Comparison of Bedside Index for Severity in Acute Pancreatitis and Emergency Department SpO2, Age and Systemic Inflammatory Response Syndrome Scores in Predicting Severe Acute Pancreatitis in Patients with Acute Pancreatitis in the Emergency Department.

BACKGROUND: As the mortality of severe acute pancreatitis (SAP) is significantly higher than those with mild or moderate severity, it is of clinical significance to identify patients most likely to develop SAP at the time of emergency department (ED) presentation. OBJECTIVES: The aim of this study was to compare the performance of the Bedside Index for Severity in Acute Pancreatitis (BISAP) and the Emergency Department SpO2, Age and SIRS (ED-SAS) scoring systems as early risk assessment tools for identifying patients at high-risk of developing SAP. METHODS: We retrospectively reviewed adult patients with AP presented to ED between January 2019-September 2022. We calculated the scores of each patient with the parameters of the initial data. The primary outcome was SAP. The secondary outcomes were 30-day mortality, intensive care admission, and identifying low-risk patients without complications. RESULTS: Of 415 patients, 34 (8.2%) developed SAP and 15 (3.6%) died. With regard to predicting SAP, BISAP and ED-SAS scores had similar discriminative ability with area under the curves (AUCs) of 0.84 (95% confidence interval [CI]:0.80-0.88) and 0.83 (95% CI:0.79-0.86), respectively (p = 0.642). At a cut-off score of ≥2 for SAP, sensitivity/specificity values were 73.5%/82.4% for BISAP, 76.5%/83.2% for ED-SAS. BISAP and ED-SAS scores of ≥3, yielded sensitivity/specificity values of 50%/95.8% and 35.3%/95.5%, respectively. BISAP and ED-SAS were also similar in predicting mortality (AUCs of 0.92 vs. 0.90, respectively) and intensive care unit admission (AUCs 0.91 vs. 0.91). CONCLUSION: The BISAP and ED-SAS scores performed similarly in predicting SAP, mortality, and intensive care unit admission. As an easily calculated tool early in the ED, ED-SAS may be helpful in disposition decisions for emergency physicians.

Clinical characteristics of neutrophilic, eosinophilic and mixed-type exacerbation phenotypes of COPD.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) comprises a significant number of emergency department (ED) presentations, and hematological phenotypes may have prognostic significance. The aim of this study was to investigate the effect of hematological phenotypes on serious outcomes in COPD exacerbations. METHODS: A prospective cohort study was carried out in patients with COPD exacerbation presenting to the ED. The patients were classified into three groups, including neutrophilic, eosinophilic, and mixed-type (including neutrophilic and eosinophilic features) COPD exacerbation. Outcome measures were defined as mortality, hospitalization, and need for intensive care unit (ICU) care within three months, and these outcomes were compared among groups. RESULTS: A total of 173 COPD patients were assessed for eligibility, and 147 of them were included in the final analysis. The study population consisted of 90 patients with neutrophilic exacerbation (61.2%), 26 patients with eosinophilic exacerbation (17.7%), and 31 patients with mixed-type exacerbation (21.1%). The neutrophilic exacerbation group was older, was more often tachycardic and desaturated, and had more sputum production compared with the eosinophilic exacerbation group. Mortality was seen in 35 patients in the neutrophilic exacerbation group (38.9%), whereas 5 patients in the eosinophilic group (19.2%) and 6 patients in the mixed-type group (19.4%) died (p = .044). No difference was observed among groups in terms of hospital and ICU admission. CONCLUSION: COPD exacerbations with neutrophilic phenotypes presented to the ED with more serious clinical findings compared with eosinophilic exacerbations. This may also have a possible effect on mortality.

Intravenous metoclopramide in the treatment of acute migraines: A randomized, placebo-controlled trial.

