Pneumocystis jirovecii pneumonia (PCP) can cause severe hypoxemic respiratory failure in immunocompromised patients. Contemporary outcomes of venovenous extracorporeal membrane oxygenation (VV ECMO) support for PCP are poorly characterized, and existing reports are limited to small case series.

Retrospective cohort study.

International registry study using the Extracorporeal Life Support Organization (ELSO) registry.

Adults with PCP-associated hypoxemic respiratory failure supported with VV ECMO between 2011 and 2024.

VV ECMO.

A total of 209 patients with PCP-associated respiratory failure supported with VV ECMO were identified. The overall in-hospital mortality was 60.8%. Survivors were younger than nonsurvivors (median age 41.9 vs. 46.8 yr; p = 0.047). Duration of mechanical ventilation before VV ECMO was longer among nonsurvivors (median 4.7 vs. 1.6 d; p = 0.019). The proportion of patients with HIV infection was similar among survivors and nonsurvivors (19.5% vs. 22.1%; p = 0.73). Pre-ECMO vasopressor use, prone positioning, and renal replacement therapy were common and did not differ between groups. Clinical course was characterized by prolonged VV ECMO support (median 18.6 d) and frequent complications, including pneumothorax (21.1%), renal replacement therapy during VV ECMO (31.6%), intracranial hemorrhage or stroke (7.7%), and major pulmonary or gastrointestinal hemorrhage (16.8%). PCP accounted for a small proportion of VV ECMO runs reported to the ELSO registry throughout the study period at 0.36% of reported cases. No significant temporal trend in mortality was observed.

PCP-associated respiratory failure supported with VV ECMO is associated with substantial mortality and prolonged VV ECMO support. These findings provide contemporary benchmarks that may inform VV ECMO candidacy discussions and expectations in this challenging patient population.

 The coronavirus disease 2019 (COVID-19) pandemic placed unprecedented strain on healthcare systems worldwide, potentially exacerbating existing vulnerabilities in maternal healthcare. This study examines the pandemic's impact on obstetric haemorrhage-related mortality in South Africa using the data from the Confidential Enquiry into Maternal Deaths (CEMD).

 We conducted a retrospective analysis of maternal mortality data from 2017-2023, focusing on obstetric haemorrhage mortality trends before, during and after the COVID-19 pandemic. Data were extracted from national confidential enquiries, including institutional maternal mortality ratios (iMMR) and absolute death numbers.

 The analysis revealed a significant increase in obstetric haemorrhage mortality during the peak pandemic years (2020-2021), with deaths rising from 179 in 2019 to 237 in 2021, and iMMR increasing from 18.1 to 23.3 per 100 000 live births. This was followed by a substantial decline in subsequent years (2022-2023). The findings suggest that initial pandemic disruptions severely impacted maternity care services, while subsequent recovery reflects adaptive strategies and resource reallocation.

 The COVID-19 pandemic exposed critical vulnerabilities in South Africa's ability to maintain essential maternity services during health system shocks.Contribution: The confidential enquiry process provides invaluable insights for strengthening health system resilience and preparing for future emergencies.

 Maternal mortality highlights health system effectiveness and social fairness. South Africa's Confidential Enquiry into Maternal Deaths (CEMD) monitors and improves maternal healthcare. While initial decreases in maternal mortality were positive, the COVID-19 pandemic and ongoing provincial inequalities jeopardise reaching the Sustainable Development Goal (SDG) target.

 This analysis evaluated South Africa's maternal mortality reduction path by examining CEMD data trends, the pandemic's effect and provincial disparities to gauge progress towards its SDG commitments.

 A longitudinal trend analysis was conducted using secondary data from CEMD reports (2017-2022). The analysis focused on national and provincial institutional Maternal Mortality Ratio (iMMR) trends. Comparative analysis quantified changes and identified patterns of disparity.

 Pre-pandemic improvement was abruptly reversed by a significant 42% surge in the national iMMR during the pandemic, underscoring the fragility of previous gains. Although a decrease was observed in 2022, the rate remained above the 2019 baseline, indicating an incomplete recovery. Furthermore, profound inter-provincial disparities were evident, with only two provinces sustaining a downward trend, the majority showing no clear improvement and three provinces consistently exhibiting exceptionally high and volatile iMMRs.

