Intracoronary electrocardiogram detects coronary microvascular dysfunction and ischemia in patients with no obstructive coronary arteries disease.

BACKGROUND: Coronary microvascular dysfunction (CMD) is the leading cause of ischemia with no obstructive coronary arteries disease (INOCA) disease. Diagnosis of CMD relies on surrogate physiological indices without objective proof of ischemia. OBJECTIVES: Intracoronary electrocardiogram (icECG) derived hyperemic indices may accurately and objectively detect CMD and reversible ischemia in related territory. METHODS: INOCA patients with proven ischemia by myocardial perfusion scan (MPS) and completely normal coronary arteries underwent simultaneous intracoronary electrophysiological (icECG) and physiological (intracoronary Doppler) assessment in all 3 coronary arteries during rest and under adenosine induced hyperemia. RESULTS: Sixty vessels in 21 patients were included in the final analysis. All patients had at least one vessel with abnormal CFR. 41 vessels had CMD (CFR < 2.5), of which 26 had increased microvascular resistance (structural CMD, HMR > 1.9 mmHg.cm-1.s) and 15 vessels had CMD (CFR < 2.5) with normal microvascular resistance (functional CMD, HMR <= 1.9 mmHg.cm-1.s). Only one-third of the patients (n = 7) had impaired CFR < 2.5 in all 3 epicardial arteries. Absolute ST shift between hyperemia and rest (∆ST) has shown the best diagnostic performance for ischemia (cut-off 0.10 mV, sensitivity: 95%, specificity: 72%, accuracy: 80%, AUC: 0.860) outperforming physiological indices (CFR: 0.623 and HMR: 0.653 DeLong's test P = .0002). CONCLUSIONS: In INOCA patients, CMD involves coronary artery territories heterogeneously. icECG can accurately detect CMD causing perfusion abnormalities in patients with INOCA outperforming physiological CMD markers, by demonstrating actual ischemia instead of predicting the likelihood of inducible ischemia based on violated surrogate thresholds of blunted flow reserve or increased minimum microvascular resistance. CONDENSED ABSTRACT: In 21 INOCA patients with coronary microvascular dysfunction (CMD) and myocardial perfusion scan proved ischemia, hyperemic indices of intracoronary electrocardiogram (icECG) have accurately detected vessel-specific CMD and resulting perfusion abnormalities & ischemia, outperforming invasive hemodynamic indices. Absolute ST shift between hyperemia and rest (∆ST) has shown the best classification performance for ischemia in no Obstructive Coronary Arteries (AUC: 0.860) outperforming Doppler derived CMD indices (CFR: 0.623 and HMR: 0.653 DeLong's test P = .0002).icECG can be used to diagnose CMD causing perfusion defects by demonstrating actual reversible ischemia at vessel-level during the initial CAG session, obviating the need for further costly ischemia tests. CLINICALTRIALS: GOV: NCT05471739.

Circulating Levels of MicroRNAs in Hypertrophic Cardiomyopathy: The Relationship With Left Ventricular Hypertrophy, Left Atrial Dilatation and Ventricular Depolarisation-Repolarisation Parameters.

BACKGROUND: MicroRNAs are small, endogenous, non-coding RNAs that regulate the expression of many genes. It has recently been shown that circulating microRNAs may be biomarkers of hypertrophy and fibrosis in patients with hypertrophic cardiomyopathy (HCM). OBJECTIVE: To determine whether circulating levels of microRNAs involved in HCM are associated with electrocardiographic and echocardiographic parameters. METHODS: This study enrolled 20 patients with familial HCM and 20 blood donors. Peripheral serum levels of miR-29a-3p, miR-199a-5p and miR-451a were assessed by quantitative real-time polymerase chain reaction and compared with levels in the control group. Whether circulating levels of miRNAs in HCM patients correlated with electrocardiographic and echocardiographic parameters was also assessed. RESULTS: Median circulating levels of miR-29a and miR-451a were significantly higher in HCM than the control group. Median miR-199a levels did not differ between groups. However, circulating levels of miR-199a negatively correlated with corrected QT duration (Bazett formula). Median miR-29a levels positively correlated with QRS duration. In addition, circulating levels of miR-29a correlated with maximal wall thickness, left ventricular mass index and left atrial volume index. CONCLUSIONS: The data suggested that serum levels of miR-29a and miR-451a were significantly increased in HCM patients. As the circulating level of miR-29a correlated with QRS duration, left ventricular hypertrophy and left atrial dilatation, the serum miR-199a level negatively correlated with corrected QT duration. These miRNAs may be seen as potential biomarkers for further research in HCM pathophysiology.

