Journal of Practical Emergency Medicine

Background: Nutritional risk is relevant to early inpatient and acute-care pathways because early recognition of malnutrition may support timely referral. This study estimated the prevalence of malnutrition risk among adult inpatients in Sulaimani using the Malnutrition Universal Screening Tool (MUST) and Subjective Global Assessment (SGA), and examined its association with age, sex, length of hospital stay, and primary cause of admission.

Methods: This observational cross-sectional study was conducted in four public hospitals in Sulaimani from March 1 to March 31, 2024. Individual-level data from 169 adult inpatients aged 18 years or older who had remained hospitalized for more than three days were analyzed. Nutritional status was assessed between days 3 and 7 of hospitalization using MUST and SGA. Therefore, the findings reflect patients who remained hospitalized beyond three days rather than nutritional status at the exact time of emergency department arrival or hospital admission.

Results: The mean age was 53.6 ± 18.08 years, and 87 participants (51.5%) were female. MUST identified 131 patients (77.5%; 95% CI: 70.6-83.2) as being at medium or high risk of malnutrition, while SGA classified 140 patients (82.8%; 95% CI: 76.4-87.8) as moderately or severely malnourished. Hospital stay of 8 days or longer was associated with SGA-defined moderate/severe malnutrition after adjustment for available covariates (adjusted OR: 12.30; 95% CI: 1.60-94.78; P = 0.016), although the temporal direction of this association cannot be determined. Severe malnutrition was present in 69 patients (40.8%; 95% CI: 33.7-48.4) and was associated with age >65 years, hospital stay ≥8 days, and oncological admission after adjustment for available covariates. MUST and SGA showed high observed agreement after dichotomization (92.3%), with Cohen's kappa = 0.759.

Conclusion: Malnutrition risk was very common among adult inpatients who remained hospitalized for more than three days in Sulaimani. The findings may be relevant to early acute-care screening, particularly for patients who remain hospitalized after urgent admission pathways. However, this study was not designed to estimate malnutrition at emergency department triage, and causal conclusions about malnutrition and length of stay should be avoided.

Background: Carpal tunnel syndrome (CTS) is a common median nerve entrapment neuropathy that may present in emergency or urgent-care settings with hand pain, numbness, paresthesia, or weakness. Because clinicians must distinguish chronic CTS from acute median nerve compression and other neurologic or vascular mimics, this study evaluated serum vitamin D and vitamin B12 levels across electrodiagnostic CTS severity grades.

Methods: This cross-sectional study included 100 adults with clinically suspected and electrodiagnostically confirmed CTS. Participants were classified by Bland electrodiagnostic severity as mild, moderate, or severe CTS. Fasting serum 25-hydroxyvitamin D and vitamin B12 levels were measured on admission (the same day as electrodiagnostic testing). Continuous variables were compared across severity groups using one-way analysis of variance, categorical variables using chi-square testing, and correlations using Pearson correlation coefficients.

Results: Among 100 patients, 32 had mild CTS, 41 moderate CTS, and 27 severe CTS. Mean serum vitamin D levels declined progressively across mild, moderate, and severe groups (28.6 ± 7.2, 19.4 ± 6.8, and 12.1 ± 5.3 ng/mL, respectively; p<0.001). Vitamin D deficiency increased from 12.5% in mild CTS to 51.2% in moderate CTS and 81.5% in severe CTS (p<0.001). Mean serum vitamin B12 levels also declined with increasing severity (342.5 ± 88.4, 241.3 ± 76.2, and 163.7 ± 54.9 pg/mL, respectively; p<0.001), while B12 deficiency increased from 9.4% to 34.1% and 70.4% across the same groups (p<0.001). Vitamin D and vitamin B12 showed inverse correlations with the nerve-conduction-derived severity score (r= -0.71 and r= -0.67, respectively; both p<0.001).

