Virtual care technologies have rapidly expanded in emergency medicine, particularly following the COVID-19 pandemic. However, comprehensive economic evaluations of their cost-effectiveness remain fragmented across different clinical applications and health care settings, creating uncertainty for policymakers and health care administrators considering implementation.

This study aimed to systematically review and synthesize evidence on the cost-effectiveness of virtual emergency care models compared to traditional in-person emergency care across diverse clinical conditions, populations, and health care settings.

We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, searching 8 electronic databases (PubMed, Embase, Scopus, Web of Science, CINAHL, Cochrane Library, MEDLINE, and PsycINFO) from inception to February 2025. We included full economic evaluations comparing virtual emergency care interventions with usual care. Two reviewers independently screened studies, extracted data, and assessed quality using the Drummond checklist and Consensus Health Economic Criteria (CHEC) list. Evidence certainty was evaluated using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Given heterogeneity in interventions and methods, we conducted a narrative synthesis by virtual care modality and clinical application.

From 5817 identified references, 13 studies met inclusion criteria, representing diverse virtual care modalities across 6 countries (United States, Australia, Italy, Canada, Haiti, and Belgium). All included studies reported favorable economic outcomes for virtual emergency care. Video consultation was the most common modality (11/13 studies), achieving 31% to 73% reduction in patient transfers and cost savings of US $73 (AUD $105) to US $5118 per encounter. A total of 6 (46%) studies found virtual care to be dominant (both less costly and more effective). Incremental cost-effectiveness ratios ranged from US $1273 (€990) to US $108,363 per quality-adjusted life year, with most below accepted willingness-to-pay thresholds. Transfer avoidance was the primary economic driver, particularly in rural settings. Quality assessment revealed high methodological rigor (mean Drummond score 92.3%, SD 6.0%; mean CHEC score 95%, SD 4.2%). Using GRADE, evidence certainty was rated high for cost-effectiveness, moderate for transfer reduction and quality of life improvements, and low for emergency department length of stay and mortality benefits.

Virtual emergency care demonstrates strong and consistent cost-effectiveness across diverse clinical conditions, populations, and health care settings. The evidence particularly supports implementation for stroke care, pediatric emergencies, and rural/remote populations where transfer avoidance drives substantial economic benefits. All evaluated modalities achieved favorable economic outcomes, suggesting technology should match context rather than maximize sophistication. These findings provide robust economic justification for expanding virtual emergency care access and removing regulatory barriers. As health care systems face mounting pressures from aging populations, workforce shortages, and budget constraints, virtual emergency care offers a proven strategy for improving access and quality while reducing costs.

PROSPERO CRD42025648218; https://www.crd.york.ac.uk/PROSPERO/view/CRD42025648218.

Recent crises involving zoonotic diseases (Ebola, COVID-19, and Mpox) have highlighted the limitations of fragmented public health systems for the prevention and response to health emergencies at the international and continental level, and particularly in Africa, more specifically in the Democratic Republic of the Congo (DRC). In this context, the One Health (OH) approach and its extension, One Digital Health (ODH), articulated with the findable, accessible, interoperable, reusable (FAIR) principles, offer a framework for rethinking the digital transition in health in the DRC. This study analyzes the reality of this transition in Kinshasa, DRC, and questions the feasibility of ODH in this context.

This study aimed to (1) explore how stakeholders across human, animal, and environmental health sectors perceive and experience digital tool integration and data interoperability in Kinshasa; (2) identify structural, institutional, and technical constraints affecting cross-sectoral data sharing; and (3) analyze the sociotechnical conditions required for the operationalization of ODH in a fragmented digital health (DH) context.

A qualitative study was conducted in Kinshasa, DRC, between November 10, 2025, and November 25, 2025, combining semistructured interviews with key actors (health professionals, administrative officials, digital experts, and engaged citizens) and a document review of strategic and regulatory texts related to DH in the DRC. The data were analyzed using a thematic approach to identify the representations, uses, and constraints related to DH and the operationalization of ODH.

Overall, 22 stakeholders participated (n=9, 40.9% human health; n=8, 36.4% animal health; n=4, 18.2% environmental health; n=1, 4.50% digital sector), predominantly male (n=15, 68.2%) and mainly in operational roles (n=12, 54.5%). Three interrelated topics emerged. First, a dual-track digital ecosystem characterized by the coexistence of formal platforms (eg, District Health Information Software 2 and electronic records) and informal tools (eg, WhatsApp [Meta]), with persistent paper-digital double-entry generating inefficiencies. Second, structural and governance bottlenecks, including electricity instability, limited connectivity, software incompatibility, external data-hosting concerns that affect sovereignty, and institutional silos that privilege human health over animal and environmental sectors. Third, prerequisites for operationalizing ODH emphasize foundational infrastructure (energy and internet), sustainable capacity building beyond one-off training, interoperable "bridges" between fragmented systems, and high-level political leadership. These elements were synthesized into an ODH-FAIR DRC conceptual model structured around three enabling pillars linking sectors for integrated zoonotic surveillance.

