A 20-year-old male was referred for echocardiography after presenting to his GP with tonsillitis. A new loud pansystolic murmur was detected. He was previously fit and well with a past medical history of thyrotoxicosis treated with subtotal thyroidectomy and stable immune thrombocytopenia (ITP).

A Transthoracic Echocardiogram (TTE) and Transesophageal Echocardiogram (TOE) confirmed the diagnosis of a bicuspid aortic valve with severe aortic regurgitation. The aortic root was dilated, maximally 4.2cm. The left ventricle was dilated 5.9cm on echo and 7.0cm on a cardiac CT with a borderline low Ejection Fraction of 50%. It was therefore decided to refer and discuss at a congenital multidisciplinary team meeting. The main options discussed were aortic valve repair, aortic valve replacement and a Ross procedure. A CT scan was performed, and, due to discrepant valve sizes, valve replacement was deemed the only viable option for this patient. He then underwent a mechanical aortic valve replacement (CarboMedics supra-annular top hat 27mm). He recovered well; however, 9 months post-operation he presented with weakness and aphasia, and CT head showed a left Middle Cerebral artery infarct. He also underwent thrombectomy. It was noted that he had periods of subtherapeutic INR.

This case presentation highlights complications that can arise with valve replacement and durability of surgical operation versus the complications of lifelong anticoagulation. We review the different surgical options available for severe aortic regurgitation, especially in the younger, congenital cohort of patients. This case increases awareness of the possibility of referring to congenital centers for the consideration of the Ross procedure.

Introduction

Testicular torsion (TT) is a time-dependent urological emergency. Surgical exploration within six hours of symptom onset is reported to have a testicular salvage rate exceeding 90% , but this rapidly declines to below 50% if the delay extends past 12 hours. In 2017, the merger between Hinchingbrooke Hospital (HH) and Peterborough City Hospital (PCH) centralised urological services. This study aimed to evaluate whether this service reorganisation impacted key outcomes, including time to theatre and testicular salvage rates.

Methods

We conducted a retrospective cohort study of 98 patients who underwent scrotal exploration for suspected torsion. Data were collected from electronic and hard copy notes for the periods 2014–2020 at HH and 2016–2018 at PCH. The data points collected included the time of pain onset, presentation, referral, operative findings, and outcomes. Patients from HH transferred to PCH after the merger were included in the PCH post-merger group for analysis.

Results

A total of 98 patients were included. Pre-merger, HH had a 25% salvage rate for its 4 confirmed torsion cases. Post-merger, all 5 torsion cases from HH were salvaged (100% salvage rate). In contrast, PCH had a 100% salvage rate for its 10 pre-merger torsion cases, which fell to 82.4% for 17 torsion cases after the merger. The six-hour benchmark for timely exploration was rarely achieved across all groups, with mean times to theatre far exceeding this critical window.

Conclusion

The centralisation of services significantly improved outcomes for HH patients, with a 100% salvage rate post-merger. However, the decline in PCH’s salvage rate suggests that the centralisation of services and increased workload may have negatively impacted the primary surgical site. The persistent failure to meet the six-hour benchmark highlights significant multifactorial delays. These are likely due to a combination of late patient presentation and systemic inefficiencies in the care pathway. Further work is needed to optimise referral protocols and improve public awareness to minimise time to surgery

Background:

Post‑lumbar puncture headache (PLPH) is the commonest complication of lumbar puncture (LP). It worsens patient experience, prolongs length of stay and drives additional interventions. Meta-analytic data demonstrate that atraumatic (non-cutting) needles significantly reduce the incidence of post-LP headache and related interventions.(Nath et al., 2018) The primary aims of our audit were to assess the prevalence and severity of post-LP headache, documentation quality, and needle choice (traumatic versus atraumatic needles) across departments in a tertiary hospital in the East Midlands.

Methods:
We retrospectively reviewed the healthcare records of 62 patients who developed post-lumbar puncture headaches between January 2020 and February 2025. Data on demographics, procedural details (needle type, LP site) and outcomes were analysed. An anonymised electronic questionnaire assessed clinicians’ knowledge of PLPH and perceived barriers to using atraumatic needles.

Results:

Most PLPH episodes (64.5 %) followed LPs performed in acute medicine, where traumatic needles are still widely used. Documentation was poor: needle type was recorded in only 8% of cases (all cutting needles). Pain scores were missing in 61.3% but when documented, 83.3% were reported as severe (8–10/10). 80% of post LP headaches required readmission, with patients either being readmitted or if not, requiring a 4 times prolonged length of stay.