Conclusions: Lower serum vitamin D and vitamin B12 levels were significantly associated with greater electrodiagnostic severity of CTS in this cohort. For stable subacute or chronic CTS discharged from emergency or urgent care, identifying vitamin D or B12 deficiency may be reasonable as part of outpatient follow-up, especially in moderate-to-severe, bilateral, recurrent, or metabolically complex cases.

Background: Paranasal sinus computed tomography (CT) is often examined in urgent sinonasal conditions, especially when complicated infection or possible intervention is being considered. The aim is to highlight how these factors are important in emergency radiology, especially in urgent sinonasal situations.

Methods: A retrospective cross-sectional study was performed at Sulaimani Teaching Hospital between November 2023 and December 2024 on rhinosinusitis patients. The depth of the olfactory fossa on both sides was recorded and classified according to the Keros classification using patients' files.

Results: The study included 501 patients (57.1% male; mean age 38.37 ± 13.82 years). Most of the patients were classified as Keros type II, found in 360 of the right fossae (71.9%) and 361 of the left fossae (72.1%). In addition, 297 patients (59.3%) exhibited symmetrical Keros type II configurations, while 128 patients (25.5%) showed olfactory fossa asymmetry. The most common asymmetry seen was subtype IVc (right type II, left type I). We observed a moderate level of right–left agreement (Cohen’s kappa = 0.421). Overall, 156 patients (31.1%) had skull base anatomy that was clinically significant, highlighting the importance of surgical awareness.

Conclusion: Our findings indicate that Keros type II is the most prevalent configuration, and nearly a quarter of the patients presented with olfactory fossa asymmetry. Additionally, about one-third of the patients had clinically significant skull base anatomy. These results emphasize the necessity of a thorough evaluation to improve communication and operative planning in urgent sinonasal assessments.

Background: Acute abdomen is a common and clinically important emergency department presentation that requires timely evaluation and appropriate imaging selection. Ultrasonography (US) and computed tomography (CT) are widely used in this setting, but their real-world use may vary according to disease type, patient characteristics, admission time, and local resource availability. This study aimed to describe and compare the utilization frequency and acute-pathology detection rates of US and CT among emergency department patients hospitalized with acute abdomen.

Methods: This retrospective cross-sectional study included adult patients hospitalized with a final diagnosis of acute abdomen in the emergency department of a secondary-care hospital between January 1 and December 31, 2024. Demographic characteristics, admission profile, final diagnoses, imaging use, and imaging report results were extracted from the hospital electronic data system. Acute-pathology detection rate was defined as the proportion of imaged patients with an acute pathological finding reported on the corresponding modality. Paired US-CT findings were evaluated among patients who underwent both modalities. Because an independent reference standard was not available, the findings were interpreted as utilization and detection patterns rather than formal diagnostic accuracy estimates.

Results: Of 862 screened patients, 741 were included in the final analysis. The mean age was 50.43 +/- 19.85 years, and 413 patients (55.7%) were male. Acute appendicitis was the most common diagnosis (301 patients, 40.6%), followed by ileus (169 patients, 22.8%) and acute cholecystitis (124 patients, 16.7%). CT was performed in 689 patients (93.0%; 95% CI 90.9-94.6), whereas US was performed in 122 patients (16.5%; 95% CI 14.0-19.3). Both modalities were performed in 104 patients (14.0%; 95% CI 11.7-16.7). Acute pathological findings were reported in 69 of 122 US examinations (56.6%; 95% CI 47.7-65.0) and 629 of 689 CT examinations (91.3%; 95% CI 89.0-93.2). In paired cases, both modalities were acute-positive in 45 patients, US was acute-negative/CT acute-positive in 43 patients, US was acute-positive/CT acute-negative in 8 patients, and both were acute-negative in 8 patients.

