respectively. These findings are presented descriptively and should not be interpreted as comparisons between units because comparable operational data were unavailable for Units 2 and 3. Conclusion:Available data indicate important gaps in infrastructure, documentation, standardized reporting, and performance monitoring within Bangkok's water-based EMS system. Strengthening the system will require improved docking infrastructure, standardized medical equipment, digitized reporting systems, and the implementation of continuous quality improvement processes.
Purpose:This study investigated how emergency medical service personnel perceive the implementation of prehospital emergency care protocols in the Philippines, with particular attention to the discrepancy between self-reported adherence and reported operational barriers. Patients and Methods:The research utilized a sequential explanatory mixed methods design. Quantitative data collection involved a 56-item questionnaire answered by 114 EMS personnel from four regions in the Philippines (Metro Manila, Luzon, Visayas, Mindanao). Data collection for the qualitative component involved 4 focus group discussions and 6 in-depth interviews. Statistical techniques for analyzing qualitative data include descriptive statistics and chi-square tests of independence, while thematic analysis according to Braun and Clarke's six-step model, with two independent coders (Cohen's k=0.87), was used to analyze qualitative data. Results:Results obtained from the quantitative analysis suggested consistent high levels of implementation in all five domains of pre-hospital care (safety on the scene: mean=3.71, primary survey: mean=3.64, secondary survey: mean=3.61, detailed physical examination: mean=3.58, ongoing assessment: mean=3.74, all considered as high implementation). Qualitative results, however, demonstrated significant challenges in terms of operation, including time pressure while managing the scene, lack of airway and breathing devices, lack of standardization in training, no reassessment, insufficient documentation, and lack of communication between facilities. The contrast found in these results constitutes the core finding of the research. Conclusion:System-level effectiveness cannot be assumed from these self-report perceptions. Instead, the Philippine EMS system maintains a high level of normative protocol awareness yet is structurally weak in its implementation. The "paradox of implementation" indicates that intervention must focus more on resource provision, standardization, and coordination than on protocol dissemination.
Purpose:Pediatric septic shock is frequently associated with myocardial dysfunction and high mortality. Cardiac troponin I (cTnI) is a biomarker of myocardial injury, while the Ultrasonic Cardiac Output Monitor (USCOM) enables non-invasive hemodynamic assessment. This study aimed to explore the correlation between USCOM-derived hemodynamic parameters and serum cTnI levels in pediatric septic shock, and to examine the association of inotropic therapy with troponin levels. Patients and Methods:A prospective observational study was conducted in 32 pediatric patients with septic shock admitted to Hasan Sadikin Hospital, Bandung, between May and September 2025. Serial USCOM measurements were performed at 1, 3, 6, 12, and 24 hours to assess cardiac index (CI), stroke volume index (SVI), Smith-Madigan Inotropy Index (SMII), and systemic vascular resistance index (SVRI). Serum cTnI levels were measured at 6 and 24 hours using a high-sensitivity assay. Correlations were analyzed using Spearman's test, and multivariable regression was applied to explore independent associations. Results:Median cTnI levels increased significantly from 71 pg/mL at 6 hours to 201 pg/mL at 24 hours (p < 0.01). Early changes in SVI (1-6 hours) were negatively correlated with cTnI at 6 hours (r = -0.409; p = 0.020). SMII at 1 hour was positively correlated with cTnI at 24 hours (r = 0.409; p = 0.025), while SVI at 24 hours showed a positive correlation with cTnI at 24 hours (r = 0.387; p = 0.035). The number of inotropic agents was independently associated with higher cTnI levels at both 6 and 24 hours. Conclusion:Serum cTnI levels increased during the first 24 hours of pediatric septic shock and were associated with dynamic hemodynamic changes. These findings suggest a potential role for integrating serial troponin measurement with non-invasive hemodynamic monitoring. Further studies with larger cohorts are needed to validate these observations.
This commentary examines cyberwarfare targeting healthcare supply chains as an underrecognized threat to emergency medical services (EMS) in the United States, using the March 2026 Stryker cyberincident as a case study. We argue that in the context of prehospital settings, cybersecurity is inseparable from patient safety, operational continuity, and equipment readiness.
