The aging of the population is a global phenomenon, with projections indicating a significant increase in the proportion of individuals aged 65 years and older by 2050. This demographic shift requires adapting emergency department (ED) services to meet the specific demands of older patients, who often present with multiple comorbidities and face challenges such as sensory and cognitive difficulties. EDs, traditionally designed for acute illness and injury management, may not be adequately equipped to meet the unique needs of this vulnerable population. This can result in suboptimal patient experiences, prolonged ED stays, increased hospitalizations, and poorer outcomes. This study protocol outlines a before-and-after study to evaluate the impact of implementing a comfort menu and cart on the experience and outcomes of older patients treated in the ED. The study will be conducted in the ED of Hospital Sírio-Libanês (HSL), a tertiary private hospital in São Paulo, Brazil. Patients aged 65 and older who presented to the ED will be eligible for inclusion. Participants will be recruited in two phases: pre-intervention and post-implementation of the comfort menu and cart. Data will be collected through patient and staff interviews, chart reviews, and a 30-day follow-up interview. Patient experience, staff experience, length of hospital stays, hospital costs, ED readmissions, falls, delirium incidence, quality of life, functional status, cognitive performance, and mortality will be assessed. We expect to demonstrate the positive impact of implementing the comfort menu and cart in the ED on patient-centered outcomes. We anticipate improvements in the experience of older patients and medical and multidisciplinary staff, and hope to identify improvements in other exploratory outcomes. ClinicalTrials.gov NCT06681376.

Introduction Locoregional anesthesia using local anesthetics has been proposed as a highly selective method for perioperative acute pain management because it helps prevent the onset of noxious stimuli. However, a limitation of this technique is the possibility of nerve block failure. Infrared thermography (IRT) has been suggested as a non-invasive tool to assess the success of peripheral nerve blocks by detecting temperature changes related to vasodilation. This study aimed to evaluate the effect of peripheral nerve blocks on the superficial thermal response of limbs in dogs undergoing trauma or orthopedic surgery. Methods A total of 26 dogs of various breeds, classified as ASA 1 or 2 and undergoing thoracic or pelvic limb, or abdominal surgery, were divided into two groups based on the analgesic technique used. In the experimental group [peripheral nerve block (PNB) n = 20], composed of animals undergoing trauma or orthopedic surgery, bupivacaine was infiltrated into the brachial plexus or the saphenous and sciatic nerves. The control group ( n = 6) underwent general anesthesia and surgery, and they received conventional injectable analgesia. The variables assessed included maximum (T max ), mean (T mean ), and minimum (T min. ) temperatures of the axillary region, groin, and lateral femoral area, as well as rectal temperature (T°C). Measurements were taken at baseline (T Basal ), and 5 (T 5min. ), 10 (T 10min. ), and 15 min (T 15min. ) after treatment. Results T max , T mean , and T min were significantly higher in the PNB group (by 2–3 °C) compared to the control group ( p = 0.01). In the PNB group, superficial temperatures decreased by approximately 1 °C from baseline ( p = 0.001), whereas the control group exhibited a greater decrease of approximately 3 °C at the same time points ( p = 0.001). Rectal temperature was 2 °C higher in the PNB group compared to the control group ( p = 0.01), although only the control group showed a progressive decrease over time ( p = 0.05). No significant correlation was found between surface and rectal temperatures. Discussion Peripheral nerve blocks with bupivacaine induced localized vasodilation, resulting in increased superficial heat radiation. This thermal response may serve as an indirect indicator complementary of nerve block effectiveness, supporting the use of IRT as a clinical tool to evaluate peripheral nerve block success in dogs. Further studies are recommended to confirm and validate its clinical application.

Thanks to the improvement of surgical, interventional techniques and medical care, the survival of the adult population with congenital heart disease is constantly increasing with more frequent access to the emergency department because of residual defects and cardiovascular sequelae. This review article examines in alphabetical order the main clinical conditions for which an urgent cardiological evaluation may be required, providing some indications about diagnosis, acute management and possible transfer to dedicated centers.

