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Background: Prisoners of war (POWs) are usually at risk of suicide due to problems such as torture, social and emotional deprivation, etc. The present study aimed to investigate suicide cases among Iranian prisoners of war (POWs) over ten years of their presence in the camps in Iraq (1980-1990). Methods: Data required in this study were collected in two ways: 1- Iranian ex-POWs' death certificate by the Iraqi army clinic setting; 2- we interviewed 1 9 Iranian ex-POWs with sufficient information from detention camps and their events. The collected data were age, sex, duration of captivity, date of death, the suicide, and places of suicide (camp name). Results: During eight years of the Iraq-Iran war, about 40000 Iranian soldiers captured by Iraqi soldiers. Of them, at least 11 persons (0.0275%) lost their lives due to suicide. The rate of suicide among Iranian ex-POWs in Iraq was variable from zero to 28 per 1 00000 people. Nine (82%) of deceased were among registered prisoners of war, and three (%27.3) were civilians. The highest rate was among prisoners that spent seven years of captivity. The most common method of suicide was hanging and burning, with 45.5% (5/11) and 18.2% (2/1 1), respectively. Conclusion: Social support and providing suitable treatment for chronic and incurable diseases or creating situations for returning such patients to their home could be essential for suicide prevention. Transferring them to a third country (under the supervision of international groups such as International Committee of the Red Cross (ICRC) could be another way to reduce the amount of psychological stress and will also be helpful in their treatment.

Introduction: People who use drugs in community settings are at risk of a fatal overdose, which can be mitigated by naloxone administered via bystanders. In this study we sought to investigate methods of estimating and tracking opioid overdose reversals by community members with take-home naloxone (THN) to coalesce possible ways of characterizing THN reach with a metric that is useful for guiding both distribution of naloxone and advocacy of its benefits. Methods: We conducted a scoping review of published literature on PubMed on August 15, 2022, using PRISMA-ScR protocol, for articles discussing methods to estimate THN reversals in the community. The following search terms were used: naloxone AND (“take home” OR kit OR “community distribution” OR “naloxone distribution”). We used backwards citation searching to potentially find additional studies. Overdose education and naloxone distribution program-based studies that analyzed only single programs were excluded. Results: The database search captured 614 studies, of which 14 studies were relevant. Backwards citation searching of 765 references did not reveal additional relevant studies. Of the 14 relevant studies, 11 were mathematical models. Ten used Markov models, and one used a system dynamics model. Of the remaining three articles, one was a meta-analysis, and two used spatial analysis. Studies ranged in year of publication from 2013–2022 with mathematical modeling increasing in use over time. Only spatial analysis was used with a focus on characterizing local naloxone use at the level of a specific city. Conclusion: Of existing methods to estimate bystander administration of THN, mathematical models are most common, particularly Markov models. System dynamics modeling, meta-analysis, and spatial analysis have also been used. All methods are heavily dependent upon overdose education and naloxone distribution program data published in the literature or available as ongoing surveillance data. Overall, there is a paucity of literature describing methods of estimation and even fewer with methods applied to a local focus that would allow for more targeted distribution of naloxone.