 South Africa is not yet on track to meet its SDG target for maternal mortality. The pandemic exposed and exacerbated systemic weaknesses, while deep-rooted provincial inequities persist. Achieving sustainable progress requires a dual strategy: building a more resilient health system capable of withstanding future shocks and implementing targeted, equity-focused interventions in underperforming regions to ensure that maternal healthcare is accessible and effective for all.

Thoracic amyloidosis is a rare disorder that often mimics malignancy or chronic infections. In tuberculosis-endemic regions, diagnostic confusion frequently leads to unnecessary empiric treatments. This study was aimed at describing the clinical and radiological characteristics of thoracic amyloidosis and evaluating the safety profile of diagnostic biopsy procedures.

We retrospectively analyzed 19 patients with histopathologically confirmed thoracic amyloidosis at the National Lung Hospital, Hanoi, Vietnam, between 2022 and 2025. Clinical symptoms, high-resolution computed tomography (CT) features, and biopsy outcomes were recorded.

The mean age was 55 ± 16 years. Common symptoms included cough (n = 15, 88.2%) and dyspnea (n = 9, 52.9%). Isolated airway involvement was the most frequent phenotype (n = 6, 31.6%), followed by isolated nodular (n = 3, 15.8%) and diffuse alveolar septal (n = 2, 10.5%) patterns. Mixed radiological patterns were observed in five patients (26.3%), while isolated extrapulmonary thoracic involvement accounted for the remaining three patients (15.8%). Notably, isolated cystic disease was absent. Among the cases with nodular involvement (n = 5), 80.0% (n = 4) exhibited spiculated margins, mimicking malignancy. Calcification was a frequent finding, present in 14/19 cases (73.7%). CT-guided transthoracic needle biopsy (TTNB) and endobronchial biopsy (EBB) achieved diagnostic yields of 87.5% (7/8) and 69.2% (9/13), respectively, with no major complications, suggesting they are generally well-tolerated. All collected specimens were negative for Mycobacterium tuberculosis, reducing the likelihood of active pulmonary tuberculosis.

Thoracic amyloidosis presents with diverse and often overlapping radiological patterns. Isolated nodular lesions frequently exhibit spiculated margins, posing a diagnostic challenge. However, the high prevalence of calcification and the acceptable safety profile of EBB and TTNB facilitate definitive diagnosis. In endemic areas, early tissue diagnosis is essential to differentiate amyloidosis from tuberculosis and avoid inappropriate therapy.

IntroductionGrowing elective surgical waiting lists remain a persistent global challenge, exacerbated by the COVID-19 pandemic, which led to the widespread suspension of non-urgent procedures. In the Gulf region, elective surgery cancellation rates reached up to 72% by 2020, compounding surgical backlogs. At Salmaniya Medical Complex, Bahrain's largest public tertiary hospital, the resulting backlog overwhelmed existing systems that relied on fragmented spreadsheets and manual logs. This Quality Improvement Project (QIP) aimed to improve surgical waiting list management using a centralized, data-driven approach to reduce backlog, improve scheduling, and enhance theatre utilization.MethodsThis retrospective pre-post QIP included all adult patients (≥18 years) listed for elective, non-cancer surgery across secondary and tertiary surgical specialties between January 2019 and December 2023. Interventions, implemented from January to August 2024, included: (1) consolidating all waiting list data into a single computerized system; (2) validating and updating entries through direct patient contact; and (3) integrating a centralized repository within the Electronic Patient Record (EPR) system. This enabled real-time tracking, automated prioritization, and flexible scheduling. The primary outcome was waiting list volume. Secondary outcomes were mean waiting time to surgery and theatre utilization. Descriptive statistics and paired t-tests were applied to assess the significance of any differences observed with a significance of p<0.05.ResultsFrom January to August 2024, the surgical waiting list decreased by 51.74%, from 9,597 to 4,627 patients. Major reductions (relative to the baseline waiting list) were observed in Ophthalmology (69.40%), Urology (59.23%), and Orthopedics (58.59%). Mean waiting times (SD) decreased from 12.7 (7.72) to 7.2 (4.75) months (p = 0.014), corresponding to a 158-day reduction. Mean monthly caseload in the main operating theatres (MOT) increased from 1,469 (139.3) cases in 2023 to 1,608 (94.4) in 2024 (p < 0.001).ConclusionA centralized, EPR-integrated surgical waiting list system significantly reduced surgical backlogs and delays, while improving coordination, prioritization, and theatre utilization. Differences in outcomes across departments reflect varying case complexities and highlight the need for tailored strategies. This scalable model supports more efficient post-pandemic recovery and long-term service resilience.

