Journal of Practical Emergency Medicine

Large language models (LLMs) are moving into clinical medicine faster than the evidence needed to define their safest role. Emergency medicine makes that gap particularly difficult to ignore. In the emergency department (ED), a convincing answer is not necessarily a safe answer, and a seemingly small error in prioritization may delay care for a patient with a time-sensitive condition. The relevant question, therefore, is no longer whether an LLM can produce a plausible diagnosis or assign an acuity category. It is whether the use of such a model can improve emergency care without introducing an unacceptable risk of under-triage, misplaced confidence, or loss of clinically important context.

Triage is an especially demanding test case. Decisions are made early, often with incomplete information, before the diagnostic picture has matured. A patient may be unable to provide a coherent history; laboratory and imaging results may not yet exist; and clinical deterioration can occur after the initial assessment. Moreover, triage errors are asymmetric. Over-triage consumes resources, but under-triage may postpone recognition of stroke, sepsis, acute coronary syndrome, internal bleeding, or another immediately threatening condition. Any technology positioned at this point in the care pathway should therefore be judged not only by overall accuracy but also by the clinical consequences of its errors.

Early evidence has nevertheless been impressive enough to justify serious attention. Williams et al. evaluated an LLM using data from 251,401 adult ED visits. In a balanced sample of 10,000 pairs of patients with different Emergency Severity Index (ESI) levels, the model correctly identified the patient with higher acuity in 8,940 pairs, corresponding to an accuracy of 89%. In a 500-pair subset reviewed by physicians, LLM accuracy was 88% compared with 86% for physicians (1).

These results are encouraging, but the task should not be mistaken for prospective triage. The model was asked to compare two written clinical histories and determine which represented the higher-acuity patient. It was not independently assessing patients arriving at a triage desk, nor was it operating prospectively within an ED workflow. The study therefore demonstrated that an LLM could extract useful acuity information from clinical text; it did not establish that autonomous LLM-based triage is safe.

Other evidence makes that distinction even more important. Zaboli et al. retrosp­ectively compared ChatGPT-4.0 with human triage decisions in 2,658 ED patients. Agreement between human and AI triage was low, with a Cohen κ of 0.125 (95% CI, 0.100–0.134). Human triage also performed better in predicting clinically important outcomes. For 30-day mortality, the area under the receiver operating characteristic curve was 0.88 for human triage and 0.70 for AI triage (P<0.001). For the need for life-saving interventions, the corresponding values were 0.98 and 0.87 (P=0.014). The authors specifically identified lower sensitivity in high-risk patients and consequent under-triage as a concern (2).

Yet another prospective study produced a different picture. Arslan et al. compared ChatGPT Plus, Copilot Pro, and triage nurses against ESI assessments assigned by an emergency physician. Overall accuracy was 66.5% for ChatGPT, 61.8% for Copilot, and 65.2% for nurses. Notably, identification of high-acuity patients was more frequent with ChatGPT and Copilot than with nurses in that study 87.8% and 85.7% versus 32.7%, respectively (3).

The apparent contradiction among these studies is itself informative. LLM performance cannot be treated as a fixed property of “AI.” Results depend on the model and version tested, the information supplied to it, the prompt, the reference standard, the triage system, the patient population, and the exact task being evaluated. A model that performs well when ranking two written cases may not perform equally well when assigning an absolute triage category. Likewise, good average accuracy can conceal clinically unacceptable errors in a small but high-risk subgroup.

How information is supplied to the model may be as important as the model itself. Yazaki et al. examined a retrieval-augmented generation (RAG) approach using 100 simulated triage scenarios derived from modified cases from the Japanese National Examination for Emergency Medical Technicians. GPT-3.5 combined with RAG achieved 70% correct triage, compared with 35% and 38% for two emergency medical technicians and 50% and 47% for two emergency physicians. Under-triage occurred in 8% of cases with GPT-3.5 plus RAG, compared with 33% for GPT-3.5 without RAG and 39% for GPT-4 without RAG (4). The findings suggest that connecting an LLM to task-specific knowledge may improve performance. At the same time, the study used simulated scenarios rather than live emergency encounters, which limits how far these results can be extended to routine practice.

Gaber et al. similarly evaluated several LLM configurations and a RAG-assisted workflow using 2,000 cases derived from the MIMIC-IV ED database. Their framework addressed triage, specialty referral, and diagnosis rather than treating the model as a stand-alone question-answering system (5). This is an important shift in emphasis. The relevant unit of evaluation may ultimately be the LLM-enabled clinical workflow, not the language model in isolation.

There are also reasons to remain cautious about extrapolating high performance on constrained tasks to autonomous clinical decision-making. Hager et al. evaluated selected LLMs using a curated dataset of 2,400 real patient cases involving four common abdominal pathologies. The tested models performed worse than physicians across the evaluated pathologies and showed limitations in following diagnostic and treatment guidelines, interpreting laboratory results, and responding consistently to changes in instructions (6). These findings should not be generalized automatically to every newer model—the technology evolves rapidly—but they demonstrate why conventional medical benchmarks are an incomplete proxy for bedside reliability.