Supraventricular Arrhythmias in the Child with a Structurally Normal Heart.

Acute heart failure management in the emergency setting: time to put evidence into action.

Acute and chronic effects of medicinal cannabis use on anxiety and depression in a prospective cohort of patients new to cannabis.

Application of high-resolution mass spectrometry profiling towards the diagnosis and acute management of maple syrup urine disease

To evaluate the performance of the iStar high-sensitivity cardiac troponin I (hs-cTnI) assay, focusing on its sensitivity, precision, linearity, and consistency with plasma samples, and to establish sex-specific 99th percentile upper reference limits. The iStar hs-cTnI assay was assessed using the Drawray iStar 500 analyzer. Key performance metrics such as the limits of blank (LoB), detection (LoD) and quantitation (LoQ), precision, linearity, and agreement between sample types were evaluated according to Clinical and Laboratory Standards Institute (CLSI) guidelines. A methodological comparison was performed with the Abbott ARCHITECT hs-cTnI assay, and cross-reactivity with others troponins was assessed. The iStar hs-cTnI assay demonstrated robust sensitivity with a LoB of 0.09 ng/L and LoD of 0.31 ng/L. The LoQ was 0.79 ng/L for 20 % coefficient of variation (CV) and 1.85 ng/L for 10 % CV. Precision testing revealed CVs of 1.4-4.8 % near the 99th percentile upper reference limit (URL). The assay exhibited excellent linearity (r=1.00) and high agreement between whole blood and plasma samples (slope=0.936). Methodological comparison with the Abbott ARCHITECT hs-cTnI showed a high correlation coefficient of 0.983. Cross-reactivity with skeletal muscle troponin I, cardiac troponin C, and cardiac troponin T was negligible. In healthy individuals, the overall 99th percentile URL was 16 ng/L, with sex-specific values of 18 ng/L for males and 14 ng/L for females. The iStar hs-cTnI assay demonstrates high sensitivity and precision, supporting it suitable for the rapid diagnosis of acute myocardial infarction using whole blood samples. Its high agreement with plasma and established sex-specific URL support its potential for clinical use in acute coronary syndrome management.

Acute home-based management initiatives for COVID-19 patients needing oxygen: observational study reporting mortality and hospital admission outcomes.

Objective Acute ischemic stroke (AIS) is a leading cause of mortality and long-term disability worldwide, with clinical outcomes highly dependent on the timeliness and coordination of emergency care. Emergency nurses are at the frontline of acute stroke management, contributing significantly to early recognition, rapid triage, thrombolysis preparation, and prevention of in-hospital complications. However, the real-world impact of structured emergency nursing interventions on both pre-hospital and in-hospital stroke outcomes remains underexplored. This study aimed to evaluate the feasibility and clinical effectiveness of emergency nursing interventions in reducing treatment delays and improving short-term neurological recovery in patients with AIS. Methods A retrospective cohort study was conducted at Wuhan Fourth Hospital, including 217 adult AIS patients admitted between January 2020 and April 2024. Patients were divided into two groups based on the presence or absence of structured emergency nursing protocols, including pre-hospital triage coordination, stroke code activation, focused neurological monitoring, and post-thrombolysis care. Primary endpoints included door-to-needle time (DNT), thrombolysis rate, and early neurological deterioration. Secondary outcomes were NIHSS score changes at 72 h, hospital length of stay, and 7-day in-hospital mortality. Results Patients receiving emergency nursing interventions ( n = 107) had significantly shorter median DNT (42 vs. 56 min, p < 0.001), higher thrombolysis rates (71.0% vs. 51.4%, p = 0.004), and reduced early neurological deterioration (10.3% vs. 21.5%, p = 0.018). NIHSS improvement ≥4 points was more frequent in the intervention group (64.5% vs. 43.1%, p = 0.003). No significant difference in 7-day mortality was observed. Conclusion The implementation of structured emergency nursing interventions in AIS care significantly improves treatment timeliness and short-term functional outcomes. These findings support the inclusion of specialized nursing protocols in emergency stroke pathways to enhance quality and efficiency of care.

