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BackgroundStroke is a very time-sensitive pathology, and many new solutions target the optimization of prehospital stroke care to improve the stroke management process. In-ambulance telemedicine, defined by live bidirectional audio-video between a patient and a neurologist in a moving ambulance and the automated transfer of vital parameters, is a promising new approach to speed up and improve the quality of acute stroke care. Currently, no evidence exists on the cost effectiveness of in-ambulance telemedicine. ObjectiveWe aim to develop a first cost effectiveness model for in-ambulance telemedicine and use this model to estimate the time savings needed before in-ambulance telemedicine becomes cost effective. MethodsCurrent standard stroke care is compared with current standard stroke care supplemented with in-ambulance telemedicine using a cost-utility model measuring costs and quality-adjusted life-years (QALYs) from a health care perspective. We combine a decision tree with a Markov model. Data from the UZ Brussel Stroke Registry (2282 stroke patients) and linked hospital claims data at individual level are combined with literature data to populate the model. A 2-way sensitivity analysis varying both implementation costs and time gain is performed to map the different cost-effective combinations and identify the time gain needed for cost effectiveness and dominance. For several modeled time gains, the cost-effectiveness acceptability curve is calculated and mapped in 1 figure. ResultsUnder the base-case scenario (implementation cost of US $159,425) and taking a lifetime horizon into account, in-ambulance telemedicine is a cost-effective strategy compared to standard stroke care alone starting from a time gain of 6 minutes. After 12 minutes, in-ambulance telemedicine becomes dominant, and this results in a mean decrease of costs by US –$30 (95% CI –$32 to –$29) per patient with 0.00456 (95% CI 0.00448 to 0.00463) QALYs on average gained per patient. In over 82% of all probabilistic simulations, in-ambulance telemedicine remains under the cost-effectiveness threshold of US $47,747. ConclusionsOur model suggests that in-ambulance telemedicine can be cost effective starting from a time gain of 6 minutes and becomes a dominant strategy after approximately 15 minutes. This indicates that in-ambulance telemedicine has the potential to become a cost-effective intervention assuming time gains in clinical implementations are realized in the future.

Heatwaves are periods of unusual heat, whose frequency and intensity is increasing. Heatwaves also translate into emergency healthcare dysfunctions, but evidence on how to mitigate these effects still needs to be provided. This multicentric study aimed to identify the interactions between heatwaves and prehospital emergency medicine (PHEM). After obtaining informed consent, PHEM personnel working full-time in different districts of the Veneto Region, Northern Italy, were recruited. Their perspective was captured through semi-structured interviews and analyzed using content analysis methodology. Thirteen subjects participated in the study. Their insights were categorized into four themes: perception of heatwaves; clinical impact of heatwaves; social factors and heatwaves; heatwaves and emergency medical service (EMS). According to the interviewees, the strain on EMSs during heatwaves may be partially reduced by interventions targeting vulnerable populations, primary care, social networks, and education and information. Specific public health actions could follow the surge science principles of staff, stuff, structure, and system to help policymakers improve EMS surge capacity planning, preparedness, and responses. The present study also identified PHEM vulnerabilities and targets of interventions to implement heat–health action plans, mitigate the risk of prehospital emergency care dysfunction, and improve EMS sustainability and preparedness against heatwaves and the changing climate. [ABSTRACT FROM AUTHOR]

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe hypersensitivity reaction characterized by cutaneous rash, lymphadenopathy, fever, eosinophilia, leukocytosis, and life-threatening organ dysfunctions. We describe the case of a 26 year old patient admitted to the Emergency Department for DRESS syndrome after sulfasalazine treatment for rheumatoid arthritis in the right knee. Whole body computer tomography showed multiple neck, chest, and abdominal lymphadenopathy with splenomegaly, massive ascites and severe hepatic cytolysis. Serology results for Epstein-Barr Virus (EBV), influenza, measles, rubella, hepatitis A and B were negative. The histologic analysis of skin, lymph node and bone marrow biopsies could not indicate a classical Hodgkin's Disease or iatrogenic immunodeficiency/EBV-associated lymphoproliferative disorder (LPD), Hodgkin type. The relatively small caliber of the CD30 + immunoreactive blastoid cells in the lymph nodes suggested reactive immunoblasts rather than Hodgkin cells. The morphologic aspects of the lymph node biopsies with predominance of T-cells were compatible with the diagnosis of a sulfasalazine-induced DRESS syndrome as the patient had a high RegiSCAR score for DRESS. [DRESS Syndrome Foundation: Diagnosis and Treatment. (2023)] The patient's complex clinical course, marked by two hospital admissions, highlights the challenges in diagnosing and managing DRESS. This case underscores the need for individualized care, close patient monitoring, and further research to better understand DRESS's underlying mechanisms and optimal therapeutic strategies. [ABSTRACT FROM AUTHOR]