The same caution applies to the concept of the AI “co-pilot.” Human supervision alone does not guarantee that an LLM will improve decisions. In a randomized clinical trial involving 50 physicians from internal medicine, family medicine, and emergency medicine, Goh et al. compared physicians using GPT-4 with physicians using conventional resources. Median diagnostic reasoning scores were 76% and 74%, respectively, an adjusted difference of 2 percentage points (95% CI, −4 to 8; P=0.60). Interestingly, the LLM operating alone scored 16 percentage points higher than the conventional-resources physician group (95% CI, 2–30; P=0.03) (7). Only five participants were emergency physicians, so the results are not an ED-specific effectiveness trial. Nevertheless, they expose an important problem: access to a capable model does not automatically translate into better human performance. Interface design, clinician training, appropriate reliance, and the way disagreement between clinician and model is handled may determine whether assistance is useful.

For this reason, the first successful applications of LLMs in emergency care may emerge from narrower tasks in which benefit can be measured without transferring final clinical authority to the model. Song et al. provide an instructive example. In a study involving six emergency physicians and 50 representative ED cases, LLM-assisted discharge documentation reduced median writing time from 69.5 seconds (95% CI, 65.5–78.0) to 32.0 seconds (95% CI, 29.5–36.0; P<0.001). LLM-assisted notes also received higher ratings than manually written notes for completeness, correctness, conciseness, and clinical utility (all P<0.001) (8). The study was performed in a single tertiary center and involved a limited validation set, but it illustrates a practical principle: the safest path to clinical adoption may begin with bounded tasks that reduce workload while leaving consequential decisions under direct clinician control.

Emergency triage requires an equally pragmatic standard. Before an LLM is used as more than supervised decision support, prospective multicenter studies should evaluate outcomes that matter to patients rather than relying predominantly on agreement with historical labels. Under-triage deserves particular attention, as do delays to time-sensitive treatment, unexpected intensive care unit admission, early ED return, and adverse clinical outcomes. Performance should also be examined across patient groups and clinical presentations rather than reported only as a single aggregate accuracy measure.

Model identity and version should be treated as part of the intervention. An evaluation performed with one version cannot be assumed to remain valid after a major model update. Similarly, changes in prompts, retrieval sources, or local workflow may alter performance. Clinical deployment will therefore require version control, post-implementation surveillance, and an auditable record of when AI-generated recomme­ndations are accepted or overridden.

Accountability must be designed before deployment rather than after an adverse event. If an LLM assigns a lower acuity level than the triage clinician, should its recommendation be ignored, reviewed, or trigger a mandatory second assessment? If the model recommends escalation and the clinician disagrees, what should be documented? These are not peripheral legal questions. They determine how the technology will influence actual behavior in the ED.

The current evidence does not support either extreme position. It would be premature to dismiss LLMs as unreliable text generators when they have demonstrated substantial ability to interpret clinical narratives and, in selected tasks, match or exceed human performance. It would be equally premature to treat those findings as evidence that autonomous AI triage is ready for routine deployment. What has been established is capability under specific experimental conditions. What remains to be established is dependable clinical benefit.

For emergency medicine, that distinction matters. The front door of the hospital is an unforgiving place to discover that benchmark performance does not translate into patient safety. For now, the most defensible role for LLMs in emergency triage is not that of an autonomous gatekeeper, but of a supervised clinical co-pilot whose recomme­ndations can be questioned, overridden, and continuously evaluated. The threshold for moving beyond that role should be set by prospective evidence of safer or better care not by the fluency of the model's answers.

Background: Status epilepticus is a time-sensitive neurologic emergency in which delayed treatment may reduce responsiveness to benzodiazepines and increase the risk of treatment refractoriness and adverse outcomes. We evaluated emergency medical services (EMS) call-to-scene response and call-to-hospital intervals among transported seizure-related EMS encounters in Shiraz, Iran.

Methods: We conducted a retrospective observational study of routinely recorded EMS data from 21 March 2022 through 20 March 2023. Calls containing the keyword “seizure” in the caller’s chief complaint, the initial telephone diagnosis, or the final on-scene EMS diagnosis were identified. Seizure-related EMS calls that resulted in hospital transport were included, and the transported EMS encounter was the unit of analysis. EMS response interval was defined as EMS arrival at the scene minus call time, and the call-to-hospital interval as hospital arrival minus call time. The proportions of encounters with EMS arrival within 10 minutes and hospital arrival within 30 minutes were reported as descriptive timing thresholds rather than guideline-based treatment targets. Numerical variables were summarized according to distribution, categorical variables as counts and percentages, and 95% confidence intervals (CIs) for proportions using the Wilson score method.

Results: Among 3,063 seizure-related EMS calls, 1,092 (35.7%) resulted in hospital transport and were included. Mean EMS response interval was 15.9 minutes (SD, 7.8; range, 3.7–67.8). EMS units arrived within 10 minutes of the emergency call for 221 encounters (20.2%; 95% CI, 18.0%–22.7%). Median call-to-hospital interval was 53.9 minutes (IQR, 23.9; range, 12.3–197.1). No transported encounter reached a hospital within 10 minutes of the call, and 27 encounters (2.5%; 95% CI, 1.7%–3.6%) reached a hospital within 30 minutes. Prehospital benzodiazepine treatment was recorded in 214 encounters (19.6%).

Conclusion: Among transported seizure-related EMS encounters, call-to-scene and call-to-hospital intervals were substantial. Because the available timestamps were anchored to the emergency call rather than seizure onset, these findings should not be interpreted as direct measures of status epilepticus treatment delay or guideline adherence. They quantify real-world operational intervals relevant to time-sensitive seizure care.

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: Serum zinc has been examined as a possible correlate of febrile seizures, but its interpretation during acute illness is difficult and published findings are inconsistent. To compare serum zinc concentrations in children with febrile seizures and children without seizures, and to examine whether serum zinc and recorded clinical characteristics were associated with seizure recurrence within 3 months.

