The National Institutes of Health Stroke Scale (NIHSS) is used to determine the severity of the disease and to make treatment decisions in ischemic stroke patients. However, the need for a neurologist to assess NIHSS before thrombolytic therapy may prolong the treatment process. This prospective, single-center, observational, planned study included patients who presented to the emergency department in the first 24 h after the onset of symptoms and were diagnosed with ischemic stroke between September 2022 and June 2023. The NIHSS was evaluated by the emergency medicine physicians and neurologists who evaluated the patients in the emergency department, and the decisions on whether to administer thrombolytics and the time taken for this decision were recorded and compared. A very high agreement was found when the total NIHSS scores of emergency medicine physicians and neurologists were compared (intraclass correlation coefficient = 0.947 [95% confidence interval 0.92-0.96]). Emergency medicine physicians and neurologists showed high agreement with thrombolytic therapy decisions. In patients given thrombolytic therapy, emergency medicine physicians made the decision earlier than neurologists, and there was a significant difference of 14 ± 12 min between the decisions of emergency physicians and those of neurologists. There is high agreement between emergency medicine physicians and neurologists in the NIHSS evaluation and thrombolytic decisions for patients with acute ischemic stroke. According to our results, emergency medicine physicians can provide thrombolytic treatment in accordance with neurologists, thus shortening the time for thrombolytic treatment.
The healthcare sector is a labor-intensive service domain that operates on the basis of multidisciplinary collaboration. Effective service delivery in this field is not solely dependent on individual expertise, but also closely linked to the cooperation and cohesion established among team members. Team cohesion plays a critical role in various aspects, including patient safety, quality of care, team performance, and the prevention of medical errors. Particularly in healthcare services, where human life is directly at stake, the importance of team cohesion becomes even more evident in ensuring effective and safe care delivery. In this context, the present study aimed to validate the Turkish version of the Erlangen Team Cohesion at Work Scale and to assess the level of team cohesion among paramedics. This methodological study was conducted between June 15 and July 15, 2024, with 219 paramedics who are members of the Association of Paramedics and Prehospital Emergency Medicine. To validate the Turkish version of the Erlangen Team Cohesion at Work Scale, the following procedures were carried out: For content validity: cultural adaptation, linguistic and content validation, and a pilot study. For construct validity: Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). For reliability: Cronbach's alpha, item-total correlations, split-half reliability, and test-retest reliability analyses. The Turkish version of the scale, consisting of 12 items under a single factor, demonstrated excellent psychometric properties: Cronbach's alpha = 0.93; KMO = 0.94; explained variance = 59.76%. The fit indices from CFA were: χ²/df = 2.5, RMSEA = 0.08, SRMR = 0.04, GFI = 0.90, NFI = 0.93, RFI = 0.90, IFI = 0.95, TLI = 0.94, and CFI = 0.95. These findings confirmed that the Turkish version of the Erlangen Team Cohesion at Work Scale has high content and construct validity as well as strong reliability. Additionally, the paramedics who participated in the study were found to have a high level of team cohesion, with a mean score of 2.86 ± 0.63. The Turkish version of the Erlangen Team Cohesion at Work Scale demonstrated robust validity and reliability, supporting its applicability among healthcare professionals in Turkey. Furthermore, the high cohesion levels observed among paramedics highlight the presence of effective collaborative dynamics in prehospital emergency medical services.
We aimed to evaluate the performance of a large language model (ChatGPT) in answering official sample questions from the Turkish Board of Emergency Medicine (TBEM). Two versions of the model, GPT-4 and GPT-4o, were assessed to explore consistency and accuracy across iterations. A cross-sectional observational study was conducted using 25 standardized multiple-choice questions publicly released by TBEM. Each question was manually entered into GPT-4 and GPT-4o through the OpenAI interface. Both models were prompted to select the best single answer from the provided options without additional clarification or training context. Model responses were evaluated for accuracy, consistency upon repetition, and domain-specific error types. This study is compliant with the STROBE statement and the MedinAI reporting guidelines. GPT-4 correctly answered 20 out of 25 questions (80%) on the first attempt. On repetition, its score improved to 84%. GPT-4o also achieved a score of 88% (22/25) on its first attempt and showed consistent results upon a second evaluation, providing identical answers in both trials. Errors occurred in the domains of trauma during pregnancy, pediatric resuscitation, and adult resuscitation protocols. Both models demonstrated strong performance in fact-based domains and in questions involving image descriptions. GPT-4 and GPT-4o performed above the TBEM passing threshold, showing solid accuracy across a range of emergency medicine topics. Both excelled in fact-based and image-related questions. However, they showed limitations in clinical reasoning, particularly in scenarios requiring nuanced judgment. These tools may support examination preparation but should not replace the expertise of trained emergency physicians.