Elevated D-dimer levels on admission are associated with severity and increased risk of mortality in COVID-19: A systematic review and meta-analysis.

BACKGROUND: In this systematic review and meta-analysis, we aimed to investigate the correlation of D-dimer levels measured on admission with disease severity and the risk of death in patients with coronavirus disease 2019 (COVID-19) pneumonia. MATERIALS AND METHODS: We performed a comprehensive literature search from several databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in abstracting data and assessing validity. Quality assessment was performed using the Newcastle-Ottawa quality assessment scale (NOS). D-dimer levels were pooled and compared between severe/non-severe and surviving/non-surviving patient groups. Weighted mean difference (WMD), risk ratios (RRs) and 95% confidence intervals (CIs) were analyzed. RESULTS: Thirty-nine studies reported on D-dimer levels in 5750 non-severe and 2063 severe patients and 16 studies reported on D-dimer levels in 2783 surviving and 697 non-surviving cases. D-dimer levels were significantly higher in patients with severe clinical status (WMD: 0.45 mg/L, 95% CI: 0.34-0.56; p < 0.0001). Non-surviving patients had significantly higher D-dimer levels compared to surviving patients (WMD: 5.32 mg/L, 95% CI: 3.90-6.73; p < 0.0001). D-dimer levels above the upper limit of normal (ULN) was associated with higher risk of severity (RR: 1.58, 95% CI: 1.25-2.00; p < 0.0001) and mortality (RR: 1.82, 95% CI: 1.40-2.37; p < 0.0001). CONCLUSION: Increased levels of D-dimer levels measured on admission are significantly correlated with the severity of COVID-19 pneumonia and may predict mortality in hospitalized patients.

The relationship between T-wave peak-to-end interval and hemodynamic parameters in patients with pulmonary arterial hypertension.

BACKGROUND: T-wave peak-to-end interval (TPEI) is a measure of repolarization dispersion on surface electrocardiogram (ECG). TPEI has been reported as a prognostic parameter with heart disorders. In this study, we aimed to evaluate the relationship between echocardiogram-derived right heart parameters, right heart catheterization (RHC) measurements, and TPEI in patients with precapillary pulmonary arterial hypertension (PAH). METHODS: Thirty-eight patients (29 females and 9 males, mean age of 54.9 ± 10.9 years) who had undergone RHC for a preliminary diagnosis of pulmonary hypertension (PH) were included in the study. We performed transthoracic echocardiography (TTE), and resting 12-lead ECG was recorded before RHC. TPEI was measured from leads of V1-V6, DII, DIII, and aVF, and these values are averaged to obtain the global TPEI. RESULTS: Duration of TPEI was significantly correlated with mean PAP, pulmonary vascular resistance (PVR), and cardiac index (CI). Longer TPEI was associated with higher N terminal probrain natriuretic peptide (NT pro-BNP) level, lower 6-min walk distance (6MWD), and lower tricuspid annular plane systolic excursion (TAPSE). CONCLUSION: Prolongation of TPEI could be a new predictor of adverse outcome in PAH and may provide additional prognostic information for patients with PAH.

How reliable are electrolyte and metabolite results measured by a blood gas analyzer in the ED?