Methods: This hospital-based case-control study included 40 children with febrile seizures and 40 afebrile emergency-department controls without seizures, recruited by convenience sampling during the same study period. Serum zinc was measured at presentation using a reagent-based colorimetric 5-Bromo-PAPS assay on an APEL PD-303 UV-visible spectrophotometer. Children in the case group were followed for 3 months by telephone. The primary adjusted analysis used linear regression with age category and sex as covariates. Logistic regression was used to examine the association between serum zinc and recurrence; the model additionally including seizure type was considered exploratory because of the small number of recurrence events and complex seizures.

Results: Mean serum zinc concentrations were 78.71 (SD 18.28) µg/dL in cases and 80.36 (SD 30.83) µg/dL in controls (P=0.772). After adjustment for age category and sex, the mean difference was -4.66 µg/dL (95% CI -16.30 to 6.98; P=0.433). Fourteen of 40 children with febrile seizures (35.0%) had at least one recurrence within 3 months. No statistically significant association was detected between a 10 µg/dL lower serum zinc concentration and recurrence (OR 0.94, 95% CI 0.66 to 1.34; P=0.732).

Conclusion: No statistically significant difference in serum zinc concentration was detected between children with febrile seizures and afebrile controls, and no statistically significant association with 3-month recurrence was detected in this sample. The estimates were imprecise, particularly for recurrence. Larger prospective studies using appropriately comparable febrile controls are needed to determine whether serum zinc has clinical predictive value.

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: To characterize final clinical seizure diagnoses, age-stratified clinical factors, emergency department management, and disposition among adults presenting with seizure-related complaints. Methods: This retrospective cross-sectional study included adults aged ≥18 years who presented to the Emergency Department of Imam Reza (AS) Hospital, Tabriz, Iran, between March 2019 and March 2022 with a chief complaint of seizure. Records with incomplete clinical information required for analysis were excluded. Patients were categorized as 18-39, 40-65, and >65 years. Categorical variables were compared using Pearson’s chi-square test or Fisher’s exact test, as appropriate. Results: Of 1,686 eligible patients, 1,284 (76.2%) received a final clinical diagnosis of seizure, whereas 402 (23.8%) did not. A documented history of seizure or epilepsy was more frequent among patients with a final seizure diagnosis than among those without one (18.1% vs 11.9%; p=0.004). Among patients with a final seizure diagnosis, the proportion with documented stroke increased from 0.3% in those aged 18-39 years to 2.2% in those aged 40-65 years and 8.1% in those aged >65 years; corresponding proportions for structural brain lesions were 1.8%, 4.7%, and 6.5%. Overall, 1,456 patients (86.4%) remained in the ED for 0-6 hours. Diazepam was administered to 865 patients (51.3%), including 231 of 402 patients (57.5%) without a final seizure diagnosis. Ten patients (0.6%) died during the ED episode. Conclusion: Most adults presenting to the emergency department with seizure-related complaints received a final clinical diagnosis of seizure, while nearly one-quarter were ultimately assigned an alternative diagnosis. A previous history of seizure or epilepsy was more frequent among patients with a final seizure diagnosis, and stroke and structural brain lesions were proportionally more common in older patients. These findings provide a clinically relevant characterization of seizure-related emergency presentations across age groups and may support more focused diagnostic assessment and age-sensitive clinical evaluation in routine emergency care.

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: Methanol poisonings (MP) are responsible for a considerable number of fatal intoxications on an annual basis. It has been demonstrated that even relatively small ingestions of these alcohols can produce significant toxicity. It is imperative to recognize the signs of methanol poisoning promptly in order to initiate treatment in a timely manner. The objective of this study was to evaluate the clinical and laboratory data of patients with the aim of predicting the prognosis of MP cases brought to the Emergency Department (ED).

Methods: This single-center, retrospective, observational study was conducted with MP cases that were brought to the ED of Health Sciences University Antalya Training and Research Hospital between January 1, 2018 and December 31, 2022. The demographic, clinical, laboratory, and outcome data were systematically recorded and analyzed, and survivors were compared with non-survivors.

Results: The study's sample size was 40 patients. The mean age of the patients was 48.62 years (±12.8 years), 17.5% of whom were female and 82.5% of whom were male. The most prevalent symptoms were altered consciousness, observed in 80% of cases, and visual symptoms, noted in 50% of cases. The mean Glasgow Coma Scale (GCS) value was 8.55 ± 5.33, and 25% of the patients were comatose. Renal replacement therapy (RRT) was administered to 90% of the patients, ethanol therapy to 82.5%, and mechanical ventilation to 45% of the patients. Non-surviving patients exhibited a larger anion gap, higher partial pressure of carbon dioxide (PCO2) levels, and higher lactate levels, while non-surviving patients demonstrated lower pH levels and lower bicarbonate levels. The area under the curve (AUC) analysis revealed that pH (AUC= 0.911 [95% confidence interval (CI): 0.820, 0.970]) and base excess (AUC=0.906 [95% CI: 0.819, 0.970]) were the blood gas parameters with the highest AUC values in relation to in-hospital mortality.

Conclusion: The in-hospital mortality rate was 47.5%. In MP cases, coma on arrival at the emergency department, more severe metabolic abnormalities, and the need for mechanical ventilation were associated with in-hospital mortality.