OBJECTIVES: The present study aimed to evaluate the efficacy and safety of intravenous metoclopramide for acute migraine treatment. MATERIALS AND METHODS: A double-blind, randomized, parallel-group, placebo-controlled trial was carried out in an academic emergency department. After the patients were assessed for eligibility via the International Headache Society criteria for migraines, they were randomized into 10 mg intravenous metoclopramide and normal saline groups. The headache intensity was evaluated using an 11-point numeric rating scale (NRS) score. The primary outcome measure was determined as the median between-group change in the score at the 30th minute. The secondary outcome measures were rescue medication needs, adverse events, and emergency department (ED) revisits after discharge. RESULTS: A total of 148 patients were randomized into two equal groups with similar baseline characteristics, including the baseline NRS scores (8 points). The median reduction in the NRS scores at the 30th minute was 4 [interquartile range (IQR): 2-6)] in the metoclopramide group and 3 (IQR: 1-4) in the normal saline group [median difference: -1.0, 95% confidence interval (CI): -2.1 to 0.1]. No serious adverse events were observed, and the rescue medication needs were similar in both groups. CONCLUSION: No difference was found between intravenous metoclopramide and placebo regarding efficacy and safety in patients with acute migraines.

The value of lactate clearance in admission decisions of patients with acute exacerbation of COPD.

BACKGROUND: Lactate and lactate clearance are being used as biomarkers in several critical conditions. The aim of this study was to examine the value of sixth hour lactate clearance in patients who were hospitalized with chronic obstructive pulmonary disease (COPD) exacerbations. METHODS: This single-center, cross-sectional study was conducted in a tertiary emergency department (ED) on patients who presented with acute exacerbation of COPD. Discharge or admission decisions were specified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria and the clinician's decision. In the study, lactate clearance was defined as the percent decrease in lactate from the time of presentation to the ED to the sixth hour. RESULTS: A total of 495 patients were evaluated and 397 patients were excluded. Among included patients, 53 (54.1%) were admitted to the hospital and 45 (45.9%) were discharged. The median lactate clearance was found to be -11.8% (95% CI: -50.0 to 34.5) in the admitted group and 14.7% (95% CI: -11.3 to 42.3) in the discharged group. Between the two groups, the median difference of lactate clearance was found to be 26.5% (95% CI: 0.6 to 52.4). Multivariate logistic regression analysis revealed that the delta lactate value can determine the hospitalization need of patients (OR: 0.91, 95% CI: 0.85 to 0.97). CONCLUSION: Lactate clearance can be evaluated as a useful marker in patients with COPD exacerbations. This study suggests that lactate monitoring in the ED has clinical benefits in addition to GOLD guidelines when deciding whether to discharge or hospitalize a patient.

Intranasal Lidocaine in Acute Treatment of Migraine: A Randomized Controlled Trial.

STUDY OBJECTIVE: The study aims to evaluate the efficacy and safety of intranasal lidocaine administration for migraine treatment. METHODS: This single-center, double-blind, randomized, controlled trial was conducted in a tertiary care emergency department. Included patients met the migraine criteria of the International Headache Society. Patients were randomized to intranasal lidocaine or saline solution; all participants received 10 mg of intravenous metoclopramide. Patient pain intensity was assessed with an 11-point numeric rating scale score. The primary outcome measure was the change in pain scores at 15 minutes; secondary outcomes were changes in pain intensity after pain onset and need for rescue medication. RESULTS: Patients (n=162) were randomized into 2 groups with similar baseline migraine characteristics and numeric rating scale scores. The median reduction in numeric rating scale score at 15 minutes was 3 (interquartile range [IQR] 2 to 5) for the lidocaine group and 2 (IQR 1 to 4) for the saline solution group (median difference=1.0; 95% confidence interval 0.1 to 2.1). The reduction in pain score at 30 minutes was 4 (IQR 3 to 7) for the lidocaine group and 5 (IQR 2 to 7) for the saline solution group (median difference=1.0; 95% confidence interval 0.1 to 2.1). Need for rescue medication did not differ between the groups, and local irritation was the most common adverse event in the lidocaine group. CONCLUSION: Although intranasal lidocaine was found no more efficacious than normal saline solution in our study, future studies should focus on patients who present earlier after headache onset.

