Search Results (1,846)

Background: Left ventricular systolic dysfunction (LVSD) is a precursor to heart failure arising from diverse cardiac conditions. Although echocardiography remains the reference standard for LVSD diagnosis, its routine use in the emergency department (ED) may be constrained by cost, time, equipment availability, and the need for specialized expertise. We evaluated the diagnostic performance of an artificial intelligence-based electrocardiogram analysis model (AI-ECG model) for detecting LVSD in patients presenting to the ED. Methods: This retrospective observational study included patients treated at a single tertiary hospital between 2020 and 2022 who underwent 12-lead electrocardiography within 24 h of ED admission and echocardiography within 30 days. Electrocardiographic data were analyzed using AiTiALVSD version 1.00.00, with a predefined cutoff score of 9.7 used to classify patients as being at high or low risk of LVSD. Diagnostic performance was assessed using standard discrimination and classification metrics. Results: Among 4529 included patients, 531 had LVSD. The AI-ECG model demonstrated high discrimination, with an area under the receiver operating characteristic curve (AUROC) of 0.934 (95% confidence interval [CI]: 0.923–0.945). Performance remained robust in patients with a shock index ≥ 0.9 (n = 453; AUROC, 0.895; 95% CI: 0.854–0.937) and in those with hypotension (n = 75; AUROC, 0.885; 95% CI: 0.786–0.984). Conclusions: The AI-ECG model accurately identified LVSD in ED patients in this cohort despite heterogeneous acquisition conditions and retained good discrimination in hemodynamically unstable subgroups, although findings in the smaller hypotensive subgroup should be interpreted as exploratory. Full article

Background/Objectives: Posttraumatic infections are common in emergency hand surgery. Amputation is the worst outcome and can occur at admission or during the course of antibiotic treatment and iterative surgical debridement. We wondered if the prolongation of antibiotic treatment beyond the usual indication, and more surgical debridement besides its immediate benefit, could reveal additional preventive effect against amputation during or immediately after therapy. Methods: We investigate 166 risk association (variables) of community-acquired (traumatic) hand infection with overall treatment failure using a specifically designed retrospective single-center cohort between 1 November 2018 and 31 October 2020. Results: Among 600 patients (362 males; 71 (11.8%) with diabetes mellitus), 58 (9.7%) required initially unplanned amputation during the therapeutic ourse. Multivariate Cox regression analysis identified only inherent risks associated with “amputation”: male sex (hazard ratio [HR] 3.12, 95% confidence interval [CI] 1.28–7.69, p = 0.01), age (HR 1.03, 95% CI 1.01–1.04, p = 0.03), diabetes (HR 2.40, 95% CI 1.15–5.01, p = 0.02), whereas no interventional variables such as early flapping or antibiotic-related parameters (early empirical antibiotic use, total duration of antibiotics including its initial parenteral use, and choice of agent) altered outcomes. Conclusions: In severe (traumatic) hand infections among 600 patients, the outcomes were determined by the extent of trauma and underlying comorbidities. The outcomes do not seem to be effectively reduced by more surgery or initial antibiotic treatment. Full article

