Introduction: Creatine kinase (CK) has frequently been introduced as a predictive factor of rhabdomyolysis induced acute kidney injury (AKI) in several studies. However, its value, especially in traumatic and disaster settings, remains to be fully clarified. Methods: Online databases of Medline (via PubMed), Embase, Scopus, and Web of Science were systematically searched until May 15th, 2026 and studies evaluating the association between serum CK and AKI in traumatic rhabdomyolysis patients were included. Reports of CK were collected as mean differences between the AKI and non-AKI groups, odds ratios (ORs), and performance metrics such as sensitivity and specificity. Analyses were performed using STATA 17.0 statistical software. The study’s protocol has been registered with PROSPERO (CRD420251250906). Results: 17 articles were included in this study. Twelve studies encompassing 3122 rhabdomyolysis patients (AKI: 30.94%) evaluated mean CK values in AKI and non-AKI patients with a pooled mean difference of 21770.75 (95% CI: 8987.39 to 34554.11) IU/L between groups. Four studies of 3549 patients (AKI: 20.29%) reported a pooled adjusted OR of 7.62 (95% CI 2.80 to 20.76). Ten articles, including 3421 patients (AKI: 18.42%), reported prediction accuracy measures. The pooled analysis showed an AUC of 0.73 (95% CI: 0.69 to 0.77), with sensitivity 0.68 (95% CI: 0.55 to 0.78) and specificity of 0.68 (95% CI: 0.54 to 0.78). Conclusion: Our findings indicate that, across traumatic rhabdomyolysis populations, AKI was associated with higher CK levels, with a more pronounced elevation observed in earthquake-related settings, although heterogeneity was high. CK alone demonstrated only fair discriminatory performance, suggesting its use as part of a broader clinical risk assessment rather than as a sole predictor of AKI.
Introduction: Minocycline as a tetracycline derivative agent with anti-inflammatory and neuroprotective properties, has been investigated in both experimental and clinical settings. This study aimed to evaluated the therapeutic efficacy of Minocycline in acute traumatic spinal cord injury (SCI). Methods: This systematic review and meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Major electronic databases were comprehensively searched to identify preclinical animal studies and human clinical studies evaluating minocycline, alone or in combination therapies, for acute traumatic SCI management. Risk of bias was assessed using Joanna Briggs Institute (JBI) critical appraisal tools tailored to study design. Qualitative synthesis included all eligible studies, while quantitative synthesis was restricted to clinical studies reporting extractable effect estimates for neurological improvement. Results: A total of 9 studies met inclusion criteria for qualitative synthesis. Preclinical studies demonstrated consistent biological effects of minocycline on inflammatory markers, oxidative stress, and histopathological outcomes, particularly in combination therapies, although functional recovery with minocycline monotherapy was inconsistent. Clinical studies indicated that minocycline was generally well tolerated; however, most trials did not demonstrate statistically significant improvements in neurological or functional outcomes. Only two clinical studies provided suitable data for meta-analysis, yielding a pooled odds ratio of 1.70 (95% confidence interval (CI): 0.95–3.06) for neurological improvement, which did not reach statistical significance. Conclusion: Current evidence suggests that while minocycline exhibits promising biological activity and an acceptable safety profile in acute traumatic SCI, robust clinical efficacy has not been conclusively demonstrated. Well-designed, adequately powered randomized controlled trials with standardized outcome reporting are required to determine whether these biological effects translate into meaningful functional recovery.