Comparison of loop and primary incision & drainage techniques in adult patients with cutaneous abscess: A preliminary, randomized clinical trial.

OBJECTIVES: The aim of this study is to compare efficacy of loop drainage and standard incision & drainage (I&D) in adult patients with cutaneous abscess in the emergency department. METHODS: This study is an interventional, parallel group, randomized clinical trial. Adult patients with cutaneous abscess were randomized into loop drainage and standard I&D groups. The primary outcome was defined as change in diameter of abscess and cellulitis 7days after procedure. Secondary outcome measures were pain intensity at the end of the procedure and procedure duration. Also patient satisfaction, need for antibiotics and repetitive drainage were recorded. RESULTS: A total of 46 patients were included in the study (23 in each group). Both groups had similar baseline characteristics. Median abscess diameters were 3.2 (1.9-4.0) cm and 3.0 (2.4-4.8) cm in loop drainage and I&D groups respectively. In the loop drainage group there was a -0.6cm (95% CI: -1.7-0.5) difference in abscess diameter compared to the I&D group. There was also a reduction in cellulitis diameter (-1.3cm, 95% CI: -3.4-0.8). No statistically significant difference was found between groups in patient satisfaction, use of antibiotics or need for repetitive drainage. CONCLUSION: This preliminary study revealed that, loop drainage technique is similar to standard I&D technique in abscess resolution and complications. (Clinical Trials Registration ID: NCT02286479).

Comparison of the therapeutic efficacy of intravenous dimenhydrinate and intravenous piracetam in patients with vertigo: a randomised clinical trial.

BACKGROUND: The present study aimed to compare the therapeutic efficacy of dimenhydrinate and piracetam in patients with vertigo. METHODS: A blinded, parallel group, superiority, randomised clinical trial was carried out on patients who presented to the emergency department (ED) with vertigo. Healthy adult patients presenting to the ED with undifferentiated vertigo were included in the study. The efficacy of intravenous dimenhydrinate (100 mg) and intravenous piracetam (2000 mg) for reducing the intensity of vertigo was compared in two randomised treatment groups using a 10-point numeric rating scale (NRS). The determination of NRS scores was performed at presentation and at the 30th minute of presentation, after the study drug was implemented, both in immobile and ambulatory positions. The primary outcome variable was reduction in vertigo intensity documented on the NRS at the 30th minute after medication administration, analysed by intention to treat. RESULTS: A total of 94 patients were included in the randomisation (n=47 in both groups). The baseline NRS scores were 7.55±2.00 in the dimenhydrinate group and 8.19±1.79 in the piracetam group. The changes from baseline for dimenhydrinate and piracetam were 2.92±3.11 and 3.75±3.40 (difference -0.83 (95% CI -2.23 to 0.57)) in the immobile position and were 2.04±3.07 and 2.72±2.91 (difference -0.68 (95% CI -2.03 to 0.67)) in the ambulatory position. Rescue medication need was similar in both treatment groups (p=0.330), and only one adverse reaction was reported. CONCLUSIONS: We found no evidence of a difference between dimenhydrinate and piracetam in relieving the symptoms of vertigo. TRIAL REGISTRATION NUMBER: Clinical Trials Registration ID: NCT01890538.

Asymptomatic Chronic Epidural Hematoma in a Child As a Result of Extracranial Decompression.

BACKGROUND: Epidural hematoma (EDH) in children is a diagnostic challenge due to its nonspecific clinical presentation. Asymptomatic chronic epidural hematoma is a very rare entity. Reports of spontaneous decompression into the subgaleal spaces are limited with acute epidural hematomas in the literature. OBJECTIVE: We report a child presenting with chronic epidural hematoma at 15 days after a head trauma. She remained asymptomatic, owing to spontaneous decompression via a skull fracture. We intend to remind emergency physicians to be alert about epidural hematomas in asymptomatic children in the presence of a history of, even minor and distant, trauma. CASE PRESENTATION: An 8-year-old girl presented to the Emergency Department with a swelling in the right parietal region. She had fallen at the playground and struck her head on the ground 15 days prior. Computed tomography showed a mixed-density subacute-chronic parietal epidural hematoma with a linear fracture overlying it. There was no evidence of midline shift or ipsilateral ventricular compression. CONCLUSION: An initially minimal but expanding EDH in a child can remain asymptomatic even in the later phases, owing to the spontaneous decompression through a skull fracture.