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: Timely access to patient information is essential for emergency care. In Nigeria’s public tertiary hospitals, reliance on paper records, limited Electronic Health Record (EHR) availability, and frequent system downtimes contribute to digital health deficits that can delay decisions, reduce coordination, and affect outcomes. This study examined the combined effect of these deficits on emergency care performance.

Methods: A cross-sectional study was conducted from February to April 2025 in five federal tertiary hospitals in Southwest Nigeria. A stratified random sample of 267 healthcare professionals completed a validated 5-point Likert-scale questionnaire (Cronbach’s α = 0.85–0.89). Three digital deficit measures (paper reliance, limited EHR availability, and system downtime) were aggregated to form a composite Digital Deficit Index (DDI). Five emergency care performance indicators were aggregated into a single Emergency Care Efficiency score. Both scores were internally validated through pilot testing and reliability analysis. Analyses included descriptive statistics, Spearman’s rank correlation, Chi-square tests for tertile associations, and multivariable linear regression with 95% confidence intervals.

Results: Participants reported notable inefficiencies: 69.3% indicated that reliance on paper records delayed treatment, 72.7% reported limited EHR access during emergencies, and 81.6% experienced frequent system downtimes. DDI scores ranged from 2.73 to 4.53 (mean = 3.63, Standard Deviation (SD) = 0.33), and Emergency Care Efficiency scores ranged from 2.80 to 4.60 (mean = 3.74, SD = 0.34). Higher DDI was significantly associated with lower Emergency Care Efficiency (Spearman’s ρ = –0.285, p < 0.001; χ²(4) = 13.77, p = 0.008). Adjusted regression showed each one-point DDI increase corresponded to a 0.30-point decrease in Emergency Care Efficiency (β = –0.300, 95% CI = –0.423 to –0.176, p < 0.001). No significant hospital-site or professional-role interaction with DDI was detected in the adjusted model.

Conclusion: Healthcare workers perceived that paper reliance, limited EHR access, and downtimes hinder emergency services. When combined into a composite Digital Deficit Index, these factors showed a statistically significant negative association with emergency care performance. Given its statistically significant association with emergency care efficiency, reducing reliance on paper-based records may represent a potentially important area for improving emergency care delivery in Nigerian public tertiary hospitals.

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.

Acute pain is a common and time-sensitive problem in adult emergency care, but the optimal intervention varies with pain mechanism, severity, comorbidity, route of administration, and expected clinical trajectory. This narrative review evaluates contemporary multimodal analgesic strategies while distinguishing direct emergency-department (ED) evidence from postoperative, outpatient, or other indirect evidence. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen remain foundational therapies for selected patients. Direct ED trials indicate that intravenous acetaminophen does not routinely confer clinically important short-term benefit over oral administration when enteral treatment is feasible, and higher single doses of ibuprofen or ketorolac have not shown greater short-term analgesia than standard analgesic doses. Sub-dissociative-dose ketamine provides short-term analgesia comparable with morphine in selected ED populations, although psychoperceptual adverse effects remain relevant. Evidence for intravenous lidocaine is heterogeneous and does not support routine use for undifferentiated pain. Nitrous oxide and, where locally available, low-dose inhaled methoxyflurane offer selected noninvasive options. Ultrasound-guided regional anesthesia has strengthened direct ED evidence for hip- and rib-fracture pain, but current trials do not establish a universally superior block technique. Suzetrigine, a selective NaV1.8 inhibitor, adds a new non-opioid mechanism and is FDA-approved for moderate-to-severe acute pain, but its pivotal efficacy evidence is predominantly postoperative and its comparative effectiveness in heterogeneous ED pain remains uncertain. The practical objective is therefore not opioid elimination; it is timely, diagnosis-sensitive, multimodal analgesia with appropriate reassessment and the least avoidable treatment burden.

Early-career researchers (ECRs) occupy a heterogeneous set of career stages, from doctoral training and postdoctoral appointments to the transition toward independent research leadership. Across countries and disciplines, the evidence repeatedly identifies challenges related to insecure career structures, access to research funding, mentorship, professional networks, research and communication skills, publishing and research-evaluation pressures, and work-life and mental-health concerns. This narrative review synthesizes peer-reviewed evidence and current reports from research-funding and scientific organizations to examine these barriers and the support strategies most consistently proposed or evaluated. The literature indicates that no single definition of an ECR is universally applicable and that experiences differ substantially by career stage, discipline, national research system, gender, and family circumstances. Mentoring is generally associated with career development, but the evidence favors structured and network-based approaches over reliance on a single informal mentor. Capacity-building programs can address gaps in scientific writing, communication, grant development, and broader academic competencies, particularly where institutional training is limited. Recent evidence also documents a substantial burden of psychological distress among doctoral and early postdoctoral researchers, while qualitative studies link poor well-being to job insecurity, high expectations, and limited institutional support. Policies for ECRs should therefore combine career-stage-appropriate funding, transparent career development, high-quality mentoring, skills training, responsible research assessment, publishing support, and measures that address work-family and equity barriers. The evidence base remains heterogeneous, and many interventions require stronger longitudinal evaluation.

