Predictive performance of the common red flags in emergency department headache patients: a HEAD and HEAD-Colombia study.

OBJECTIVES: Only a small proportion of patients presenting to an ED with headache have a serious cause. The SNNOOP10 criteria, which incorporates red and orange flags for serious causes, has been proposed but not well studied. This project aims to compare the proportion of patients with 10 commonly accepted red flag criteria (singly and in combination) between patients with and without a diagnosis of serious secondary headache in a large, multinational cohort of ED patients presenting with headache. METHODS: Secondary analysis of data obtained in the HEAD and HEAD-Colombia studies. The outcome of interest was serious secondary headache. The predictive performance of 10 red flag criteria from the SNNOOP10 criteria list was estimated individually and in combination. RESULTS: 5293 patients were included, of whom 6.1% (95% CI 5.5% to 6.8%) had a defined serious cause identified. New neurological deficit, history of neoplasm, older age (>50 years) and recent head trauma (2-7 days prior) were independent predictors of a serious secondary headache diagnosis. After adjusting for other predictors, sudden onset, onset during exertion, pregnancy and immune suppression were not associated with a serious headache diagnosis. The combined sensitivity of the red flag criteria overall was 96.5% (95% CI 93.2% to 98.3%) but specificity was low, 5.1% (95% CI 4.3% to 6.0%). Positive predictive value was 9.3% (95% CI 8.2% to 10.5%) with negative predictive value of 93.5% (95% CI 87.6% to 96.8%). CONCLUSION: The sensitivity and specificity of the red flag criteria in this study were lower than previously reported. Regarding clinical practice, this suggests that red flag criteria may be useful to identify patients at higher risk of a serious secondary headache cause, but their low specificity could result in increased rates of CT scanning. TRIAL REGISTRATION NUMBER: ANZCTR376695.

Emergency Response and Clinical Insights from a Non-Epicenter Hospital during the 2023 Turkey-Syria Earthquake: A Retrospective Analysis.

BACKGROUND The Turkey-Syria earthquake of February 6, 2023, impacted 11 provinces and necessitated widespread emergency medical support. Although not at the disaster's epicenter, Ankara Mamak State Hospital in Ankara, Turkey, offered critical multidisciplinary support. This retrospective study evaluates the factors that drove 124 admissions to the hospital's Emergency Department (ED) following the earthquake. MATERIAL AND METHODS We recorded patient demographic data, dates of arrival at the ED, provinces of origin, diagnoses, treatments, consultations during the ED visit, and patient outcomes. The majority of the 124 admissions were due to trauma and multi-organ damage, and the primary diagnostic tools were physical examination and radiological imaging. Of these patients, 85.5% (106) recovered and were discharged directly from the ED, 11 were admitted for continued care, and 7 were referred to another hospital. RESULTS The 124 cases consisted of adults injured within the first 20 days post-earthquake, with a mean age of 46.5±17.4 years, and a higher number of females. A peak in admissions was observed on the third and fourth days following the earthquake, with the most cases originating from the Hatay province. The most frequently injured body region was the lower extremity, and orthopedic consultations significantly outnumbered other surgical consultations. CONCLUSIONS Our findings underscore the vital role of robust, multidisciplinary disaster preparedness in all EDs, especially in regions prone to natural disasters.

Thunderclap headache syndrome presenting to the emergency department: an international multicentre observational cohort study.