Background Gamification in medical education has gained popularity over the past several years. We describe a virtual escape box in emergency medicine clerkship didactics to teach chest pain and abdominal pain and compare this instructional method to a traditional flipped classroom format. Methods A virtual escape box was designed at our institution and incorporated into the mandatory two-week emergency medicine clerkship. The game consisted of a PDF with four cases containing puzzles to unlock a final clue. Likert scale surveys were administered to assess participants’ perceptions of the escape box format; of clerkship didactics as a whole; and of the clerkship overall. These responses were compared to the prior year’s evaluations on flipped classroom didactics and clerkship. Results One hundred thirty-four learners participated in the escape box and completed the survey. Eighty-six percent strongly agreed with feeling more engaged with the escape box, 84% strongly agreed with learning something new, 81% strongly agreed with finding the escape box to be satisfying, 78% strongly agreed with being able to apply knowledge gained, and 74% strongly agreed with wanting more escape boxes incorporated into medical education. The escape box showed a higher average score (3.6 ± 0.63) compared to chest pain (3.5 ± 0.67) and abdominal pain (3.2 ± 0.77) flipped classroom sessions ( p  = 0.0491) for the category of “lecturer explaining content clearly and at the proper level of complexity.” For the category of “lecturer provided effective instructional materials,” the escape box showed higher scores (3.6 ± 0.63) compared to flipped classroom for chest pain (3.4 ± 0.77) and abdominal pain (3.1 ± 0.80) ( p  < 0.001). Conclusions Escape boxes are adaptable to a virtual format and can teach abstract concepts such as teamwork and communication in addition to traditional lecture content. Ratings of didactics were higher for the escape box compared to the flipped classroom, while ratings of overall clerkship experience were not found to change significantly.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic significantly altered emergency department (ED) utilization patterns. This study quantifies the statistics at a Level I trauma center in Southern California from 14 months before to nine months after the start of the pandemic (January 2019–December 2020). We hypothesized that during the COVID-19 pandemic, changes in ED use patterns impacted patient acuity, as measured by admission rate, mortality rate, ED volume, Emergency Severity Index (ESI), and female:male ratio, even when controlling for COVID-19 cases. Methods: In this study we examined 97,793 ED visits from January 2019–December 2020 at the University of California, Irvine Medical Center in Orange, CA, via an administrative database comprised of anonymized datapoints from the electronic health record. We included all months from January 2019–December 2020 to account for potential secular trends by calendar month. Primary outcome measures were hospital admission rate and all-causes mortality rate among non-COVID-19 patients who presented to the ED. Secondary outcome measures included the mean number of ED visits per month, mean ESI, and female:male ratio among non-COVID-19 patients. Statistical analyses were performed. Results: We found an increase in the mortality rate per ED visit of 0.8859% before the pandemic to 1.2706% (P < .001) during the pandemic. After excluding COVID-19 cases, the mortality rate per ED visit remained elevated at 1.1746% (P < .001), a relative increase of 32.6%. Hospital admission rate increased from 26.0% before the pandemic to 32.3% during the pandemic (P < .001). The mean number of ED visits per month decreased from 4,271.2 ± 193.1 before the pandemic to 3,558.7 ± 437.1 per month during the pandemic (P < .001), a relative decrease of 16.7% when excluding COVID-19 cases. The mean ESI of non-COVID-19 related cases during the pandemic decreased from 2.85 pre-pandemic to 2.84 during the pandemic (P = .03). The female:male ratio decreased from 1.003 pre-pandemic to 0.885 during the pandemic (P < .001). Conclusion: This study reveals a decrease in patient volume with an increase in mortality and admission rate, demonstrating an association between shifts in ED utilization patterns and increased patient acuity during the pandemic. Understanding patients’ emergency care-seeking behavior during this period is essential for preparing for future large-scale public health crises and optimizing ED resource allocation and mobilization based on lessons learned from COVID-19. Overall, these findings highlight the need for further research into the development of strategies to address changes in care-seeking behavior during access-limiting scenarios.

Introduction: Prehospital information is valuable but often under-used by physicians. In both the emergency and inpatient settings, information about a patient’s condition prior to their arrival is important to provide optimal care. Historically, prehospital responders’ electronic patient care reports (ePCR) have not been integrated with the hospital’s electronic health record (EHR). In this study, we aimed to assess physician attitudes towards the ePCR and patient care decisions before and after integration of prehospital ePCR and hospital EHR systems. We hypothesized that this would increase accessibility and use of prehospital ePCR in patient care decisions. Methods: In 2023, our local academic health center implemented software that made prehospital documentation available to hospital staff within 30 minutes of patient arrival to the emergency department (ED). Before this, we surveyed attendings, fellows, and residents from both the ED and internal medicine (IM) department on their attitudes and behaviors regarding ePCR and clinical practice. We administered the same survey six months after implementation, and compared responses with a Wilcoxon signed-rank test. Results: Sixty-six physicians responded to the pre survey, including 39 (59.1%) from the ED and 27 (40.9%) from the IM department. Fifty-two completed the post survey, including 33 (63.5%) emergency physicians and 19 (36.5%) IM physicians. The pre- survey response rates were 92.9% and 54% for the ED and IM groups, respectively, while the post-survey response rates were 84.6% and 70.4%. Change in rank was significant (P < .01) for the following categories: knowledge;, ability; ease of use; time to access; and frequency of accessing the ePCR. Change in rank was not significant for the importance of ePCR in patient care and medical decision-making, and whether the ePCR would be used more frequently if it were easier to access. Conclusion: Pre- and post-survey responses regarding accessibility showed a significant change in rank, while the importance of the ePCR on clinical decision-making did not. This suggests that while system integration increased accessibility to prehospital information, it did not significantly alter patient care decision-making.