Introduction:Endotracheal intubation is a life-saving procedure, but it can result in complications such as hypotension, hypoxia, and cardiac arrest. This study aimed to identify physiological factors associated with difficult intubation in emergency departments (ED), in order to derive an exploratory bedside risk score. Methods:This retrospective cohort study included patients aged ≥15 years who underwent endotracheal intubation in the ED. Pre-intubation physiological variables, procedural characteristics, and peri-intubation severe adverse events (severe hypoxemia, hypotension, and cardiac arrest) were extracted from standardized intubation records and electronic medical records. Independent physiological predictors of peri-intubation severe adverse events were extracted using logistic regression analysis, and an exploratory point-based bedside risk score was derived and internally validated. Results:Among 720 eligible patients, 137 (19.0%) experienced peri-intubation severe adverse events. Five clinically relevant physiological predictors were retained in the exploratory score: suspected sepsis, pre-intubation hypoxemia, low serum bicarbonate level, vasopressor requirement before intubation, and shock index >0.9. The simplified score ranged from 0 to 11 points and showed modest discrimination, with an optimism-corrected C-statistic of 0.686. At a threshold of ≥5 points, the score had limited sensitivity (32.1%) but high specificity (90.1%), with a positive predictive value of 43.1% (95% confidence interval (CI): 33.4--53.3) and a positive likelihood ratio of 3.23 (95% CI: 2.29--4.56). Conclusion:The exploratory physiological difficulty score showed modest discrimination for peri-intubation severe adverse events. A threshold of ≥5 points identified a subgroup of patients who may require more preparation and closer monitoring before intubation. However, the score should not replace comprehensive clinical assessment and requires external validation.
Background:DNA methylation markers have been proposed as molecular triage tools for detecting cervical precancer and cancer, particularly among HPV-positive women. However, diagnostic performance varies across markers, assays, specimens, and clinical settings. This study aimed to evaluate the marker-specific diagnostic accuracy of DNA methylation markers and methylation panels for detecting CIN2+ and CIN3+ in cervical cancer screening, triage, and related diagnostic contexts. Methods:This systematic review and diagnostic test accuracy meta-analysis was reported according to PRISMA-DTA 10. Marker-specific analyses were performed separately by endpoint to avoid double counting. Pooled sensitivity, specificity, diagnostic odds ratio, clinical utility estimates, risk of bias, publication bias, and certainty of evidence were assessed using diagnostic test accuracy methods, QUADAS-2 11, Deeks' test 14, and GRADE-DTA 12,13. Results:The broad main diagnostic meta-analysis included 74 eligible studies 15-88, contributing 260 diagnostic test accuracy comparisons across 130 marker-endpoint-sample analyses. A strict sensitivity dataset included 164 comparisons from 51 studies. Seven marker analyses were available for CIN2+ and seven for CIN3+. Diagnostic performance varied by marker and endpoint. For CIN2+, S5 EPB41L3 plus HPV16/18/31/33 methylation showed the highest sensitivity but lower specificity, whereas PAX1, JAM3, SOX1, PAX1/JAM3, and Six-gene/GynTect showed higher specificity. For CIN3+, S5 showed the highest sensitivity, while PAX1/JAM3, JAM3, SOX1, PAX1, and Six-gene/GynTect had more balanced performance. Deeks' test did not show strong evidence of publication bias for most analyses, although borderline findings were observed in selected marker-endpoint analyses. GRADE-DTA certainty was low or very low across marker-endpoint analyses. Conclusions:DNA methylation markers showed heterogeneous diagnostic accuracy for detecting CIN2+ and CIN3+. Some markers demonstrated potentially useful sensitivity- or specificity-oriented profiles, but certainty of evidence was low or very low. Further standardized prospective validation is required before routine clinical implementation.
Introduction:Cardiopulmonary Resuscitation (CPR) is a critical emergency procedure that needs to be promptly administered to prevent irreversible damage and enhance the chances of survival. This systematic review and meta-analysis aimed to determine the success rate of CPR and the rate of survival to hospital discharge among patients who underwent CPR in hospitals throughout Iran. Methods:This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO) (CRD420251185276). A comprehensive search was conducted without time restriction until July 2026 in PubMed, Scopus, Web of Science, Google Scholar, SID, and Magiran databases. A random-effects model was used for meta-analysis, and heterogeneity was assessed using the I² index. Publication bias was evaluated using Begg's test. Data analysis was performed using STATA software (version 14). Results:Initially, 903 records were identified, and after removing duplicates and applying screening procedures, 47 studies met the inclusion criteria. The pooled analysis revealed that the rates of successful CPR, survival to discharge among successful CPR cases, and survival to discharge among all CPR attempts were 29.48% (95% confidence interval (CI): 25.04--33.92), 32.11% (95% CI: 24.00--40.21; I²=95.7%), and 8.63% (95% CI: 6.72--10.53), respectively. Meta-regression indicated an increasing trend over time for successful CPR, a decreasing trend for survival to discharge among cases with Return of Spontaneous Circulation (ROSC), and a significant increase in overall survival to discharge. Conclusion:This systematic review highlights that while the initial quality of CPR in Iran is generally satisfactory, there is a notable gap between successful resuscitation and survival to hospital discharge, primarily attributed to limitations in post-resuscitation care. Enhancing post-CPR management, expanding ICU capacity, improving team coordination, and standardizing equipment could significantly impact patient outcomes.