BACKGROUND: Most headache presentations to emergency departments (ED) have benign causes; however, approximately 10% will have serious pathology. International guidelines recommend that patients describing the onset of headache as 'thunderclap' undergo neuroimaging and further investigation. The association of this feature with serious headache cause is unclear. The objective of this study was to determine if patients presenting with thunderclap headache are significantly more likely to have serious underlying pathology than patients with more gradual onset and to determine compliance with guidelines for investigation. METHODS: This was a planned secondary analysis of an international, multicentre, observational study of adult ED patients presenting with a main complaint of headache. Data regarding demographics, investigation strategies and final ED diagnoses were collected. Thunderclap headache was defined as severe headache of immediate or almost immediate onset and peak intensity. Proportion of patients with serious pathology in thunderclap and non-thunderclap groups were compared by χ² test. RESULTS: 644 of 4536 patients presented with thunderclap headache (14.2%). CT brain imaging and lumbar puncture were performed in 62.7% and 10.6% of cases, respectively. Among patients with thunderclap headache, serious pathology was identified in 10.9% (95%CI 8.7% to 13.5%) of cases-significantly higher than the proportion found in patients with a different headache onset (6.6% (95% CI 5.9% to 7.4%), p<0.001.). The incidence of subarachnoid haemorrhage (SAH) was 3.6% (95% CI 2.4% to 5.3%) in those with thunderclap headache vs 0.3% (95% CI 0.2% to 0.5%) in those without (p<0.001). All cases of SAH were diagnosed on CT imaging. Non-serious intracranial pathology was diagnosed in 87.7% of patients with thunderclap headache. CONCLUSIONS: Thunderclap headache presenting to the ED appears be associated with higher risk for serious intracranial pathology, including SAH, although most patients with this type of headache had a benign cause. Neuroimaging rates did not align with international guidelines, suggesting potential need for further work on standardisation.

Seasonal variations of patients presenting dyspnea to emergency departments in Europe: Results from the EURODEM Study

Background/aim: To describe seasonal variations in epidemiology, management, and short-term outcomes of patients in Europe presenting to an emergency department (ED) with a main complaint of dyspnea. Materials and methods: Anobservational prospective cohort study was performed in 66 European EDs which included consecutive patients presenting to EDs with dyspnea as the main complaint during 3 72-h study periods. Data were collected on demographics, comorbidities, chronic treatment, prehospital treatment, mode of arrival of patient to ED, clinical signs at admission, treatment in the ED, ED diagnosis, discharge from ED, and in-hospital outcome. Results: The study included 2524 patients with a median age of 69 (53­80) years old. Of the patients presented, 991 (39.3%) were in autumn, 849 (33.6%) were in spring, and 48 (27.1%) were in winter. The winter population was significantly older (P < 0.001) and had a lower rate of ambulance arrival to ED (P < 0.001). In the winter period, there was a higher rate for lower respiratory tract infection (35.1%), and patients were more hypertensive, more hypoxic, and more hyper/hypothermic compared to other seasons. The ED mortality was about 1% and, in hospital, mortality for admitted patients was 7.4%. Conclusion: The analytic method and the outcome of this study may help to guide the allocation of ED resources more efficiently and to recommend seasonal ED management protocols based on the seasonal trend of dyspneic patients.

The factors predicting pneumonia in COVID-19 patients: preliminary results from a university hospital in Turkey

Background/aim: Pneumonia is the most serious clinical presentation of COVID-19. This study aimed to determine the demographic, clinical, and laboratory findings that can properly predict COVID-19 pneumonia. Materials and methods: This study was conducted in the Gazi University hospital. All hospitalized patients with confirmed and suspected SARS-CoV-2 infection between 16 March 2020 and 30 April 2020 were analyzed retrospectively. COVID-19 patients were separated into two groups, pneumonia and nonpneumonia, and then compared to determine predicting factors for COVID-19 pneumonia. Variables that had a P-value of less than 0.20 and were not correlated with each other were included in the logistic regression model. Results: Of the 247 patients included in the study 58% were female, and the median age was 40. COVID-19 was confirmed in 70.9% of these patients. Among the confirmed COVID-19 cases, 21.4% had pneumonia. In the multivariate analysis male sex (P = 0.028), hypertension (P = 0.022), and shortness of breath on hospital admission (P = 0.025) were significant factors predicting COVID-19 pneumonia. Conclusion: Shortness of breath, male sex, and hypertension were significant for predicting COVID-19 pneumonia on admission. Patients with these factors should be evaluated more carefully for diagnostic procedures, such as thorax CT.

The predictive value of Alvarado score, inflammatory parameters and ultrasound imaging in the diagnosis of acute appendicitis.