For more than three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has provided a framework to quantify health loss due to diseases, injuries, and associated risk factors. This paper presents GBD 2023 findings on disease and injury burden and risk-attributable health loss, offering a global audit of the state of world health to inform public health priorities. This work captures the evolving landscape of health metrics across age groups, sexes, and locations, while reflecting on the remaining post-COVID-19 challenges to achieving our collective global health ambitions. The GBD 2023 combined analysis estimated years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 375 diseases and injuries, and risk-attributable burden associated with 88 modifiable risk factors. Of the more than 310 000 total data sources used for all GBD 2023 (about 30% of which were new to this estimation round), more than 120 000 sources were used for estimation of disease and injury burden and 59 000 for risk factor estimation, and included vital registration systems, surveys, disease registries, and published scientific literature. Data were analysed using previously established modelling approaches, such as disease modelling meta-regression version 2.1 (DisMod-MR 2.1) and comparative risk assessment methods. Diseases and injuries were categorised into four levels on the basis of the established GBD cause hierarchy, as were risk factors using the GBD risk hierarchy. Estimates stratified by age, sex, location, and year from 1990 to 2023 were focused on disease-specific time trends over the 2010-23 period and presented as counts (to three significant figures) and age-standardised rates per 100 000 person-years (to one decimal place). For each measure, 95% uncertainty intervals [UIs] were calculated with the 2·5th and 97·5th percentile ordered values from a 250-draw distribution. Total numbers of global DALYs grew 6·1% (95% UI 4·0-8·1), from 2·64 billion (2·46-2·86) in 2010 to 2·80 billion (2·57-3·08) in 2023, but age-standardised DALY rates, which account for population growth and ageing, decreased by 12·6% (11·0-14·1), revealing large long-term health improvements. Non-communicable diseases (NCDs) contributed 1·45 billion (1·31-1·61) global DALYs in 2010, increasing to 1·80 billion (1·63-2·03) in 2023, alongside a concurrent 4·1% (1·9-6·3) reduction in age-standardised rates. Based on DALY counts, the leading level 3 NCDs in 2023 were ischaemic heart disease (193 million [176-209] DALYs), stroke (157 million [141-172]), and diabetes (90·2 million [75·2-107]), with the largest increases in age-standardised rates since 2010 occurring for anxiety disorders (62·8% [34·0-107·5]), depressive disorders (26·3% [11·6-42·9]), and diabetes (14·9% [7·5-25·6]). Remarkable health gains were made for communicable, maternal, neonatal, and nutritional (CMNN) diseases, with DALYs falling from 874 million (837-917) in 2010 to 681 million (642-736) in 2023, and a 25·8% (22·6-28·7) reduction in age-standardised DALY rates. During the COVID-19 pandemic, DALYs due to CMNN diseases rose but returned to pre-pandemic levels by 2023. From 2010 to 2023, decreases in age-standardised rates for CMNN diseases were led by rate decreases of 49·1% (32·7-61·0) for diarrhoeal diseases, 42·9% (38·0-48·0) for HIV/AIDS, and 42·2% (23·6-56·6) for tuberculosis. Neonatal disorders and lower respiratory infections remained the leading level 3 CMNN causes globally in 2023, although both showed notable rate decreases from 2010, declining by 16·5% (10·6-22·0) and 24·8% (7·4-36·7), respectively. Injury-related age-standardised DALY rates decreased by 15·6% (10·7-19·8) over the same period. Differences in burden due to NCDs, CMNN diseases, and injuries persisted across age, sex, time, and location. Based on our risk analysis, nearly 50% (1·27 billion [1·18-1·38]) of the roughly 2·80 billion total global DALYs in 2023 were attributable to the 88 risk factors analysed in GBD. Globally, the five level 3 risk factors contributing the highest proportion of risk-attributable DALYs were high systolic blood pressure (SBP), particulate matter pollution, high fasting plasma glucose (FPG), smoking, and low birthweight and short gestation-with high SBP accounting for 8·4% (6·9-10·0) of total DALYs. Of the three overarching level 1 GBD risk factor categories-behavioural, metabolic, and environmental and occupational-risk-attributable DALYs rose between 2010 and 2023 only for metabolic risks, increasing by 30·7% (24·8-37·3); however, age-standardised DALY rates attributable to metabolic risks decreased by 6·7% (2·0-11·0) over the same period. For all but three of the 25 leading level 3 risk factors, age-standardised rates dropped between 2010 and 2023-eg, declining by 54·4% (38·7-65·3) for unsafe sanitation, 50·5% (33·3-63·1) for unsafe water source, and 45·2% (25·6-72·0) for no access to handwashing facility, and by 44·9% (37·3-53·5) for child growth failure. The three leading level 3 risk factors for which age-standardised attributable DALY rates rose were high BMI (10·5% [0·1 to 20·9]), drug use (8·4% [2·6 to 15·3]), and high FPG (6·2% [-2·7 to 15·6]; non-significant). Our findings underscore the complex and dynamic nature of global health challenges. Since 2010, there have been large decreases in burden due to CMNN diseases and many environmental and behavioural risk factors, juxtaposed with sizeable increases in DALYs attributable to metabolic risk factors and NCDs in growing and ageing populations. This long-observed consequence of the global epidemiological transition was only temporarily interrupted by the COVID-19 pandemic. The substantially decreasing CMNN disease burden, despite the 2008 global financial crisis and pandemic-related disruptions, is one of the greatest collective public health successes known. However, these achievements are at risk of being reversed due to major cuts to development assistance for health globally, the effects of which will hit low-income countries with high burden the hardest. Without sustained investment in evidence-based interventions and policies, progress could stall or reverse, leading to widespread human costs and geopolitical instability. Moreover, the rising NCD burden necessitates intensified efforts to mitigate exposure to leading risk factors-eg, air pollution, smoking, and metabolic risks, such as high SBP, BMI, and FPG-including policies that promote food security, healthier diets, physical activity, and equitable and expanded access to potential treatments, such as GLP-1 receptor agonists. Decisive, coordinated action is needed to address long-standing yet growing health challenges, including depressive and anxiety disorders. Yet this can be only part of the solution. Our response to the NCD syndemic-the complex interaction of multiple health risks, social determinants, and systemic challenges-will define the future landscape of global health. To ensure human wellbeing, economic stability, and social equity, global action to sustain and advance health gains must prioritise reducing disparities by addressing socioeconomic and demographic determinants, ensuring equitable health-care access, tackling malnutrition, strengthening health systems, and improving vaccination coverage. We live in times of great opportunity. Gates Foundation and Bloomberg Philanthropies.
