Vaccination status among patients with the need for emergency hospitalizations related to COVID-19.

BACKGROUND: It is thought vaccines allowed for emergency use significantly reduce hospitalizations and emergency room visits. It is a matter of curiosity how many of the patients who come to the emergency department (ED) are vaccinated. We aimed to examine the characteristics of ED patients needing hospitalizations related to moderate and severe COVID-19 by vaccination status. METHODS: A retrospective study of 559 rRT-PCR-confirmed SARS-CoV-2 infection cases with moderate or severe COVID-19 needing hospitalization was performed in August 2021. Univariate and multivariate logistic regression analyses were performed for factors associated with mortality. RESULTS: The mean age of the patients was 60.8 ± 18.1 years old, and 54.2% (n = 303) of the patients were women. The most common comorbidities were hypertension (37.2%), diabetes mellitus (31.1%) and chronic obstructive pulmonary disease (13.8%), respectively. The number of patients with alpha variant was 399 (71.4%), and delta variant was 83 (14.8%). Fifty point 6% (n = 283) of the patients were fully vaccinated. The total number of patients who died in the study was 114 (20.4%), and the number of patients hospitalized in the intensive care unit was 168 (30.1%). The day between the last dose of vaccine and hospitalization was 117 ± 45.9 days. In multivariate logistic regression analysis: age (odds ratio (OR), 1.05; 95% confidence intervals (95% CI) 1.03-1.08- year increase), male gender (OR, 1.8; 95% CI, 1.1-2.9), presence of at least one comorbid disease (OR, 2; 95% CI, 1.1-3.7) and partial (OR, 0.24;95% CI, 0.09-0.6) and fully vaccinated status (OR, 0.1; 95% CI, 0.05-0.18) were associated with mortality among COVID-19 patients. CONCLUSIONS: In this study, age older than 65, unvaccinated, and comorbidities had significantly higher mortality. In multivariate regression analyses, age, vaccination status, comorbidities and the male gender were associated with mortality. Our study did not evaluate the vaccine efficacy but, a lower mortality rate was observed in those fully vaccinated with CoronaVac and Pfizer-BioNTech. Additionally, Alpha, Delta and other variants had the same mortality rates.

[Misdiagnosis of pulmonary embolism and causes]. / Pulmoner embolide yanlis tani ve sebepleri.

INTRODUCTION: Pulmonary thromboembolism (PTE) is not only one of the prevelant diseases with a high mortality risk but also has a high ratio of delayed diagnosis and misdiagnosis. In this study, it was aimed to determine the demographical characteristics, risk factors, clinical and laboratory findings of the patients that were diagnosed as PTE at their first hospital visit and of the PE patients who were misdiagnosed at their first admission. We aimed to investigate the factors which can leads to misdiagnosis of PE, and to determine the ways to avoid misdiagnosis. MATERIALS AND METHODS: One hundred PTE patients who were admitted to University Hospital between the dates January 2007-December 2011 were included in the study. Clinical and laboratory findings of these patients were evaluated. Among these patients, 26 were misdiagnosed at their first admission but diagnosed accurately (as PTE) in our hospital and 74 were diagnosed accurately. Two groups were compared with respect to various data of the patients clinical and demographical characteristics. RESULTS: Between the two groups, there was no difference in terms of physical examination and laboratory findings. The patients with the symptoms onset was over a week ago had a higher misdiagnosis rate (p= 0.002). The patients with no risk of PTE had a higher misdiagnosis rate (p= 0.017). Misdiagnosis rate of the patients with cardiac diseases was lower (p= 0.033) According to Geneva risk score, we observed that the misdiagnosis risk was reduced in the patients with higher clinical probability (p= 0.011). CONCLUSION: In conclusion, misdiagnosis rate was found to be statistically significant in the patients with low score according to the Geneva risk classification, and whose pre-diagnosis period lasted for more than a week and with no risk factors of PTE or cardiac diseases. We are in the opinion that considering these parameters will help to reduce in misdiagnosis of pulmonary embolism cases.