Background and Objectives: The C-reactive protein-to-albumin ratio (CAR) is associated with mortality and poor outcome after acute ischemic stroke, but the association is not the same as added clinical usefulness. We evaluated whether admission CAR and follow-up CAR provide prognostic information beyond a prespecified parsimonious clinical reference model comprising age, neurological severity, and admission glucose in critically ill patients with acute ischemic stroke. Materials and Methods: In this single-center retrospective cohort of 146 adults with acute ischemic stroke managed in intensive care, CAR was calculated from C-reactive protein and serum albumin at emergency department admission and at the first intensive care laboratory assessment. The primary outcome was 90-day all-cause mortality. A clinical reference model (age, admission National Institutes of Health Stroke Scale [NIHSS] score, admission glucose) was compared with the same model augmented by log-transformed CAR using the area under the receiver operating characteristic curve (AUC), the DeLong test, likelihood-ratio (LR) testing, and bootstrap optimism-corrected performance. Results: Ninety-day mortality occurred in 32 of 146 patients (21.9%) (full cohort; primary complete-case analysis: 141 patients with 31 events). In the primary complete-case analysis (n = 141; 31 events), admission CAR was not independently associated with mortality (odds ratio per 1-SD log CAR 1.46, 95% confidence interval 0.91–2.33; p = 0.115). Adding admission CAR changed the AUC from 0.768 (0.676–0.860) to 0.783 (0.693–0.874) (ΔAUC +0.016, 95% confidence interval −0.024 to +0.055; DeLong p = 0.444; LR p = 0.113), with optimism-corrected point estimates of 0.750 and 0.754. Follow-up CAR did not add value (LR p = 0.159), and change in CAR did not improve discrimination (ΔAUC +0.001; LR p = 0.945); because intensive care sampling times were not standardized, these analyses assess incremental prognostic information rather than CAR kinetics. Admission CAR was not associated with poor 90-day functional outcome (odds ratio 1.09, 95% confidence interval 0.83–1.44; p = 0.530). Conclusions: Admission CAR did not demonstrate measurable incremental prognostic value beyond the prespecified clinical reference model, and follow-up CAR and change-based analyses did not improve prediction, although non-standardized sampling times mean that serial CAR kinetics were not fully evaluated. The confidence intervals remain compatible with both no effect and a positive effect of uncertain clinical relevance, but the observed improvement was insufficient to support CAR as a stand-alone or routinely additive prognostic marker in this setting. Full article

Alcohol consumption contributes substantially to global morbidity and mortality. The alcohol-harm paradox describes the phenomenon where more deprived areas experience higher levels of alcohol-related harms despite reporting similar or lower levels of alcohol consumption compared to less deprived areas. This paradox is particularly evident in Gwent, South-East Wales, where more deprived areas experience greater levels of harms despite having lower annual alcohol consumption. This research aims to explore the impacts of various hypothesised contributors to the alcohol-harm paradox in Gwent. Publicly available cross-sectional data sources are used to explore health behaviours, demographics, alcohol outlet density, and proximity to alcohol-related venues. Factors are studied in relation to both annual alcohol consumption and binge drinking prevalence. Alcohol-related harms are considered in terms of alcohol-specific deaths and alcohol-attributable hospital admissions. The findings reinforce the known complexity of the alcohol-harm paradox, and suggest that it is unlikely to be attributable to a single factor. Elevated prevalence of unhealthy behaviours in more deprived areas and proximity to alcohol venues traditionally associated with cheaper alcohol emerged as potential influential factors. These exploratory findings highlight the importance of targeted public health messaging addressing an overall healthier lifestyle and less harmful consumption behaviours, to reduce alcohol-related health inequalities. Full article

Background: Pediatric head trauma is a common reason for emergency department presentation. Although most children have minor injuries, a small proportion harbor clinically important traumatic brain injuries requiring urgent intervention. Artificial intelligence (AI) may offer structured support in computed tomography (CT) decision making, but evidence regarding the performance of general-purpose large language models in pediatric head trauma remains limited. Objective: To evaluate the association between AI-based cranial CT recommendations and clinically meaningful outcomes in pediatric patients with blunt head trauma and to assess the diagnostic performance and clinical utility of the model. Methods: This retrospective single-center observational study included pediatric patients younger than 18 years with blunt head trauma who underwent cranial CT imaging and had complete outcome data. A general-purpose large language model generated binary CT recommendations (“CT recommended” or “CT not recommended”) using structured clinical information available at the time of emergency department presentation. The primary outcome was a composite adverse clinical outcome defined as the occurrence of at least one of the following: emergency surgical intervention, intensive care unit admission, intubation, neurological sequelae or mortality. Diagnostic performance metrics, calibration analysis and decision curve analysis were performed. Results: A total of 819 pediatric patients were included, and the AI model recommended CT in 530 patients (64.7%). The primary outcome occurred in 143 patients (17.5%) and was significantly more frequent in the CT-recommended group than in the CT-not recommended group (24.5% vs. 4.5%; OR 6.90, 95% CI 3.82–12.45; p < 0.001). Abnormal CT findings, emergency surgery, intubation and neurological sequelae were also significantly more common in patients for whom CT was recommended by the AI system. For the primary outcome, the AI recommendation demonstrated a sensitivity of 90.9%, specificity of 40.8%, positive predictive value of 24.5% and negative predictive value of 95.5%. Calibration analysis showed acceptable agreement between predicted probabilities and observed event rates. Decision curve analysis demonstrated greater net benefit than both the “treat-all” and “treat-none” strategies across a range of threshold probabilities. Conclusions: In this clinically selected cohort of pediatric patients with blunt head trauma who underwent cranial CT imaging, AI-based CT recommendations were strongly associated with adverse clinical outcomes and demonstrated high sensitivity and negative predictive value for identifying children at risk of clinically important events. These findings suggest that, within a clinically selected cohort of children who underwent cranial CT imaging, AI-generated CT recommendations were associated with clinically meaningful outcomes. However, these results should not be interpreted as validation of CT decision making in the broader pediatric head trauma population and require prospective validation in unselected cohorts. Full article