Background:Emergency department shock rooms provide immediate care for critically ill patients requiring life-saving interventions. Rapid diagnosis and treatment are crucial determinants of survival, yet factors predicting outcomes in this population remain poorly understood. This study evaluated factors associated with survival among patients hospitalized after shock room treatment in a tertiary medical center. Methods:In this retrospective cohort study, medical records of patients treated in the emergency department shock room of a tertiary referral center were reviewed. Patients were categorized according to hospital survival. Variables analyzed included age, sex, comorbidities, etiology of the acute event, vital signs at admission and discharge from the SR (including blood pressure, heart rate, respiratory rate, body temperature, and oxygen saturation), out-of-hospital mechanical ventilation, and laboratory values including creatinine, hemoglobin, lactate, electrolytes, and coagulation parameters. Results:A total of 101 patients treated over 24 consecutive months were included. The cohort comprised 50 men and 51 women with a mean age of 68±20 years (range 18-100). The mean shock room stay was 4.69±4.3 hours. Sixteen patients (16%) arrived following out-of-hospital resuscitation and were invasively ventilated. Overall, 60 patients (60%) died during hospitalization. Approximately half of all admissions were related to respiratory system morbidity. Mortality was significantly higher among patients aged >65 years than among those aged ≤65 years (75% vs 34%, p=0.046). Oncological disease as a comorbidity was significantly more prevalent in deceased patients (38% vs 10%, p=0.001). Admission creatinine was higher in deceased patients (1.5 vs 0.9 mg/dL, p=0.004) and hemoglobin was lower (11.9 vs 12.9 g/dL, p=0.044). Respiratory rate was significantly higher (18 vs 12 breaths/min, p=0.002) and diastolic blood pressure lower (67.5 vs 79.0 mmHg, p=0.011) in patients who died. Diastolic blood pressure remained significantly lower at shock room discharge in deceased patients (p=0.010). Shock room stay duration (≤4 vs >4 hours) was not significantly associated with mortality (OR 0.66, p=0.320). Conclusion:Age over 65, elevated creatinine, low hemoglobin, high respiratory rate, and low diastolic blood pressure at admission were associated with in-hospital mortality. Persistent diastolic hypotension at shock room discharge was a novel finding. Shock room stay duration was not independently associated with mortality. These findings are exploratory and prospective validation in larger cohorts is needed.
Yousef Shukha,1 Salam Ghanayim,2 Hisam Hossen Zaidani,2 Ihab Dabbah,2 Jubran Boulos,1 Ahmad Hassan,3 Shadi Hamoud1,41Department of Internal Medicine, Rambam Health Care Campus, Haifa, Israel; 2Department of Emergency Medicine, Rambam Health Care Campus, Haifa, Israel; 3Department of Cardiology, Bnai-Zion Medical Center, Haifa, Israel; 4Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, IsraelCorrespondence: Shadi Hamoud, Department of Internal Medicine E, Rambam Health Care Campus, and Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel, Tel +97247772300, Fax +97247771691, Email s_hamoud@rmc.gov.ilBackground: Emergency department shock rooms provide immediate care for critically ill patients requiring life-saving interventions. Rapid diagnosis and treatment are crucial determinants of survival, yet factors predicting outcomes in this population remain poorly understood. This study evaluated factors associated with survival among patients hospitalized after shock room treatment in a tertiary medical center.Methods: In this retrospective cohort study, medical records of patients treated in the emergency department shock room of a tertiary referral center were reviewed. Patients were categorized according to hospital survival. Variables analyzed included age, sex, comorbidities, etiology of the acute event, vital signs at admission and discharge from the SR (including blood pressure, heart rate, respiratory rate, body temperature, and oxygen saturation), out-of-hospital mechanical ventilation, and laboratory values including creatinine, hemoglobin, lactate, electrolytes, and coagulation parameters.Results: A total of 101 patients treated over 24 consecutive months were included. The cohort comprised 50 men and 51 women with a mean age of 68± 20 years (range 18– 100). The mean shock room stay was 4.69± 4.3 hours. Sixteen patients (16%) arrived following out-of-hospital resuscitation and were invasively ventilated. Overall, 60 patients (60%) died during hospitalization. Approximately half of all admissions were related to respiratory system morbidity. Mortality was significantly higher among patients aged > 65 years than among those aged ≤ 65 years (75% vs 34%, p=0.046). Oncological disease as a comorbidity was significantly more prevalent in deceased patients (38% vs 10%, p=0.001). Admission creatinine was higher in deceased