INTRODUCTION: Blood gas analysis is a frequently ordered test in emergency departments for many indications. It is a rapid technique that can analyze electrolyte and metabolites in addition to pH and blood gases. The aim of this study was to investigate the correlation of electrolyte and metabolite results measured by blood gas and core laboratory analyzers. METHODS: This was a prospective, single-center observational study conducted in a tertiary care center's emergency department. All adult patients requiring arterial/venous blood gas analysis and core laboratory tests together for any purpose were consecutively included in the study between April 2014 and July 2015. Patients younger than 16 years, having any intravenous infusion or blood transfusion prior to sampling, or who were pregnant were excluded. RESULTS: A total of 1094 patients' (male = 547, female = 547) paired blood samples were analyzed. The mean age was 58.10 ± 21.35 years, and there was no difference between arterial and venous sampling groups by age, pH, or sex (P = .93, .56, and .41, respectively). Correlation coefficients for hemoglobin, hematocrit, glucose, potassium, sodium, and chloride levels measured by blood gas analyzer and core laboratory analyzers were 0.922, 0.896, 0.964, 0.823, 0.854, and 0.791, respectively. CONCLUSION: Blood gas analysis results were strongly correlated for hemoglobin, hematocrit, glucose, potassium, and sodium levels but were only moderately correlated for chloride levels. These parameters as measured by a blood gas analyzer seem reliable in critical decision making but must be validated by core laboratory results.

A rare cause of pulmonary embolism: panax.

INTRODUCTION: The aim of this case report is to present a patient with pulmonary embolism during a high-dose course of panax. CASE: A 41-year-old woman was admitted to the emergency department with sudden complaints of shortness of breath, sweating,weakness, and loss of conscious after panax pills intake. At pulmonary computed tomography angiography, hypodense filling defect compatible with pulmonary emboli was seen at the bifurcation level of right and left distal pulmonary arteries and at each of pulmonary lobary arteries. The patient was treated with pulmonary artery selective thrombolysis. Conclusion: Herbal products, which are used all over the world to support health, should not be taken indiscriminately because their ingredients' amounts and what kind of adverse effects may come up whether used alone or in combination cannot be known.

A life-threatening complication of warfarin therapy in ED: diffuse alveolar hemorrhage.

Warfarin have some serious adverse effects, and bleeding is one of the most serious and frequent of them. In this case report, we present the diffuse alveolar hemorrhage case as a rare and life-threatening complication of warfarin.

Posttraumatic stress disorder in health-care workers after two major earthquakes centered in Kahramanmaras, Turkey.

OBJECTIVES: Earthquakes are one of the most studied uncontrollable natural conditions that cause negative psychological consequences. Although health-care workers (HCWs) are trained to manage trauma in the out-of-hospital area, uncontrollable tragic events in the earthquake field and exposure to life-threatening situations may cause psychological disorders. This study aimed to investigate the risk of the development of probable posttraumatic stress disorder (PTSD) and the factors affecting it in HCWs working in the region during major earthquakes centered in Kahramanmaras. METHODS: The questionnaire, which consists of the Turkish version of the 20-item PTSD Checklist for DSM-5 (PCL-5) self-report measure assessing DSM-5 symptoms of PTSD, was applied to HCWs. The Turkish version of the PCL-5 proved validity and reliability, with a cutoff point of ≥47 to diagnose probable PTSD. RESULTS: In this study, of the 79 HCWs, 62.7% were male. The overall probable PTSD rate was 37.9% (n = 30). Female participants had a significantly higher probable PTSD rate than males (P < 0.001). The nurses met probable PTSD criteria statistically significantly more than the doctors (P = 0.026). The multiple regression analysis for predictors of probable PTSD revealed that female gender, previously working in a level 1 hospital, and being a nurse were among the independent risk factors. CONCLUSION: This study showed that the probable PTSD rate was high among HCWs and that female HCWs were at higher risk for PTSD. HCWs, especially females working in the disaster area, should be closely monitored, and more mental health services should be provided to ensure that HCWs receive the necessary support in the postdisaster period.

Comparison of ketamine-low-dose midozolam with midazolam-fentanyl for orthopedic emergencies: a double-blind randomized trial.