Background: Reliable biomarkers integrating inflammatory and nutritional status are crucial for sepsis risk stratification. While indices like the Systemic Immune-Inflammation Index (SII) and Systemic Inflammation Response Index (SIRI) are widely studied, the prognostic value of the modified Hemoglobin, Albumin, Lymphocyte, and Platelet (m-HALP) score in sepsis remains unclear. This study aimed to compare the prognostic accuracy of m-HALP, HALP, SII, and SIRI for 90-day mortality in patients diagnosed with sepsis in the emergency department. Materials and Methods: This single-center, retrospective observational study included 188 adult patients diagnosed with sepsis according to the Surviving Sepsis Campaign guidelines. Routine hemogram and biochemistry parameters obtained at admission were used to calculate SII, SIRI, HALP, and m-HALP scores. The primary endpoint was 90-day mortality, and secondary endpoints included 7-day mortality, ICU admission, and mechanical ventilation requirement. The discriminative performance of the indices was assessed using Receiver Operating Characteristic (ROC) curve analysis. Results: The median age of the cohort was 75.5 years, and the 90-day mortality rate was 49.5%. Among the evaluated indices, only the lower m-HALP scores demonstrated a statistically significant association with 90-day mortality in the overall cohort (AUC: 0.590, 95% CI: 0.509–0.671, p = 0.030). In the pneumosepsis subgroup, the prognostic performance of m-HALP was numerically higher (AUC: 0.667, 95% CI: 0.548–0.785, p = 0.006) with a sensitivity of 57.4% and specificity of 76.7% at a cut-off value of 522.11. Conversely, standard HALP, SII, and SIRI did not show statistically significant predictive value for 90-day mortality (p > 0.05). None of the indices successfully predicted 7-day mortality, ICU admission, or mechanical ventilation requirement. Conclusions: While m-HALP showed a statistically significant association with 90-day mortality, particularly in the pneumosepsis subgroup, its overall discriminative ability was poor-to-modest (overall AUC 0.590; pneumosepsis AUC 0.667). Consequently, m-HALP lacks sufficient accuracy for standalone clinical decision-making, rendering these findings strictly exploratory and hypothesis-generating. Future prospective, multicenter studies are needed to validate this independent association. Full article

Background and Objectives: This retrospective cohort study aimed to analyze the surgical evolution, clinical outcomes, and adoption of uterus-preserving techniques in placenta previa (PP) and placenta accreta spectrum (PAS) cases managed by a single senior surgeon over an uninterrupted 13-year period. Materials and Methods: A total of 324 patients who underwent cesarean section by a single experienced surgeon with a diagnosis of placenta previa between 1 January 2013 and 1 January 2026 were included in the study. The demographic and obstetric characteristics of the patients, the surgical methods applied, perioperative blood product requirements, complications, and neonatal outcomes were evaluated retrospectively. Uterus-preserving surgical methods included a temporary uterine tourniquet, intrauterine hemostatic sutures, bilateral internal iliac artery ligation (IIAL), Bakri balloon tamponade, B-Lynch suture, uterine lower segment resection, and uterine packing, applied in a stepwise manner. The perioperative hemoglobin change (ΔHb) was calculated as an objective indicator of blood loss. Results: Placenta previa constituted a substantial proportion of all cesarean sections performed by the same surgeon during the study period. Total previa was the predominant type, and almost half of the operations were carried out under emergency conditions. Peripartum hysterectomy was required in a minority of patients, and placenta accreta spectrum was histopathologically confirmed in most of these hysterectomy specimens. The proportion of cases managed with uterus-preserving techniques increased progressively across the series, rising from none in the first year to the great majority of cases in the later years, while the peripartum hysterectomy rate declined correspondingly. On multivariable analysis, a greater number of previous cesarean sections independently increased, and operation during the later years of the series independently reduced the likelihood of peripartum hysterectomy. Perioperative transfusion of at least one blood product was required in more than half of the patients, whereas intensive care admission and perioperative complications were infrequent; bladder perforation was the most common complication. Compared with women whose uterus was preserved, those undergoing hysterectomy were older and had markedly longer operative times, greater blood product consumption, longer hospital stays, and a substantially higher complication rate. No maternal death occurred throughout the 13-year period. Conclusions: In this 13-year single-surgeon experience, the gradual adoption of uterus-preserving techniques was sustainably associated with low maternal morbidity and zero maternal mortality. The markedly higher complication burden observed in the hysterectomy group compared with the uterus-preserving group demonstrates that a standardized step-up surgical approach offers an applicable and effective management strategy even in resource-limited centers. Full article