patients (1.5 vs 0.9 mg/dL, p=0.004) and hemoglobin was lower (11.9 vs 12.9 g/dL, p=0.044). Respiratory rate was significantly higher (18 vs 12 breaths/min, p=0.002) and diastolic blood pressure lower (67.5 vs 79.0 mmHg, p=0.011) in patients who died. Diastolic blood pressure remained significantly lower at shock room discharge in deceased patients (p=0.010). Shock room stay duration (≤ 4 vs > 4 hours) was not significantly associated with mortality (OR 0.66, p=0.320).Conclusion: Age over 65, elevated creatinine, low hemoglobin, high respiratory rate, and low diastolic blood pressure at admission were associated with in-hospital mortality. Persistent diastolic hypotension at shock room discharge was a novel finding. Shock room stay duration was not independently associated with mortality. These findings are exploratory and prospective validation in larger cohorts is needed.Keywords: shock room, mortality, critical illness, prognostic factors, resuscitation
Kelsey R Gordon,1 Edward E Denton,2 Carlos Talledo,1 Grace Mathew,1 Jessie Nicholson,1 Christian Angelo I Ventura11Kansas College of Osteopathic Medicine, Kansas Health Science University, Wichita, KS, USA; 2College of Medicine, University of Arkansas for Medical Science, Little Rock, AR, USACorrespondence: Christian Angelo I Ventura, Kansas College of Osteopathic Medicine, Kansas Health Science University, Wichita, KS, USA, Tel +1 732 372-2141, Email cventura@mail.kansashsc.orgAbstract: This commentary examines cyberwarfare targeting healthcare supply chains as an underrecognized threat to emergency medical services (EMS) in the United States, using the March 2026 Stryker cyberincident as a case study. We argue that in the context of prehospital settings, cybersecurity is inseparable from patient safety, operational continuity, and equipment readiness.Keywords: cyberwarfare, emergency medical services, STEMI, LIFENET, prehospital ECG transmission, rural health disparities, Stryker, healthcare cybersecurity
Background:Communication failures in the emergency department (ED) can delay consultations and worsen crowding. Hospitals now use phone-based systems, EMR-integrated secure chat, and EMR-adjacent messaging platforms for consultant communication, but few studies describe ED clinician experience with these workflows. Objective:To describe ED clinicians' perceived acceptability of, and experience with, an EMR-adjacent Microsoft Teams-based consultation workflow used alongside a telephone-based consultation pathway. Methods:We conducted a single-center post-implementation survey of clinicians who used a Microsoft Teams consultation workflow in an academic ED. The primary analysis focused on ED clinician responses; consulting clinician responses were reported descriptively because of the low estimated non-ED response rate. Results:Of 121 respondents, 82 were ED clinicians, and 39 were consulting clinicians. Among ED clinicians, 78.0% reported high acceptability of the Teams consultation workflow, 85.4% perceived improvements in the workflow, and 89.0% perceived a positive impact on patient care. Delays remained common, with 24.4% of ED clinicians reporting that responses were often delayed. Consulting clinician responses are reported descriptively only because of the low estimated non-ED response rate. Conclusion:ED clinicians reported high perceived acceptability of an EMR-adjacent Microsoft Teams consultation workflow used alongside a telephone-based consultation pathway. These results reflect post-implementation clinician perceptions and do not establish improved consultation timeliness, patient flow, or clinical outcomes.
Background:Acute stroke, particularly posterior circulation stroke, is often missed in emergency departments due to non-specific symptoms. We aimed to evaluate the diagnostic performance of the BE-FAST-V scale, which adds Vertigo assessment to the original BE-FAST, for acute stroke screening. Methods:The study included 1,094 patients presenting to a tertiary hospital's emergency department with suspected stroke. On arrival, the BE-FAST-V scale, which assesses Balance, Eyes, Face, Arm, Speech, Time, and Vertigo, was administered. Stroke diagnoses were confirmed through imaging. Diagnostic accuracy metrics, including sensitivity, specificity, and predictive values, were calculated. Results:The BE-FAST-V scale demonstrated high diagnostic accuracy, strong sensitivity, and moderate specificity. Adding vertigo improved the detection of posterior circulation strokes, which are often missed due to nonspecific symptoms. Conclusion:The BE-FAST-V tool presented a highly sensitive and practical value for stroke screening in the emergency department. Its ability to identify posterior circulation strokes, including those presenting with vertigo, addresses a critical gap in stroke diagnosis and supports early treatment initiation. Broader implementation and further validation across multiple centers could enhance its role in improving stroke outcomes globally.