The value of C-reactive protein velocity (CRPv) on mortality in sepsis patients who are emergently hospitalized in the ICU: A retrospective single-center study.

Purpose: The C-reactive protein (CRP) velocity (CRPv) is an indicator of the change in CRP over time. In individuals with sepsis, the second values of CRP and CRPv have been shown to have more importance than the first CRP value measured at admission. This study examined the importance of CRPv for mortality among individuals who were hospitalized in the intensive care unit (ICU). Methods: The study was conducted between January 2021 and December 2022. CRPv was calculated according to the change in the second CRP value compared to the first. Results: The median age of the patients was 79 years (interquartile range (IQR), 69-85 years), and 53.2 % were male. The in-hospital mortality rate was 45.5 %. The presence of diabetes increased the odds of mortality by 2.17 times (confidence interval (CI): 1.06-4.4, p=0.032). Each increase in CRPv by 1 mg/dl/hour increased the odds of mortality by 1.07 times (CI: 1.01-1.14, p=0.015), while each one-point increase in the Sequential Organ Failure Assessment (SOFA) score increased the odds of mortality by 1.21 times (CI: 1.07-1.35, p=0.002). The SOFA score had the highest area under the curve (AUC) value for in-hospital mortality (AUC = 0.699 p=<0.001). When the SOFA was >7, its sensitivity in predicting mortality was 46.7 %, and its specificity was 85.1 %. The AUC value of CRPv in predicting mortality was 0.629 (p=0.006). When CRPv was >0.75, its sensitivity in predicting mortality was 68.2 %, and its specificity was 57 %. Conclusion: CRPv performed well in predicting mortality and had satisfactory discriminative ability. Additionally, diabetes, SOFA score, and CRPv elevation were significant risk factors for mortality.

Quick COVID-19 Severity Index, CURB-65 and Quick SOFA Scores Comparison in Predicting Mortality and Risk Factors of COVID-19 Patients.

BACKGROUND: This study aimed to investigate CURB-65, quick COVID-19 Severity Index (qCSI) and quick Sepsis Related Organ Failure Assessment (qSOFA) scores in predicting mortality and risk factors for death in patients with COVID-19. METHODS: We retrospectively analyzed a total of 1919 cases for whom the rRT-PCR assay for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive. For mortality risk factors, univariate and multivariate logistic regression analyses were used. Receiver operator characteristics (ROC) analysis and Kaplan-Meier survival analysis were performed for CURB-65, qCSI and qSOFA scores. RESULTS: The patients' average age was 45.7 (21.6) years. Male patients accounted for 51.7% (n=992). In univariate analysis, some clinical variables including age over 65 years and comorbid diseases such as hypertension, chronic kidney disease, malignancy, lymphopenia, troponin, lactate dehydrogenase (LDH) and fibrinogen elevation were associated with the mortality rate. In multivariate logistic regression analysis: Neutrophil lymphocyte ratio (NLR) 3.3 and above (OR, 9.1; 95% CI, 1.9-42), C-reactive protein (CRP)30 mg/L and above (OR, 4.1; 95% CI, 1.2-13.6), D-dimer 1000 ng/mL and above (OR, 4; 95% CI, 1.5-10.7) and age (OR, 1.11; 95% CI, 1.04-1.18-year increase) were identified as risk factors for mortality among COVID-19 patients. The CURB-65 and qCSI scores exhibited a high degree of discrimination in mortality prediction (AUC values were 0.928 and 0.865, respectively). Also, the qSOFA score had a moderate discriminant power (AUC value was 0.754). CONCLUSION: CURB-65 and qSCI scores had a high discriminatory power to predict mortality. Also, this study identified CURB-65, qCSI and qSOFA scores, NLR, CRP, D-dimer level, and annual age increase as important mortality risk factors.

Comparison of CURB-65 Pneumonia Severity Score, Quick COVID-19 Severity Index, and Brescia-COVID Respiratory Severity Scale in Emergently Hospitalized COVID-19 Patients with Pneumonia.