Adolescents and young adults (AYA) living with sickle cell disease (SCD) transitioning to adult hematology care are at risk of dropping out of care and relying on emergency departments (ED) for acute crisis management. This can result in decreased continuity of care, an increase in serious health complications, and a greater mortality risk. This study aimed to investigate how transitioning to adult care is associated with SCD treatment outcomes, and test whether this association is moderated by comorbid mental health concerns (i.e., symptoms of anxiety and depression). We tested differences by age group (16-20, 21-25, 26-33years) in the number of opioid prescriptions, hydroxyurea prescriptions, and ED visits using unadjusted comparisons and multivariable regression models, hypothesizing increased acute care use and decreased preventive treatment among the older age groups due to the complications associated with transitioning to adult care. We also tested whether there was an exacerbating effect of depression and anxiety symptoms on transition by assessing interaction terms between age group and symptoms in regression models. After adjusting for sociodemographic and mental health symptoms, the 26-33-year-old group had a significantly higher number of opioid prescriptions, and the 21-25 and 26-33year groups had fewer hydroxyurea prescriptions and a greater number of ED visits than their 16-20-year-old counterparts. The higher number of opioid prescriptions among the older age group was even more pronounced among those with moderate to severe anxiety symptoms. Transitioning from pediatric to adult hematology poses a significant risk for AYA with SCD, especially for those with anxiety symptoms.

Background Dual antiplatelet therapy (DAPT) with aspirin and ticagrelor is standard treatment for ST-elevation myocardial infarction (STEMI). While the optimal ticagrelor dose is established, the ideal aspirin maintenance dose remains debatable, particularly in East Asian populations who demonstrate enhanced bleeding sensitivity with standard antiplatelet regimens compared to Western populations. Methods The Low-dose Evaluation of Aspirin in patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention (LEAST) trial is a multicenter, randomized, double-blind, placebo-controlled trial comparing low-dose (50 mg/d) versus standard-dose (100 mg/d) aspirin combined with ticagrelor (90 mg twice daily) in Chinese STEMI patients post-percutaneous coronary intervention. A total of 3612 patients will be enrolled from 34 centers across China using stratified randomization by age and multivessel disease status. The primary endpoint is 12-month composite of cardiac death, non-fatal myocardial infarction, non-fatal stroke, and ischemia-driven target vessel revascularization (non-inferiority testing with 1.5% absolute difference margin). The key secondary endpoint is Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding (superiority testing). A hierarchical testing strategy ensures bleeding benefits are only claimed when ischemic safety has been established. Results This trial will provide evidence regarding optimal aspirin maintenance dose in Chinese STEMI patients receiving DAPT with ticagrelor. The findings may support development of population-specific antithrombotic strategies that better balance efficacy and safety in East Asian populations. Conclusion The LEAST trial addresses an important knowledge gap regarding optimal aspirin dosing in Chinese STEMI patients and may influence future guideline recommendations for acute coronary syndrome management in Asian populations. Trial Registration ClinicalTrials.gov (NCT06756945)

Comparison of inhalational methoxyflurane, intranasal fentanyl, and intravenous morphine for treatment of prehospital acute pain in Norway (PreMeFen): a randomised, non-inferiority, three-arm, phase 3 trial.