Cardiovascular diseases (CVDs) are the leading cause of mortality and are among the foremost causes of disability globally. CVD burden has continued to increase in most countries since 1990, with trends driven by changing exposures to harmful risk factors, population growth, and population aging. We report estimates of global, national, and subnational CVD burden, including 18 subdiseases and 12 associated modifiable risk factors. We analyzed change in CVD burden from 1990 to 2023 and identified drivers of change including population growth, population aging, and risk factor exposure. The Global Burden of Disease (GBD) 2023 study, a multinational collaborative research study, quantified burden due to 375 diseases including CVD burden and identified drivers of change from 1990 to 2023 using all available data and statistical models. GBD 2023 estimated the population-level burden of diseases in 204 countries and territories from 1990 to 2023. CVDs were the leading cause of disability-adjusted life years (DALYs) and deaths estimated in the GBD. As of 2023, there were 437 million (95% UI: 401 to 465 million) CVD DALYs globally, a 1.4-fold increase from the number in 1990 of 320 million (292 to 344 million). Ischemic heart disease, intracerebral hemorrhage, ischemic stroke, and hypertensive heart disease were the leading cardiovascular causes of DALYs in 2023 globally. As of 2023, age-standardized CVD DALY rates were highest in low and low-middle Socio-demographic Index (SDI) settings and lowest in high SDI settings. The number of CVD deaths increased globally from 13.1 million (95% UI: 12.2 to 14.0 million) in 1990 to 19.2 million (95% UI: 17.4 to 20.4 million) in 2023. The number of prevalent cases of CVD more than doubled since 1990, with 311 million (95% UI: 294 to 333 million) prevalent cases of CVD in 1990 and 626 million (95% UI: 591 to 672 million) prevalent cases in 2023 globally. A total of 79.6% (95% UI: 75.7% to 82.5%) of CVD burden is attributable to modifiable risk factors 347 million [95% UI: 318 to 373 million] DALYs in 2023). Globally, high systolic blood pressure, dietary risks, high low-density lipoprotein cholesterol, and air pollution were the modifiable risks responsible for most attributable CVD burden in 2023. Since 1990, changes in exposure to modifiable risk factors have had mixed effects on CVD burden, with increases in high body mass index, high fasting plasma glucose, and low physical activity leading to higher burden, while reductions in tobacco usage have mitigated some of these increases. Population growth and population aging were the main drivers of the increasing burden since 1990, adding 128 million (95% UI: 115 to 139 million) and 139 million (95% UI: 126 to 151 million) CVD DALYs to the increase in CVD burden since 1990. CVD remains the leading cause of disease burden and death worldwide with the greatest burden in low, low-middle, and middle SDI regions. Large variation exists in CVD burden even for countries at similar levels of development, a gap explained substantially by known, modifiable risk factors that are inadequately controlled. The decades-long increase in CVD burden was the result of population growth, population aging, and increased exposure to a subset of risk factors led by metabolic risks. Countries will need to adopt effective health system and public health strategies if they are to progress in achieving global goals to reduce the burden of CVD.
Emergency physicians may experience intense fatigue and burnout due to factors related to occupational conditions. The group experiencing burnout most frequently among physicians is emergency medicine (EM) physicians, with 63%. They also endure high levels of fatigue. This study evaluated the fatigue levels and factors of fatigue in EM residents nationwide. It aimed to determine the factors affecting fatigue. The study includes EM residents working across the country between January 2024 and April 2024. It was conducted using a survey. The survey included the Maslach Burnout Inventory (MBI), the Chalder Fatigue Scale, and questions about demographic characteristics. Multivariate logistic regression analysis was used to analyze the data. The median age of participants was 28 years (interquartile range = 3), and 203 (56.4%) were male. Factors affecting the level of fatigue were analyzed by multivariate logistic regression analysis. The gender (male) (odds ratio [OR] =0.322, 95% confidence interval [CI] =0.128-0.812) and the daily sleep duration (OR = 0.589, 95% CI = 0.423-0.822) variables had a negative effect on fatigue. Depression in medical history increased the likelihood of fatigue (OR = 3.515, 95% CI = 0.930-13.287). Emotional exhaustion (EE) (OR = 1.082, 95% CI = 1.037-1.130) and depersonalization (OR = 1.097, 95% CI = 1.015-1.186) increased the fatigue level. However, personal accomplishment had no significant effect on fatigue (OR = 1.019, 95% CI = 0.966-1.075). Being female gender, having shorter daily sleep duration, having a diagnosis of depression in medical history, and having higher levels of depersonalization and EE from MBI subdimensions increase the level of fatigue. Optimizing the sleep duration of EM residents and supporting their psychological health will prevent fatigue and fatigue-related problems.