OBJECTIVE: Acute appendicitis (AA) is one of the most common surgical emergencies. Despite extraordinary advances in modern investigations, the accurate diagnosis of AA remains an enigmatic challenge. The aim of this study was to compare and evaluate the diagnostic accuracy of inflammatory parameters [C-reactive protein (CRP), procalcitonin (PCT), erythrocyte sedimentation rate (ESR)], ultrasound (US) and Alvarado score (AS) in reducing the rate of negative appendectomies. MATERIAL AND METHODS: Two hundred seventy-eight patients were included in this study. Patients were separated into two main groups as the surgery group (n=184) and non-operative group (n=94). Complete blood count, ESR and PCT levels were assessed, abdominal US was performed and AS was calculated for all patients. RESULTS: In the surgery group, clinical predictive factors for histopathologic results such as AS ≥7, AA signs on US, neutrophilia and leukocytosis were significant. Neutrophilia and leukocytosis had the highest accuracy rate among these factors. Inflammatory parameters were not predictive for histopathologic results, although higher CRP and PCT levels were significant in perforated and necrotizing appendicitis. Multifactorial regression analyses showed that AS was not of significant predictive value in the non-operative group. CONCLUSION: There was no superiority of AS and/or US in the diagnosis of AA. Recent findings have shown the most reliable parameters in the diagnosis of AA to be primarily 'neutrophilia' and secondarily 'leukocytosis'. Other results of this study indicated that inflammatory parameters (CRP, PCT, ESR) were not superior to other parameters but CRP and PCT levels were significantly high in complicated cases.

Acute Serum Calcium Level Changes Following Non-Massive Blood and Blood Product Transfusion in Emergency Department; a Cross-sectional Study.

Introduction: The specific impact on calcium dynamics after non-massive blood transfusions remains relatively unexplored. This study aimed to compare pre- and post-transfusion calcium levels in patients receiving blood and blood product in the emergency department. Methods: This is a single-center, prospective, cross-sectional study conducted at the Emergency Department of Gazi University Health Research and Application Center Hospital in Ankara, Turkey, from January 1, 2020, to August 31, 2020. The study included adult patients who underwent blood and blood product transfusions, and serum calcium levels were measured and compared from samples taken before and after transfusion. Results: A total of 292 participants were enrolled in the study, with 242 participants included in the final analysis. The mean total calcium level was 8.41 ± 0.76 mg/dL before transfusion and 8.34 ± 0.71 mg/dL after transfusion (p=0.012). When examining the corrected calcium values after receiving blood products based on the type of blood products, participants who received apheresis platelets had a post-transfusion corrected calcium value of 8.26 ±0.41 mg/dL, with a pre-transfusion value of 9.09 ±0.49 mg/dL (p<0.01). The post-transfusion ionized calcium value for participants receiving apheresis was 1.04 ±0.08 mg/dL, compared to 1.15 ±0.09 mg/dL for those who did not receive apheresis (p=0.049). There was a significant relationship between receiving fresh frozen plasma and post-transfusion ionized calcium values (p=0.024). Conclusion: This study demonstrated that transfusion-associated hypocalcemia can occur even at mild levels in patients receiving blood and blood product transfusions in the emergency department. However, it is suggested that the clinical effects of hypocalcemia, even when occurring based on the type and quantity of blood products, are minimal and negligible.

Microscopic hematuria as a marker of blunt abdominal trauma in rats: description of an experimental model.

BACKGROUND: Microscopic hematuria is an extremely important sign in blunt abdominal trauma (BAT) patients. Controversies still exist in the literature on whether microscopic hematuria is a sign of intra-abdominal extrarenal organ injury and is an indication for radiographic assessment of BAT patients. In this study, a new BAT rat model was developed, and we tried to determine the relationships between microscopic hematuria and extrarenal intra-abdominal organ injury. METHODS: After verifying our model, lethal and maximal sublethal intensity of impact energy determined in the rats. Animals allocated into six sublethal impact energy groups. BAT was induced by dropping a standard mass from variable heights. After 2 hours of examining period, macroscopic laparotomy findings, histopathological liver, spleen and renal injury grades, and microscopic hematuria levels were recorded in these six groups. RESULTS: According to our results, while the trauma intensity increase severity of the histopathological injury increases for all organs. Although there was a significant correlation between microscopic hematuria and trauma intensity, we could not show same relationship between microscopic hematuria and histopathological organ injury. On the other hand, microscopic hematuria was correlated with the macroscopic laparotomy findings. CONCLUSIONS: Microscopic hematuria could serve as a predictor of the severity of trauma and intra-abdominal organ injury. This study would support the use of abdominal imaging and attentive assessment for intra-abdominal organ injury in stable BAT patients with hematuria. The laparotomy threshold may be lowered for unstable BAT patients with hematuria.