Operationalizing ODH in DRC requires addressing foundational enablers beyond tools: synchronized energy-digital policies, decompartmentalized governance, and context-adapted capacity building. These insights inform low- and middle-income countries' DH strategies, urging donors and ministries to prioritize interoperability over isolated pilots to achieve sustainable zoonotic surveillance.

Epidemiological and biological risks frequently expose Caribbean territories to emerging infectious threats. Martinique, a French overseas territory, is particularly vulnerable due to its tropical climate, insular geography, and recurrent exposure to arboviral epidemics. During exceptional health crises such as the COVID-19 pandemic, health care systems must rapidly adapt to a potentially sustained patient influx, evolving scientific knowledge, and heightened population anxiety. In March 2020, following the first confirmed COVID-19 cases in Martinique, the emergency medical service (EMS) implemented a teleconsultation follow-up unit dedicated to home-based patients with suspected SARS-CoV-2 infection, in the context of uncertainty regarding disease progression.

This study aimed to evaluate the health and psychological impact of this EMS-based teleconsultation follow-up unit during the first COVID-19 wave, in order to assess its potential as an organizational response strategy for future infectious health emergencies.

We conducted a single-center, retrospective, descriptive study including all adult patients monitored by the EMS COVID-19 teleconsultation unit during the first wave of the COVID-19 pandemic, between March 10 and May 31, 2020. Patients were initially triaged through the EMS call center and followed remotely using a standardized daily questionnaire. Follow-up frequency was determined according to clinical presentation. Collected data included sociodemographic characteristics, medical history, symptoms, polymerase chain reaction (PCR) testing status, clinical outcomes (recovery, hospitalization, or death), anxiety levels assessed using a 5-point Likert scale at the beginning and end of follow-up, and satisfaction measured on a 10-point numeric scale.

Among 1255 patients monitored during the study period, 908 met inclusion criteria (mean age 45, SD 17 years; 57.6% female). Most patients (n=724, 79.7%) had no prior medical history. The most frequently reported symptoms were fever (n=177, 19.5%), respiratory difficulties (n=165, 18.2%), cough (n=152, 16.7%), myalgia (n=114, 12.6%), and diarrhea (n=91, 10.0%). Only 10.6% of patients underwent PCR testing due to limited availability during the early epidemic phase, of whom 62.5% tested positive. During follow-up, 68 patients (7.5%) required hospitalization, and 2 (0.2%) died during their hospital stay. The presence of at least 1 pre-existing medical condition and older age were both significantly associated with hospitalization for suspected COVID-19 (P<.001). Among 590 respondents, mean anxiety scores decreased significantly from 3.9 (SD 0.8) at baseline to 1.4 (SD 1.1) at the end of follow-up, representing a 64.1% reduction (P<.001). Overall patient satisfaction with the teleconsultation service was high (mean score 8.7, SD 1.2, of 10).

In the context of a novel epidemic with limited diagnostic and therapeutic knowledge, an EMS-integrated teleconsultation follow-up system enabled safe outpatient management while significantly reducing patient anxiety and preserving hospital resources. This approach may represent a scalable organizational model for maintaining access to care and supporting population reassurance during future infectious disease emergencies in geographically constrained or resource-limited settings such as small island territories.

A substantial proportion of hospitalized COVID-19 patients require ICU admission, often associated with an imbalance between antiviral responses and inflammatory signaling leading to uncontrolled cytokine secretion. The SARS-CoV-2 nucleocapsid (N) protein is a known immune antagonist, but its role in macrophage-driven cytokine storms is unclear. We demonstrate that N functions in a stimulus-specific manner, specifically amplifying extracellular and dampening intracellular RNA sensing. Moreover, we show that this is a conserved feature of pathogenic betacoronaviruses through distinct mechanisms. Our interaction networks with SARS-CoV-2 variant N proteins suggest that the Delta variant N drives inflammation through interactions with several proteins, most notably, cGAS. Profiling of secreted cytokines revealed that N disrupts the secretome in a variant-specific manner. Most notably, we found that supernatants from the Delta variant N-expressing macrophages dramatically disrupt heart endothelial barriers, implicating N in COVID-19-associated cardiac complications. Our findings highlight N-mediated immune imbalance as a driver of severe COVID-19 and identify N as a promising therapeutic target to mitigate hyperinflammation.