Prognostic value of early warning scores in patients presenting to the emergency department with exacerbation of COPD.

OBJECTIVE: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a condition that frequently presents to the emergency department (ED) and its prognosis is not very well understood. Risk tools that can be used rapidly in the ED are needed to predict the prognosis of these patients. METHODS: This study comprised a retrospective cohort of AECOPD patients presenting to a single center between 2015 and 2022. The prognostic accuracy of several clinical early warning scoring systems, Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), NEWS­2, Systemic Inflammatory Response Syndrome (SIRS) and the quick Sepsis-related Organ Failure Assessment (qSOFA), were compared. The outcome variable was determined as one-month mortality. RESULTS: Of the 598 patients, 63 (10.5%) had died within 1 month after presenting to the ED. Patients who died had more often congestive heart failure, altered mental status, and admission to intensive care, and they were older. Although the MEWS, NEWS, NEWS­2, and qSOFA scores of those who died were higher than those who survived, there was no difference between the SIRS scores of these two groups. The score with the highest positive likelihood ratio for mortality estimation was qSOFA (8.5, 95% confidence interval [CI] 3.7-19.6). The negative likelihood ratios of the scores were similar, the NEWS score had a negative likelihood ratio of 0.4 (95% CI 0.2-0.8) with the highest negative predictive value of 96.0%. CONCLUSION: In AECOPD patients, most of the early warning scores that are frequently used in the ED were found to have a moderate ability to exclude mortality and a low ability to predict mortality.

Comparison of dental force applied during endotracheal intubation with hyper-angulated and macintosh-type video laryngoscopy blades used by emergency medicine trainees: A randomized cross-over manikin study.

OBJECTIVES: This study aimed to compare the effects of Macintosh-type and hyperangulated video laryngoscopy (VL) blades on dental force during endotracheal intubation (ETI) using Glidescope and McGrath VL devices. METHODS: In this randomized, crossover, manikin study conducted at a university emergency medicine (EM) program, 65 EM trainees included interns and residents performed 520 intubations using four different VL blades (GlideScope VL with Macintosh-type Mac T3 and hyperangular Lo Pro T3 blades and McGrath VL Macintosh-type MAC 4 and hyperangular McGrath X3 blades) in normal and difficult airway scenarios. The primary outcome of this study was the dental pressure (Newton) exerted during ETI. The secondary outcomes included c-spine motion (degree), intubation success (%), duration (seconds), successful glottic view (%), and intubator comfort (7-point Likert). RESULTS: Significant differences were observed in dental force (H(3) = 11.7, P = 0.008), c-spine motion (H(3) = 8.34, P = 0.039), duration (H(3) = 16.56, P = 0.001), and comfort (H(3) = 174.96, P < 0.001) across blade types. Glidescope LoPro T3 provided a significant lower dental force (adjusted P = 0.01), less c-spine motion (adjusted P = 0.031), and shorter intubation duration (adj P < 0.01) than the McGrath Mac 4. First attempt success and intubator comfort were significantly better with all Glidescope blades (z score of 3.7 and 4.7) than with McGrath blades (z score of-4.1 and-4.4). CONCLUSION: The Glidescope LoPro T3 blade demonstrated advantages in dental force, c-spine motion, and intubation duration compared with McGrath Mac 4. Overall, the Glidescope blades provided superior comfort and higher first attempt success rates.

Prospective, multicenter, Turkish out-of-hospital cardiac arrest study: TROHCA.