Purpose:This study describes the transformation of a rural trauma center in the Upper Mountain West, which expanded from 280 to 305 beds between 2011 and 2022, and from an American College of Surgeons (ACS) verified Level II to Level I facility, serving a four-state region. Patients and Methods:A retrospective analysis of all 8947 trauma activations from 2011-2022 was conducted using the institution's trauma registry. A structured gap analysis assessed alignment with ACS Level I principles. Results:The gap analysis identified four priority areas for growth and development of our trauma program to become an ACS Level I Trauma Center: patient volumes, absence of a Surgical Intensive Care Unit (SICU), lack of a surgical residency program, and limited trauma research infrastructure. Targeted interventions led to the establishment of a dedicated SICU, initiation of PGY-4 surgical rotations, and the development of trauma-focused research capacity. By 2023, the number of severely injured patients (Injury Severity Score (ISS) ≥16) exceeded ACS thresholds despite total admissions remaining below 1200. Between 2011 and 2022, 8947 trauma patients were treated. Mean patient age increased from 42.6 to 51.8 years (p <0.0001), with geriatric cases rising from 19.8% to 37.1% and female patients from 33.3% to 41.2%. Overall injury severity decreased (mean ISS 10.4 to 9.7; p <0.0001), but ICU patient acuity rose (ISS 15.9 to 17.9; p <0.0001). Mortality remained stable (3.3-4.0%). ICU admissions declined from 33.1% to 22.6%, while length of stay and patient acuity increased (49.6% and 4.7%, respectively). Interfacility transfer rates decreased from 2.8% to 1.1% (p=0.0372), reflecting improved system capacity. Conclusion:Strategic investments in infrastructure, workforce development, education, and research enabled this rural trauma center to achieve Level I criteria while adapting to changing patient demographics and clinical demands. These implementation strategies may inform similar resource-constrained rural trauma systems pursuing ACS Level I verification.
Carly Rosen,1,2 Norman Ng,1,2 Arsalan Shawl,1,2 Kurien Mathews,1,2 Alexia Armanious,1,2 Boris Khodorkovsky,1,2 Amin Mohamadi,1,2 Barry Hahn1– 31Northwell Health, New Hyde Park, NY, USA; 2Department of Emergency Medicine, Staten Island University Hospital, Staten Island, NY, USA; 3Department of Emergency Medicine, Hadassah University Medical Center–Ein Kerem, Jerusalem, IsraelCorrespondence: Barry Hahn, Department of Emergency Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY, 10305, USA, Email bhahn@northwell.eduBackground: Communication failures in the emergency department (ED) can delay consultations and worsen crowding. Hospitals now use phone-based systems, EMR-integrated secure chat, and EMR-adjacent messaging platforms for consultant communication, but few studies describe ED clinician experience with these workflows.Objective: To describe ED clinicians’ perceived acceptability of, and experience with, an EMR-adjacent Microsoft Teams–based consultation workflow used alongside a telephone-based consultation pathway.Methods: We conducted a single-center post-implementation survey of clinicians who used a Microsoft Teams consultation workflow in an academic ED. The primary analysis focused on ED clinician responses; consulting clinician responses were reported descriptively because of the low estimated non-ED response rate.Results: Of 121 respondents, 82 were ED clinicians, and 39 were consulting clinicians. Among ED clinicians, 78.0% reported high acceptability of the Teams consultation workflow, 85.4% perceived improvements in the workflow, and 89.0% perceived a positive impact on patient care. Delays remained common, with 24.4% of ED clinicians reporting that responses were often delayed. Consulting clinician responses are reported descriptively only because of the low estimated non-ED response rate.Conclusion: ED clinicians reported high perceived acceptability of an EMR-adjacent Microsoft Teams consultation workflow used alongside a telephone-based consultation pathway. These results reflect post-implementation clinician perceptions and do not establish improved consultation timeliness, patient flow, or clinical outcomes.Keywords: emergency service, communications, consultations