While 83 % of operators recognised that atraumatic needles reduce PLPH risk, only 28 % reported using them routinely; the remainder relied on whichever needle was available. Reported barriers were limited stock (50 %) and lack of hands‑on training (33 %) .

Conclusion:
PLPH imposes a measurable inpatient burden yet key procedural details, especially needle type, are seldom documented. High PLPH rates likely reflect routine use of cutting needles in acute medicine, where atraumatic alternatives are rarely stocked. Ensuring consistent ward‑level availability of atraumatic needles, mandating needle‑type recording and delivering practical training could close the knowledge‑practice gap and reduce PLPH related morbidity and related resource use.

1) Introduction: Kounis syndrome (KS) is an acute coronary syndrome (ACS) triggered by hypersensitivity or allergic reactions, most commonly following exposure to allergens such as insect stings, drugs, or environmental factors. This syndrome is likely underdiagnosed due to its rarity and varied clinical presentation.

2) Methods: This is a single-patient case report based on clinical encounter and follow-up in the emergency department, conducted with patient consent. Key clinical events, diagnostic findings, and therapeutic interventions are detailed to illustrate the diagnosis and management of KS secondary to bee sting.

3) Case: This is the case of a 45-year-old man with known past medical history of type 2 diabetes mellitus and hypertension. This gentleman presented to the Emergency Department 45 minutes after sustaining multiple bee stings to his neck. He reported generalized itching, chest pain, and difficulty breathing. Examination revealed urticarial wheals on the back and chest, pruritus, tachycardia (heart rate 121 bpm), tachypnea (respiratory rate 32/min), oxygen saturation of 97% on room air, and hypotension (BP 88/42 mmHg). Standard guidance was followed to treat anaphylaxis. Due to persistent chest pain, an ECG was recorded, which demonstrated an anterior wall ST-elevation myocardial infarction (STEMI). The patient was admitted under cardiology, underwent coronary angiography, and received a stent to the left anterior descending (LAD) artery. This presentation of STEMI in the context of anaphylaxis is consistent with Kounis syndrome.

4) Conclusion: This case highlights the need for clinicians to maintain a high index of suspicion for Kounis syndrome in patients presenting with ACS symptoms in the context of an allergic reaction, particularly following bee stings. Prompt recognition and coordinated management of both the allergic and cardiac components are essential for optimal outcomes. Increased awareness and reporting of such cases will aid in early diagnosis and improve patient care.

Background
Malignant peritoneal mesothelioma (MPM) is a rare and aggressive cancer originating from the peritoneal lining, accounting for less than 10% of all mesothelioma cases. It is strongly linked to prior asbestos exposure, typically presenting after a latency of several decades. The clinical presentation is often vague—abdominal pain, distension, or altered bowel habits—making early diagnosis challenging. Presentation as an acute abdomen is exceptionally rare and can lead to misdirection in initial management.

Case Presentation
We report the case of a 60-year-old man with remote occupational asbestos exposure who presented with acute abdominal pain and localized tenderness, initially raising concerns for a surgical emergency. He was referred to the surgical team with presumed peritonitis. Initial imaging revealed omental thickening, peritoneal enhancement, and a pelvic soft tissue lesion. Upper and lower GI endoscopy were inconclusive. The diagnostic process was prolonged due to the non-specific presentation, with malignancy not initially suspected. Subsequent biopsy confirmed epithelioid peritoneal mesothelioma.

He was reviewed by the specialist peritoneal mesothelioma multidisciplinary team and commenced on dual immunotherapy (ipilimumab and nivolumab). During treatment, he developed right-sided neck pain and was found to have an internal jugular vein thrombosis—a rare thrombotic complication in the context of malignancy. He was started on anticoagulation. The disease later progressed, with increasing ascites requiring repeated paracentesis. He is currently receiving palliative care.

Conclusion
This case highlights the diagnostic complexity of MPM when it presents atypically, as in this patient mimicking an acute surgical abdomen. Initial misdirection delayed diagnosis, underscoring the importance of considering malignancy in unexplained abdominal presentations, especially with relevant exposure history. The development of an unusual thrombotic event further reflects the systemic and unpredictable nature of mesothelioma. A high index of suspicion, early multidisciplinary involvement, and awareness of atypical presentations are key to timely diagnosis and improved patient outcomes.

Introduction
Emergency departments (EDs) are often the first point of contact for individuals in acute suicidal crisis. While immediate care may stabilize the crisis, the days following discharge remain one of the most dangerous periods, with suicide attempts frequently occurring within hours or days (Chung et al., 2017). Despite long-standing recognition of this risk, health systems across the world continue to lack standardized protocols to ensure safe transitions (Boudreaux et al., 2015).