Introduction: Augmented reality (AR) and gamification have shown promise in medical education. This study aimed to examine their combined application in surgical instrument training for medical students. Methods: This 2×2 factorial randomized assignment involved 164 operating room students from two universities. Participants were categorized by university and randomly allocated to four intervention groups: Group A (AR + game-based learning; n = 41), Group B (AR only; n = 41), Group C (game only; n = 41), or Group D (traditional instruction; n = 41). The 3-week intervention comprised one 30-minute session per week. Outcomes included knowledge retention (assessed at baseline, 1 week, 1 month, and 3 months) and Objective Structured Clinical Examination (OSCE) performance, evaluating surgical suite recognition, instrument arrangement, instrument use, and time efficiency. Results: Group A (AR + game) showed better knowledge retention, with scores increasing from 44.7 ± 2.2 at baseline to 84.4 ± 2.7 at 1 week and remaining stable at 3 months (71.6 ± 1.9). Group D (traditional instruction) performed worst (56.7 ± 6.8 at 1 week; 48.6 ± 6.7 at 3 months). Total OSCE scores showed a similar trend: Group A scored 86.5 ± 4.3 out of 97, compared with Group D (62.7 ± 6.2). Factorial analysis confirmed significant benefits for AR versus non-AR (knowledge gain: 76.4 ± 9.1 vs. 62.3 ± 8.7; p < 0.001) and game versus non-game interventions (75.7 ± 8.9 vs. 63.0 ± 9.3; p < 0.001). Gender effects were sporadic and explained minimal variance. Conclusions: The integration of AR and gamification appeared to be the most effective approach in this study for improving knowledge retention and procedural proficiency in surgical instrument training. Gamification alone showed stable long-term retention and may serve as a cost-effective alternative when AR integration is not feasible.
Introduction: By reducing the need for certain in-demand services, the virtual clinics could increase overall healthcare accessibility and operational effectiveness. This study aimed to examine the effect of establishing these clinics on the frequency of emergency department (ED) and primary healthcare (PHC) visits across Saudi Arabia. Methods: A nationwide cross-sectional survey was carried out on 10,000 patients who had used virtual clinics in various parts of the country, between May 2024 and October 2025. A self-administered questionnaire was used in the study to collect information on the frequency and reasons for ED and PHC visits both before and after the introduction of virtual clinics. Fisher's exact tests, Pearson's chi-squared, and descriptive statistics were used in the data analysis process. Results: Among the participants, 44% used virtual clinics once, 23% twice, and 33% more than twice. The establishment of virtual clinics led to 20% decrease in ED visits and 18% decrease in PHC visits. Preferred services included general consultations (76%), prescription renewals (49%), and follow-up appointments (48%). Factors contributing to reduction in in-person visits were shorter wait times (45.18%), better accessibility (39.61%), and reduced costs (36.23%). Demographic factors such as age, gender, and income level significantly influenced virtual clinic utilization patterns (p < 0.001). Conclusion: Virtual clinics have raised operational efficiency while simultaneously enhancing the accessibility and quality of healthcare. The findings align with Saudi Arabia's Vision 2030 objectives on the digitization of the healthcare sector.