Telemedicine in emergency and remote care relays medical images from ambulances and rural clinics to a hospital edge-computing server over a congested wireless uplink. Existing work prices such transmissions per bit or per quality-of-experience; neither metric captures the clinical value of a medical transmission. Diagnostic utility vanishes below a modality-specific acceptability floor rather than degrading gracefully, the deadline is determined by triage acuity rather than by the network, and a missed finding is far costlier than a false alarm. A per-bit clearing price therefore disadvantages the node that has expended local compute to produce a compact, diagnostically sufficient stream. We propose SemAuc, a triage-aware truthful mechanism for medical-image admission over a rate-splitting uplink, in which the shared semantic knowledge base rides the common stream, and case-specific residuals ride private streams. SemAuc filters tiers below the diagnostic floor and beyond the clinical deadline, reserves a regulated-price lane for life-threatening cases, and allocates remaining capacity through a single-parameter contestable auction whose bid-independent pre-selection step satisfies the conditions of Myerson’s lemma. The contestable lane is dominant-strategy truthful, individually rational, near-linear in the number of nodes, and achieves a constant-factor density-greedy welfare guarantee; the clinical lanes follow from triage policy without disturbing these properties. Diagnostic value is grounded by an offline kernel fitted on BraTS and CheXpert. On a Rayleigh-faded uplink at two hundred contending nodes, SemAuc preserves the high-acuity diagnostic service-level objective where bit-centric benchmarks fail, and tracks the offline optimum. Full article

Refugees and asylum seekers in Germany face significant barriers to accessing routine dental care, leading to untreated conditions that escalate into costly emergency hospital admissions and increased public healthcare expenditures. This study evaluates the economic impact of an NGO-led dental care facility designed to address this critical gap in care for uninsured populations. Using a retrospective cost-effectiveness analysis, we compare three scenarios: (1) the NGO intervention, (2) the “status quo” reliance on emergency care, and (3) a dental clinic arm-based model. We test the hypothesis that NGO-led interventions reduce public healthcare costs by curbing preventable emergency admissions, thereby addressing systemic policy and market failures. Results demonstrate that the NGO facility is a cost-effective solution, generating a return of €0.60 for every euro invested, while the alternative scenarios yielded no financial returns. By providing equitable, preventive dental care, the NGO model reduced emergency admissions by addressing delayed treatment-seeking behaviors and structural access barriers. These findings confirm that NGO-led interventions can mitigate market failures by serving as a Pareto-improving solution, optimizing resource allocation and reducing long-term fiscal burdens. The study underscores the potential of NGOs to complement public health systems in achieving equitable and sustainable healthcare delivery. Policymakers should consider scaling such models to alleviate disparities in underserved populations while curbing avoidable costs linked to emergency care. This research contributes critical evidence for integrating NGO-led initiatives into healthcare strategies, particularly in contexts marked by fragmented access and systemic inefficiencies. Full article