OBJECTIVE: Most of the fractures and dislocations are reduced in the emergency setting. Many drugs are available for procedural sedation and analgesia in the emergency department (ED); however, the adverse effects are still a common problem. The aim of our study was to compare the 2 drug combinations. METHOD: We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED after a traumatic event and required urgent reduction either for a fracture or dislocation. Patients were randomized to midazolam-fentanyl (MF) group or ketamine-low-dose midazolam (KM) group. Hypoxia, duration of hypoxia, need for oxygen, time to onset of sedation, recovery time, pain scores during reduction, and sedation depth were set as primary outcome measures and were recorded. RESULTS: A total of 498 patients who presented to ED with extremity injury and required closed reduction were assessed; 130 of them were approached for eligibility and 69 patients were excluded. The remaining 61 patients were randomized to either KM group (n = 31) or MF group (n = 30). Hypoxia and duration of hypoxia were significantly lower in the KM group compared with the MF group. Patients in the KM group reported significantly lower pain scores during reduction; however, adverse effects were higher compared with MF group. CONCLUSION: Both drug combinations can be effectively used for procedural sedation and analgesia; however, with lower risk for hypoxia and lower pain scores, KM combination stands as a reasonable choice for orthopedic interventions in the emergency unit.

Is disposable continuous positive airway pressure system effective for the management of acute hypercapnic respiratory failure?

AIM: This study aimed to investigate the effectiveness of disposable continuous positive airway pressure (DCPAP) system in decreasing the partial pressure of carbon dioxide (PaCO2) levels in patients with acute hypercapnic respiratory failure (AHRF). MATERIAL AND METHODS: This retrospective observational study included patients treated in the emergency department (ED) with respiratory distress and PaCO2 > 45 mmHg. Patients were divided into two groups (DCPAP and non-DCPAP), depending on the treatment received to treat AHRF. The difference between the baseline PaCO2 levels in the first blood gas obtained from patients at the time of admission and the follow-up blood gas after treatment. Then, the calculated PaCO2 decrease was divided by the time elapsed to obtain the rate of decrease in PaCO2 levels in mmHg/min. The statistical analyses were performed using SPSS version 18.0 software. A p value of < 0.05 was considered statistically significant. RESULTS: A total of 61 patients were included in the study, 31 patients in the DCPAP group and 30 patients in the non-DCPAP group. The mean age of the patients was 74.03 ± 10.04, and the male/female was 23/38. The study demonstrated a statistically significant difference between the DCPAP and non-DCPAP groups in terms of PaCO2 decreasing rate, and it was found to be twice higher in the DCPAP group (0.11 ± 0.07 mmHg/min) than in the non-DCPAP group (0.05 ± 0.06 mmHg/min). CONCLUSION: The study demonstrated that the treatment of AHRF patients with a DCPAP provides a faster decrease in PaCO2 levels in hypercapnic patients compared to standard medical therapy alone.

Ventricular arrhythmias in mitral valve prolapse syndrome and their relationship with electrocardiographic repolarization parameters.

OBJECTIVE: The aim of present study is to compare ventricular and supraventricular arrhythmia incidences in subjects with and without mitral valve prolapse (MVP) syndrome and to examine if an association exists between ventricular arrhythmias and repolarization parameters in patients with MVP syndrome. METHODS: This cross-sectional study involved 41 subjects with MVP Syndrome and 41 subjects with palpitation but without MVP (control group). All subjects were subjected to lead-electrocardiogram, transthoracic echocardiography, and 24-h Holter monitoring to identify repolarization abnormalities, structural abnormalities, and supraventricular and ventricular arrhythmias. The QRS width, QTC interval, and Tpeak-Tend intervals were measured for each participant. RESULTS: The number of subjects who had premature ventricular contractions (PVCs), couplets, and non-sustained ventricular tachycardia (NSVTs) was significantly higher in the MVP group compared to the control group. Left ventricular end-systolic diameter (LVESD) and left ventricular end-diastolic diameter (LVEDD) and left atrial diameter were also significantly higher in the MVP group than the control group. QRS width and Tpeak-Tend interval were also significantly higher in subjects with MVP than the controls. Correlation analysis showed a positive correlation between the severity of mitral regurgitation (MR) and the number of PVCs and couplets, while there was a significant correlation between left atrium (LA) diameter and the number of the PVCs and NSVTs. CONCLUSION: Subjects with MVP experience ventricular arrhythmias more often including PVCs, couplets, and NSVTs compared to subjects without MVP. LVESD, LVEDD, LA diameter, QRS width, and Tpeak-Tend interval were increased in MVP subjects than those without MVP. There is an association between the severity of the MR and the frequency of the PVCs, couplets, or NSVTs.