Introduction:Admission lactate and procalcitonin (PCT) are routinely measured in pediatric sepsis; however, their prognostic performance may vary by clinical phenotype. This study aimed to evaluate the shock-stratified prognostic performance of admission lactate and PCT for predicting in-hospital mortality in children with sepsis. Methods:In this retrospective cohort study (July 2022 - July 2025), children aged 2 months to 15 years evaluated for suspected sepsis were screened; 193 met eligibility criteria and were included in analyses. Septic shock was recorded at admission, and organ dysfunction was recorded at admission or within the first 24 hours. The Phoenix Sepsis Score was calculated in 143 patients with complete lactate and other required data, whereas the Pediatric Sequential Organ Failure Assessment (pSOFA) score was calculated for all 193 patients using data recorded within the first 24 hours. Admission lactate and PCT were summarized by survival status within shock and non-shock phenotypes. Multivariable logistic regression models adjusted for age and malnutrition assessed biomarker-mortality associations and biomarker × shock interactions. Discrimination was evaluated using shock-stratified receiver operating characteristic (ROC) curves and area under the curve (AUC), with DeLong tests comparing AUCs between phenotypes. Results:Among 193 children, 93 (48.2%) had septic shock, 145 (75.1%) had organ dysfunction, and 79 (40.9%) died in hospital. The median Phoenix Sepsis Score was 2.0 (range, 0--12) among 143 patients, while the median pSOFA score was 4.0 (range: 0--21) among all 193 patients. Mortality was higher in shock than non-shock sepsis (66.7% vs 17.0%; odds ratio (OR): 9.77 (95% confidence interval (CI): 4.96-19.24)) and in those with organ dysfunction (53.1% vs 4.2%; OR = 26.03 (95% CI: 6.09-111.34)). Admission lactate was higher in non-survivors than survivors in both non-shock and shock groups (p<0.05). In adjusted interaction models, each 1 mmol/L increase in lactate (OR = 1.50, 95% CI: 1.11--2.01; p = 0.0075) and each one-unit increase in natural-log--transformed PCT (ln(PCT)) (OR = 1.34, 95% CI: 1.01-1.79; p=0.0458) were associated with mortality in non-shock sepsis. The lactate × shock interaction (OR = 0.76, 95% CI: 0.55--1.05; p = 0.092) and ln(PCT) × shock interaction (OR = 0.74, 95% CI: 0.52--1.07; p = 0.114) were not statistically significant. Shock-stratified ROC curve analysis showed better discrimination in non-shock than shock for lactate (AUC: 0.76 (95% CI: 0.67-0.85) vs 0.62 (95% CI: 0.40-0.83); DeLong p=0.233) and modest discrimination for natural-log-transformed PCT [ln(PCT)] in both phenotypes (AUC: 0.65 (95% CI: 0.55-0.75) vs 0.61 (95% CI: 0.41-0.80); DeLong p=0.695). Conclusion:Admission lactate showed moderate discrimination for in-hospital mortality in non-shock sepsis, whereas discrimination was lower in septic shock. PCT showed modest discrimination across phenotypes. Although AUCs were numerically higher in non-shock sepsis, between-phenotype differences were not statistically significant, supporting phenotype-based interpretation and the need for external validation.
The 2024 IHR amendments offer a practical roadmap for disaster and emergency health, translating clearer international alert triggers into faster local surge activation and embedding fairness into the allocation of vaccines, oxygen, and supplies for those most at risk. Strengthened national focal points and standardized data flows help bridge the stubborn gap between public health surveillance and frontline prehospital care, so Emergency Medical Teams can deploy with fewer delays. Digital tools like AI-driven forecasting can sharpen surge planning, but only when anchored in transparent, human-reviewed safeguards. Turning promise into real capability means testing new alert workflows through joint exercises, updating cross-border mutual aid agreements, and investing in field infrastructure alongside robust data governance. Ultimately, these amendments will be judged by whether they shorten the time from signal to response and narrow access gaps for the vulnerable—making future responses not just faster, but measurably fairer.