Acute scrotal pain and swelling in children and adolescents encompass conditions ranging from self-limiting inflammatory disorders to testicular torsion, a time-sensitive urological emergency. The central emergency-care problem is to identify patients in whom torsion remains sufficiently plausible to require immediate surgical assessment without allowing diagnostic testing to introduce avoidable delay. This evidence-informed narrative review synthesizes contemporary evidence on epidemiology, clinical assessment, risk stratification, ultrasonography, point-of-care ultrasound (POCUS), differential diagnosis, treatment and organization of care. A targeted search of PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online) and authoritative professional and national sources was undertaken through 2 October 2026. Current European Association of Urology guidance, the Getting It Right First Time (GIRFT) Testicular Torsion Pathway Version 2.1 from National Health Service (NHS) England, the 2024 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Twist and Shout report, systematic reviews, meta-analyses and selected validation and cohort studies were prioritized. Testicular torsion occurs at all ages but is concentrated in infancy and adolescence. The probability of testicular survival decreases with increasing symptom duration, although duration alone does not determine viability and should not be used as a reason to withhold surgical assessment. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score can structure risk assessment, but performance depends on threshold and population, and a low score does not exclude torsion. In an age-unrestricted 2026 meta-analysis, color Doppler sonography showed summary sensitivity of 95.3% and specificity of 98.3%; in the prespecified subgroup restricted to children younger than 18 years, sensitivity was 94.3% and specificity 95.8%. Preserved arterial flow can occur in early, partial or intermittent torsion. POCUS may shorten diagnostic pathways in trained services, but the evidence base is smaller and operator dependent. Standardized pathways can reduce in-hospital delay, but current observational evidence does not establish that pathway implementation alone independently reduces orchidectomy. Effective care therefore requires rapid clinical recognition, early surgical communication, selective use of diagnostic adjuncts and avoidance of preventable delay.

Hantavirus disease is an uncommon zoonotic infection that can progress rapidly from a nonspecific febrile illness to life-threatening cardiopulmonary or renal dysfunction. In the Americas, hantavirus cardiopulmonary syndrome (HCPS), also termed hantavirus pulmonary syndrome (HPS), is characterized by increased vascular permeability, pulmonary edema, hypoxemia, and circulatory failure, whereas hemorrhagic fever with renal syndrome (HFRS), encountered predominantly in Europe and Asia, is distinguished by acute kidney injury, thrombocytopenia, and variable hemorrhagic manifestations (1-3). The emergency department is an important point of recognition because patients may initially present with fever, myalgia, gastrointestinal symptoms, or headache before respiratory or hemodynamic deterioration becomes apparent. Emergency nurses participate in exposure assessment, serial physiologic observation, implementation of supportive-care protocols, fluid-balance surveillance, recognition of respiratory and circulatory deterioration, and infection-prevention measures. However, nursing-specific outcome evidence identified by the targeted search used for this mini-review is limited; the nursing role should therefore be derived cautiously from established clinical-management principles rather than presented as independently proven to improve survival. This mini-review examines evidence relevant to emergency nursing practice, including 2026 publications on critical-care management, prognosis, outbreak response, and healthcare-worker exposure. It emphasizes early recognition of HCPS, monitoring during the transition to cardiopulmonary failure, careful fluid and hemodynamic management, escalation to critical care, renal surveillance in HFRS, and infection prevention in suspected Andes virus infection. The multinational Andes virus outbreak linked to expedition cruise travel in 2026 was declared contained by WHO on 2 July 2026; nevertheless, the event illustrates the need for emergency departments to maintain operational readiness for an uncommon but potentially severe infection in which limited person-to-person transmission is operationally relevant (7,21).

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.

Dear Editor;

The recently contained 2026 multi-country cluster of Andes virus (ANDV) infection, aboard the M/V Hondius cruise ship, showed that hantavirus disease can present at the emergency department door far beyond the rural settings clinicians expect, exposing a persistent diagnostic blind spot. As of 2 July 2026, the World Health Organization (WHO) reported 13 linked cases, including three deaths (case fatality ratio, 23%) (1). Although uncommon, hantavirus carries disprop­ortionate emergency-medicine relevance: a nonspecific febrile illness can evolve rapidly into hemorrhagic fever with renal syndrome (HFRS) or hantavirus cardiop­ulmonary syndrome (HCPS)/hantavirus pulmonary syndrome (HPS), with acute kidney injury, shock, pulmonary edema, and respiratory failure (1-3).

Hantaviruses are zoonotic RNA viruses maintained in rodent reservoirs. Infection usually follows inhalation of aerosolized particles contaminated with rodent excreta, typically during farming, forestry, camping, or cleaning poorly ventilated rodent-infested spaces (3-5). Human-to-human transmission is not a general feature; the exception is ANDV, documented in Argentina and Chile, reaffirmed during the 2026 outbreak, which showed onboard spread (1, 2, 6, 7).

Geographic patterns are heterogeneous. HFRS predominates in Asia and Europe: Hantaan and Seoul viruses are major Asian causes, while Puumala and Dobrava-Belgrade viruses account for most European cases (3, 5). China recorded 166,975 HFRS cases and 1,689 deaths during 2004-2016 (8). The European Union/European Economic Area (EU/EEA) reported 1,885 cases in 2023 (0.4/100,000), mostly from Finland and Germany (9). These figures are not directly comparable given differing surveillance (5, 9).

HCPS occurs predominantly in the Americas, caused by New World hantaviruses including Sin Nombre virus (North America) and ANDV (southern South America); it is less frequent than HFRS but more fatal (2, 3). In 2025, eight American countries reported 229 confirmed HPS cases and 59 deaths, concentrated in the Southern Cone (10). In the United States, 890 laboratory-confirmed hantavirus cases, 859 meeting the HPS definition, were reported from 1993-2023; local epidemiology is more informative than continental estimates (11, 12).