OBJECTIVES: There is no sufficient data to provide a clear picture of out-of-hospital cardiac arrest (OHCA) across Türkiye. This study is the first to present the prognostic outcomes of OHCA cases and the factors associated with these outcomes. MATERIALS AND METHODS: The study was conducted in a prospective, observational, multicenter design under the leadership of the Emergency Medicine Association of Turkey Resuscitation Study Group. OHCA cases aged 18 years and over who were admitted to 28 centers from Türkiye were included in the study. Survived event, return of spontaneous circulation (ROSC), survival to hospital discharge, and neurological outcome at discharge were investigated as primary outcomes. RESULTS: One thousand and three patients were included in the final analysis. 61.1% of the patients were male, and the average age was 67.0 ± 15.2. Cardiopulmonary resuscitation (CPR) was performed on 86.5% of the patients in the prehospital period by emergency medical service, and bystander CPR was performed on only 2.9% by nonhealth-care providers. As a result, the survived event rate was found to be 6.9%. The survival rate upon hospital discharge was 4.4%, with 2.7% of patients achieving a good neurological outcome upon discharge. In addition, the overall ROSC and sustained ROSC rates were 45.2% and 33.4%, respectively. In the multiple logistic regression analysis, male gender, initial shockable rhythm, a shorter prehospital duration of CPR, and the lack of CPR requirement in the emergency department were determined to be independent predictors for the survival to hospital discharge. CONCLUSION: Compared to global data, survival to hospital discharge and good neurological outcome rates appear to be lower in our study. We conclude that this result is related to low bystander CPR rates. Although not the focus of this study, inadequate postresuscitative care and intensive care support should also be discussed in this regard. It is obvious that this issue should be carefully addressed through political moves in the health and social fields.

Relationship between clinical anxiety and patient outcomes in patients with chronic obstructive lung disease exacerbation in the emergency department.

PURPOSE: Anxiety is a comorbidity that is not routinely addressed in patients with chronic obstructive lung disease (COPD) exacerbation in the emergency department (ED). Anxiety in patients with COPD exacerbation can be related with negative outcomes. The Generalized Anxiety Disorder 7 (GAD-7) score is an easy-to-use tool to determine anxiety. This study aimed to investigate the relationship between GAD­7 score and patient outcomes in patients with COPD exacerbation in the ED. METHODS: A prospective, cross-sectional study was conducted in a tertiary academic ED between July 2019 and January 2021. Patients admitted to the ED with COPD exacerbation were included. A GAD­7 score of ≥ 10 was defined as clinically significant anxiety. Negative outcomes were defined as a composite outcome that included recurrent ED visits, intensive care unit admission, and mortality. The relationship between clinically significant anxiety and negative outcomes within 30 days was determined. RESULTS: A total of 92 patients were assessed for eligibility and 80 were included in the study. Thirty-seven patients (46.3%) experienced negative outcomes. Although no significant difference was detected in median GAD­7 scores between patients with positive and negative outcomes, negative outcomes were significantly higher in patients who had a GAD­7 score of ≥ 10 (n = 25, p = 0.03). A sensitivity of 43.2%, specificity of 79.1%, positive likelihood ratio of 2.1 and negative likelihood ratio of 0.7 were determined for GAD­7 score in predicting negative outcome. CONCLUSION: In patients with COPD exacerbation in the ED, a GAD­7 score of ≥ 10 was associated with 30-day negative outcomes.

Adherence to Clinical Practice Guidelines for Non-ST Elevation Acute Coronary Syndrome in the Emergency Department: Exploring the Role of Social, Healthcare-system, and Clinical Determinants.