Introduction: Artificial intelligence (AI) models applied to non-contrast brain computed tomography (CT) scan have demonstrated promising performance in hematoma detection, segmentation, and outcome prediction. Explainable artificial intelligence (XAI) has been proposed as a strategy to improve transparency and facilitate clinical integration. This study aimed to map and summarize XAI methods used in CT scan-based studies of intracranial hemorrhage (ICH), and to assess their validation approaches, transparency, and clinical relevance. Method: The scoping review was conducted in accordance with the PRISMA-ScR guidelines and was registered on the Open Science Framework (osf.io/5kxbt). In this review, original studies of adult and pediatric patients with spontaneous ICH that used AI or deep learning on non-contrast brain CT scan and included an explainability or interpretability method were eligible. Reviews, editorials, conference abstracts without full text, and studies without XAI components were excluded. PubMed, Embase, and Scopus were searched from inception to September 2025. Data were extracted on study design, imaging inputs, AI task, explainability technique, validation strategy, and reported clinical relevance. Results: A total of twelve studies met inclusion criteria. Most investigations focused on hematoma detection, segmentation, or prediction of functional outcome or mortality. Gradient-based visualization techniques, particularly Grad-CAM and saliency maps, were the most commonly used explainability approaches. XAI outputs predominantly highlighted hematoma regions and perihematomal tissue; however, reporting and interpretation of explainability varied substantially across studies. External validation was infrequent, and few studies formally assessed alignment between XAI outputs and established radiological or clinical reasoning. The evidence was small, heterogeneous, and largely retrospective, with inconsistent reporting of explainability quality and limited external validation. Conclusion: Explainable AI applied to non-contrast brain CT scan in ICH cases, is an evolving field with growing methodological diversity but limited standardization. While XAI techniques offer potential to enhance transparency and clinician confidence, current evidence remains insufficient to support routine clinical implementation. Future studies should emphasize standardized reporting, external validation, and clinically grounded evaluation of explainability outputs.
Introduction:Prehospital care plays a crucial role in early recognition and timely management of foreign body airway obstruction (FBAO). This study aimed to identify factors associated with dispatcher performance and prehospital outcomes in the telephone-assisted management of FBAO. Methods:This cross-sectional study was conducted through a review of recorded emergency telephone calls related to FBAO. Data were collected from the prehospital emergency medical services center over a one-year period, from March 20, 2024 to March 20, 2025. Demographic characteristics of dispatcher were obtained through self-reported questionnaires. Recorded calls were assessed using validated 13-item researcher-developed checklist based on the standardized telephone assistance algorithm for FBAO, categorized across three age groups (score range 0-1). Patient demographic characteristics, clinical characteristics, and prehospital outcomes, including recovery without dispatch of an operational team and dispatch of an operational team, were extracted from electronic medical records. Data were entered and analyzed using SPSS version 16. A p-value < 0.05 was considered statistically significant. Results:A total of 262 telephone assistance FBAO cases were included in the final analysis, of which 45.8% involved infants. The overall mean dispatcher performance score was 0.87 ± 0.10. Multivariable logistic regression analysis demonstrated that patient's age (adjusted odds ratio (AOR) = 1.60, 95% confidence interval (CI): 1.13-2.26, p = 0.008) and dispatcher's clinical experience (AOR = 1.44, 95% CI: 1.05-1.98, p = 0.023) were significant positive predictors of better performance of dispatcher. In contrast, contractual employment (AOR = 0.37, 95% CI: 0.21-0.68, p = 0.001), higher monthly overtime hours (AOR = 0.33, 95% CI: 0.16-0.68, p = 0.002), and non-participation in stress management workshops (AOR = 0.40, 95% CI: 0.23-0.68, p = 0.001) were negatively associated with dispatcher performance. Complete airway obstruction (AOR = 0.08, 95% CI: 0.03-0.17, p < 0.001), occurrence in an outdoor setting (AOR = 4.86, 95% CI: 1.60-16.40, p = 0.007), and involvement of non-edible foreign bodies (AOR = 0.16, 95% CI: 0.06-0.37, p < 0.001) were significant predictors of outcomes. Conclusion:The findings indicate that dispatcher performance in telephone-assisted management of FBAO was generally acceptable. Enhancing performance requires not only simulation-based training but also consideration of individual and occupational factors affecting dispatchers. Moreover, improving patient outcomes depends on dispatchers' awareness of patient-specific characteristics to ensure timely and context-appropriate interventions.
Hantavirus infection is an uncommon but potentially life-threatening zoonotic disease that requires early recognition in the emergency department. This letter summarizes the epidemiology, transmission, clinical manifestations, diagnostic approaches, and current management of hantavirus pulmonary syndrome (HPS) and hemorrhagic fever with renal syndrome (HFRS). Although the initial presentation is often nonspecific, rapid progression to respiratory failure, shock, or acute kidney injury may occur, necessitating prompt diagnosis and aggressive supportive care. Serologic testing remains the primary diagnostic modality, while treatment is largely supportive, with extracorporeal membrane oxygenation reserved for selected patients with severe HPS. Increased awareness among emergency physicians and timely implementation of infection-control measures are essential to improve patient outcomes and reduce mortality.