The Effect of Platelet and Mean Platelet Volume Levels on Standard-dose Methylprednisolone Treatment Response in Primary Immune Thrombocytopenia.

Objective: Standard-dose methyl-prednisolone (methyl-Pd) is generally preferred as the first-line treatment in immune thrombocytopenia (ITP) unless there is an urgent indication to increase the platelet value. A significant proportion of patients (around 40%) does not benefit from this treatment. This study investigated whether pretreatment platelet level and other hemogram indices in patients with ITP patients can be used to predict early response to standard-dose methyl-Pd treatment. Methods: Patients who received first-line standard-dose methyl- Pd therapy with the diagnosis of primary ITP were included. Patients were categorized as complete responder (CR), responder (R), and non-responder (NR) according to the response status obtained within the first 14 days of treatment. The hemogram indices of the CR, R, and NR groups measured at the start of the treatment were compared retrospectively. Results: One hundred forty four patients with ITP were included in the study. The number of patients with NR, R, and CR were 47 (33%), 40 (28%), and 57 (39%), respectively. The mean platelet level of the NR group was lower than responders (R and CR groups) (p=0.002 and p=0.049, respectively). The mean platelet volume (MPV) levels of the NR group were statistically lower than that of the CR group (p=0.018). If MPV ≥10 fL and platelet >12,000/mm³, the probability of an early response with methyl-Pd is higher [sensitivity =98.1% (95% confidence interval (CI) =89.7-99.9%), specificity =45% (95% CI =23.1-68.5%), positive predictive value =82.3% (95% CI =75.7-87.4%), negative predictive value =90% (95% CI =54.9-98.5%)]. Conclusions: Patients with ITP with low platelet and MPV levels were less responsive to standard-dose methyl-Pd treatment. It may be more appropriate to apply more effective treatments to these patients other than standard-dose methyl-Pd alone.

Primary versus iatrogenic (post-PCI) coronary microvascular dysfunction: a wire-based multimodal comparison.

BACKGROUND: Although there are studies examining each one separately, there are no data in the literature comparing the magnitudes of the iatrogenic, percutaneous coronary intervention (PCI)-induced, microvascular dysfunction (Type-4 CMD) and coronary microvascular dysfunction (CMD) in the setting of ischaemia in non-obstructed coronary arteries (INOCA) (Type-1 CMD). OBJECTIVES: We aimed to compare the characteristics of Type-1 and Type-4 CMD subtypes using coronary haemodynamic (resistance and flow-related parameters), thermodynamic (wave energy-related parameters) and hyperemic ECG changes. METHODS: Coronary flow reserve (CFR) value of <2.5 was defined as CMD in both groups. Wire-based multimodal perfusion markers were comparatively analysed in 35 patients (21 INOCA/CMD and 14 CCS/PCI) enrolled in NCT05471739 study. RESULTS: Both groups had comparably blunted CFR values per definition (2.03±0.22 vs 2.11±0.37; p: 0.518) and similar hyperemic ST shift in intracoronary ECG (0.16±0.09 vs 0.18±0.07 mV; p: 0.537). While the Type-1 CMD was characterised with impaired hyperemic blood flow acceleration (46.52+12.83 vs 68.20+28.63 cm/s; p: 0.017) and attenuated diastolic microvascular decompression wave magnitudes (p=0.042) with higher hyperemic microvascular resistance (p<0.001), Type-4 CMD had blunted CFR mainly due to higher baseline flow velocity due to post-occlusive reactive hyperemia (33.6±13.7 vs 22.24±5.3 cm/s; p=0.003). CONCLUSIONS: The perturbations in the microvascular milieu seen in CMD in INOCA setting (Type-1 CMD) seem to be more prominent than that of seen following elective PCI (Type-4 CMD), although resulting reversible ischaemia is equally severe in the downstream myocardium.