OBJECTIVES: The aim of this study was to assess adherence to the European Society of Cardiology 2020 non-ST elevation acute coronary syndrome (NST-ACS) guidelines, identify factors affecting this compliance, and explore the link between adherence and adverse cardiac outcomes. METHODS: This prospective cohort study was conducted in a tertiary-level academic hospital between January 2022 and January 2023. Patients diagnosed with NST-ACS in the emergency department (ED) were included. The primary outcome measured was the rate of adherence to the guidelines, and secondary outcomes were factors affecting this adherence in the ED and its association with 28-day adverse cardiac outcomes. RESULTS: Of the 298 patients included, guideline adherence was achieved in 32.2% in the ED. The highest compliance was observed in performing a 12-lead electrocardiogram (ECG) within 10 minutes (99.7%), while the lowest was found for obtaining additional right and posterior ECG leads when ongoing ischemia was suspected (42.3%). Factors associated with better adherence included the experience level of the treating physician, the presence of cardiac-quality chest pain, initial ischemic ECG findings, higher initial troponin levels, and advanced history, electrocardiogram, age, risk factors, and troponin score and Charlson comorbidity index. Complete guideline adherence over 28 days was achieved in 19.1% of patients and was found to be significantly associated with lower rates of adverse cardiac outcomes. CONCLUSIONS: Adherence to NST-ACS guidelines was generally low but was associated with improved patient outcomes. This study highlighted the importance of various factors associated with guideline adherence. Future research should explore further barriers to guideline adherence and develop targeted interventions.

Predictors of prolonged hospitalization in patients with mild and moderate pancreatitis presenting to the emergency department.

BACKGROUND: Patients with acute pancreatitis often present to the emergency department (ED) and usually require hospital admission. The aim of this study was to determine predictors of prolonged hospital stays in patients with mild forms of acute pancreatitis. METHODS: This retrospective cohort study was conducted in patients diagnosed in the ED with mild and moderate acute pancreatitis according to the revised Atlanta classification. Patients with available data between 2007 and 2017 were included and were divided based on their admission duration. Eight days or more was considered a long hospitalization. A multivariate logistic regression model was constructed to determine the independent predictors of prolonged hospital stays. RESULTS: Of the 485 evaluated patients, 335 were included in the analysis. Baseline characteristics, determined by vital signs and laboratory parameters, were similar between the short and long hospitalization groups. However, the long hospitalization group received more intravenous crystalloid in the ED, and this group used more diuretics and more angiotensin-converting enzyme inhibitor and angiotensin-receptor blocker (ACEI/ARB) drugs than the other group. Diuretic use was present in 8 patients (4.8%) in the short hospital length of stay group and in 26 patients (15.3%) in the long hospital length of stay group. Age, gender, ACEI/ARB use, diuretic use, total amount of intravenous crystalloid administered in the ED, aPTT, BUN, creatinine, and presence of biliary pathology were included in the multivariate analysis. Regarding the final analysis, diuretic use was an independent predictor of prolonged hospitalization (odds ratio 2.89, 95% confidence interval 1.05-8.00, p = 0.041). CONCLUSION: Diuretic use is an independent predictor of long hospitalization in patients with mild and moderate pancreatitis. Drugs affecting total volume balance may prolong hospital stays in these patients.

Comparison of PECARN clinical decision rule and clinician suspicion in predicting intra-abdominal injury in children with blunt torso trauma in the emergency department.

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) developed a clinical decision rule to identify children at low risk for intra-abdominal injury requiring acute intervention (IAI-I) for reducing unnecessary radiation exposure of ab-dominal computed tomography (CT) after blunt torso trauma. This study aimed to compare the PECARN decision rule with clinician suspicion in identifying children at low risk of intra-abdominal injuries that an abdominal CT scan can be safely avoided. METHODS: This study is a retrospective review of children with blunt torso trauma in an academic emergency department (ED) between 2011 and 2019. Patients were considered positive for the PECARN rule if they exhibited any of the variables. Clinician suspi-cion was defined as actual CT ordering of the treating physician. The primary outcome was IAI-I detected by imaging or surgery within 1 month after the trauma, and the secondary outcome was any intra-abdominal injury (IAI) presence. RESULTS: Among the 768 children included, 48 (6.25%) had intra-abdominal injuries and 21 (2.73%) of whom underwent acute in-tervention. Four hundred and fifty-three (59%) children underwent abdominal CT scanning. If the PECARN rule had been applied, 232 patients would have undergone abdominal CT. The rule revealed 90.48% (95% CI=68.17-98.33%) sensitivity for IAI-I and 81.25% (95% CI=66.9-90.56%) for IAI. Clinician suspicion revealed sensitivities of 100% (95% CI=80.76-00%) and 93.75% (95% CI=81.79-98.37%) for IAI-I and IAI, respectively. Sensitivities of the rule and clinician suspicion were statistically similar for both IAI-I (p=0.5) and IAI (p=0.146). CONCLUSION: In this study, the PECARN abdominal rule and clinician suspicion performed similarly in identifying intra-abdominal injuries in children with blunt torso trauma. However, our study supports the use of PECARN abdominal rule in addition to clinical judgment to limit unnecessary abdominal CT use in pediatric patients with blunt torso trauma in the ED.