Purpose:This study aims to evaluate and compare the prognostic performance of shock index (SI) and systolic blood pressure (SBP) for predicting mortality among trauma patients at risk of hemorrhage in South Africa, a high-trauma burden setting with resource constraints. Patients and Methods:This is a secondary analysis of data from the EpiC study, a prospective, multicenter observational investigation of trauma patients in the Western Cape, South Africa. Adult patients with blunt or penetrating injuries and no significant head injury were included. The predictor variables-SI and SBP at facility arrival-and the outcome (30-day mortality) were analyzed through a sequential analytical framework. Segmented logistic regressions identified inflection points; ROC analyses with Youden's J statistic determined optimal thresholds. Model comparisons employed DeLong's test, calibration plots, Brier scores, and decision curve analysis. Subgroup analyses were conducted by injury mechanism and severity. Results:Among 3609 patients, 6.1% died within 30 days. SI demonstrated an inflection point at 0.69 and SBP at 82 mmHg. ROC analysis yielded similar AUCs of 0.62 (SI) and 0.60 (SBP) (p=0.418). However, SI showed superior calibration (Brier score: 0.054 vs 0.058), a higher positive likelihood ratio (2.70 vs 2.01; p<0.001), and greater net benefit across a broader range of predicted-risk thresholds on decision curve analysis. The optimal SI cutoff of ≥1.21 yielded 85.1% specificity and 40.3% sensitivity. Conclusion:Both SI and SBP demonstrated only modest discrimination for 30-day mortality, reflecting the inherent limitations of single vital-sign predictors in complex trauma populations. Within these constraints, SI showed marginally better calibration and rule-in performance than SBP; however, neither predictor alone is sufficient for definitive mortality risk prediction. An SI threshold of ≥1.21 may serve as a practical screening tool to flag high-risk patients warranting closer monitoring or escalated care, particularly in resource-limited settings where laboratory and imaging resources are constrained.
Background:Heat stroke is a leading cause of mortality during the Hajj season, yet data on its clinical progression remain limited. Objective:This study evaluates the clinical characteristics, complications, and outcomes of heat stroke among pilgrims. Methods:This prospective exploratory cohort study included adult pilgrims (≥18 years) who were admitted with a confirmed diagnosis of heat stroke, defined as a core temperature ≥40°C and central nervous system dysfunction, across nine hospitals. The primary endpoint measure is the frequency of at least one heat stroke-related complication. Patients were stratified into those discharged from the treating ICU and those transferred to an advanced referral center, with transfer used as a pragmatic surrogate for greater clinical severity within the Hajj healthcare system. Results:Twenty-three patients were included (mean age 65.1 ± 10.5 years; 56.5% male). Fifteen (65.2%) were discharged from the treating ICU, whereas eight (34.8%) were transferred to an advanced referral center. Compared with discharged patients, the transferred group showed higher ccreatinine upon admission (165.50 (146.00-185.50) vs. 130.50 (114.25-152.25); P=0.02), Peak creatinine values (275.90 (223.32-328.80) vs. 143.00 (126.00-160.50); p = 0.001), peak Urea values (17.40 (13.70-23.95) vs. 11.00 (8.70-13.00); p = 0.01); and the highest AST during admission was also higher in the transferred group (P=0.015). The lowest platelet counts during the patient's admission were significantly reduced in the transferred group (p = 0.007). Mechanical ventilation was required more often in the transferred group (75.0% vs. 26.7%; p = 0.026), and its duration was longer (p = 0.019). Given the small sample size, these findings should be considered exploratory. Conclusion:In this small, exploratory cohort, patients requiring transfer to an advanced referral center generally had a greater burden of organ dysfunction and required more critical care interventions. These observations should not be interpreted as establishing predictors of severe heat stroke because transfer status may also reflect healthcare system factors. Larger prospective multicentre studies are required to determine whether these observed differences are reproducible and clinically meaningful.