Heatwaves pose an important risk for population health and are associated with an increased demand for emergency care. To find factors causing such overload, an online Delphi study included 15 experts in emergency medicine, disaster medicine, or public health. One open-ended question was delivered in the first round. After content analysis, the obtained statements were sent to the experts in two rounds to be rated on a 7-point linear scale. Consensus was defined as a standard deviation ≤ 1.0. Thirty-one statements were obtained after content analysis. The experts agreed on 18 statements, mostly focusing on the input section of patient processing and identifying stakeholders, the population, and primary care as targets of potential interventions. Additional dedicated resources and bed capacity were deemed important as per throughput and output sections, respectively. These findings could be used in the future to implement and test solutions to increase emergency healthcare resilience during heatwaves and reduce disaster risk due to climatic change. [ABSTRACT FROM AUTHOR]

Background: As emergency department (ED) leaders started integrating geriatric emergency guidelines on a facultative basis, important variations have emerged between EDs in care for older patients. The aim of this study was to establish a consensus on minimum operational standards for Geriatric ED care in Belgium. Methods: A two-stage modified Delphi study was conducted. Twenty panellists were recruited from Dutch and French speaking regions in Belgium to join an interdisciplinary expert panel. In the first stage, an online survey was conducted to identify and define all possible elements of geriatric emergency care. In the second stage, an online survey and online expert panel meeting were organized consecutively to determine which elements should be recognized as minimum operational standards. Results: Between March 2020 and February 2021, the expert panel developed a broad consensus including ten statements focusing on the target population, specific goals, availability of geriatric practitioners and quality assurance. Additionally, the expert panel also determined which protocols, materials and accommodation criteria should be available in conventional EDs (39 standards) and in observational EDs (57 standards). Conclusions: This study presents a consensus on minimum operational standards for geriatric emergency care in two ED types: the conventional ED and the observational ED. These findings may serve as a starting point towards broadly supported minimum standards of care stipulated by legislation in Belgium or other countries. [ABSTRACT FROM AUTHOR]

This study explores the relevance of integrating mental health and psychosocial support (MHPSS) into physical rehabilitation services in conflict settings. Symptoms of psychological distress and daily functioning of 132 physical rehabilitation service users in Eastern Democratic Republic of Congo were assessed before and after MHPSS. Logistical regression models were used to identify factors associated with these symptoms. Prior to receiving MHPSS, "extreme" symptoms of depression were reported by 64% of the service users. Amputation predicted high levels of depression (aOR 5.12, p = 0.021), anxiety (aOR 7.09, p = 0.004) and stress (aOR 3.37, p = 0.035), while having witnessed violence predicted high symptoms of stress (aOR 3.65, p = 0.014). Lack of social support was associated with high symptoms of stress prior to MHPSS (aOR 3.17, p = 0.046) as well as a large reduction in symptoms of depression following MHPSS (aOR 3.91, p = 0.019). Most physical rehabilitation service users reported a reduction in symptoms of depression (100.00%), anxiety (98.03%) and stress (100.00%) along with improved functioning (81.13%) after MHPSS. MHPSS needs of physical rehabilitation service users in conflict settings stem from the combined impact of disability and exposure to violence. MHPSS care, particularly the mobilization of peer support, appears necessary and relevant. In conflict settings, mental health and psychosocial support (MHPSS) needs of physical rehabilitation service users must address the combined impact of physical disability and exposure to violence. Physical rehabilitation service users who lacked social support prior to receiving MHPSS were more likely to report a large reduction in symptoms of depression following MHPSS. The study underlines the importance of social support, particularly peer support, in addressing MHPSS needs. [ABSTRACT FROM AUTHOR]

The field of discrete-event simulation for medical disaster management is relatively new. In such simulations, human victims are generated using pre-determined transitions from one health state to the next, based on a set of triggers that correspond to treatment or the clinical progression of untreated injuries or diseases. However, this approach does not account for subtle differences in clinical progression. We propose a parameter-based model to characterize the evolution of symptoms at first for physical and nerve agent chemical injuries. We used a Gompertz function to predict the time of death in trauma based on forensic data. Then we separately considered the effects of the chemical warfare agent sarin (GB) being the origin of the chemical injuries for the purpose of modelling a GB attack in a metro station. We emphasize that our approach can be extended to other CBRN threats pending knowledge of clinical progressions available in the literature for the purpose of casualty estimations. The intent is to provide an estimate of time to death without any treatment and overlay this model with a treatment model, improving the evolution of the health state. A modification for non-life-threatening injuries is included without losing generality. Improvement functions modelling medical treatment are proposed. We argue that the availability of injury scores vs mortality can greatly enhance the validity of the model. [ABSTRACT FROM AUTHOR]