Background and objectives Despite the availability of effective vaccines, diphtheria continues to cause morbidity and mortality in parts of India. We analysed 15 yr of hospital-based data from a tertiary care infectious disease hospital to describe the epidemiology of diphtheria in northern India. Methods We analysed data from January 2007 to December 2021 on suspected diphtheria cases (defined as upper respiratory tract illness with an adherent membrane in pharynx, tonsils, larynx, or nose) hospitalised at an infectious diseases hospital. Information on demographic characteristics, vaccination status, laboratory findings, and clinical outcomes was abstracted from the records. We described the distribution of diphtheria by person, place, and time. Multivariable logistic regression was used to examine the association between vaccination status and culture-confirmed diphtheria. Results Among 5,493 suspected diphtheria cases hospitalised during the study period, C. diphtheriae was isolated from 2,131 (38.8%). 408 diphtheria patients died (case-fatality ratio: 19.1%). Culture positivity among suspected cases remained consistently high (range: 15% to 56%) over time. The median age of culture-confirmed cases increased from 5 yr [interquartile range (IQR) 4-8)] during 2007-2011 to 7 yr (IQR 5-9) during 2012-2016 and 7 yr (IQR 6-10) during 2017-2021. Most (n=1876, 88.0%) cases were from Uttar Pradesh and Delhi. Only 23 (1.1%) reported being fully vaccinated for age. Compared with fully vaccinated individuals, partially vaccinated [adjusted odds ratio (aOR): 4.5; 95% confidence interval (CI): 2.8-7.4] and unvaccinated or unknown-status individuals (aOR: 4.2; 95% CI: 2.7-6.5) had higher odds of having diphtheria. Interpretation and conclusions Sustained high diphtheria positivity over 15 yr indicates ongoing transmission in parts of northern India, likely driven by immunity gaps due to suboptimal booster-dose coverage. Strengthening the Universal Immunization Programme with focus on timely booster doses among preschool- and school-aged children is essential to reduce transmission.

The cost-effective treatment strategy for radiation-induced lung injury (RILI) remains unclear. Our recent phase II randomized clinical trial has proved pirfenidone to be safe and effective for grade 2 or 3 RILI. Here, we aim to assess the cost-effectiveness of pirfenidone plus glucocorticoids versus glucocorticoids alone for the treatment of grade 2 or 3 RILI.

We constructed a Markov model based on the individual-level data from our trial (NCT03902509) to evaluate the cost-effectiveness of pirfenidone plus glucocorticoids. Outcomes were simulated in a 4-week cycle over a 24-week time horizon to model patients who had acute pulmonary exacerbation or RILI progression. Costs and utilities were discounted at 3% annually. Health outcomes were measured using incremental cost-effectiveness ratio (ICER), representing incremental costs per quality-adjusted life year (QALY) gained between the two treatment groups. One-way and probabilistic sensitivity analyses were conducted to evaluate the model uncertainties. The simulated RILI pattern in the Markov model closely matched the pattern in the trial cohort, indicating that the model accurately described the disease process of RILI. Compared with glucocorticoids alone, pirfenidone plus glucocorticoids yielded an additional 0.028 QALYs at an incremental cost of $590, with an ICER of $20,956 per QALY gained. The ICER was considerably below the commonly accepted willingness-to-pay (WTP) threshold of $100,000 per QALY. In one-way sensitivity analyses, the variables with the greatest influence on the ICER included the acute pulmonary exacerbation-free survival and the probability of non-response among patients with grade 2 or 3 RILI in glucocorticoid group. Moreover, the probabilistic sensitivity analysis demonstrated that pirfenidone plus glucocorticoids had a 99.98% probability of being cost-effective at the WTP threshold of $100,000/QALY. Limitations include the phase II trial data with limited sample size and follow-up. An ongoing phase III trial will provide further evidence.

For grade 2 or 3 RILI, pirfenidone plus glucocorticoids is cost-effective compared with glucocorticoids alone. This strategy offers a practical and evidence-based option for RILI clinical management.

Long COVID is associated with poor health-related quality of life (QoL), with substantial interindividual variations. This study aimed to investigate the association between QoL and a diagnosis of functional somatic disorder (FSD) among patients seeking care for long COVID.

Data were drawn from the CASPer-COVID program, a multidisciplinary tertiary care program for patients with persistent symptoms following COVID-19. QoL was evaluated with the 36-Item Short-Form health survey (SF-36), yielding a Physical Component Summary (PCS) and a Mental Component Summary (MCS). Multivariable linear regression analyses were performed to investigate the associations between PCS or MCS scores and a diagnosis of FSD, adjusting for age, gender, body mass index, comorbidities, hospitalization for acute COVID-19, core persistent symptoms, symptom duration, depressive and anxiety symptoms, and physical activity.