Conclusion: In this hospitalized acute abdomen cohort, CT was used substantially more often than US and had a higher acute-pathology detection rate. These findings reflect real-world imaging practice in a secondary-care emergency setting and should not be interpreted as definitive diagnostic superiority because imaging selection was not standardized and no independent reference standard was available.

Background: Abnormal uterine bleeding (AUB) is a frequent gynecologic problem that may present to acute-care settings when bleeding is heavy, persistent, or associated with symptoms suggestive of anemia. Initial emergency evaluation prioritizes exclusion of pregnancy-related bleeding and assessment for hypovolemia or hemodynamic instability; however, background gynecologic and metabolic characteristics may also help clinicians recognize patients likely to have clinically significant AUB. This study examined factors associated with AUB among reproductive-aged women attending a tertiary gynecology outpatient clinic and interpreted the findings for acute-care practice.

Methods: This retrospective case-control study included 700 women aged 15-55 years: 350 with AUB and 350 controls without AUB. Demographic, reproductive, metabolic, and gynecologic variables were extracted from medical records. The primary outcome was AUB status. Bleeding patterns were summarized among cases. Group comparisons, crude odds ratios (ORs), and a clinically selected multivariable logistic regression model were used. Findings were interpreted as associations, not prevalence, incidence, or causal effects.

Results: The mean age was 41.7 ± 9.7 years among cases and 40.7± 9.4 years among controls. Women with AUB had higher BMI than controls (27.5± 4.0 vs 25.8± 3.6 kg/m2; p<0.001), and obesity was more common among cases (21.7% vs 10.9%). Menorrhagia was the most common recorded bleeding pattern (53.1%), followed by intermenstrual bleeding (18.9%). After adjustment, uterine fibroid had the strongest association with AUB (adjusted OR 62.90; 95% CI 22.37-176.89), followed by PCOS (adjusted OR 23.02; 95% CI 8.18-64.76), history of anemia (adjusted OR 4.17; 95% CI 2.37-7.32), hypertension (adjusted OR 3.46; 95% CI 2.00-6.01), number of pregnancies (adjusted OR 1.19 per pregnancy; 95% CI 1.05-1.36), BMI (adjusted OR 1.13 per kg/m2; 95% CI 1.08-1.20), and family history of AUB (adjusted OR 1.66; 95% CI 1.01-2.71). IUCD use was associated with AUB in crude analysis but not after adjustment.

Conclusion: In this clinic-based case-control study, fibroid and PCOS were the dominant gynecologic factors associated with AUB. BMI, anemia history, hypertension, number of pregnancies, and family history also remained associated after adjustment. These findings are relevant to acute-care clinicians as background risk-recognition information, but the study was not emergency-department-based and did not include pregnancy test results, vital signs, hemoglobin values, transfusion, admission, treatment, or short-term outcomes. Prospective ED-based studies are needed to develop severity and disposition models for women presenting with AUB.

Hyponatremia is a frequent electrolyte disorder in emergency and inpatient care, but its clinical meaning varies widely according to acuity, severity, symptoms, and underlying mechanism. Beer potomania is an important low-solute form of hypotonic hyponatremia that develops when heavy beer intake is combined with markedly reduced dietary protein and salt intake. The condition is clinically distinctive because the kidney is not primarily failing to dilute urine; rather, it lacks enough urinary osmoles to eliminate the patient's free-water load safely. As a result, even when antidiuretic hormone (ADH) is appropriately suppressed, maximal water excretion may be capped at a relatively low volume. Emergency clinicians must recognize this mechanism because treatment can be paradoxically hazardous: solute reintroduction through food, isotonic saline, hypertonic saline, potassium chloride, or saline-containing vitamin infusions may abruptly restore water excretion and produce rapid autocorrection of serum sodium. This narrative review synthesizes guideline recommendations, mechanistic literature, expert discussions, recent systematic reviews of case reports, and representative case reports on beer potomania-associated hyponatremia. It emphasizes a practical bedside approach: confirm hypotonicity, assess neurologic severity, evaluate volume status and solute intake, interpret urine studies in clinical context, avoid reflexive isotonic fluid administration in stable patients, and monitor closely for brisk aquaresis and overcorrection. Severe symptomatic hyponatremia should be treated promptly with hypertonic saline boluses to achieve an initial limited rise, whereas stable patients usually require careful fluid restriction, gradual nutritional repletion, and frequent reassessment. Prevention of osmotic demyelination syndrome depends on controlled correction, recognition of high-risk features such as alcohol use disorder and malnutrition, accounting for the sodium-raising effect of potassium replacement, and individualized use of 5% dextrose in water (D5W), desmopressin, or both when sodium rises faster than intended.