Objective: This study aimed to assess the performance of the CURB-65, the quick COVID-19 severity index (qCSI), and the Brescia-COVID respiratory severity scale (BCRSS) scores in predicting ICU (intensive care unit) hospitalization and in-hospital mortality in emergently hospitalized patients with COVID-19 pneumonia. Materials and Methods: We retrospectively reviewed the emergently hospitalized 258 patients with COVID-19 pneumonia consecutively. The required sample size was calculated to compare the areas under the two ROC (receiver operating characteristic) curves (AUC) using the MedCalc 20.0 program (MedCalc Software Ltd., Ostend, Belgium). In addition, we actualized ROC analyses of the CURB-65, the qCSI, and the BCRSS scores and compared the ROC curves of these three scores. Results: The median age of the patients was 73, and 63.6% (n=164) were male. Of 258 patients, 29.5% (n=76) were hospitalized in the intensive care unit (ICU), and 15.9% (n=41) died. The CURB-65 and the qCSI scores predicted ICU admission at a moderate level (p≤0.001; AUC values were 0.743 and 0.723, respectively). However, the predictive effect of the BCRSS score for ICU admission was lower (p≤0.001; AUC value was 0.667). The CURB-65 predicted in-hospital mortality at a moderate level ( p≤0.001; AUC value was 0.762). However, the predictive effect of the qCSI and the BCRSS scores for in-hospital mortality were lower ( p≤0.001 and p=0.012, respectively; AUC values were 0.655 and 0.612, respectively). Conclusion: The CURB-65 score predicted ICU hospitalization and in-hospital mortality better than the qCSI and the BCRSS scores. Also, the qCSI score predicted ICU admission better than the BCRSS score.The predictive effect of the BCRSS score was the lowest. We recommend future studies to evaluate the value and utility of COVID-19 risk classification models.

Non-urgent adult patients in the emergency department: Causes and patient characteristics.

OBJECTIVE: Non-urgent patients are one of the important causes of emergency department (ED) overcrowding. In this study, it is aimed to identify the characteristics of these patients and the reasons why they prefer the ED. METHOD: This study was conducted during regular office hours. The characteristics of non-urgent patients, their complaints, the frequency of visits to family physicians (FPs), the frequency of using the Central Hospital Appointment System (CHAS) and reasons for preferring the ED were questioned by a questionnaire. RESULTS: This study was conducted on 624 patients. Among them, 326 (52.2%) were male. The mean age was 38.4 years (SD: 14.4). It was identified that 80.3% of the patients had no chronic disease and that 97.4% had health insurance. The most common complaints at presentation were musculoskeletal system pain (25.2%) and upper respiratory tract infections symptoms (19.7%). It was identified that 28.7% of the patients did not prefer to visit their FPs and that 48.6% did not use the CHAS. The reasons of preferring ED were as follows: rapid physical examination (36.4%), not being able to book an earlier appointment at alternative health facilities (30.9%), being close to the facility (12.8%) and being at the hospital for a different reason (12.3%). Among the patients, 20.2% did not express any particular reason. CONCLUSIONS: Non-urgent patients who admitted to the ED are mostly middle-aged patients with no chronic disease. They usually visit the ED for preventable reasons. The use of alternative health facilities and CHAS should be encouraged.

Tetanus immunity status among adult trauma patients in an ED.

OBJECTIVES: Tetanus is a vaccine-preventable infectious disease. It is caused by the bacterium Clostridium tetani. The aim of this study was to investigate tetanus immunity among adult trauma patients. MATERIAL AND METHODS: This study was performed with 267 trauma patients who were admitted to the emergency department of Tepecik Training and Research Hospital in Izmir City, Turkey over a six month period. After obtaining a written informed consent from each patient, a questionnaire concerning demographic information and tetanus vaccination history was filled in by the physician. Patients' blood samples (4-5 cc) were drawn into a test tube while creating an intravenous (IV) access prior to making any attempt for therapy. And the tetanus antibody level (IgG) was measured using the enzyme-linked immunosorbent assay method. Tetanus antibody levels ≥0.1 IU/mL were considered protective. RESULTS: Among 267 patients, 192 and 75 of the cases (71.9% and 28.1%) were male and female, respectively. The median age of the patients was 39 (IQRs = 28-52). Seventy-five percent of the patients (n = 201) had protective immunity rates for tetanus. DISCUSSION AND CONCLUSION: In our study, which was conducted among adults, it was found that the protective ratio of tetanus immunity decreased with age with an additional, significant decline in elderly patients.