The analyses included 773 patients (median age [interquartile range (IQR)]: 44 [36-55] years; 64% women). QoL was markedly impaired (median PCS [IQR]: 44 [31-60]; median MCS [IQR]: 39 [31-49]). A diagnosis of FSD (76.5% of patients) was not associated with MCS (β [95% CI]: 1.11 [-1.30, 3.53]) or PCS (β [95% CI]: -1.60 [-3.88, 0.67]) scores in adjusted analyses. Lower PCS and MCS scores were associated with higher depressive and anxiety symptoms, lower physical activity levels, and pain. In addition, lower PCS scores were associated with female gender, hospitalization for acute COVID-19 and longer symptom duration.

In patients seeking care for long COVID in a tertiary care setting, QoL did not differ significantly between those diagnosed with FSD and other patients.

Preserved ratio impaired spirometry (PRISm) is an intermediate phenotype between normal lung function and chronic obstructive pulmonary disease (COPD), and it carries a high risk of progressing to COPD. Due to unique factors such as hypobaric hypoxia, the detection rate of PRISm is significantly higher in high-altitude environments than in plain areas. High-altitude hypoxia may contribute to the development and progression of PRISm through multiple mechanisms, including induction of systemic inflammatory responses, oxidative stress injury, abnormal activation of hypoxia-inducible factor (HIF) signaling pathways, and an increased cardiopulmonary compensatory burden. However, direct evidence regarding the specific mechanisms involved still requires further investigation. Unique risk factors for PRISm in high-altitude regions include elevated white blood cell count, elevated red blood cell distribution width, and a history of tuberculosis. Current research on PRISm at high altitude faces challenges including a lack of diagnostic criteria, insufficient epidemiological data, and limited mechanistic exploration. Future efforts should focus on establishing altitude-specific reference values for lung function, conducting multicenter longitudinal cohort studies and multi-omics mechanistic research, developing appropriate screening and intervention tools, promoting interdisciplinary collaboration, and improving the comprehensive prevention and control system for PRISm in high-altitude regions.

Klebsiella pneumoniae (KP) has emerged as a formidable nosocomial pathogen in the era of antimicrobial resistance, with mortality from pneumonia caused by carbapenem-resistant strains exceeding 50%. Phage therapy has re-emerged as a promising alternative or adjunctive strategy for managing refractory KP infections. This review consolidates the current preclinical and clinical evidence base, outlines the molecular mechanisms of phage-host interactions, and appraises evolving therapeutic approaches. Preclinical investigations in murine pneumonia models have consistently demonstrated that intranasal or nebulization phage administration markedly reduces pulmonary bacterial burden, attenuates inflammatory lung injury, and improves survival, often exhibiting synergistic effects when combined with conventional antibiotics. Clinical case reports and small compassionate-use series have further provided preliminary yet compelling evidence supporting the safety and therapeutic promise of personalized phage formulations in critically ill patients with multidrug-resistant KP pneumonia who have exhausted standard treatment options. Mechanistically, phage tropism is mediated through the specific recognition of bacterial surface receptors-principally capsular polysaccharide and, to a lesser extent, lipopolysaccharide-by phage-encoded receptor-binding proteins, culminating in bacterial lysis. In response, KP has evolved a multilayered defensive arsenal encompassing receptor modification to impede adsorption, nucleic acid interference systems (e.g., CRISPR-Cas and restriction-modification), and abortive infection mechanisms that curtail phage propagation at the population level. To surmount the inherent limitations of narrow host range and the inevitable emergence of phage-resistant mutants, a suite of optimization strategies is under active refinement, including rationally designed phage cocktails, genetically engineered phages with extended tropism, artificial intelligence-assisted host-range prediction, and innovative delivery platforms such as hydrogel encapsulation to enhance pulmonary bioavailability. Despite ongoing challenges in mechanistic complexity, manufacturing standardization, and regulatory uncertainty, current initiatives- such as the establishment of geographically diverse phage libraries, real-time surveillance of phage resistance, and the development of phage-derived enzyme products-hold promise for establishing precision phage therapy as a viable and sustainable component of the antimicrobial stewardship armamentarium.

Acute high-risk pulmonary embolism (HRPE), particularly in patients progressing to catastrophic pulmonary embolism (PE), is associated with extremely high mortality. As a cardiopulmonary support technique, extracorporeal membrane oxygenation (ECMO) provides critical circulatory and respiratory support. Whether used as a standalone treatment or a bridge to definitive therapy (such as surgical embolectomy or catheter-based intervention), ECMO plays a pivotal role in the management of catastrophic PE. This review summarizes the role of ECMO in combination with various therapeutic strategies for catastrophic PE, aiming to inform clinical practice.