Introduction:Therapeutic hypothermia as a neuroprotective strategy can reduce secondary injury after acute traumatic spinal cord injury (SCI). We conducted a systematic review and metaanalysis to evaluate the impact of systemic or local hypothermia on neurological outcomes, mortality, and Intensive Care Unit (ICU) stay of SCI patients. Methods:A systematic search in PubMed, Scopus, Web of Science, Embase, and The Cochrane Central Register of Controlled Trials (CENTRAL) with no limitation of time and language was performed. Following PRISMA 2020 guidelines, two independent reviewers screened records across four databases up to 20 September 2025. Eligibility was determined using PICOS criteria: adults with acute traumatic SCI (P), receiving any hypothermic protocol (I), compared with standard normothermic management (C), with reported functional, sensory, or survival outcomes (O), and original human clinical designs (S). Data extraction and risk-of-bias evaluation were performed independently using the Joanna Briggs Institute (JBI) checklist. Pooled relative risks (RR) or mean differences (MD) were calculated with randomeffects models using RevMan 4.5.1. Results:From 305 initial records, six human studies (156 patients) met inclusion criteria. There were three systemic hypothermia trials and one local extradural protocol, plus two supportive cohorts providing timing and assessment data, but only three studies met the minimum criteria for meta-analysis processes. Overall methodological quality of included studies was lowtomoderate and none of the studies were randomized. Intervention methods included surface, and endovascular techniques maintaining body temperature at 32-34 Celsius for 24-72 hours, initiated between 1.6 -70 hours postinjury. Pooled analyses showed decreased mortality with RR = 0.57 (95% CI: 0.05 -5.88; p = 0.6883), improvement in Association Impairment Scale (AIS) with RR = 2.96 (95% CI: 0.01- 939.31; p = 0.3098); and decrease in the ICU length of stay with MD = -1.27 (95% CI: -2.46 to -0.07; p = 0.9658) days in SCI patients receiving hypothermia. Complications included pneumonia, hypotension, and bradycardia. No hypothermiarelated deaths were reported. Early initiation (< 6 hours) was consistently linked with superior functional improvement. Conclusions:The findings of six human studies reveal that therapeutic hypothermia may be a feasible, safe, and effective intervention in acute traumatic SCI. While current evidence cannot yet demonstrate mortality benefit, the observed results were directed toward neurological improvement, especially when therapy is initiated early and systemically, supporting ongoing investigation.
Introduction: Although anticoagulation is a well-established risk factor for intracranial hemorrhage (ICH) following trauma, its role in determining the need for neuroimaging in patients with nontraumatic headache is less clear. This study evaluated whether anticoagulation alone justifies brain computed tomography (CT) scan imaging in non-traumatic headache. Methods: We conducted a retrospective cohort study at a tertiary care center in Riyadh, Saudi Arabia, including adults presenting with nontraumatic headache between January 2020 and 2023. Patients who underwent brain CT scan were assessed for hemorrhage and potential associated factors of ICH were explored. Results: Among 909 patients who presented with non-traumatic headache, 162 (17.82%) cases were on anticoagulation therapy, and 20 (2.2%) had ICH on brain CT scan. Anticoagulation use alone was not significantly associated with the risk of ICH following nontraumatic headache (p = 0.068). A history of prior ICH or ischemic stroke emerged as a predictor of ICH, in the overall cohort and among anticoagulated patients (p <0.001 for all comparisons). No statistically significant associations were observed with antiplatelet use, anticoagulant type, combined anticoagulant-antiplatelet therapy, or neurological deficits. Conclusion: It seems that, in patients presenting with nontraumatic headache, anticoagulation use alone should not dictate the decision to perform brain CT scan. A history of prior ICH or ischemic stroke is a more reliable predictor of ICH risk and should be prioritized in imaging decisions. These findings support a more targeted imaging strategy to minimize unnecessary scans and improve emergency department resource utilization.