Widening participation spans the whole student lifecycle, from access through to success within higher education and progression beyond it, yet policy and evaluation have concentrated on the access stage alone. Far less is known about how students admitted through widened access routes come to understand the legitimacy of their place, and the terms of their belonging, once inside an elite university. Reporting twenty-one (n = 21) walking interviews with students who entered the University of Cambridge through its Foundation Year, a one-year pre-degree programme for applicants whose educational opportunities have been constrained by structural disadvantage, this article examines a tension at the heart of meritocracy. Belonging is approached throughout as a relational and processual accomplishment practised in situ rather than as a psychological state to be measured, and the article asks on what terms it is made available along a visibly marked route. Participants recognized that admissions standards are shaped by unequal opportunity, though the recognition appeared not to weaken their commitment to meritocratic judgement, and they endeavored to suffuse their belonging with proof of deservingness. Such a pattern sits uneasily with Bourdieusian accounts of symbolic domination grounded in misrecognition, and points towards a compliance sustained through lucid perception of meritocracy and its ideological demands. Analysis of the walks suggests that the route organizes this tension by marking students publicly as different, by tying belonging to a competitive progression threshold, by collapsing heterogeneous experiences into a single administrative category, and by locating institutional judgement in everyday encounters with teaching staff. Belonging emerges less as a settled outcome of admission than as a conditional status that must be repeatedly earned. Widening access may therefore secure entry without securing the later stages of participation, so long as the legitimacy of membership continues to be organized through meritocratic evaluation that students simultaneously critique and reproduce. Full article

Future low Earth orbit (LEO) communication constellations are evolving into integrated multi-mission infrastructure. Their signals of opportunity (SoP) are therefore becoming attractive for Doppler positioning. However, the conventional coverage- or rate-optimized configurations may not provide favorable Doppler geometry under realistic link-quality constraints. This paper considers this emerging requirement at the constellation-configuration design level and proposes a multi-layer Walker optimization framework for integrated communication and SoP Doppler positioning. A system-level positioning metric is developed to move beyond visibility and dilution-of-precision indicators. A link-quality-constrained multi-epoch Fisher information matrix (FIM) incorporates $C/N_0$-based link measurability and a general carrier-to-noise-density-dependent Doppler-noise formulation. In the reported simulations, $C/N_0$ controls observation admission, while all admitted Doppler observations use a fixed noise standard deviation of 0.5 m/s. An effective position-error bound is then obtained by marginalizing clock-drift and frequency-bias nuisance states. Based on a unified satellite–ground geometry, weighted service coverage, weighted best-link achievable rate, and the proposed positioning metric are jointly optimized using a constrained mixed-integer multi-objective artificial hummingbird algorithm (CMI-MOAHA). The FIM-based metric is consistent with the positioning root mean square error (RMSE) from a separately implemented nonlinear Doppler solver under matched observation and noise assumptions. With the total number of satellites fixed at 2000, the Pareto archive reveals clear trade-offs among coverage, best-link achievable rate, and positioning. When the positioning objective is included, the best obtained positioning metric decreases across all tested constellation sizes, with a maximum reduction of 77.1%. These results show that constellation-level joint optimization is warranted when LEO communication satellites also serve as SoP for Doppler positioning. Full article

Background: The most appropriate management of glucose-lowering therapies in patients exposed to iodinated contrast media (ICM) is still debated. The recent development of antidiabetic drugs that improve cardiovascular and renal outcomes leads to questions regarding their impact on the risk of contrast-associated acute kidney injury (CA-AKI). The present study aimed to assess the effect of different glucose-lowering therapies on the rate of CA-AKI among patients undergoing coronary angiography and/or angioplasty. Methods: Diabetic patients exposed to ICM for coronary procedures were retrospectively identified and divided according to the strategy for the management of diabetes mellitus. The use of a new antidiabetic drug (NAD) was defined for patients treated with SGLT2-I, DDP4-I or GLP-1 receptor agonists on admission. The primary endpoint was the occurrence of CA-AKI within 72 h after contrast medium exposure. Results: We included 462 patients with diabetes mellitus, 51.5% treated with insulin, 44.4% treated with metformin and 50.9% receiving NAD. Among them, 48 (10.4%) experienced CA-AKI. Patients experiencing acute renal injury were more often treated with calcium channel blockers (p = 0.04) and diuretics (p = 0.004), and less often P2Y12 inhibitors (p = 0.04), and presented lower levels of hemoglobin (p = 0.02). Patients receiving NADs displayed a significantly lower occurrence of CA-AKI (33.3% vs. 53.6%, p = 0.009), mainly for those treated with SGLT2-I. On the contrary, patients treated with sulfonylureas and meglitinides displayed a significant increase in the rate of CA-AKI (10.4% vs. 3.9%, p = 0.05). The results were confirmed via multivariable analysis, with NADs and diuretics emerging as the only independent predictors of CA-AKI (NAD: adjusted OR = 0.42 [0.21–0.81], p = 0.01; diuretics: adjusted OR = 2.22 [1.14–4.35], p = 0.02). The independent predictors of CA-AKI were the use of NADs (adjusted OR = 0.45 [0.24–0.86], p = 0.02) and diuretics (adjusted OR = 2.57 [1.33–4.97], p = 0.005). Conclusions: Among patients with diabetes mellitus undergoing coronary angiographic procedures, the use of diuretics, sulfonylureas and meglitinides is associated with an increased occurrence of CA-AKI, whereas the rate of events was significantly lower among users of new antidiabetic drugs and especially SGLT2-I. Full article