Recent surveys indicate that 48% of consumers actively use generative artificial intelligence (AI) for health-related inquiries. Despite widespread adoption and the potential to improve health care access, scant research examines the performance of AI chatbot responses regarding emergency care advice. We assessed the quality of AI chatbot responses to common emergency care questions. We sought to determine qualitative differences in responses from 4 free-access AI chatbots, for 10 different serious and benign emergency conditions. We created 10 emergency care questions that we fed into the free-access versions of ChatGPT 3.5 (OpenAI), Google Bard, Bing AI Chat (Microsoft), and Claude AI (Anthropic) on November 26, 2023. Each response was graded by 5 board-certified emergency medicine (EM) faculty for 8 domains of percentage accuracy, presence of dangerous information, factual accuracy, clarity, completeness, understandability, source reliability, and source relevancy. We determined the correct, complete response to the 10 questions from reputable and scholarly emergency medical references. These were compiled by an EM resident physician. For the readability of the chatbot responses, we used the Flesch-Kincaid Grade Level of each response from readability statistics embedded in Microsoft Word. Differences between chatbots were determined by the chi-square test. Each of the 4 chatbots' responses to the 10 clinical questions were scored across 8 domains by 5 EM faculty, for 400 assessments for each chatbot. Together, the 4 chatbots had the best performance in clarity and understandability (both 85%), intermediate performance in accuracy and completeness (both 50%), and poor performance (10%) for source relevance and reliability (mostly unreported). Chatbots contained dangerous information in 5% to 35% of responses, with no statistical difference between chatbots on this metric (P=.24). ChatGPT, Google Bard, and Claud AI had similar performances across 6 out of 8 domains. Only Bing AI performed better with more identified or relevant sources (40%; the others had 0%-10%). Flesch-Kincaid Reading level was 7.7-8.9 grade for all chatbots, except ChatGPT at 10.8, which were all too advanced for average emergency patients. Responses included both dangerous (eg, starting cardiopulmonary resuscitation with no pulse check) and generally inappropriate advice (eg, loosening the collar to improve breathing without evidence of airway compromise). AI chatbots, though ubiquitous, have significant deficiencies in EM patient advice, despite relatively consistent performance. Information for when to seek urgent or emergent care is frequently incomplete and inaccurate, and patients may be unaware of misinformation. Sources are not generally provided. Patients who use AI to guide health care decisions assume potential risks. AI chatbots for health should be subject to further research, refinement, and regulation. We strongly recommend proper medical consultation to prevent potential adverse outcomes.

The Accreditation Council for Graduate Medical Education's (ACGME) proposal to mandate 48-month training for all emergency medicine residency programs represents a significant departure from the current system where both 36- and 48-month formats successfully coexist.The ACGME's justification relies on a methodologically flawed survey that never directly asked program directors about optimal training duration. Instead, it calculated totals by summing individual rotation estimates without considering integrated curricula or practical constraints. Even if these results were to be accepted, directors of three-year programs reported a mean desired duration of only 41.6 months-hardly justifying a universal 48-month mandate.Current evidence contradicts the ACGME's rationale. Three-year graduates achieve higher board pass rates (93.1% vs 90.8%) and demonstrate equivalent clinical performance to four-year graduates. The mandate would impose substantial financial burdens on trainees-an opportunity cost exceeding $200,000-$250,000-while potentially deterring qualified applicants and discouraging fellowship training.We urge the ACGME to pause implementation and provide compelling evidence that a 48-month mandate is necessary and demonstrably superior to the current model.