A rare cause of elbow injury.

We present the case of a patient who presented to the emergency department complaining of elbow pain after falling. Radiographic views of the elbow were shown.

[Predictive calue of leucocyte count, neutrophil percent and C-reactive protein concentration "cut-off value" on the diagnosis of appendicitis]. / Lökosit sayisi, yüzde nötrofil orani ve C-reaktif protein konsantrasyonlarinin "kesim degeri" düzeylerinde apandisit tanisindaki degerleri.

BACKGROUND: The present study aimed to investigate the predictive importance of cut-off levels of preoperative WBC, neutrophil and CRP concentrations in operated appendicitis patients. METHODS: Patients operated for acute appendicitis between January 2008 and November 2010 were retrospectively screened. Patients were divided into three groups according to postoperative histopathology. Group I: normal appendix, Group II: Uncomplicated appendicitis, Group III: complicated appendicitis. ROC curves are intended for positive distinguishing pathological laboratory measurements. Cut-off values were determined and distinguishing performances were assessed. RESULTS: 175 of the 320 patients were males (54.7%) and 145 were females (45.3%). Average age was 35.95±14.75. While cut-off value for WBC was 12.080 and it was found significant in distinguishing total appandisitis (group II+group III) from normal appendixes and distinguishing group II from group I (p<0.001), it was determined that it was not significant in distinguishing group II from group III (p=0.768). While cut-off value for neutrophil was 73% and it was significant in distinguishing group II+group III from group I and group II from group I (p<0.001), it was detected that it was not significant in distinguishing group II from group III (p=0.681). While cut-off value for CRP was 45.98, it was not found significant in distinguishing group II+group III from group I and group II from group I; however it was significant in distinguishing group II from group III (p<0.001). When all measurements were evaluated together, it was detected that the increase in only the neutrophil percentage rised the non-complicated acute appendisitis (OR: 1.082; p<0.001), and the increase in both neutrophiles and CRP resulted in a rise in the risk of complication (OR: neutrophil=1.066; p=0.009- CRP=1.005; p=0.013). DISCUSSION: The cut-off value of labaratuary tests may help determine the diagnosis and treatment. Especially, cut-off value of CRP may be helpful to determine the method of incision during the operation as conventional appendectomy or laparoscopic appendectomy.

Occupational stress experienced by residents and faculty physicians on night shifts.

BACKGROUND: Occupational stress is an undesired factor causing discomfort for healthcare workers. Stressors in work can lead to dissatisfaction and in turn, this may affect patient care adversely. The aim of this study was to evaluate the occupational stress among residents and faculty physicians of various medical specialties working night shifts. METHODS: Residents and faculty physicians working night shifts in the emergency departments, medical and surgical wards were questioned with Swedish Demand Control Support Questionnaire. Also, various factors (specialty, marital status, sex, number of patients during a typical shift, number of night shifts per month, decision about career making in that specialty, having chronic disease and/or sleep problem) originated from social life or working conditions were investigated that could affect the demand, job-control and job strain model. RESULTS: Of the 108 participants, the mean age was 31 ± 6 years, 40.7% were female, and 78.7% were residents. Job strain was similar among the three physician groups (p > 0.05). Job control and social support was found to be lower among residents while job stress was higher. The social support-scores were lower in residents who were responsible for more than 60 patients, and who had a chronic disease. The demand-scores were lower in faculty physicians who worked 1 to 4 night shifts per month. Job strain was higher in residents with respect to faculty physicians. DISCUSSION: Stress and psychosocial risk factors are considered critical issues in the field of occupational health. Workload and job stress are stated as predictors of workers' health, productivity, and motivation. We found a few job stressors by physician working night shifts such as number of taken care of patient, having chronic disease. But, these physicians were significantly residents, due to their high workload sense. Interestingly, job stress was not more by emergency physicians than others. CONCLUSIONS: Job strain was found to be higher among the residents as compared to the faculty physicians. Job strain was not significantly different among the physicians of emergency medicine than the physicians of the other specialties working night shifts.