Incidence reflects reservoir ecology and human behavior, though effects vary by virus and region (3, 13). A key diagnostic blind spot lies in reducing exposure assessment to "Have you seen a rodent?" More useful questions address cleaning dusty spaces, agricultural work, sleeping in cabins, camping, travel to endemic areas, and contact with a person with suspected ANDV infection (4, 5).

Early recognition is difficult because the prodrome, fever, headache, myalgia, gastroi­ntestinal symptoms, resembles influenza, coronavirus disease 2019 (COVID-19), sepsis, leptospirosis, or dengue (2, 4, 5). This nonspecificity is the central diagnostic blind spot; subsequent organ involvement is more informative. HFRS features increased vascular permeability, hypotension, thrombo­cytopenia, proteinuria/hematuria, occasionally disseminated intravascular coagulation (DIC), and acute kidney injury (5, 14, 15). HCPS may progress within 5-10 days to bilateral pulmonary edema, hypoxemic respiratory failure, and shock; thrombo­cytopenia, hemocon­centration, leukocytosis with left shift, and circulating immunoblasts are prodromal clues, though none replaces epidemiologic assessment and confirmatory testing (2, 4, 16).

The practical task is not universal testing but risk-stratified early recognition. Thrombo­cytopenia with worsening respiratory failure after plausible rodent exposure warrants greater suspicion than uncomplicated viral illness. Fever with thrombo­cytopenia, proteinuria/hematuria, oliguria, rising creatinine, or unexplained hypotension should raise concern for HFRS when exposure history is compatible (4, 5, 14). Because pulmonary deterioration in HCPS may be abrupt, patients with evolving respiratory or hemodynamic abnormalities warrant close monitoring and early transfer if needed (2, 4, 17).

Confirmation relies on detection of immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies, typically by enzyme-linked immunosorbent assay (ELISA), with reverse transcription-quantitative polymerase chain reaction (RT-qPCR) offering earlier detection and species differe­ntiation (2). Because turnaround time varies, escalation of care often must precede confirmation, a delay clinicians cannot afford. Early consultation with infectious-disease, critical-care, nephrology, and public-health teams should follow the dominant syndrome (2, 4, 5). When ANDV is suspected, infection-prevention measures and contact tracing require prompt public-health involvement (1, 6, 7).

Hantavirus should not become a reflex diagnosis for every febrile patient, but it deserves a defined place in the differential when exposure, geography, thrombo­cytopenia, renal dysfunction, vascular leakage, pulmonary edema, or rapid deterioration form a coherent picture. Closing this blind spot means recognizing hantavirus not by frequency, but by common illnesses, how quickly it progresses, and how little time remains to act.

Basic Life Support (BLS) provided by bystanders is an important component of the early response to cardiac arrest. Effective bystander cardiop­ulmonary resuscitation (CPR) has been associated with improved survival after out-of-hospital cardiac arrest (1). Nevertheless, surveys across different settings have documented substantial gaps in public knowledge of CPR (2,3).

Educational interventions can improve BLS knowledge. Studies of school students and undergraduates have reported improved CPR knowledge after structured BLS education (4,5), while performance-based research has shown that lay rescuers may still have difficulty correctly following BLS algorithms, supporting the need for practical training and reinforcement (6). Current American Heart Association (AHA) guidance separately addresses adult and pediatric BLS competencies and emphasizes evidence-informed approaches to resuscitation education (7-9).

Against this background, we evaluated immediate changes in BLS knowledge before and after a one-day workshop delivered to public-service personnel in Kamburupitiya, southern Sri Lanka. The purpose of this report is to describe item-level changes in correct responses and to identify knowledge domains that may require greater emphasis in future training.

This was a single-group pre-post evaluation of a one-day BLS educational workshop. The final sample comprised 54 participants from public service sectors, including law enforcement and administrative personnel. Participant charact­eristics are presented in Table 1.

The workshop was delivered by certified instructors and included a morning lecture followed by an evening practical session involving individual hands-on practice of CPR and airway maneuvers. This format provided both theoretical instruction and practical exposure within the same training day.

Knowledge was assessed using a structured 10-item questionnaire covering pulse assessment, adult compression-to-ventilation ratio, features and rate of chest compressions, rescue-breath trouble­shooting, recognition of airway obstruction, and selected child and infant BLS topics. Because the questionnaire included both adult and pediatric content, interpretation of these domains was considered in relation to current adult and pediatric BLS guidance (7,8). Formal psychometric validation data for this questionnaire were not available for the present report.

The pre-test was administered before the morning teaching session and the post-test immediately after the practical session on the same day. For this report, outcomes are presented as the number and percentage of correct responses for each questionnaire item, exactly as reported in Table 2. The available results are aggregate item-level frequencies; therefore, paired inferential statistics were not reconstructed from these data, because valid paired analyses require participant-level paired outcomes.

The study included 54 participants with a mean age of 40 years (SD 10.555). Twenty participants (37.0%) were male, and 34 (63.0%) were female. Police officers comprised 50.0% of the sample, followed by other occupations (24.1%), non-officer roles (14.8%), and departmental officers (11.1%).

Item-level pre- and post-training results are shown in Table 2. Several questionnaire items showed higher percentages of correct responses after the workshop. The largest observed increases were for the recommended chest-compression rate, from 19 (38.8%) correct responses before training to 36 (75.0%) afterward, and for the appropriate action when the chest does not rise during rescue breaths, from 20 (40.0%) to 35 (72.9%). Two items did not show higher post-training percentages: pulse-check location in a child older than 1 year changed from 9 (17.0%) to 8 (16.7%), and the item on hand placement for chest compressions in children older than 1 year decreased from 4 (7.4%) to 0 (0.0%).