Can high-sensitive troponin levels within the normal range predict positivity in treadmill test?

BACKGROUND: This study aimed to determine whether a high level of high-sensitivity troponin T (hsTnT) predicts a positive treadmill test in patients with suspected stable ischemic heart disease (SIHD). METHODS: In all, 366 patients with suspected SIHD were included in the study. We measured the serum hsTnT levels before the treadmill test. The treadmill test was performed according to the Bruce protocol. RESULTS: Of the 366 patients, 97 had positive treadmill tests. The hsTnT levels were significantly higher in the positive group than in the negative group. In the binary logistic regression analysis, hsTnT, pretest probability, metabolic equivalents (METs), target heart rate (THR) percentage, and Duke treadmill score (DTS) were independent predictors of a positive treadmill test [hsTnT odds ratio (OR): 2.178, P < 0.001; pretest probability OR: 1.036, P = 0.007; METs OR: 0.755, P = 0.008; THR OR: 0.773, P < 0.001; DTS OR: 2.661, P = 0.012]. In the receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) value of the model with the combined parameters of hsTnT, pretest probability, METs, THR, and DTS was statistically significant in predicting a positive treadmill test [combined model AUC: 0.945 (0.922-0.968), P < 0.001]. CONCLUSIONS: In sum, high pretest hsTnT levels predicted a positive treadmill test in patients with suspected SIHD. Analysis of the hsTnT levels before the treadmill test can increase the sensitivity and specificity of the treadmill test. The methods for measuring hsTnT levels are cheap and easily accessible and can be used before the treadmill test in patients with suspected SIHD.

A randomized clinical trial comparing the effect of rapidly infused crystalloids on acid-base status in dehydrated patients in the emergency department.

STUDY OBJECTIVE: To compare the effect of normal saline (NS), lactated Ringer's, and Plasmalyte on the acid-base status of dehydrated patients in the emergency department (ED). METHOD: We conducted a prospective, double-blind, randomized trial of consecutive adult patients who presented to the emergency department with moderate-severe dehydration. Patients were randomly allocated to blindly receive normal saline (NS), lactated Ringer's or Plasmalyte at 20 ml/kg/h for 2 hours. Outcome measures of the study were pH and changes in electrolytes, including serum potassium, sodium, chloride and bicarbonate levels at 0, 60, and 120 minutes in venous blood gas samples. RESULTS: Ninety patients participated in the study and were randomized to NS (30 patients), lactated Ringer's (30 patients) and Plasmalyte (30 patients) groups. Mean age was 48±20 years and 50% (n=45) of the patients were female. All pH values were in the physiological range (7.35-7.45) throughout the study period. In the NS group there was a significant tendency to lower pH values, with pH values of 7.40, 7.37, and 7.36 at 0, 1, and 2 hours respectively. Average bicarbonate levels fell in the NS group (23.1, 22.2, and 21.5 mM/L) and increased in the Plasmalyte group (23.4, 23.9, and 24.4 mM/L) at 0, 1, and 2 hours, respectively. There were no significant changes in potassium, sodium, or chloride levels. CONCLUSIONS: NS, lactated Ringer's, and Plasmalyte have no significant effect on acid-base status and all can be used safely to treat dehydrated patients in the emergency department. However, NS can effect acidosis which might be significant in patients who have underlying metabolic disturbances; thus, its use should be weighed before fluid administration in the ED.

Comparing the efficacy of intravenous tenoxicam, lornoxicam, and dexketoprofen trometamol for the treatment of renal colic.