Background Mental health disorders (MHD) impose a considerable burden on public health systems. With an increasing worldwide trend in urbanization, urban mental health stressors are affecting a larger population. In this study, we evaluated the epidemiology of mental health disorders in the citizens of Tehran using the Tehran Cohort Study (TeCS) data. Methods We utilized data from the TeCS recruitment phase. A total of 10,247 permanent residents of Tehran metropolitan (aged 15 years and older) were enrolled in the study from March 2016 to 2019 via systematic random sampling from all 22 districts of Tehran. The participant's demographic, socioeconomic, and medical characteristics were evaluated by conducting comprehensive interviews. The standardized Persian version of the General Health Questionnaire version 28 was utilized to assess the mental status of the patients according to four central mental health disorders. Results Almost 37.1% of Tehran residents suffered mental health problems (45.0% of women and 28.0% of men). The greatest incidence of MHDs was seen in the 25–34 and over 75 age groups. The most common mental health disorders were depression (43%) and anxiety (40%), followed by somatization (30%) and social dysfunction (8.1%). Mental health disorders were more frequent in the southeast regions of the city. Conclusions Tehran residents have a significantly higher rate of mental health disorders compared to nationwide studies, with an estimated 2.7 million citizens requiring mental health care services. Awareness of mental health disorders and identifying vulnerable groups are crucial in developing mental health care programs by public health authorities.

Background Research demonstrates that Point-of-care ultrasound (POCUS) improves clinical outcomes for patients. Improving clinician satisfaction with POCUS should promote utilization into everyday practice, leading to improved clinical outcomes. Despite this benefit, there are still barriers to use including POCUS workflow. This project was undertaken to improve the functionality of the existing POCUS workflow and move toward an “encounter-based” system by automating worklist generation. It aimed to streamline the POCUS workflow, primarily determine if there was improved clinician satisfaction with the new workflow, and secondarily determine the change in revenue generation from decreased errors in data entry. Methods A new workflow was created which automatically populated every registered Emergency Department (ED) patient into the worklist upon patient registration. Clinician feedback on their use of the new workflow was sought via survey after implementation. The number of medical record number (MRN) entry errors prior to and following implementation was manually reviewed and calculated. Results There was a strong preference for the new workflow, with 36 of 38 (94.7%) clinicians finding it to be more convenient and 37 of 38 (97.4%) finding it to be preferable to use compared to the old workflow. Implementation also resulted in a 36% reduction in database studies containing an MRN data entry error. Conclusions An “encounter-based” workflow is strongly preferred over manual data entry for POCUS workflow among clinicians. Additionally, there was no cost to the intervention and the total data entry errors were significantly reduced, allowing for improved quality review and increased revenue.

Introduction: Food and housing insecurity in childhood is troublingly widespread. Emergency departments (ED) are well positioned to identify and support food- and housing-insecure children and their families. However, there is no consensus regarding the most efficient screening tools or most effective interventions for ED use. Objective: In this cross-sectional study we aimed to investigate the implementation of a food/ housing insecurity screening tool and resource referral uptake in a pediatric ED. Methods: During the study period (March 1–December 9, 2021), there were 67,297 ED visits at the study institution, which is a freestanding children’s hospital. Caregivers of patients presenting to the ED were approached for participation in the study; 1,908 families participated (2.8% of all ED visits during the study period) and were screened for food and housing insecurity. Caregiver surveys included demographic, food and housing insecurity, caregiver/patient health status, and healthcare utilization questions. Caregivers who screened positive for food and/or housing insecurity received printed materials with food and/or housing resources. We analyzed data using descriptive statistics, one-way analysis of variance, and the Pearson chi-squared test. Results: A total of 1,908 caregivers were surveyed: 416 (21.8%) screened positive for food and/or housing insecurity. Of those who screened positive, 147/416 completed follow-up surveys. On follow-up, 44 (30.0%) no longer screened positive for food and/or housing insecurity, while 15 (10.2%) reported using at least one resource referral. The most frequently reported referral utilization barrier was loss or reported non-receipt of the referral. Conclusion: This study demonstrates high food- and housing-insecurity rates among families presenting to a pediatric ED, emphasizing the urgency and necessity of screening and intervening in this environment. The food and housing insecurity change between baseline and follow-up reported here and the overall low resource uptake highlights challenges with ED-based screening and intervention efficacy.