Introduction:The Ottawa Ankle Rules (OAR) have demonstrated conflicting results across studies, with generally high sensitivity but relatively low and variable specificity. This updated meta-analysis aims to evaluate the overall diagnostic characteristics of the OAR for early identification of ankle fractures in adult patients. Methods:In this systematic review and meta-analysis, a comprehensive literature search was conducted from database inception through May 2026 across three electronic databases, including Medline, Web of Science, and Scopus. The MIDAS package in STATA and Meta-Disc software were used to pool the findings of the diagnostic accuracy studies. Clinical application of the OAR was assessed using Fagan's nomogram and scattergram. Results:The pooled sensitivity and specificity of OAR were 0.92 (95% confidence interval (CI): 0.91-0.93) and 0.35 (95% CI: 0.34-0.36), respectively. The pooled positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 1.76 (95% CI: 1.46-2.13) and 0.13 (95% CI: 0.09-0.19), respectively. Furthermore, the pooled diagnostic odds ratio (DOR) was 16.21 (95% CI: 10.15-25.89). Conclusion:In conclusion, the OAR demonstrate excellent sensitivity and a very low negative likelihood ratio, confirming their value as a reliable screening tool for ruling out ankle fractures in clinical practice. With pooled sensitivities exceeding 90% and a post-test probability reduced to approximately 1% following a negative result, the OAR can safely reduce unnecessary radiographic imaging.
The rapid growth of diagnostic meta-analyses has highlighted concerns regarding heterogeneity assessment and statistical model selection. Although heterogeneity is commonly evaluated using the Cochrane Q test and I² statistic, conceptual and methodological judgment should guide model choice. Inadequate reporting of statistical models and reliance on software default settings can lead to discrepancies in pooled diagnostic estimates. Differences between Meta-DiSc and MIDAS are minimal under low heterogeneity but become pronounced with high heterogeneity, underscoring the need for transparent reporting and informed methodological decisions.
Introduction:Emergency department length of stay (ED-LOS) is a key indicator of crowding and care quality. This study aimed to identify patient-level, temporal, and real-time operational predictors of prolonged ED-LOS. Methods:We conducted a retrospective cohort study using routinely collected data from all ED visits at Foch Hospital, France, between January and November 2025. Prolonged ED-LOS was defined as ED-LOS >8 hours. Data were split chronologically into a training period from January to September and a held-out test period from October to November. Three logistic regression models were evaluated: Model 1 included patient-level and temporal variables; Model 2 additionally included dynamic congestion indicators; and Model 3 further included early process delays. Results:Among 41,818 ED visits, 41,431 were included in the final analytic sample. Overall, 8,119 (19.6%) visits had ED-LOS >8 hours. In the test set, Model 1 showed good discrimination (area under the receiver operating characteristic curve (AUC): 0.752, 95% confidence interval (CI): 0.740 - 0.766), which improved modestly after adding dynamic congestion variables in Model 2 (AUC: 0.761, 95% CI: 0.749 - 0.775). Model 3 achieved the best performance (AUC: 0.804 (95% CI: 0.793 - 0.815); Brier score: 0.127 (95% CI: 0.122 - 0.132)). Older age, triage acuity level 3 (classification infirmière des malades aux urgences: CIMU ), weekend arrival, dynamic congestion at arrival, and early process delays were the main predictors of prolonged ED-LOS. Conclusion:Based on the findings, older age, intermediate triage acuity, weekend arrival, dynamic congestion at arrival, and early process delays were the independent predictors of prolonged ED stay. The addition of dynamic congestion variables improved prediction beyond patient-level and temporal characteristics, while the strongest performance was achieved after incorporating early delays to triage and physician assessment.