Liping Zhou, Yiqing Xu, Beibei Hu, Jiexiang Lou, Xinying Zhou, Huilin Chu, Zhihong YeNursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China*These authors contributed to the work equallyCorrespondence: Zhihong Ye, Email Yezh@srrsh.comBackground: Acute stroke, particularly posterior circulation stroke, is often missed in emergency departments due to non-specific symptoms. We aimed to evaluate the diagnostic performance of the BE-FAST-V scale, which adds Vertigo assessment to the original BE-FAST, for acute stroke screening.Methods: The study included 1,094 patients presenting to a tertiary hospital’s emergency department with suspected stroke. On arrival, the BE-FAST-V scale, which assesses Balance, Eyes, Face, Arm, Speech, Time, and Vertigo, was administered. Stroke diagnoses were confirmed through imaging. Diagnostic accuracy metrics, including sensitivity, specificity, and predictive values, were calculated.Results: The BE-FAST-V scale demonstrated high diagnostic accuracy, strong sensitivity, and moderate specificity. Adding vertigo improved the detection of posterior circulation strokes, which are often missed due to nonspecific symptoms.Conclusion: The BE-FAST-V tool presented a highly sensitive and practical value for stroke screening in the emergency department. Its ability to identify posterior circulation strokes, including those presenting with vertigo, addresses a critical gap in stroke diagnosis and supports early treatment initiation. Broader implementation and further validation across multiple centers could enhance its role in improving stroke outcomes globally.Keywords: BE-FAST-V, stroke, emergency department, screening scale, posterior circulation stroke, vertigo
Background: Small bowel adenocarcinoma (SBA) is considered an unusual malignancy with vague presentations thus risk of delayed diagnosis. Despite being rarely reported in the literature, SBA can present with gynecological manifestations, especially adnexal mass, misleading surgeons in dealing with it as a primary gynecological malignancy. Methods: We report a case of a 60 year old female patient who had SBA with pelvic mass as initial presentation. Identification of intestinal origin was done intraoperatively. Surgical resection of tumor and adnexal involvement with referral for oncological chemotherapy was done. Through this case we highlight the challenges experienced by surgeons in diagnosing SBA with gynecological disease, as well the clinical implications of atypical SBA presentations. Reported following CARE guidelines. In addition to the case reported, a focused narrative review of literature was performed. Searching Pubmed database from inception to December 2025 using related keywords, identification of case reports reporting SBA presentation with gynecological disease was done. Data related to patient demographics, clinical manifestations, diagnostic, treatment strategies, and oncological outcomes, were extracted and pattern identification was conducted. A diagnostic algorithm was developed and presented to improve diagnostic delay in approaching adnexal masses with "Red Flags" suspicious of SBA. Results: Fourteen cases describing small bowel adenocarcinoma (SBA) presenting with gynecologic manifestations were identified-published between the years (1995-2024). Approximately the age range of patients was between 12 and 65 years with most patients presenting in the fifth and sixth decades. The jejunum was the most common primary tumor site (10/14 cases, 71%), followed by the ileum (4/14 cases, 29%). The most common initial presentation reported across the studies was ovarian/adnexal mass. Diagnostic delay was common, ranging from several weeks to over 12 months, with SBA rarely suspected preoperatively. Recurrent red flags included iron-deficiency anemia, chronic gastrointestinal symptoms, unintentional weight loss, obstructive symptoms, disproportionate ovarian tumor size, and discordance between clinical presentation and gynecologic findings. Ovarian metastases were present in all reported cases (14/14 cases, 100%), while peritoneal, mesenteric, nodal, hepatic, and uterine involvement occurred less frequently. The definitive diagnosis was established following surgical exploration through histopathological and immunohistochemistry evaluation. Surgical management was dependent on timely diagnosis, with both bowel and gynecological resections required, followed by postoperative chemotherapy. Outcomes were also dependent on disease stage at the time of diagnosis. Conclusion: Atypical adnexal masses in association with gastrointestinal or systemic red flags should raise the possibility of SBA. We propose a clinical diagnostic framework to help general surgeons and gynecologists with early identification of SBA presenting as pelvic mass, thus providing appropriate management of this rare clinical entity.
Background:Emergency departments (EDs) play a critical role in managing individuals experiencing mental health crises who are involuntarily transported under mental health legislation. Although collaborative models such as co-responder teams and diversion services have shown operational benefits, their implementation is inconsistent and rarely embedded within systems that support sustained practice development. Communities of Practice (CoPs), which emphasise ongoing social learning and shared practice, may offer a framework to address this gap. Objective:To map the scope of published research on involuntary mental health presentations to EDs and to assess whether the evidence supports the existence, implementation, or potential value of CoP approaches in this context. Eligibility Criteria and Information Sources:Peer-reviewed studies published in English from 2008 onwards were included if they examined responses to involuntary mental health presentations in EDs within common law countries (Australia, Canada, Aotearoa New Zealand, the United Kingdom, and the United States). Searches were conducted in Medline, PubMed, Embase, PsycINFO, and Google Scholar, supplemented by targeted grey literature searches and an AI-assisted search tool. Methods:Following Joanna Briggs Institute scoping review methodology, studies were screened and selected by two independent reviewers. Data extraction and synthesis were conducted using a structured framework, with studies analysed for evidence of CoP-consistent elements such as collaborative learning, interagency communication, and shared practice development. Results:Sixty-five studies met inclusion criteria (40 quantitative retrospective, 11 quantitative prospective, 10 qualitative, and 4 mixed methods), predominantly from the United States (n=30) and Australia (n=23). Only one study explicitly evaluated a CoP, and no sustained CoP structures were identified. While many studies described collaborative practices consistent with CoP principles-such as interagency coordination, shared training, and improved communication-these were typically operational and episodic rather than embedded in ongoing systems of shared learning and practice development. Conclusion:Despite the growth of research and the demonstrated benefits of collaborative service models, there is little evidence of formalised CoP approaches in emergency mental health care for involuntary patients. This absence suggests a gap in sustained collaborative learning mechanisms that may limit system level improvement. CoPs may offer a theoretically coherent framework to address this gap. Future research should examine the feasibility, implementation, and impact of CoPs, particularly through qualitative and mixed-methods approaches.