STUDY OBJECTIVE: The aim of this study was to compare the efficacy and safety of 3 nonsteroidal anti-inflammatory drugs-intravenous tenoxicam, lornoxicam, and dexketoprofen trometamol-for the treatment of patients with renal colic. METHODS: We conducted a prospective double-blind randomized trial of consecutive adult patients who presented to the emergency department with a chief complaint of acute flank pain and had a clinical diagnosis of suspected acute renal colic. Patients were randomly allocated to receive an intravenous bolus of tenoxicam, lornoxicam, or dexketoprofen trometamol in a blinded fashion. Primary outcome measure of the study was visual analog scale (VAS) score difference at 30 minutes. Secondary outcome measures were VAS scores at 5, 15, and 120 minutes as well as rescue analgesic need at 30 minutes and adverse events during the follow-up period. RESULTS: A total of 445 patients were screened, and 123 patients were enrolled in the study. The mean age was 36 ± 10 years. The mean reduction in VAS pain scores at 30 minutes was 42 ± 26 mm for tenoxicam, 57 ± 23 mm for lornoxicam, and 52 ± 25 mm for dexketoprofen (P = .047). Lornoxicam demonstrated the fastest rate of VAS score reduction over the first 30 minutes. The mean reduction values in VAS pain scores at 5, 15, and 120 minutes were similar among the 3 groups. Rescue analgesics at 30 minutes were required by 16 patients (39%) receiving tenoxicam, 10 patients (24%) receiving lornoxicam, and 8 patients (19%) receiving dexketoprofen (P = .121). No serious adverse events were observed. CONCLUSIONS: Intravenous tenoxicam, lornoxicam, and dexketoprofen are all effective in the treatment of renal colic, although lornoxicam appears to reduce VAS pain scores with the fastest rate in this comparison.

Evaluation of mid-regional pro-atrial natriuretic peptide, procalcitonin, and mid-regional pro-adrenomedullin for the diagnosis and risk stratification of dyspneic ED patients.

OBJECTIVE: The aim of this study was to evaluate the diagnostic and the prognostic value of a laboratory panel consisting of mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) for patients presenting to the emergency department (ED) with acute dyspnea. METHODS: We prospectively enrolled ED patients who presented with a chief complaint of dyspnea and who had an uncertain diagnosis after physician evaluation. Final primary diagnosis of the cause of shortness of breath was confirmed through additional testing per physician discretion. We recorded inpatient admission and 30-day mortality rates. RESULTS: One hundred fifty-four patients were enrolled in the study. Congestive heart failure exacerbation was the final primary diagnosis in 42.2% of patients, while infectious etiology was diagnosed in 33.1% of patients. For the diagnosis of congestive heart failure exacerbation, MR-proANP had a sensitivity of 92.7% and specificity of 36.8%, with a negative likelihood ratio (LR-) of 0.16 and a positive likelihood ratio (LR+) of 1.44 (cut-off value: 120 pmol/L). For the diagnosis of an infectious etiology, PCT had a 96.5% specificity and 48.8% sensitivity (LR-: 0.58, LR+: 13.8, cutoff value: 0.25 ng/mL). As a prognostic indicator, MR-proADM demonstrated similar values: odds ratio for 30-day mortality was 8.5 (95% CI, 2.5-28.5, cutoff value: 1.5 nmol/L) and the area under the receiver operating characteristic curve in predicting mortality was 0.81 (95% CI, 0.71-0.91). CONCLUSION: The good negative LR- of MR-proANP and the good positive LR+ of PCT may suggest a role for these markers in the early diagnosis of ED patients with dyspnea. Furthermore, MR-proADM may assist in risk stratification and prognosis in these patients..

Efficacy of high-flow oxygen therapy in all types of headache: a prospective, randomized, placebo-controlled trial.

OBJECTIVE: We aimed to assess the efficacy of oxygen inhalation therapy in emergency department (ED) patients presenting with all types of headache. METHOD: We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED with a chief complaint of headache. The patients were randomized to receive either 100% oxygen via nonrebreather mask at 15 L/min or the placebo treatment of room air via nonrebreather mask for 15 minutes in total. We recorded pain scores at 0, 15, 30, and 60 minutes using the visual analog scale. At 30 minutes, the patients were assessed for the need for analgesic medication. Patient headache type was classified by the treating emergency physician using standardized diagnostic criteria. RESULTS: A total of 204 patients agreed to participate in the study and were randomized to the oxygen (102 patients) and placebo (102 patients) groups. Patient headache types included tension (47%), migraine (27%), undifferentiated (25%), and cluster (1%). Patients who received oxygen therapy reported significant improvement in visual analog scale scores at all points when compared with placebo: 22 mm vs 11 mm at 15 minutes (P < .001), 29 mm vs 13 mm at 30 minutes (P < .001), and 55 mm vs 45 mm at 60 minutes (P < .001). When questioned at 30 minutes, 72% of patients in the oxygen group and 86% of patients in the placebo group requested analgesic medication (P = .005). CONCLUSION: In addition to its role in the treatment of cluster headache, high-flow oxygen therapy may provide an effective treatment of all types of headaches in the ED setting.