To the Editor,

Accurate, reproducible assessment of consciousness is fundamental to decision-making in acute and critical care settings, guiding prioritization of imaging, airway protection and intubation strategies, escalation pathways, and reliability and interpretability of serial handoffs. Despite its ubiquity, contemporary evidence suggests that the Glasgow Coma Scale (GCS), particularly when reported as a single total score, can obscure clinically meaningful between-patient variability and compress distinct neurologic states into the same overall score (1). A particular challenge in applying the three GCS components (eye, verbal, and motor) in critical care is that verbal response is not reliably measurable in patients with airway compromise or intubation, facial trauma, aphasia, intoxication, or sedative exposure (2). This represents a major limitation and supports the need for alternative assessment tools that remain fully scorable under such conditions.

In analyses from TRACK-TBI, patients with similar total GCS scores exhibited discrepancies in consciousness levels, underscoring that an overall GCS score alone may not reliably represent the underlying neurologic states. Notably, a GCS score of 8 was associated with minimally conscious state without language function (MSC-) in 78% of patients, MSC with language function (MSC+) in 17% and vegetative state in 5% (1). Moreover, any sum score can arise from different combinations of GCS components, which may not carry equivalent prognostic value. Among TBI patients with a total GCS of 8, the reported discharge mortality rate ranges from 21% for E1V2M5 (eye 1, verbal 2, motor 5) to 43% for E4V1M3 (3). The practical consequence is that identical total scores can map to varying neurologic profiles, rendering threshold-based pathways inherently ambiguous. The GCS was originally developed as a bedside clinical communication tool, and the entrenched use of an “initial GCS ≤8” threshold, widely applied in TBI patients, to dichotomize “severe” from mild to moderate injury, has been challenged as an outdated heuristic that has migrated from research convenience into clinical care and triage and rigid reliance on this threshold may delay care for patients requiring urgent care (4). More broadly, expert commentary at the 50-year milestone of the GCS has emphasized that modern TBI assessment is shifting toward multidimensional assessment frameworks that incorporate modifiers beyond a single consciousness score, reflecting the need for more comprehensive evaluation (5). In non-TBI contexts, a multicenter trial on comatose patients with acute poisoning and a GCS <9 reported clinical benefit for composite in-hospital endpoints with a conservative strategy of withholding intubation, illustrating that a low GCS alone is an insufficient basis for airway decisions (6). The key question is not whether to completely discard the GCS, but how to preserve its familiar structure while mitigating recognized limitations, particularly in patients for whom more precise neurologic discrimination is most consequential.