Trends in medical students' career choice of emergency medicine: A 14-year study.

INTRODUCTION: The long-term trends of medical students' choice for emergency medicine (EM) in Turkey are unclear. With this background, we aimed to determine the change in the rate of EM preferences of students over the years. METHODS: This was a cross-sectional study originated from 6th-year medical students' feedback forms, to examine trends of EM carrier preferences between 2005 and 2018 in a tertiary care academic emergency department. There are two main questions containing "would you choose EM as a specialty?" and "why?" as open-ended questions in the form. The answers to the open-ended question were classified as six main factors, which were perception of work, lifestyle, nature of work, personal job preference, mentorship/department experiences, and income. RESULTS: During the study, 2957 forms (80.6% of 3668) were completed by 6th-year medical students. Of the students, 26.5% (n = 784) responded "yes" to the question, which was "would you choose EM as a specialty?," 6.1% (n = 181) responded "do not know," and 67.4% (n = 1992) responded "no." In 2005, 15% of students stated that they would choose EM, while this rate increased to 29% in 2018 (χ 2: 9.67; P trend = 0.003). Perception of work was the most common reason for "yes" (46.3%), "no" (46%), and "do not know" answers. CONCLUSION: The rate of EM choice of medical students doubled during the study, and approximately one in three students stated that they could choose EM as their future career in the past year. Perception of work was the main factor for choosing or rejecting to EM.

Blunt abdominal trauma: evaluation of diagnostic options and surgical outcomes.

BACKGROUND: In the present study, it is intended to outline the diagnostic tests and their influences on decisions of the surgeon about patients presented with blunt abdominal trauma. METHODS: One hundred forty-four patients (98 males, 46 females; mean age 36; range 17 to 84 years) admitted to Gazi University School of Medicine due to blunt abdominal trauma (BAT) between May 2003-May 2005 were reviewed retrospectively. Age, gender, injury mechanism, Glasgow Coma Scale, revised trauma score, follow-up period, applied diagnostic procedures, and treatment methods were evaluated. RESULTS: The underlying cause was traffic accident in 126 (87.5%) patients, fall from height in 14 (9.7%) patients, and blows in 4 (2.8%) patients. Isolated abdominal trauma was seen in 21 patients and multisystem trauma in 123 patients. The most frequent associated trauma was head injury (66.6%). Abdominal ultrasonography (USG) was applied in 139 (97%) of the patients, and abdominal computed tomography (CT) was performed in 73 (51%). Diagnostic peritoneal lavage (DPL) was applied in 41 (28%) patients, and 15 (37%) of them proved to be positive. While emergency laparotomy was applied in 19 (13.2%) of the patients, 21 hemodynamically stable patients were diagnosed to have free fluid through USG and CT and were followed-up. During the follow-up period, 2 patients were scheduled to be operated, and small intestine perforation was found in these patients. The overall mortality rate for all patients was 16%, and the postoperative mortality rate with respect to the operated patients was 14.3%. CONCLUSION: If USG, CT, and DPL are applied in a complementary manner, a large number of patients with solid organ injuries secondary to blunt trauma can be managed nonoperatively. Thus, unnecessary laparotomies can be avoided and related morbidities and mortalities decreased.

Resveratrol Rescues Kidney Mitochondrial Function Following Hemorrhagic Shock.