The principle "time is brain" applies to epileptic seizures as well as stroke. Despite existing guidelines, delays in treatment initiation remain common. In 2020, we developed a consensus statement aiming to improve the acute management of emergency seizures and implement a "Seizure Code" (SC) in Madrid, Spain. A multidisciplinary group of 105 professionals from 27 hospitals across the Madrid regional health service collaborated to design a structured healthcare process for emergency seizure care. This included seven key subprocesses: pre-hospital care, SC activation, emergency department management, hospital ward care, referral to specialized centers, intensive care units (ICUs) treatment, and discharge planning with follow-up. Three additional cross-cutting areas-training, research, and quality control-were included to ensure continuous improvement. Ten coordinators oversaw protocol development and standardization. The plan emphasized education for families and caregivers, standardized transfer pathways, and unified pre- and in-hospital treatment across all ages. Implementation began in November 2021, with official approval in August 2022. The SC protocol was formally launched on November 15, 2023. Over 200 patients meeting SC criteria have since been registered and monitored. The coordinated effort has led to the region-wide implementation of the SC. The next step is to evaluate its impact on emergency seizure management and patient outcomes. PLAIN LANGUAGE SUMMARY: Although time is crucial in epilepsy management, there are still gaps in care that lead to delays in treating these patients. To improve this, we have developed a Process-Based Healthcare Network for the acute management of epileptic seizures, which includes the implementation of a SC. Our goal is to better organize care across different levels of the healthcare system, facilitate therapeutic decision-making, and improve response times and patient outcomes. Here, we present the development and implementation of this care pathway designed to enhance coordination and efficiency in the management of urgent epileptic seizures.

BackgroundTimely access to a neurologist is essential for optimal management of acute stroke. To address disparities in neurological care within the SEHA Healthcare Network, the LEO360® AI-assisted tele-stroke robot was implemented at Sheikh Tahnoon bin Mohammed Medical City (STMC) and Al Tawam Hospital.MethodsThis case series presents six patients evaluated remotely via the LEO360® platform. Key metrics included consultation time, transfer rates, and system performance. Data were contextualized using pre-implementation benchmarks, and both AI functionalities and telepresence capabilities were analyzed. Challenges, ethical considerations, and system limitations were also examined.ResultsThe average neurologist consultation time was 10.7 minutes. In 80% of cases, unnecessary interfacility transfers were avoided. The integration of AI-assisted decision support enhanced assessment efficiency and diagnostic confidence.ConclusionThe LEO360® tele-stroke system demonstrates strong potential to improve access, efficiency, and accuracy in acute stroke management. Its successful implementation underscores the scalability of AI-assisted telemedicine in regions facing neurology workforce shortages, offering a sustainable model for acute neurological care.

Introduction: Evaluating patients with acute neurologic deficits is a regular occurrence in the emergency department (ED), but some presentations warrant increased concern. This case highlights the importance of repeat evaluations and how resolution of symptoms does not rule out a more ominous underlying pathology. Case Report: A 59-year-old male with a past medical history of coronary artery disease and Human immunodeficiency viruses (HIV) presented to a Level II trauma and comprehensive stroke center for left-sided facial droop and left- sided hemiparesis. Computed tomography of the brain including angiography and perfusion was performed revealing no hemorrhage or large vessel occlusion. Given his National Institutes of Health Stroke Scale score of 11, he received alteplase and subsequently experienced several episodes of resolution and recurrence of his symptoms while in the ED. Magnetic resonance imaging revealed an acute ischemic infarct in the right basal ganglia and insular region, which along with his clinical presentation was consistent with capsular warning syndrome. Conclusion: Capsular warning syndrome is a rare clinical entity with an incidence ranging from1.5-5% in stroke patients. Its recognition is crucial when making decisions concerning management,as resolution of symptoms should still garner a high level of attention given that the the increased risk of stroke with permanent neurological disability is highest within the first 48 hours. The role ofthrombolysis continues to be an area of focus as its benefit has not yet been determined but continues to be the mainstay therapy in the correct clinical setting. This is especially true in the cases of recurrent episodes post thrombolysis, which does not preclude the diagnosis of capsular warning syndrome but should heighten the need for acute management of these patients and close monitoring. This case illustrates its unique presentation and the need for increased recognition and understanding within the field of emergency medicine.

Comparative effectiveness of reduced dose Ticagrelor, full dose Ticagrelor, and clopidogrel in acute stroke management.