The Full Outline of UnResponsiveness (FOUR) score offers a practical alternative approach by retaining eye and motor assessment while replacing the verbal domain with brainstem reflexes and respiratory pattern, enabling structured scoring in intubated patients and improving distinction among deeply impaired states. Brainstem reflexes and respiratory drive could reflect the severity of coma and evolving deterioration, representing clinically valuable features that the GCS does not explicitly assess (7, 8). Across a range of medical, neurological and neurosurgical intensive care unit (ICU) cohorts, encompassing patients with traumatic and non-traumatic brain injury, stroke, sepsis and cardiac arrest, the FOUR score has generally achieved higher predictive accuracy for hospital and short-term mortality than GCS and has shown greater responsiveness when patients are clustered at very low GCS scores (9). In TBI, our systematic review and meta-analysis comparing the FOUR score and GCS for the prediction of in-hospital mortality yielded broadly comparable results (10), supporting clinical interchangeability in contexts where an untestable verbal response constrains GCS. Studies on non-traumatic altered mental status, one of the most challenging emergency department (ED) presentations, although limited, further support the feasibility and clinical comparability of the two scores. In a prospective ED study of adults with non-traumatic altered mental status, the FOUR score demonstrated comparable prognostic performance to GCS for predicting mortality and poor functional outcome. The study further proposed FOUR score strata aligned with familiar GCS severity bands (11).

There may be concerns that the FOUR score is less reproducible and more difficult to teach. Nevertheless, a quantitative systematic review spanning ICU and ED professionals has reported high reliability and validity for both tools, with the analyses slightly favoring the FOUR score (12). Considering that neurologic assessment is inherently serial and team-based, even modest gains in interrater reliability can reduce inconsistencies and improve the quality of decisions based on change over time. Additionally, it has been reported that emergency medicine residents find the FOUR score easy to learn and interpret (11), which supports the notion that the FOUR score can be implemented without an undue training burden.

The clinical implication is subtle but important. When two tools perform similarly for key outcomes, the one that preserves more useful bedside information is often the more rational choice for routine documentation. What should change in practice, therefore, is a refinement of how neurologic status is captured and communicated. First, the FOUR score should be routinely added, or preferentially used, when the verbal component is unavailable or unreliable, and when brainstem reflexes and respiratory pattern are expected to inform decision-making meaningfully (9, 12). Second, when GCS is used, given the demonstrated variability within patients with similar total scores, documenting each component should be prioritized over a sum score alone (1). Third, care and decision pathways should abandon rigid dichotomies, such as “GCS ≤8,” in favor of a structured, multidomain assessment and trajectory-based decision-making (4, 5).

In conclusion, we propose that GCS can be replaced with the FOUR score to reduce information loss and enhance specificity, particularly in intubated and deeply obtunded patients. Future multicenter implementation studies should standardize scoring strata and examination time points, and evaluate whether the FOUR score-guided documentation improves communication, earlier detection of deterioration, and escalation accuracy in acute care practice.

A 43-year-old man with hypertension and insulin resistance presented with an 8-month history of pulsating left hemicranial headache that worsened over the preceding 4 days and culminated in an acute thunderclap exacerbation that reached maximal intensity in less than one minute. The headache was severe (10/10), non-radiating, and accompanied by photophobia, phonophobia, a retro-orbital burning sensation, and right temporal visual-field loss. Neuroimaging revealed a 38 x 27 x 25 mm sellar/suprasellar pituitary neuroendocrine tumor with predominantly subacute hemorrhagic components and marked optic pathway compression, consistent with pituitary apoplexy. Vascular imaging (CTA, MRA, or MRV) and lumbar puncture were not performed because non-contrast head CT and sellar MRI demonstrated a hemorrhagic sellar/suprasellar lesion explaining the presentation, without clinical features mandating additional vascular or cerebrospinal fluid evaluation. The patient underwent urgent subtotal endoscopic transsphenoidal resection/decompression and received stress-dose hydrocortisone for suspected central adrenal insufficiency. Histopathology confirmed a corticotroph PitNET/adenoma (WHO 2022), ACTH/synaptophysin/CAM5.2 positive, prolactin-negative, with Ki-67 1%. Prolactin decreased from 555.09 ng/mL at presentation to 55.09 ng/mL on February 16, 2024, supporting stalk-effect hyperprolactinemia rather than prolactinoma. Follow-up evaluations showed headache resolution, stable visual function, secondary panhypopituitarism requiring hormonal replacement, and a small residual sellar lesion under surveillance.