This study aimed to analyze patients who presented to the emergency department of a state hospital following the devastating earthquakes of February 6, 2023, centered in Kahramanmaraş and to contribute updated evidence to the literature. In this retrospective study, data were collected on patients presenting to the emergency department between February 6 and 13, 2023. Variables included demographic characteristics, patterns of presentation, province of origin, time elapsed since the event, chief complaints, clinical findings, treatments administered in the emergency department and during hospitalization, and patient outcomes. Comparisons were made between traumatic and nontraumatic cases, as well as between patients who arrived walk-in and those transported by ambulance. A total of 652 patients were evaluated. Of these, 58.6% were female, with a mean age of 30.87 ± 22.80 years. Most patients (84.2%) were discharged. The most frequent injury types were soft tissue injuries (31.7%), crush injuries (17.3%), and rhabdomyolysis (10.5%). Among patients admitted to the intensive care unit, 86.4% had traumatic injuries. Two-thirds (66.7%) of deceased patients were also traumatic cases. Ambulance transport was recorded in 24.8% of traumatic patients compared with 4.9% of nontraumatic patients. Notably, none of the traumatic patients transported by ambulance were discharged; 72.4% were hospitalized, 25% required intensive care, and 2.6% died. Unlike previous studies that focused mainly on epicentral hospitals, this study provides novel insights by evaluating both traumatic and nontraumatic patient presentations in a nonepicentral, secondary-care hospital located far from the disaster zone. This perspective highlights the delayed but significant healthcare burden in peripheral hospitals, which has been largely overlooked in the literature.
This study aimed to evaluate the validity and reliability of the Turkish version of the Questionnaire on Best Practices for Short Peripheral Intravenous Catheter Maintenance. A methodological design was employed between February and May 2025, involving a sample of 276 nurses. Participants were drawn from emergency departments, internal medicine units, surgical wards, and intensive care units across hospitals in two provinces in eastern Turkey. Data were collected using two instruments: the Nurses' Information Form and the Questionnaire on Best Practices for Short Peripheral Intravenous Catheter Maintenance. Descriptive statistics, including frequencies, percentages, means, standard deviations, medians, and minimum and maximum values, were used to describe participant characteristics. Content validity was assessed through expert review, and the Content Validity Index was calculated using the Davis technique. Item discrimination and difficulty indices were computed using Microsoft Excel. Reliability analysis involved calculation of the Kuder-Richardson Formula 20 (KR-20) coefficient, alongside item-total score correlation analysis. The KR-20 coefficient for the Questionnaire on Best Practices for Short Peripheral Intravenous Catheter Maintenance was 0.974. Analysis of the test mean scores revealed that the items were generally easy but exhibited high discriminatory power. The Turkish version of the Questionnaire on Best Practices for Short Peripheral Intravenous Catheter Maintenance demonstrated high reliability, as evidenced by its KR-20 value. The use of this questionnaire enables the identification of knowledge gaps among nursing professionals regarding best practices in short peripheral catheter care.
We aimed to identify the ability of end-tidal carbon dioxide (EtCO2) to predict inhospital mortality of patients presenting to the emergency department (ED) with nontraumatic circulatory shock. We also attempted to assess the correlation between EtCO2 and other traditional vital signs and laboratory parameters in this patient population at different time points during their resuscitation. This was a single-center prospective observational study conducted among patients with nontraumatic circulatory shock who presented to the ED of a tertiary care teaching institute in India. EtCO2 measurement was done using mainstream capnography in both intubated and nonintubated patients at presentation and at 120 min of resuscitation. Heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure (MAP), respiratory rate, oxygen saturation, and laboratory parameters (lactate, base deficit [BD], and partial pressure of carbon dioxide) were measured at the same time points. All patients were followed up till hospital discharge. One hundred and ten patients were recruited to the study. An EtCO2 of ≤ 23 mm Hg at presentation was 87% sensitive (95% CI: 73-95 %) and 43% specific (95% CI: 31-56 %) in predicting in-hospital mortality of patients presenting with no-traumatic circulatory shock in emergency department [area under curve (AUC): 0.735 (95% CI: 0.638-0.832, p<0.001)]. EtCO2 ≥23 mmHg at presentation had a significant predictive value on the risk of in-hospital mortality with an adjusted odd's ratio of 0.08 (95% CI: 0.02-0.3, P < 0.001). EtCO2 values at presentation and 120 min as well as the change between the time points showed statistically significant weak-to-moderate positive correlations with corresponding values of MAP and BD. Similarly, a significant negative correlation was demonstrated with lactate levels at the same time points. EtCO2 values at presentation are an independent predictor of inhospital mortality of patients with circulatory shock of nontraumatic etiology presenting to the ED.