To explore experiences and challenges faced by regional and municipal health care leaders during the COVID-19 pandemic, with a focus on primary health care and care of older adults.

A longitudinal qualitative study based on two rounds of semi-structured interviews 2-3 months apart.

Fifteen health care leaders strategically recruited from regions and municipalities across Sweden. The first interviews took place in November-December 2020, the second in January-March 2021.

Four themes were identified. The first captured the challenge of navigating uncharted territory during an unprecedented crisis. The second addressed ethical dilemmas arising from public health priorities. The third highlighted the growing significance and evolving role of infection prevention and control. Finally, the fourth illustrated how initially productive and solution-oriented local collaboration and communication gradually gave way to tensions and conflicting responsibilities.

In the early phases of the pandemic, the Swedish Public Health Agency's leadership and measures were generally appreciated, although the initial response was widely perceived as slow and insufficient. The high mortality among older adults was regarded as a major failure, raising ethical concerns and exposing tensions in collaboration between actors. Pandemic work was experienced as exhausting yet meaningful, and the field of infection prevention and control gained increased recognition and status. Some distinctive features of Sweden's pandemic response - such as decentralised decision-making and an emphasis on individual responsibility - may have been shaped by the constitutional prohibition of ministerial rule and the substantial autonomy granted to regional and local authorities.

BACKGROUND Foreign body aspiration (FBA) is a life-threatening pediatric emergency, most common in 1-3-year-olds due to immature swallowing reflexes and exploratory oral behaviors. Common aspirated items include nuts, food particles and small toys, presenting with variable symptoms such as cough, dyspnea, wheezing or acute respiratory failure. Delayed diagnosis or improper management causes severe complications like post-obstructive pneumonia, atelectasis, bronchiectasis and irreversible airway stenosis, increasing morbidity and treatment complexity. CASE REPORT A 16-month-old girl was admitted with persistent cough, progressive dyspnea, intermittent fever, hoarseness, and occasional cyanosis that developed 6 days after accidental pine nut ingestion. Initial flexible bronchoscopy at a local hospital failed due to the foreign body's rigid texture and deep impaction in the right lower lobe basilar bronchus. Chest CT confirmed a pine nut shell in the B9/B10 segmental bronchus with surrounding inflammation. She was transferred for combined rigid-flexible bronchoscopy to establish a secure airway and enable precise visualization before holmium laser fragmentation broke the shell into retrievable fragments for complete removal. Two-week follow-up showed symptomatic B9/B10 stenosis, which improved significantly after sequential 3.5 mm and 4.0 mm balloon dilation. Her respiratory symptoms resolved and imaging confirmed restored lobar ventilation. CONCLUSIONS Rigid-flexible bronchoscopy synergy benefits removal of large rigid foreign bodies in sub-main bronchi by combining rigid bronchoscopy's airway security with flexible bronchoscopy's maneuverability and visualization. Holmium laser safely fragments hard foreign bodies with minimal airway trauma, and sequential balloon dilation effectively treats post-FBA stenosis. Individualized application guided by clinical assessment and imaging optimizes pediatric FBA outcomes.

The global burden of injury is a key indicator for assessing public health and medical needs. During the COVID-19 pandemic, this burden was impacted. This study aims to explore how the pandemic influenced the injury burden globally and regionally, and provide recommendations to relieve this burden.

The burden of injury-related data is derived from the Global Burden of Disease (GBD) 2021 Study. Autoregressive integrated moving average (ARIMA) and ARIMA-Long short-Term Memory (LSTM) models were adopted for counterfactual inference to predict the scenario without the pandemic.