Performance of qSOFA, SIRS, and the qSOFA + SIRS combinations for predicting 30-day adverse outcomes in patients with suspected infection.

BACKGROUND: The use of the quick sequential organ failure assessment score (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria to identify patients at high risk for adverse outcomes in the emergency department (ED) remains controversial due to their low predictive performance and lack of supporting evidence. This study aimed to determine the predictive performance of qSOFA, SIRS, and the qSOFA + SIRS combinations for adverse outcomes. METHODS: All adult patients admitted to the ED with suspected infection were prospectively included. qSOFA scores ≥ 2, SIRS score ≥ 2 were defined as risk-positive for adverse outcome. Furthermore, combination­1, which was defined as either qSOFA or SIRS positivity, and combination­2, which was defined as both qSOFA and SIRS positivity, were also considered as risk-positive for adverse outcome. The predictive performance of qSOFA, SIRS, combination­1, and combination­2 for a composite adverse outcome within 30 days, including mortality, intensive care unit (ICU) admission, and non-ICU hospitalization, were determined. RESULTS: A total of 350 patients were included in the analysis. The composite outcome occurred in 211 (60.3%) patients within 30 days: mortality in 84 (24%), ICU admission in 78 (22.3%), and non-ICU hospitalization in 154 (44%). The sensitivity and specificity, respectively, were determined in predicting composite outcome as 0.34 and 0.93 for qSOFA, 0.81 and 0.31 for SIRS, 0.84 and 0.28 for combination­1, and 0.31 and 0.96 for combination­2. CONCLUSION: The study results suggest that qSOFA and combination­2 could be a useful tool for confirming patients at high risk for adverse outcomes. Although SIRS and combination­1 could be helpful for excluding high-risk patients, the requirement of white blood cell counts limits their utilization for screening.

Comparison of alprazolam versus captopril in high blood pressure: a randomized controlled trial.

UNLABELLED: OBJECTIVE. Anxiety is an important cause of acute blood pressure (BP) elevation. However, the role of anxiolysis in this situation is still controversial. In this study, the relationship of anxiety with BP and the effect of anxiolytic treatment on BP were investigated. METHODS. Emergency department (ED) patients with an initial systolic BP (SBP) ≥ 160 mmHg or diastolic BP (DBP) ≥ 100 mmHg but no end organ damage were approached for inclusion in the study. In those consenting to participate, anxiety levels were measured using the State-Trait Anxiety Index (STAI) and Visual Analog Scale for Anxiety (VAS-A). Patients were randomly assigned to receive oral alprazolam 0.5 mg or captopril 25 mg. BP and anxiety levels were measured at baseline and at 1 and 2 h after administration of the study medication. RESULTS. Of 133 patients meeting inclusion criteria, 53 patients agreed to participate. Of these, 27 patients (50.9%) received captopril and 26 patients (49.1%) received alprazolam. The majority of the patients had a high-level trait (96.2%, n = 51) and state anxiety (81.1%, n = 43). The mean SBP and VAS-A values of both patient groups dropped significantly over the 2 h, with no significant difference between the two groups. A significant association between SBP and VAS-A scores was found (F((2,50)) = 6.27, p = 0.004). CONCLUSION: A significant association exists between the level of BP and anxiety in hypertensive ED patients. Alprazolam is as effective as captopril in lowering BP in ED patients with an initial SBP > 160 mmHg.