Comprehensive, comparable, and timely estimates of demographic metrics-including life expectancy and age-specific mortality-are essential for evaluating, understanding, and addressing trends in population health. The COVID-19 pandemic highlighted the importance of timely and all-cause mortality estimates for being able to respond to changing trends in health outcomes, showing a strong need for demographic analysis tools that can produce all-cause mortality estimates more rapidly with more readily available all-age vital registration (VR) data. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is an ongoing research effort that quantifies human health by estimating a range of epidemiological quantities of interest across time, age, sex, location, cause, and risk. This study-part of the latest GBD release, GBD 2023-aims to provide new and updated estimates of all-cause mortality and life expectancy for 1950 to 2023 using a novel statistical model that accounts for complex correlation structures in demographic data across age and time. We used 24 025 data sources from VR, sample registration, surveys, censuses, and other sources to estimate all-cause mortality for males, females, and all sexes combined across 25 age groups in 204 countries and territories as well as 660 subnational units in 20 countries and territories, for the years 1950-2023. For the first time, we used complete birth history data for ages 5-14 years, age-specific sibling history data for ages 15-49 years, and age-specific mortality data from Health and Demographic Surveillance Systems. We developed a single statistical model that incorporates both parametric and non-parametric methods, referred to as OneMod, to produce estimates of all-cause mortality for each age-sex-location group. OneMod includes two main steps: a detailed regression analysis with a generalised linear modelling tool that accounts for age-specific covariate effects such as the Socio-demographic Index (SDI) and a population attributable fraction (PAF) for all risk factors combined; and a non-parametric analysis of residuals using a multivariate kernel regression model that smooths across age and time to adaptably follow trends in the data without overfitting. We calibrated asymptotic uncertainty estimates using Pearson residuals to produce 95% uncertainty intervals (UIs) and corresponding 1000 draws. Life expectancy was calculated from age-specific mortality rates with standard demographic methods. For each measure, 95% UIs were calculated with the 25th and 975th ordered values from a 1000-draw posterior distribution. In 2023, 60·1 million (95% UI 59·0-61·1) deaths occurred globally, of which 4·67 million (4·59-4·75) were in children younger than 5 years. Due to considerable population growth and ageing since 1950, the number of annual deaths globally increased by 35·2% (32·2-38·4) over the 1950-2023 study period, during which the global age-standardised all-cause mortality rate declined by 66·6% (65·8-67·3). Trends in age-specific mortality rates between 2011 and 2023 varied by age group and location, with the largest decline in under-5 mortality occurring in east Asia (67·7% decrease); the largest increases in mortality for those aged 5-14 years, 25-29 years, and 30-39 years occurring in high-income North America (11·5%, 31·7%, and 49·9%, respectively); and the largest increases in mortality for those aged 15-19 years and 20-24 years occurring in Eastern Europe (53·9% and 40·1%, respectively). We also identified higher than previously estimated mortality rates in sub-Saharan Africa for all sexes combined aged 5-14 years (87·3% higher in GBD 2023 than GBD 2021 on average across countries and territories over the 1950-2021 period) and for females aged 15-29 years (61·2% higher), as well as lower than previously estimated mortality rates in sub-Saharan Africa for all sexes combined aged 50 years and older (13·2% lower), reflecting advances in our modelling approach. Global life expectancy followed three distinct trends over the study period. First, between 1950 and 2019, there were considerable improvements, from 51·2 (50·6-51·7) years for females and 47·9 (47·4-48·4) years for males in 1950 to 76·3 (76·2-76·4) years for females and 71·4 (71·3-71·5) years for males in 2019. Second, this period was followed by a decrease in life expectancy during the COVID-19 pandemic, to 74·7 (74·6-74·8) years for females and 69·3 (69·2-69·4) years for males in 2021. Finally, the world experienced a period of post-pandemic recovery in 2022 and 2023, wherein life expectancy generally returned to pre-pandemic (2019) levels in 2023 (76·3 [76·0-76·6] years for females and 71·5 [71·2-71·8] years for males). 194 (95·1%) of 204 countries and territories experienced at least partial post-pandemic recovery in age-standardised mortality rates by 2023, with 61·8% (126 of 204) recovering to or falling below pre-pandemic levels. There were several mortality trajectories during and following the pandemic across countries and territories. Long-term mortality trends also varied considerably between age groups and locations, demonstrating the diverse landscape of health outcomes globally. This analysis identified several key differences in mortality trends from previous estimates, including higher rates of adolescent mortality, higher rates of young adult mortality in females, and lower rates of mortality in older age groups in much of sub-Saharan Africa. The findings also highlight stark differences across countries and territories in the timing and scale of changes in all-cause mortality trends during and following the COVID-19 pandemic (2020-23). Our estimates of evolving trends in mortality and life expectancy across locations, ages, sexes, and SDI levels in recent years as well as over the entire 1950-2023 study period provide crucial information for governments, policy makers, and the public to ensure that health-care systems, economies, and societies are prepared to address the world's health needs, particularly in populations with higher rates of mortality than previously known. The estimates from this study provide a robust framework for GBD and a valuable foundation for policy development, implementation, and evaluation around the world. Gates Foundation.