Vegetation distribution is important for regulating overland-flow hydraulics and reducing hydraulic erosion potential on slopes. However, quantitative procedures for determining the maximum admissible spacing of multi-row vegetation under specified soil and design rainfall conditions remain limited. This study combined fixed-bed flume experiments with a theoretical hydraulic model to determine the lateral and downslope vegetation spacings required to maintain the predicted overland-flow velocity below the critical velocity for soil-particle initiation. A total of 120 runoff tests were conducted at a slope gradient of 15° under eight flow discharges (0.3–1.0 L/s) and three vegetation configurations: single-row vegetation with varying lateral spacing b, multi-row vegetation with varying b at d = 0.030 m, and multi-row vegetation with varying downslope spacing d at b = 0.010 m. Flow depth and discharge were measured, and the cross-sectional mean velocity was calculated to evaluate the Reynolds number Re, Froude number Fr, and local resistance coefficient ξ. The measured Re and Fr ranged from 475 to 1770 and from 0.83 to 2.06, respectively, indicating laminar-to-transitional regimes based on Re and predominantly supercritical flow states based on Fr, with limited subcritical and critical cases. Increasing b, d, or Q generally reduced ξ, whereas multi-row vegetation produced greater flow resistance than single-row vegetation. At each Q level, the ξ–b and ξ–d relationships followed power functions with R² ≥ 0.73. An improved local resistance formulation incorporating b, d, Re, and Fr was developed and evaluated using 129 measured data points, yielding R² values of 0.77–0.90. The proposed model was further combined with SCS-CN runoff estimates and a critical initiation velocity criterion for five soil types characterized by mean particle diameter and particle density and five 1-h design rainfall depths of 25–125 mm. Model-derived vegetation-spacing estimates were obtained for 18 of the 25 soil–rainfall scenarios, and denser vegetation distributions were generally required as the design rainfall depth increased. These results provide experimentally informed, model-based guidance for estimating multi-row vegetation spacing under specified soil and rainfall conditions. The proposed relationships and spacing estimates are condition-specific to the fixed-bed experiments with artificial emergent vegetation at a slope gradient of 15° and to the investigated hydraulic and geometric ranges. They should not be interpreted as universal design criteria or direct predictions of field soil erosion; application beyond these conditions requires further calibration and validation. Full article