Introduction:Traumatic out-of-hospital cardiac arrest (TOHCA) in patients with traumatic brain injury (TBI) is associated with exceptionally poor survival. However, prehospital prognostic factors influencing early survival in this high-risk population remain poorly defined. This study aimed to identify prehospital factors associated with survival to hospital admission among TOHCA patients with TBI in Thailand. Methods:We conducted an 11-year nationwide retrospective cohort study using the Information Technology of Emergency Medicine System (ITEMS), Thailand's national EMS registry (2012-2022). TOHCA patients with documented TBI who were transported to the emergency department (ED) by emergency medical services (EMS) were included. The primary outcome was survival to hospital admission. Multivariable logistic regression was used to identify independent prehospital factors associated with survival. Results:Of 46,760 TOHCA cases, 22,821 involved TBI, and 16,885 met inclusion criteria with recorded ED outcomes. Overall, 2,872 patients (17.0%) survived to hospital admission. Younger age, longer on scene time, and shorter hospital-to-scene distance were independently associated with improved odds of survival. Several prehospital interventions showed significant benefit, including external bleeding control (adjusted odds ratio (aOR) 1.38, 95% confidence interval (CI): 1.20-1.58), endotracheal intubation (aOR 2.09, 95% CI: 1.69-2.57), intravenous fluid administration (aOR 1.56, 95% CI: 1.24-1.96), and defibrillation (aOR 2.05, 95% CI: 1.66-2.53). In contrast, on-scene time <10 minutes (aOR 0.65, 95% CI: 0.53-0.79) and bone and joint injuries, including closed fractures, open fractures, and dislocations, were associated with reduced survival. Conclusion:Despite the generally poor prognosis of TOHCA patients, particularly those with TBI, our findings demonstrate that adequate on-scene time and the prompt delivery of critical prehospital interventions, including external bleeding control, intubation, hydration, and defibrillation, were independently associated with improved survival to hospital admission.
Introduction: Particularly in highly tourist-active coastal locations, drowning is still a serious international public health concern. This study investigates the predictive value of machine learning approaches in estimating drowning-related mortality risk. Methods: This retrospective cohort study analyzed drowning incident data from the Emergency Management and Medical Urgency Center of Guilan Province, covering the period from 2018 to 2023. The data were preprocessed, missing values imputed using the K-Nearest Neighbors (KNN) algorithm, and balanced using the Synthetic Minority Over-sampling Technique (SMOTE). Three models including logistic regression, decision tree, and naïve Bayes were evaluated in predicting the risk of mortality following drowning and sensitivity, specificity, and accuracy of each model was calculated and compared. Results: A total of 600 consecutive cases meeting the eligibility criteria were extracted for analysis, forming the final dataset. Logistic regression exhibited the highest predictive power, with an accuracy of 51.67% and an area under the curve (AUC) of 60.02%. The most influential variables in drowning-related mortality prediction were drowning location, drowning year, gender, and age. High-risk areas posed a 33-fold higher mortality risk than safe locations (p < 0.001). Age and gender were not statistically significant predictors of fatal drowning. Conclusion: Given its superior interpretability and predictive capability, logistic regression was identified as the most effective model for assessing drowning mortality risk. Preventative measures should focus on identifying high-risk areas, installing warning signs, implementing lifeguard teams, educating tourists, and enforcing strict coastal safety regulations to mitigate drowning fatalities.
Introduction:Several studies have assessed the diagnostic accuracy of ultrasonography for detecting acute lateral ankle ligament injuries, but their findings have been inconsistent. This systematic review and meta-analysis investigated the pooled diagnostic performance of ultrasonography for early detection of acute injuries of the four lateral ankle ligaments. Methods:Major databases with a high likelihood of containing eligible studies, including Medline, Scopus, and Web of Science, were systematically searched from inception to April 2026. Diagnostic parameters were estimated using the extracted contingency table data, with MetaDisc software and the MIDAS package in Stata. Results:10 eligible studies, with a total of 454 patients, were included in the analyses. The sensitivity of ultrasonography for diagnosing injuries of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), posterior talofibular ligament (PTFL), and anterior inferior tibiofibular ligament (AITFL) were 0.95 (95% CI, 0.92-0.98), 0.82 (95% CI, 0.76-0.88), 0.33 (95% CI, 0.13-0.59), and 0.90 (95% CI, 0.74-0.98), respectively. The specificity for detecting injuries of the ATFL, CFL, PTFL, and AITFL was 0.91 (95% CI, 0.85-0.96), 0.90 (95% CI, 0.85-0.95), 0.96 (95% CI, 0.90-0.99), and 0.86 (95% CI, 0.78-0.92), respectively. Conclusion:Ultrasonography demonstrates high diagnostic accuracy for detecting lateral ankle ligament injuries, particularly for the ATFL and AITFL, with strong sensitivity and specificity. It is also effective for both confirming and excluding ATFL injuries. For CFL injuries, ultrasonography shows good diagnostic performance, although it is more effective for confirming than excluding CFL pathology. In contrast, its low sensitivity for PTFL injuries limits its diagnostic reliability for this ligament.