Background:D-dimer is a fibrin degradation product formed during fibrinolysis and reflects the activation of coagulation and fibrinolytic pathways. The role of D-dimer in acute coronary syndrome (ACS) remains uncertain. This study was designed to analyse differences in D-dimer levels in patients with different forms of ACS and the diagnostic efficiency and possible complementary role of the D-dimer biomarker. Methods:This study applied a retrospective observational design and included adult patients presenting to the emergency department with chest pain. Differences in D-dimer levels across diagnostic categories were analysed. To evaluate the diagnostic performance of D-dimer, receiver operating characteristic (ROC) analysis was conducted, which involved calculations of area under the curve (AUC), sensitivity, specificity, and likelihood ratios. Also, the incremental value of D-dimer over clinical data and cardiac troponin was determined through a multivariate logistic regression model. Results:The study found that the level of D-dimer was significantly higher in patients with ST elevation myocardial infarction (STEMI) and Non-ST elevation myocardial infarction (NSTEMI) compared to patients with unstable angina (UA) and non-specific chest pain (p < 0.001). As per ROC analysis, the level of D-dimer demonstrated modest discrimination between STEMI/NSTEMI and unstable angina (AUC 0.618; 95% CI 0.538-0.697), and a fair discrimination between STEMI/NSTEMI and non-specific chest pain (AUC 0.668; 95% CI 0.601-0.736). At a cutoff of 0.50 mg/L, sensitivity and specificity were limited. In multivariable models, D-dimer did not provide incremental diagnostic value beyond clinical variables and cardiac troponin (ΔAUC not significant). Conclusion:Despite higher D-dimer concentrations in myocardial infarction, the marker exhibited modest diagnostic performance and did not provide additional diagnostic value over cardiac troponin. Therefore, D-dimer is suggested to be used as an adjunct rather than primary diagnostic instrument in patients presenting with suspected acute coronary syndrome.
Background: Emergency preparedness is a challenge for hospital emergency departments (EDs). In the USA, over 68% of 983 EDs were not emergency prepared, while in Ghana, one hospital's emergency preparedness level was only 57.4%. At the health facility level, several barriers to emergency preparedness have been reported, including poor access to medical supplies, medications, and equipment; deficits in medical training; and the absence of formal clinical management protocols. Methodology: A cross-sectional study was conducted at the Accident and Emergency (A&E) Ward of Mbarara Regional Referral Hospital (MRRH). Data was collected using the modified WHO HEAT checklist, completed by three (3) key hospital informants, who were preferred for their key insights over a large sample of general staff. Data fell into 11 variables with items in each variable scored between 0 and 2, then the total scores generated percentages. By univariate analysis, the level of emergency preparedness and the associated barriers at the A&E Ward of MRRH were determined. Results: The overall emergency preparedness score at the A&E ward of MRRH was 62.6%, with the human resources category under ED capacity scoring the lowest (37.5%), while the consulting services category under ED resources scored the highest (71.4%). The two most common associated barriers to emergency preparedness in the A&E were medicine stockouts (35.0%) and missing emergency equipment (29.2%), while the least reported barriers were user fees (2.2%), and opening hours (0.7%). Conclusion: According to this study, the level of emergency preparedness in the A&E ward of MRRH was weak, with low level of human resource, and weak quality improvement checks the most contributing factors. The highest reported barriers to strong emergency preparedness in the A&E ward of MRRH were medication stockouts and the absence of emergency equipment.