Acute stroke due to medium vessel occlusion (MeVO) accounts for 25% to 40% of all acute ischemic stroke cases and is associated with substantial morbidity despite current best medical management. This motivated several recently published and ongoing trials that investigate(d) the benefit of endovascular thrombectomy (EVT) for MeVO stroke. Two of these trials have been published, an interim analysis of a third has been presented, and a fourth will be presented soon. The available trial results suggest no difference in outcomes between EVT and best medical management, and a possibility of harm with EVT. Preliminary post hoc analyses have identified promising patient subgroups that may derive benefit from EVT. Improving EVT tools and techniques, together with adjunctive treatments, may further increase the technical efficacy of MeVO EVT. This review summarizes clinical and imaging features of MeVO stroke, reviews current evidence for medical and endovascular treatment, discusses recent MeVO EVT trial results, and outlines possible pathways forward for future MeVO trials.

BackgroundTransitioning from undergraduate to graduate medical education is characterized by challenges related to clinical competence, professional identity formation, and the adoption of system-based practice. This transition serves as an accountability measure for medical schools, particularly for international medical graduates (IMGs). Unfortunately, there remains a gap in medical education that may compromise the fitness to practice of graduating doctors. To address this gap, this work aimed to develop, implement, and evaluate a simulation-based Transition to Residency (TTR) capstone course within a Doctor of Medicine (MD) course that aligns with the Entrustable Professional Activities (EPAs) and specifically targets the educational shortcomings experienced by new medical graduates.MethodsOur course adopted the modified Kern 7-step approach and incorporated simulation-based, Kolb’s experiential learning, and e-learning constructs. The core themes included patient safety, basic and advanced procedural skills, “night on call,” acute case management training, and life support training. The main themes were mapped to high-yield competencies that corresponded with the core EPAs. A structured study plan, clear learning objectives, assessment tools, and full integration of educational and simulation technologies were developed. The pre- and post-data regarding students’ self-assessment of competence, their performance assessment (Kirkpatrick’s level 2), and their satisfaction with the learning outcomes (Kirkpatrick’s level 1) were analyzed.ResultsThe success of this course was evident in the high student satisfaction rates and the overall increase in their self-assessment of skill acquisition across domains in all 3 years, with persistently highest improvements in the psychomotor domain (p < 0.001 and Cohen’s d = 1.02, 2.29, and 1.44) compared to cognitive and communication domains. From a course organization standpoint, centralizing communication, appointing independent assessors, managing workload, and digitizing all procedures mitigated several challenges faced.DiscussionOur study highlights systematic implementation strategies, potential challenges, sustainability concerns, and future recommendations of a flagship capstone course, including the development of residency-specific training options. The high satisfaction rates and documented enhancement in all competency domains of the capstone course affirm its role in bridging gaps in medical education.

Despite advancements in acute pain management and minimally invasive surgical techniques, persistent postsurgical pain can occur in up to 30% to 50% of patients. Psychological and social factors are increasingly recognized as contributors to pain outcomes, yet the impact of specific social determinants of health on persistent postoperative pain remains unclear. We conducted a retrospective observational study using the All of Us Research Program database. Adults who underwent surgical procedures after the year 2000 were included if they had available social determinants of health (SDoH) survey data and no prior diagnosis of persistent postoperative pain. Persistent postoperative pain was defined via SNOMED codes as a diagnosis occurring at least 1 year after the surgery date. Multivariable logistic regression was performed to assess the association between 21 independent variables derived from All of Us SDoH survey items and persistent postoperative pain, controlling for age, sex, race, ethnicity, and surgery type. A Bonferroni-corrected significance threshold (P < .002) was applied. There were 8065 participants included in the final analysis with 641 (7.9%) developing persistent postoperative pain. Food insecurity had the strongest association with persistent postoperative pain (odds ratio [OR] = 1.83, 95% confidence interval [CI], 1.45-2.30, P < .001). Having greater social support (OR = 0.96, 95% CI, 0.94-0.99, P = .002) and lower residential density (OR = 0.72, 95% CI, 0.61-0.85, P < .001) was protective. These findings underscore the importance of routinely assessing and addressing socioeconomic and psychosocial factors in perioperative care to help prevent long-term pain.