Methods
We conducted a structured review of literature published between 2010 and 2025 using PubMed, Google Scholar, and World Health Organization (WHO) reports. Studies were included if they reported outcomes following ED discharge, evaluated suicide risk assessment tools, or investigated follow-up interventions. MeSH terms included “suicidal ideation,” “emergency department,” “post-discharge,” “follow-up,” and “suicide prevention.”

Results
Patients discharged from the ED after presenting with suicidal ideation have the highest risk of repeat self-harm within the first month, especially in the first 72 hours (Chung et al., 2022; Carroll et al., 2014). Although tools such as the Columbia Suicide Severity Rating Scale (C-SSRS) and the SAD PERSONS scale are available, their predictive accuracy is limited and application in routine practice remains inconsistent (Saunders et al., 2014). Interventions that combine safety planning with proactive follow-up, such as structured phone calls or rapid linkage to outpatient care, have shown significant reductions in repeat suicide attempts (Stanley et al., 2018; Luxton et al., 2013). Nonetheless, barriers persist, with nearly 70% of patients failing to attend follow-up care after ED discharge (Chung et al., 2022).

Conclusion
Suicide prevention in the immediate post-discharge period remains a neglected global patient safety challenge. Implementing standardized discharge protocols that include suicide risk screening, effective communication, and timely follow-up could prevent avoidable deaths and should be prioritized worldwide.

Introduction

Sepsis is one of the main causes of mortality worldwide and is a life-threatening emergency that needs early recognition and rapid treatment to enhance outcomes. Emergency departments (EDs) globally continue to face difficulties in promptly identifying sepsis due to nonspecific presentations and varying resource levels.

Methods

A literature review of international ED studies from 2020 to 2025 was conducted to find and analyze advances in sepsis diagnostic criteria, triage systems, antibiotic timing, and patient outcomes. Key PubMed-indexed studies, reviews and guidelines were analyzed.

Results

The Sepsis-3 definition (infection with organ dysfunction) has been widely adopted. Numerous screening methods (e.g., qSOFA, SIRS, NEWS) are employed to aid early diagnosis. Modern approaches, such as machine-learning triage algorithms, outperform traditional scores in terms of accuracy. According to a 2024 meta-analysis, ED sepsis alert systems have improved care processes by lowering mortality and by facilitating faster delivery of sepsis bundle elements (e.g., fluids, antibiotics). Early antibiotic administration remains essential. A 2020 meta-analysis reported no significant difference in mortality between antibiotics administered at 0–1 hour of sepsis and those given at 1–3 hours, despite the fact that global guidelines recommend using antibiotics within 1 hour. However, a larger 2024 meta-analysis, encompassing around 190,000 patients, showed that antibiotics given within 3 hours significantly increases survival compared to later administration. Though outcomes depend on factors like provider buy-in and screening accuracy, implementation of ED sepsis protocols has consistently increased adherence to guidelines.

Conclusions

ED-focused sepsis initiatives worldwide have advanced early detection and accelerated management over the last five years. Protocol-driven care and enhanced triage tools have increased adherence and show promising reduction in mortality. To further enhance patient outcomes worldwide, a structured and rapid-response approach to ED sepsis care is essential.

Selenium (Se), an essential micronutrient, is potentially implicated in cardiovascular health; we hypothesized that due to Se’s established antioxidant properties and effects on nitric oxide (NO) bioavailability, Se blood serum levels may influence vascular hemodynamics.1 There is conflicting evidence on the relationship between Se and blood pressure and very limited evidence regarding the relationship between Se levels and early markers of vascular change such as pulse wave velocity (PWV) and mean arterial pressure (MAP). To clarify this association, we evaluated the relationship of serum Se with vascular parameters in a nationally representative US sample.

METHODS:

We conducted a cross-sectional analysis using data from seven NHANES cycles (2003-04 and 2011–23). Participants (n=21,793) aged ≥18 years with blood Se and blood pressure data were included. Participants were classified by age groups (18–35, 36–65, >65 years) and Se quartiles. Vascular measures included systolic and diastolic blood pressure (SBP, DBP), pulse pressure (PP), mean arterial pressure (MAP), and estimated pulse wave velocity (ePWV). Blood Se was measured by mass spectrometry.

RESULTS:

In fully adjusted models, participants in the highest Se quartile had significantly higher SBP (coefficient=1.76 mmHg; 95%CI: 0.76-2.75; p=0.001), DBP (coefficient=2.12 mmHg; 95CI:1.38-2.86; p<0.001), MAP (coefficient=2.00 mmHg; 95%CI:1.29-2.70; p<0.001), and ePWV (coefficient=0.13 m/s; 95%CI:0.08-0.18; p<0.001) compared with the lowest quartile; there was no relationship with PP. Age modified the association between Se and vascular hemodynamics (Figure) such that adults>65years had lower SBP, PP, MAP, and ePWV than adults>18-35 years (interaction p-values = 0.003, 0.04, 0.01, 0.005 respectively).