Impact of Multimodality Imaging on the Diagnosis of Left Ventricular Apical Thrombus in Patients After Anterior Myocardial Infarction.

BACKGROUND: The presence of the left ventricle (LV) apical thrombus is one of the most critical complications of anterior myocardial infarction (MI). Due to the high risk of systemic embolization, the determination of LV apical thrombus (LVAT) is essential. We aimed to compare the two-dimensional echocardiography (2DE), contrast-2DE and real-time three-dimensional echocardiography (RT-3DE) in the diagnosis of LVAT and determine which imaging modality is superior. METHODS: The study was designed as a prospective cohort study, and 161 patients were included. Patients with low ejection fraction (< 40%) and LV apical wall motion abnormality (severe hypokinetic, akinetic or dyskinetic) were included. 2DE, contrast-2DE, RT-3DE, and magnetic resonance imaging (MRI) were performed on all patients within one month after anterior MI. RESULTS: Transthoracic 2DE detected thrombi in 29 patients, contrast-2DE detected thrombi in 33 patients, RT-3DE detected thrombi in 32 patients, and MRI detected thrombi in 28 patients. While MRI is accepted as the gold standard for non-invasive imaging, the specificity of detecting thrombus with 2DE is 90%, and the sensitivity is 57%, contrast-2DE had 82% sensitivity and 92% specificity for the detection of LVAT. The specificity for detecting thrombus with RT-3DE is 93%, and the sensitivity is 85%. Accuracy was 84%, 90% and 92% with 2DE, contrast-2DE and RT-3DE, respectively. CONCLUSIONS: We found that RT-3DE was more sensitive and more specific than 2DE and contrast-2DE in the diagnosis of LVAT. The diagnostic accuracy of RT-3DE was higher than 2DE and contrast-2DE for LVAT.

Intracardiac masses: Single center experience within 12 years: I-MASS Study.

Objective: The aim of this cross-sectional, retrospective, descriptive study was to review and classify cardiac masses systematically and to determine their frequencies. Methods: The medical records of 64,862 consecutive patients were investigated within 12 years. Every patient with a cardiac mass imaged by transthoracic echocardiography (TTE) and confirmed with an advanced imaging modality such as transesophageal echocardiography (TEE), computed tomography (CT) and/or cardiac magnetic resonance imaging (CMR) was included. Acute coronary syndromes triggering thrombus formation, vegetations, intracardiac device and catheter related thrombi were excluded. Results: Data demonstrated 127 (0.195%) intracardiac masses consisting of 33 (0.050%) primary benign, 3 (0.004%) primary malignant, 20 (0.030%) secondary tumors, 3 (0.004%) hydatid cysts and 68 (0.104%) thrombi respectively. The majority of primary cardiac tumors were benign (91.67%), predominantly myxomas (78.79%), and the less malignant (8.33%). Secondary cardiac tumors were common than the primary malignant tumors (20:3), with male dominancy (55%), lymphoma and lung cancers were the most frequent. Intracardiac thrombi was the majority of the cardiac masses, thrombi accompanying malignancies were in the first range (n = 17, 25%), followed by autoimmune diseases (n = 13, 19.12%) and ischemic heart disease with low ejection fraction (n = 12, 17.65%). Conclusions: This retrospective analysis identified 127 patients with cardiac masses. The majority of benign tumors were myxoma, the most common tumors that metastasized to the heart were lymphoma and lung cancers, and the thrombi associated with malignancies and autoimmune diseases were the most frequent.