During the COVID-19 pandemic, the observed global age-standardized incidence rate (ASIR) of injury exceeded the predicted value by 107.31 per 100,000, and the observed age-standardized prevalence rate (ASPR) was higher than the predicted value by 102.81 per 100,000. Self-harm and interpersonal violence saw the largest deviations above predicted values in Europe and parts of Asia. Specifically, Armenia's ASIR was 7,829.33 per 100,000 higher than predicted, and its ASDR exceeded projections by 5,186.32 per 100,000. Besides, traffic injuries exceeded predicted levels most significantly in Southeast Asia, with Indonesia's ASIR 25.48 per 100,000 higher than projected. And the observed ASIR of unintentional injuries in China was 379.61 per 100,000 higher than the predicted value.

During the COVID-19 pandemic, the global burden of injuries surpassed the predicted levels for a scenario without the pandemic in 2020-2021, especially in Europe and Asia. In addressing an epidemic, prevention and emergency measures for high-burden injury types and key populations should be strengthened based on local socio-cultural contexts.

The prognostic implications of rheumatoid arthritis (RA) in patients with non-tuberculous mycobacterial pulmonary disease (NTM-PD) remain unclear. This study aimed to evaluate the impact of RA on survival outcomes.

We conducted a retrospective cohort study of 1420 patients newly diagnosed with NTM-PD between 2012 and 2024. Among them, 66 (4.6%) had RA, including 55 who developed NTM-PD after RA onset. These 55 patients (RA group) were compared with 1354 without RA (non-RA group). Respiratory-related mortality was assessed using Cox regression and propensity score matching. To explore mechanisms underlying the excess mortality associated with RA, we conducted sequential Cox regression with stepwise adjustment and quantified attenuation of the RA effect on the log-hazard scale.

RA was an independent predictor of respiratory-related death in multivariable Cox analysis (HR 4.30, 95% CI 2.17 to 8.52). Five-year survival was significantly lower in the RA group than in the non-RA group (74.7% vs 92.9%, log-rank p<0.001) and remained inferior after matching (p=0.029). Sequential adjustment demonstrated substantial attenuation of the RA effect after accounting for interstitial lung disease (ILD), with the HR decreasing from 3.25 to 2.44 (24.5% attenuation), and to 2.09 after adjustment for systemic inflammation burden reflected by C-reactive protein (37.5% attenuation).

RA is an independent predictor of respiratory-related mortality in patients with NTM-PD. This excess risk is partly explained by ILD and systemic inflammation burden. These findings highlight structural and systemic pathways contributing to poor prognosis, underscoring the need for comprehensive management in this high-risk population.

In people with cystic fibrosis (pwCF), identification of exocrine pancreatic insufficiency (EPI) is essential to prevent steatorrhea and, if not managed actively, can lead to catastrophic consequences. Fecal elastase-1 (FE-1) is a widely used test to screen for EPI in cystic fibrosis (CF). Once thought permanent, some patients with EPI on CF transmembrane conductance regulator (CFTR)-directed therapies (modulators) have been noted to show improvement in EPI. Here, we evaluated the utility of FE-1 in pwCF.

We performed a scoping review and searched several databases for the terms/concepts of "cystic fibrosis" and "fecal elastase-1" and their synonyms. The search period was from 1-1-2003 to 7-31-2025. We included all age groups and used a web-based platform for compiling and sorting out the articles.

We combined the eligible studies to synthesize information on four questions: Utilization of FE-1 in CF (when to screen for EPI, how often to screen); Comparison of diagnostic accuracy of FE-1 versus other tests; Definition of ideal cut-off for FE-1 in evaluating EPI in CF; Utilization of FE-1 in pwCF managed on CFTR-directed therapies.

All pwCF should have EPI evaluated at diagnosis. Among various tests, FE-1 is the most commonly utilized test for screening EPI. A value of < 200 μg/g of stool is consistent with EPI and is highly sensitive for EPI diagnosis. A value of < 100 μg/g is highly specific for severe EPI. Repeating FE-1 should be considered in the current era of modulators, especially with a change in clinical status.