Accurate differentiation between ventricular tachycardia (VT) and supraventricular tachycardia (SVT) with aberrant conduction in wide complex tachyarrhythmias (WCT) remains a significant challenge in emergency medicine. This study aimed to evaluate the efficacy of deep learning (DL) models, specifically pretrained residual network (ResNet) architectures, in classifying these arrhythmias using electrocardiography (ECG) data. A retrospective cross-sectional study was conducted, analysing 652 WCT ECGs and 248 normal sinus rhythm ECGs from an emergency medicine clinic. Three ResNet models ResNet-18, ResNet-34, and ResNet-50 were fine-tuned using transfer learning. Model performance was assessed via 10-fold cross-validation, evaluating accuracy, sensitivity, and precision. All ResNet models demonstrated high and consistent performance, achieving 95% accuracy, precision in distinguishing VT from SVT with aberrant conduction. The models exhibited robust generalization across validation folds. DL models, particularly ResNet architectures, show promise in enhancing ECG-based diagnosis of WCT. Their integration into emergency care could improve diagnostic accuracy, especially in settings with limited access to specialized cardiac expertise.
End-of-life care (EOLC) in the emergency department (ED) is a growing global necessity. This study aimed to assess the level of knowledge and attitudes toward EOLC among ED healthcare workers. A prospective and cross-sectional study was conducted involving 155 healthcare workers at a tertiary ED. The Palliative Care Knowledge Tool (PCKT) and the Frommelt Attitude toward Care of the Dying (FATCOD) Scale were adapted, translated into Malay, and validated for use. Participants completed validated, self-administered questionnaires assessing knowledge using FATCOD the PCKT and attitudes toward EOLC using the FATCOD Scale. The primary outcomes were the healthcare workers' knowledge and attitudes, with secondary analysis exploring associated factors. The overall level of knowledge on EOLC among healthcare workers was poor with a mean score of 8.54 (±2.97) out of 17. Despite this, attitudes toward EOLC were positive with a mean score of 92.61 (±8.80) out of 120. A weak positive correlation was found between knowledge and attitudes (r = 0.186, n = 155, P = 0.020). The factors such as education level, work experience, and profession were significantly associated with variations in knowledge and attitudes. This study revealed that despite poor knowledge of EOLC among healthcare workers in the ED, their attitudes toward managing dying patients were positive. The weak correlation between knowledge and attitudes suggests a modest link between these domains.
The aim of this study is to determine the most appropriate locations for the effective use of automated external defibrillators (AEDs) by examining the locations and frequency of out-of-hospital cardiac arrests (OHCAs) in a metropolitan city in Izmir. This research is a retrospective cross-sectional study. The data of the study were obtained from the Emergency Health Automation System. Data belonging to OHCA cases intervened by emergency aid ambulances were analyzed. The data were recorded and mapped by matching the regions where deaths occurred with the address records. Geographic Information Systems technologies were used in mapping the data. Kernel density analysis was used to produce density maps of point cases. Data analyses were performed with IBM SPSS Statistics 25.0 Statistical Program, and binary logistic regression analysis was used to determine the factors affecting the frequency of arrest. The significance value was accepted as P < 0.10 for logistic regression analysis and P < 0.05 for other tests. In the study, a total of 1790 OHCA cases were identified in public areas in the center of the metropolitan city between 2015 and 2020. Of the 1790 OHCAs, 34.5% were female and 65.5% were male. 49.4% of the deaths were seen in public areas and on streets and avenues where human movement is high. Approximately 34.5% of the deaths were seen in nursing homes. Only one cardiac arrest case was seen at the international airport in the city. The average arrival time of ambulances was found to be 7.3 min in the city center. This study is the first AED location determination study conducted in Turkey based on OHCA cases. Each country and region should reveal its sociocultural differences and make its plans by taking population mobility into account. Instead of making decisions based solely on the number of deaths, population mobility should be the determining factor. Countries should evaluate their AED installation policies in this context.
Glenohumeral dislocation is the most common type of shoulder dislocation and a leading cause of shoulder instability. Adequate muscle relaxation and pain control are essential for successful reduction. This study compared the effectiveness and safety of ketamine-midazolam (KM) versus ketamine-propofol (KP) for procedural sedation in anterior shoulder dislocations in the emergency department (ED). Effectiveness was evaluated using Ramsay sedation scale (RSS) scores, sedation onset, total procedure and recovery times, and reduction success. Safety was assessed by recording adverse events. This prospective, single-blind, randomized trial included patients ≥18 years presenting to a tertiary ED with anterior shoulder dislocation. Patients were randomized into two groups: KM (ketamine plus midazolam) and KP (ketamine plus propofol). Demographic and clinical characteristics, RSS scores, procedure and recovery times, adverse events, and additional sedation requirements were recorded. Sixty-four patients were analyzed, 32 in each group. The overall mean RSS score was 4.5 ± 1.0, significantly higher in the KP group (P < 0.001). Adverse events were more common in the KM group, including higher rates of respiratory depression (P = 0.023) and tachycardia (P < 0.001). The mean procedure time was 5.7 ± 4.7 min, and recovery time was 36.3 ± 14.4 min, both significantly shorter in the KP group (P = 0.025 and P < 0.001, respectively). In the ED, the ketamine-propofol combination appears to be a safe and effective option for procedural sedation and analgesia, particularly in interventions such as shoulder reduction.