CONCLUSIONS:

Our findings highlight that the relationship between Se and vascular hemodynamics is modified by age. The mechanisms responsible for these opposite effects of Se on vascular hemodynamics by age need further study.

Abstract:

Serine protease inhibitors, termed Serpins, bind and inhibit serine proteases that control central coagulation, immunity and connective tissue remodeling throughout the mammalian body. Genetic mutations in serpins including alpha-1 anti-trypsin, neuroserpin and anti-thrombin, cause severe disease ranging from emphysema and epilepsy to clotting disorders. With classic serpin inhibitory function there is cleavage of a reactive center loop (RCL) by selectively targeted proteases, forming a suicide complex with translocation of the protease to the opposite pole of the serpin, adding an additional A beta sheet sequence and forming inactive ‘suicide complexes’. In diseases caused by serpin mutations, there is RCL insertion into adjacent mutated serpin A beta sheet or binding at other sites. Large DNA viruses express serpins with highly potent immune and coagulation modifying activity, functioning at low doses with selective targeting of mammalian pathways, providing a new class of immune modulating biologics. Myxomavirus-derived Serp-1, effectively blocks immune disorders in a wide range of models, providing a new therapeutic class, improving outcomes when given systemically at low doses (microgram/kg range). In a pristane induced lupus lung hemorrhage model, PEGylated (PEGSerp-1) reduces lung hemorrhage and inflammation. Immunoprecipitation and mass spectrometry analysis demonstrated binding of PEGSerp-1 to known target proteases, inflammatory mediators and unexpectedly to selected mammalian serpins. Here we examine serpin-to-serpin interactions, specifically PEGSerp-1 binding to unrelated mammalian serpins in vivo, in vitro and in silico. We postulate a new, previously unexplored, regulatory serpinosome complex.

Keywords: Serpins, PEGylated Serp-1, Pulmonary inflammation, Immune modulation, Serpin-to-serpin interactions, Lupus lung hemorrhage, Therapeutic biologics

Introduction

Out-of-hospital cardiac arrest (OHCA) survival rates remain critically low despite decades of research, with cardiogenic causes representing the highest mortality burden. To address limitations in existing prediction tools, we developed two novel artificial neural network (ANN)-based predictive scores for return of spontaneous circulation (ROSC) and survival-to-discharge specifically in cardiogenic OHCA. This study directly compared their performance against the established Utstein comparator group—the current benchmark for OHCA outcome prediction.

Methods

Using prospectively collected data from a EuReCa_One-aligned OHCA registry (October 2014–September 2023; n=3,369 confirmed cardiogenic cases with initiated CPR), multilayer perceptron ANN modeling identified key predictive factors through iterative feature importance analysis. Scores (0–10 points) were weighted by factor contribution and categorized into low (0-3), intermediate (4-6), and high (7-10) probability tiers. Validation occurred in a temporally distinct, propensity-matched cohort (October 2023–December 2024; n=628) controlling for age, bystander involvement, and arrest location. The Utstein comparator group (witnessed arrest + bystander CPR + initial shockable rhythm) served as the primary benchmark for performance comparison using multivariate logistic regression.

Results

In the derivation cohort, ROSC occurred in 23.4% (790/3,369) and survival-to-discharge occurred in 5.0% (170/3,369). The ANN-derived scores demonstrated high discriminative accuracy: ROSC score OR 2.741 (95% CI 2.017–3.724; p<0.001) and survival score OR 4.850 (95% CI 2.083–11.294; p<0.001). Compared to the Utstein predictor, the ANN ROSC score showed non-inferior performance (Utstein OR 2.841, 95% CI 2.819–4.438; p<0.001). Critically, the ANN survival-to-discharge score significantly outperformed the Utstein predictor, which demonstrated no statistical significance for survival prediction (Utstein OR 1.610, 95% CI 0.647–4.010; p=0.306), indicating limited clinical utility for this endpoint.

Conclusion

ANN-generated scores provide clinically actionable, granular prediction of cardiogenic OHCA outcomes. While comparable to Utstein for ROSC prediction, the survival-to-discharge score offers substantially superior discriminatory power (4.85 vs. 1.61 OR), enabling more precise early field triage and resource allocation. Future implementation studies should validate these tools in prehospital settings.