The observed pattern showed higher immediate post-training correct-response percentages in several BLS domains rather than uniform improvement across all items. Prior educational studies have similarly reported improved CPR knowledge after structured BLS training (4,5). The largest increases in this workshop were in compression rate and management of ineffective rescue breaths, whereas several child-, infant-, and choking-related questions remained poorly answered. Current AHA resuscitation education guidance supports structured, skills-focused education and strategies to maintain competence over time (9). These findings support placing greater instructional emphasis on the domains that remained weak and evaluating practical performance in addition to questionnaire-based knowledge.

The pediatric results also require careful interpretation at the instrument level. Current AHA pediatric BLS guidance allows chest compressions on a child using one or two hands, depending on the child and rescuer, rather than a single, universally applicable hand technique (8). Accordingly, the questionnaire item on hand placement for chest compressions in children older than 1 year should be reviewed and revalidated before future use to ensure that its wording and answer key remain aligned with contemporary guidance. The reported responses in Table 2 have not been altered.

This evaluation has important limitations. It used a single-group design, the post-test was administered immediately after training, and no delayed follow-up was available; therefore, the findings describe immediate post-training response patterns and do not establish long-term retention or causal effectiveness. The questionnaire assessed knowledge and should not be interpreted as a direct measure of psychomotor CPR competence; formal psychometric validation data were also unavailable for this report. In addition, half of the sample consisted of police officers, limiting generalization to the wider rural population. In conclusion, several questionnaire items showed higher percentages of correct responses immediately after the workshop, while important knowledge gaps persisted. Future workshops should target the weaker pediatric and airway-obstruction domains, include objective practical-skill assessment, and incorporate follow-up testing to evaluate retention.

Dear Editor,

In the high-stakes, time-pressured environment of the emergency department (ED), triage is the critical gateway that determines the trajectory of a patient’s care. Clinicians rapidly assess heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation, the classic vital signs that offer a snapshot of physiological stability. Yet, there is a compelling argument for considering health literacy as a cognitive “vital sign” in emergency care. The proposition to measure health literacy at triage, as explored in the literature, warrants further evaluation, particularly because low health literacy has been associated with greater patient-clinician discrepancy in perceived emergency severity (1).

Health literacy, the capacity to obtain, process, and understand basic health information to make appropriate health decisions, directly concerns how patients obtain and understand information needed for health decisions. Low health literacy has been associated with higher ED utilization in adults and with non-urgent pediatric ED use among caregivers with low health literacy (2,5). In the ED, where communication is rapid, stress is high, and instructions are often complex, this deficit can become particularly consequential. A patient may nod in understanding when told about their diabetic ketoacidosis regimen or the warning signs for a concussion, yet leave fundamentally confused. By identifying this risk factor at the point of entry, clinicians can tailor their communication from the outset and identify patients who may benefit from clearer explanations or additional support.

The operational and ethical rationale for this measurement is plausible. From a systems perspective, identifying low health literacy could allow for the immediate activation of tailored interventions. This could flag the patient’s chart for use of touchback methods, prompt the involvement of a care coordinator or pharmacist for discharge counselling, or ensure follow-up instructions are written in plain language with pictograms. Proactively addressing comprehension barriers may reduce the need for clarifications later and support more accurate history-taking. Ethically, such an approach may also support more equitable communication by reducing reliance on assumptions about which patients may need additional help. Feasibility studies suggest that health-literacy tools can be administered in the ED, including in older patients, although their routine use specifically at triage requires further evaluation (3).

However, the implementation of such a strategy is fraught with significant challenges, which must be thoughtfully addressed. The foremost concern is the practical constraint of time. Triage is designed for speed. Introducing any assessment must be near-instantaneous. Lengthy instruments like the TOFHLA (Test of Functional Health Literacy in Adults) are impractical. Any triage-based approach would therefore need ultra-brief, validated screening questions (e.g., “How confident are you filling out medical forms by yourself?”) (4), with implementation tested to ensure that screening does not create bottlenecks. The risk of stigmatization is another serious consideration. The act of “testing” a patient’s literacy must be handled with extreme sensitivity to avoid shame or alienation. If such screening is used, it should be framed as a routine communication assessment rather than as a test of the patient’s abilities.

Furthermore, measurement alone is unlikely to be useful without a structured organizational response. Identifying a problem creates an obligation to solve it. EDs would need protocols and resources in place trained staff, appropriate health education materials, and clear pathways for escalation to act on the information. This would require investment in training, workflow redesign, and a cultural shift that priorities clear communication as a clinical imperative, not an optional courtesy.

In conclusion, measuring health literacy at triage offers a potentially useful extension of patient assessment by treating comprehension as a clinically relevant communication factor. While logistical and ethical hurdles are substantial, they are not insurmountable. Whether routine screening can reduce medical errors, improve patient adherence, decrease disparities, or improve resource use remains to be established. As healthcare continues to evolve towards more patient-centered and value-based models, the concept of a cognitive “vital sign” may be useful as a prompt for further study, but it should not yet be considered a standard of care. The triage encounter is the first, and perhaps most crucial, opportunity to bridge that gap.

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.