Climate change is no longer a distant threat but a present and escalating burden on emergency departments (EDs) worldwide. Its direct and indirect effects, ranging from heatstroke and hypothermia to vector-borne disease resurgence and mass casualty incidents, challenge conventional models of emergency preparedness. This narrative review explores the intersection of climate dynamics with ED operational and clinical vulnerabilities. We summarize five core physiological mechanisms by which temperature extremes disrupt homeostasis and review high-risk medication classes that may exacerbate heat-related morbidity. In addition, we examine the World Health Organization's mass casualty triage framework and its relevance in climate-driven disasters such as floods, wildfires, and explosions. Special attention is given to low-resource settings and migration-heavy regions, where infrastructure strain and health inequity amplify the impact. We propose integrative, anticipatory planning models that combine clinical vigilance, environmental monitoring, and dynamic triage protocols. By identifying EDs as both front-line responders and sentinel systems, this study underscores the urgency of embedding climate resilience into emergency care strategies. Our synthesis aims to support clinicians, policymakers, and health systems in adapting emergency services to the realities of a warming world.
Home healthcare services (HHS) have been increasingly implemented worldwide with the aim of reducing emergency department admissions and healthcare costs, particularly in geriatric populations. This study aimed to evaluate whether HHS impacts hospitalization rates, intensive care unit (ICU) utilization, mortality, 1-year survival, and hospital costs among older adults. This retrospective, cross-sectional observational study was conducted at a tertiary care hospital in Turkey between January 2021 and December 2022. Patients aged ≥ 65 years presenting to the emergency department were included and categorized into 2 groups based on whether they received home healthcare services. Demographic characteristics, comorbidities, ICU and ward length of stay, acute physiology and chronic health evaluation-II scores, 1-year survival, and hospital costs were compared between groups. Data were extracted from the hospital's electronic medical records and analyzed using appropriate statistical methods. A total of 8590 geriatric patients were included; 10.1% (n = 866) received HHS. Patients in the HHS group had significantly higher rates of comorbidities, longer hospital (8.33 ± 7.76 vs 6.99 ± 5.47 days, P < .001) and ICU stays (9.53 ± 14.60 vs 8.08 ± 13.60 days, P = .030), and higher mean hospital costs (12,784 ± 26,308 vs 10,225 ± 20,917 Turkish Lira, P < .001). One-year survival was significantly lower in the HHS group (62.9% vs 68.9%, P < .001). Acute physiology and chronic health evaluation-II scores were also significantly higher among patients receiving HHS (P = .010). HHS in its current structure appears to be delivered predominantly to severely ill geriatric patients and does not lead to reduced hospital utilization or cost savings. To improve clinical and economic outcomes, we recommend restructuring HHS to include earlier patient selection, integration with emergency services, and incorporation of standardized geriatric assessment tools.
The Rome classification was introduced to assess the severity of acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) based on easily measurable variables. However, its validation for global use has not yet reached a sufficient level. This study aims to evaluate the validity of the Rome criteria in determining the severity and prognosis of COPD AE in Turkey. This multicenter study, conducted for the first time in Turkey and for the fourth time worldwide, included 750 patients diagnosed with AE-COPD who presented to emergency departments and outpatient clinics. According to the Rome criteria, patients were classified into three groups: mild, moderate, and severe AE-COPD. The study included 99 (13.2%) patients in the mild, 479 (63.9%) in the moderate, and 172 (22.9%) in the severe group. Emergency visits, hospitalizations, and ICU admissions in the past year were more frequent in the moderate and severe groups (p < 0.001 for all comparisons). Regarding outcomes of emergency or outpatient visits, most mild exacerbation cases were discharged (p < 0.001), while most moderate and severe exacerbations required hospitalization (p < 0.001). Compared to the moderate group, the severe exacerbation group had a higher risk of ICU admission (p < 0.001), NIV (p < 0.001), IMV (p < 0.001), in-hospital mortality (p < 0.001), and 30-day mortality (p = 0.015). No significant differences were found in 90-day mortality or 30 and 90-day readmission rates (p = 0.258, p = 0.712, p = 0.681, respectively). Survival analysis revealed no significant difference between the moderate and severe groups (p = 0.764). The findings suggest that the Rome criteria can be successfully used to assess exacerbation severity in AE-COPD patients presenting to secondary and tertiary care hospitals in Turkey.
Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic viral hemorrhagic disease with a wide clinical spectrum ranging from mild clinical presentations to fatal outcomes. Reported case-fatality rates vary between 3% and 30%. Therefore, early identification of high-risk patients and referral to appropriate centers are of critical importance in reducing mortality. In this study, we aimed to evaluate the performance of the CURB-65+B score in predicting mortality in patients with CCHF and to compare it with the Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), Severity Grading System (SGS) and Severity Scoring Index (SSI) scoring systems. Data from 254 adult CCHF patients who were followed in a tertiary care center and whose diagnosis were confirmed by reverse transcription polymerase chain reaction and/or IgM positivity were retrospectively analyzed. Demographic, clinical and laboratory data were recorded and CURB-65, CURB-65+B, SOFA, APACHE II, SGS and SSI scores were calculated at admission. Survivors and non-survivors were compared; the predictive performance of each scoring system for mortality was assessed using receiver operating characteristic (ROC) analysis and multivariable logistic regression analysis was performed. The overall mortality rate was 2.8% (n= 7). Non-survivors were older and more frequently presented at admission with confusion, hypotension, tachycardia, tachypnea and bleeding. In laboratory analyses, platelet counts and fibrinogen levels were lower in non-survivors compared with survivors, whereas aspartate aminotransferase, alanine transaminase, lactate dehydrogenase, activated partial thromboplastin time, international normalized ratio, D-dimer and C-reactive protein (CRP) levels were higher. In ROC analysis, the most powerful laboratory predictors of mortality were CRP [>14.6 mg/L; area under curve (AUC)= 0.938], prothrombin time (>13.5 s; AUC= 0.996), creatinine (>1.2 mg/dL; AUC= 0.882), and D-dimer (>4770 µg/L; AUC= 0.662). The highest overall accuracy, however was obtained with the CURB-65+B score (AUC= 0.997; 100% sensitivity; 98.8% specificity; p< 0.001). In multivariable analysis, only the CURB-65+B score was identified as an independent predictor of mortality (Odds ratio≈ 14; 95% confidence interval= 2.7-72.6; p= 0.002). Moreover, mortality was markedly higher in patients with a CURB-65+B score ≥3, whereas no deaths were observed among patients with a score <3. With its simple and easily applicable structure, the CURB-65+B score represents a powerful tool for predicting mortality in CCHF. It may facilitate the rapid identification of high-risk patients, recognition of those requiring intensive care and timely referral to appropriate centers in emergency departments and endemic settings. Compared with existing mortality scoring systems, CURB-65+B appears to be more practical, distinctive and to possess a higher predictive accuracy and thus may fill an important gap in the clinical management of CCHF.
Non-judicial hanging events presenting to emergency healthcare providers exhibit a wide range of severity, from cardiac arrest to minor soft tissue neck contusions, making it essential for providers to anticipate potential injuries. This review investigated the frequency of musculoskeletal, neurologic, airway, and vascular injuries to neck structures following such events. A narrative review of the PubMed database was conducted, selecting hypothesis-testing articles based on criteria including non-judicial hanging, emergency department evaluation, and consideration of at least one of the four injury areas. Two reviewers selected the final articles, analyzed the data, and investigated three questions focusing on the frequency of these injury types. The reference lists of the selected articles were also reviewed for additional relevant studies. The analysis included 30 articles (3809 patients) for musculoskeletal and neurologic injuries, 20 articles (2047 patients) for airway injuries, and 13 articles (2717 patients) for vascular injuries. The overall injury rates in the neck region among the study population were musculoskeletal 3.0%, neurologic 0.5%, airway 5.2%, and vascular 2.5%. In conclusion, among patients surviving to emergency department arrival after a non-judicial hanging event, the rates of injury to neck structures are low, with airway injuries being the most frequent at approximately 5% of cases. Injuries were observed to be more common in adults compared to pediatric patients, and the medical significance of these injuries varied considerably. Further research is necessary to more comprehensively define the expected pathologies associated with this patient presentation and to guide the most appropriate evaluation strategies.
In acute pancreatitis (AP), the variable clinical course and high mortality have led to the use of complex and time-consuming scoring systems. This study aimed to evaluate the diagnostic performance of the hemoglobin, albumin, lymphocyte, and platelet (HALP) score in predicting mortality and intensive care unit (ICU) admission in patients with AP, and to compare it with the Atlanta classification and the Bedside Index for Severity in AP (BISAP). This single-center retrospective study included 455 patients diagnosed with AP. Demographic data, laboratory findings, and clinical course of the patients were recorded, and HALP, BISAP, and Atlanta classification scores were calculated. The Atlanta classification showed the highest predictive accuracy for both mortality and ICU admission (mortality: sensitivity 91%, specificity 96%; ICU admission: sensitivity 77%, specificity 99%). The HALP score demonstrated a moderate predictive ability for both mortality (sensitivity = 0.64; specificity = 0.79) and ICU admission (sensitivity = 0.74; specificity = 0.67). The sensitivity of the HALP score was significantly higher than that of the BISAP score for both outcomes (P < 0.001). Although the HALP score has a lower overall predictive power compared to the Atlanta and BISAP scores, its higher sensitivity and easily calculable structure compared to the BISAP score suggest that it may serve as a supportive tool for early prognostic assessment of AP patients in emergency department settings.