Background/Objectives: Respiratory intermediate care units (RICUs) manage patients with severe respiratory disease requiring advanced monitoring and non-invasive respiratory support. Early identification of patients requiring RICU care after emergency department (ED) assessment remains challenging. This study assessed whether initial admission to a conventional hospital ward followed by early RICU transfer was associated with in-hospital mortality among patients ultimately admitted to a RICU. Methods: We conducted a 10-year prospective observational cohort study including consecutive patients admitted to the RICU of a tertiary hospital after ED assessment. Patients admitted directly from the ED to the RICU were classified as the direct RICU admission group. Patients initially admitted to a conventional ward and transferred to the RICU within 48 h were classified as the early ward-to-RICU transfer group. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included ICU admission and hospital length of stay. Multivariable logistic regression was used to assess the association between admission pathway and in-hospital mortality. Results: A total of 1784 patients were included: 1285 (72%) in the direct RICU admission group and 499 (28%) in the early ward-to-RICU transfer group. In-hospital mortality was higher in the early ward-to-RICU transfer group than in the direct RICU admission group (13.43% versus 5.76%; p < 0.0001), as were ICU admission rates (6.01% versus 2.57%; p = 0.0004). In the complete-case multivariable model, early ward-to-RICU transfer remained associated with higher in-hospital mortality after adjustment for sex, ECOG performance status, APACHE II score at ED presentation, Charlson Comorbidity Index, heart failure, and interstitial lung disease (OR 2.99, 95% CI 1.96–4.56; p < 0.0001). Conclusions: Among patients ultimately admitted to a RICU after ED assessment, initial ward admission followed by early RICU transfer was associated with higher in-hospital mortality. These findings suggest that initial ward admission followed by early RICU transfer may help identify a clinically vulnerable subgroup among patients ultimately requiring respiratory intermediate care. However, because admission pathway may be influenced by evolving severity, diagnostic uncertainty, treatment decisions, and organisational factors, no causal inference can be made from this observational study. Full article

Background and Objectives: Postoperative delirium (POD) is a frequent neuropsychiatric complication following hip fracture surgery in older adults and is associated with prolonged hospitalization, functional decline, and increased mortality. Systemic inflammation is thought to play a central role in its pathogenesis, and the C-reactive protein CRP-to-albumin ratio (CAR) has emerged as a promising inflammatory biomarker. This study aimed to investigate the association between the preoperative CAR and POD and to identify clinical and perioperative factors independently associated with POD. Materials and Methods: This retrospective cohort study included 962 consecutive patients who underwent surgery for hip fractures between January 2022 and December 2025. Patients with femoral neck fractures underwent hemiarthroplasty, whereas those with intertrochanteric fractures were treated with proximal femoral nailing. Cases of postoperative delirium were evaluated following psychiatric consultation requested based on clinical suspicion by the orthopedic team, nursing staff or the patient’s caregiver; the definitive diagnosis was made by consultant psychiatrists according to the DSM-5 diagnostic criteria. Demographic characteristics, perioperative variables, and preoperative laboratory parameters were analyzed. Univariable and prespecified multivariable logistic regression analyses were performed to identify factors independently associated with POD. Model discrimination and calibration were assessed using receiver operating characteristic analysis, bootstrap internal validation, and the Hosmer–Lemeshow goodness-of-fit test. Results: Postoperative delirium developed in 112 of 962 patients (11.6%). Patients who developed POD had significantly higher preoperative CAR values than those without POD (0.76 vs. 0.33, p < 0.001). In the multivariable analysis, male sex (OR 1.567, 95% CI 1.007–2.438; p = 0.046), hemiarthroplasty (OR 1.931, 95% CI 1.213–3.075; p = 0.006), perioperative blood transfusion (OR 1.870, 95% CI 1.178–2.971; p = 0.008), general anesthesia (OR 1.829, 95% CI 1.093–3.061; p = 0.021), higher ASA physical status classification (OR 2.154, 95% CI 1.346–3.446; p = 0.001), longer time from hospital admission to surgery (OR 1.250 per 24 h increase, 95% CI 1.103–1.417; p < 0.001), and a higher log₂-transformed CAR (OR 1.184 per doubling, 95% CI 1.037–1.352; p = 0.013) were independently associated with POD. The final model demonstrated acceptable discrimination (AUC 0.764; optimism-corrected AUC 0.744) and satisfactory calibration (Hosmer–Lemeshow p = 0.242). Conclusions: A higher preoperative C-reactive protein-to-albumin ratio was independently associated with postoperative delirium after hip fracture surgery, even after adjustment for established demographic and perioperative risk factors. Male sex, hemiarthroplasty, general anesthesia, higher ASA physical status classification, perioperative blood transfusion, and delayed surgery were also independently associated with POD. These findings suggest that CAR may be a low-cost and readily available inflammatory biomarker that could be used to develop a preoperative risk classification system for the development of postoperative delirium. However, since routine standardized delirium screening was not performed during the study, cases of hypoactive delirium in particular may not have been adequately identified. For this reason, the findings should be interpreted with caution. Prospective, multicenter studies incorporating standardized delirium screening methods are needed to validate these results and determine the additional predictive value of CAR beyond established clinical risk factors. Full article