Methemoglobinemia caused by dapsone overdose: Which treatment is best?

Increase of methemoglobin level is named as methemoglobinemia characterized by functional anemia and tissue hypoxia. Methemoglobinemia can be congenital, but acquired form are more often caused by various drugs and toxins. Methylene blue is the most effective antidote for acquired methemoglobinemia. When methylene blue is not available, alternative treatments such as ascorbic acid and hyperbaric oxygen can be useful. In this paper we presented a case of methomoglobinemia due to dapsone overdose.

Retrospective analysis of poisoning cases admitted to the emergency medicine.

BACKGROUND: We aimed herein to assess demographic, etiological, and clinical characteristics of patients presenting to our hospital's emergency department with acute poisoning. METHOD: This study included a total of 509 (0.27%) patients diagnosed with poisoning at our emergency department within a 3-year period. This was a retrospective study.  RESULTS: Seventy-one point three (n = 363) percent of the patients were female. The majority of the victims were in the 18-25 years age group (P < 0.001). The poisoning incident was for suicidal purposes in 83.7% of patients. Among the patients presenting with prescription drug poisoning, 92.9% were poisoned in a suicide attempt while 73.2% of patients presenting with poisoning with non-medical substances were poisoned accidentally. Suicidal poisonings were more common in young age group and females (P < 0.001). The most common poisoning agent was antidepressants (17.6%) followed by analgesics (12.8%), and other psychotropic drugs (6.1%). Antidepressant drugs were the most common prescription drugs taken for suicidal purposes (P < 0.001). Poisonings occurred with a single agent in 72.5% of cases and with two or more agents in 27.5% of cases.  Analysis of duration of hospital stay revealed that 52.6% (n = 60) of patients stayed in hospital for 2 days. The mortality rate was 0.4%. CONCLUSION: The majority of poisonings were with prescription drugs, for suicidal purposes, in young age group, and in females. In our study, the three most common agents causing poisoning were antidepressants, analgesics, and other psychotropic substances.

Retropharyngeal Hematoma due to Oral Warfarin Usage.

Retropharyngeal hematoma due to anticoagulant usage is a rare, life-threatening situation which must be immediately diagnosed and treated. Immediate control of the airway and coagulopathy are the bases of treatment management. Patients often respond to conservative treatment but occasionally urgent tracheostomy and endotracheal intubation may be necessary. We presented a case of retropharyngeal hematoma secondary to warfarin usage in a 49-year-old male.

Determining risk factors of bleeding in patients on warfarin treatment.

Background. Warfarin is a commonly used oral anticoagulant agent. The most common adverse effects of warfarin are bleeding complications. Methods. We performed a 1-year retrospective chart review of emergency department patients using warfarin. A total of 65 patients with bleeding disorder (study group) and 63 patients without bleeding (control group) were included, making up a total of 128 subjects. Demographic data, frequency of international normalized ratio (INR) checks, and routine blood results were extracted. Logistic regression analysis was used to determine which factors were most closely associated with bleeding complications. Results. Median age was 62.0 ± 14.4 and 61.9 ± 14.5 for study group and control group, respectively. Educational status and frequency of INR checks were similar in both groups (P = 0.101 and P = 0.483, resp.). INR levels were higher in the study group (5.45 ± 3.98 versus 2.63 ± 1.71, P < 0.001). Creatinine levels were also higher in the study group (1.14 ± 0.57 mg/dL versus 0.94 ± 0.38 mg/dL, P = 0.042). Acetylsalicylic acid use was more frequent in the study group and was associated with a 9-fold increase in bleeding complications (P < 0.001). Conclusions. High INR levels, high creatinine levels, and acetylsalicylic acid use were associated with bleeding complications in ED patients using warfarin.