A 77-year-old man presented to the emergency department with a penetrating open-globe injury caused by a high-velocity nail gun while working without protective goggles. Clinical examination revealed a full-thickness scleral wound, and computed tomography confirmed a retained intraocular foreign body; however, his visual acuity was 20/20. The Ocular Trauma Score raw score was 86, corresponding to category 4. Emergency pars plana vitrectomy with removal of the intraocular foreign body was performed, and intravenous ceftazidime was administered during surgery and for three days postoperatively. The postoperative course was uneventful, and visual acuity remained 20/20 at 3 months. This case highlights the importance of prompt diagnosis using appropriate imaging, early surgical management, and infection prophylaxis in penetrating open-globe injury.

Multiple Endocrine Neoplasia type 1 (MEN1) is a rare autosomal dominant endocrine tumor syndrome characterized mainly by tumors involving the parathyroid glands, pancreatic/duodenal neuroendocrine system, and anterior pituitary gland. Primary hyperparathyroidism is the most frequent manifestation of MEN1. Although pancreatic neuroendocrine tumors are well recognized in MEN1, other pancreatic abnormalities, including chronic pancreatitis, are less clearly established and require careful interpretation. We report a case of a 35-year-old Middle Eastern female presenting with recurrent upper abdominal pain and previous episodes of acute pancreatitis. Laboratory evaluation demonstrated hypercalcemia with markedly elevated parathyroid hormone (PTH) levels, consistent with primary hyperparathyroidism. Imaging revealed a left parathyroid lesion, chronic pancreatitis with pancreatic duct dilatation and intraductal stone, and a small pituitary microadenoma without clinical evidence of hormone hypersecretion. Based on the coexistence of primary hyperparathyroidism and pituitary adenoma, a clinical diagnosis of MEN1 was considered. Genetic testing for MEN1 mutation was not performed due to financial limitations. The patient underwent parathyroidectomy, with normalization of calcium and PTH levels and improvement of abdominal symptoms. The pancreatic duct stone was managed conservatively, and the pituitary lesion remained under surveillance. This case describes a patient with a clinical MEN1 phenotype and an unusual coexistence of chronic pancreatitis with pancreatic duct stone. Although the pancreatic finding cannot be confirmed as a MEN1-associated manifestation, its presence highlights the importance of considering endocrine disorders in patients with recurrent pancreatitis and multiple endocrine abnormalities. Further evaluation and long-term surveillance are required in patients with suspected MEN1.

Background: Waterhouse-Friderichsen syndrome is a rare, rapidly fatal condition characterized by bilateral adrenal hemorrhage and acute adrenal insufficiency, most commonly associated with fulminant meningococcemia. Early manifestations may be nonspecific, and the diagnosis is often delayed or established postmortem.

Case presentation: A 65-year-old woman with a history of migraine was brought to the emergency department after awakening with aphasia and right-sided weakness. Initial neurological assessment showed severe focal deficits, with a National Institutes of Health Stroke Scale (NIHSS) score of 22, and an acute stroke pathway was activated. Her admission temperature was 36.6 °C, and no cutaneous lesions were initially documented. Brain magnetic resonance imaging showed no acute ischemic lesion, and computed tomography angiography of the head and neck showed no extracranial or intracranial vascular occlusion. During the diagnostic workup, she developed profound hemodynamic deterioration. Initial laboratory tests showed leukopenia, mild thrombo­cytopenia, acute kidney injury, markedly elevated D-dimer, and hyperlactatemia. She rapidly progressed to refractory shock, metabolic acidosis, fever, mottling, and multiorgan failure despite fluid resuscitation, vasopressors, empiric antibiotic therapy, hydrocortisone, airway management, and rescue therapy. Lumbar puncture was performed because of persistent neurological symptoms and negative neuroimaging for acute stroke. The patient died approximately 12 hours after arrival. Blood cultures were positive for Neisseria meningitidis, and clinical autopsy demonstrated bilateral adrenal hemorrhage, disseminated intravascular coagulation, and findings consistent with Waterhouse-Friderichsen syndrome.

Conclusion: Fulminant meningo­coccemia and Waterhouse-Friderichsen syndrome may initially mimic acute stroke, particularly when focal neurological deficits precede overt septic features. In patients with apparent stroke symptoms and early hemodynamic instability, hyperla­ctatemia, cytopenias, or coagulopathy, sepsis and meningo­coccemia should remain high-priority differential diagnoses.

A middle-aged woman with no known past medical history presented to the emergency department with acute visual loss that had begun approximately 4 hours before admission. She had experienced flu-like symptoms during the preceding days. Before presentation to our emergency department, she had sought care at a local clinic because of a thunderclap headache. Intravenous ketorolac was administered, after which she developed an anaphylactic reaction. After treatment of the anaphylactic reaction, she reported severe visual impairment and was transferred to our emergency department by emergency medical services.

Ophthalmologic examination showed visual acuity limited to light perception. No relative afferent pupillary defect was reported (negative Marcus Gunn sign). The remainder of the physical examination was unremarkable. Cerebrospinal fluid analysis was normal.

Axial brain computed tomography (CT) was reported to show bilateral parieto-occipital subcortical hemorrhage (Figure 1). Brain magnetic resonance imaging (MRI) showed bilateral posterior parieto-occipital abnormalities on T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences (Figure 2). Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences are shown in Figure 3. Magnetic resonance angiography (MRA), which is not included in the available figure set, was reported to show multifocal segmental narrowing and dilatation of the cerebral arteries with a string-of-beads appearance.