Post-traumatic cerebral infarction: a rare complication in a pediatric patient after mild head injury.

Because the cases of post-traumatic cerebral infarction in children are uncommon, little research has been done on this subject. The case of a 14-month-old child who had cerebral infarction after mild head injury is discussed. He fell from a height of approximately 70 cm 12 hours before. He did not use his left arm after the injury. His parents took him to the public hospital, where he was investigated in terms of mechanical complication and was observed for six hours, but no computed tomography (CT) scan was performed at that time. The patient was then presented to our department by his parents. He was not able to walk and was sitting. His neurological examination revealed right hemihypoesthesia, hemiparesis and mild left facial paresis. CT showed a hypodense region in the right basal ganglia location. The right lateral ventricle seemed mildly compressed due to edematous changes. The magnetic resonance imaging revealed hyperintense signal changes that affected the right lentiform nucleus and the head of the caudate nucleus. The aim of the case is to remind emergency physicians that post-traumatic ischemic stroke is uncommon but may be the cause of disability in pediatric patients, and a systematic physical examination must be performed in all ages even if the patients appear quite well.

Use of noninvasive volume assessment methods to predict acute blood loss in spontaneously breathing volunteers.

OBJECTIVE: The use of noninvasive volume assessment methods to predict acute blood loss in spontaneously breathing patients remains unclear. We aimed to investigate changes in the pleth variability index (PVI), vena cava collapsibility index (VCCI), end-tidal carbon dioxide (EtCO2), pulse pressure (PP), and mean arterial pressure (MAP) in spontaneously breathing volunteers after acute loss of 450 mL blood and passive leg raise (PLR). METHODS: This prospective observational study enrolled healthy volunteers in the blood donation center of an academic hospital. We measured the PVI, EtCO2, VCCI, MAP, and PP before blood donation; at the 0th and 10th minute of blood donation; and after PLR. The primary outcome was the changes in PVI, EtCO2, VCCI, MAP, and PP. RESULTS: We enrolled thirty volunteers. There were significant differences among the four obtained measurements of the PVI, EtCO2, and MAP (P<0.001, P<0.001, P<0.001, respectively). Compared to the predonation values, post-hoc analysis revealed an increase in the PVI at the 0th min postdonation (mean difference [MD], 5.4±5.9; 95% confidence interval [CI], -7.6 to -3.1; P<0.001); a decrease in the EtCO2 and MAP at the 0th and 10th minute postdonation, respectively (MD, 2.4±4.6; 95% CI, 0.019 to 4.84; P=0.008 and MD, 6.4±6.4; 95% CI, 3 to 9.7; P<0.001, respectively). Compared with EtCO2 at the 10th minute, the value increased after PLR (MD, 1.8±3.2; 95% CI, 0.074 to 4.44; P=0.006). CONCLUSION: The PVI and EtCO2 could detect early hemodynamic changes after acute blood loss. However, it remains unclear whether they can determine volume status in spontaneously breathing patients.

No significant alteration in admissions to emergency departments during Ramadan.

BACKGROUND: Dietary and lifestyle changes during Ramadan may affect the appearance rate of emergency health problems or increase emergency department (ED) use. OBJECTIVE: This study's aim was to investigate Ramadan's effects on ED use. METHODS: The study group consisted of patients admitted to the ED during Ramadan, and the control group consisted of patients admitted during the 30-day period immediately after Ramadan. The study compared the daily number, diagnosis, and demographic and clinical characteristics of the two groups. RESULTS: The study included 2079 patients. Of these, 1094 (52.6%) were admitted during Ramadan, and the remaining 985 (47.4%) formed the control group. The average number of patients admitted to the ED per day was 36.47 +/- 7.9 in the study group and 32.83 +/- 5.8 in the control group (p = 0.046). The two groups' demographic and clinical characteristics, such as age, sex, final diagnosis, admission times to ED, and diagnosis, were similar. CONCLUSIONS: Our results show that during Ramadan, the clinical features of patients admitted to the ED and the number of ED admissions for specific ailments did not change significantly.