OBJECTIVE: Hemorrhagic shock may contribute to acute kidney injury (AKI) by profoundly altering renal mitochondrial function. Resveratrol (RSV), a naturally occurring sirtuin 1 (SIRT1) activator, has been shown to promote mitochondrial function and reduce oxidative damage in a variety of aging-related disease states. We hypothesized that RSV treatment during resuscitation would ameliorate kidney mitochondrial dysfunction and decrease oxidative damage following hemorrhagic shock. METHODS: Using a decompensated hemorrhagic shock model, male Long-Evans rats (n = 6 per group) were killed prior to hemorrhage (sham), at severe shock, and following either lactated Ringer's (LR) resuscitation or LR + RSV resuscitation (RSV: 30 mg/kg). At each time point, blood samples were assayed for arterial blood gases, lactate, blood urea nitrogen, and serum creatinine. Mitochondria were also isolated from kidney samples in order to assess individual electron transport complexes (complexes I, II, and IV) using high-resolution respirometry. Total mitochondria reactive oxygen species were measured using fluorometry, and lipid peroxidation was assessed by measuring 4-hydroxynonenal by Western blot. Quantitative polymerase chain reaction was used quantify mRNA from peroxisome proliferator-activated receptor γ coactivator 1-α (PGC1-α) SIRT1, and proteins known to mitigate oxidative damage and promote mitochondrial biogenesis. RESULTS: Resveratrol supplementation during resuscitation restored mitochondrial respiratory capacity and decreased mitochondrial reactive oxygen species and lipid peroxidation. Compared with standard LR resuscitation, RSV treatment significantly increased SIRT1 and PGC1-α expression and significantly increased both superoxide dismutase 2 and catalase expression. Although RSV was associated with decreased lactate production, pH, blood urea nitrogen, and serum creatinine values did not differ between resuscitation strategies. CONCLUSIONS: Resuscitation with RSV significantly restored renal mitochondrial function and decreased oxidative damage following hemorrhagic shock.

Mean platelet volume and red cell distribution width as a diagnostic marker in acute appendicitis.

BACKGROUND: Acute appendicitis (AA) is one of the most common causes of emergent surgeries. Many methods are used for its diagnosis. OBJECTIVES: This study was conducted to investigate the diagnostic value of MPV and RDW in acute appendicitis. PATIENTS AND METHODS: This study was a retrospective multi-center cross sectional planned study. The study included 260 patients operated for AA and 158 patients as the control group. Groups were compared in terms of MPV, RDW, white blood cell count (WBC), neutrophil predominance (NP) and platelet count (PC). RESULTS: MPV was significantly lower in AA group, compared to the control group (P < 0.001). The best cut-off level for MVP in AA was ≤ 7.3 fL and the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy ratio were 45%, 89.2%, 87.3%, 49.6% and 61.7%, respectively. There was no significant difference between the two groups in terms of RDW and platelet values. CONCLUSIONS: MPV is a routinely measured parameter in complete blood count (CBC) and requires no additional cost. It significantly decreased in AA, having a greater sensitivity and NPV when combined with WBC and NP.

Can peripheral blood mononuclear cells be used as a proxy for mitochondrial dysfunction in vital organs during hemorrhagic shock and resuscitation?

INTRODUCTION: Although mitochondrial dysfunction is thought to contribute to the development of posttraumatic organ failure, current techniques to assess mitochondrial function in tissues are invasive and clinically impractical. We hypothesized that mitochondrial function in peripheral blood mononuclear cells (PBMCs) would reflect cellular respiration in other organs during hemorrhagic shock and resuscitation. METHODS: Using a fixed-pressure HS model, Long-Evans rats were bled to a mean arterial pressure of 40 mmHg. When blood pressure could no longer be sustained without intermittent fluid infusion (decompensated HS), lactated Ringer's solution was incrementally infused to maintain the mean arterial pressure at 40 mmHg until 40% of the shed blood volume was returned (severe HS). Animals were then resuscitated with 4× total shed volume in lactated Ringer's solution over 60 min (resuscitation). Control animals underwent the same surgical procedures, but were not hemorrhaged. Animals were randomized to control (n = 6), decompensated HS (n = 6), severe HS (n = 6), or resuscitation (n = 6) groups. Kidney, liver, and heart tissues as well as PBMCs were harvested from animals in each group to measure mitochondrial oxygen consumption using high-resolution respirometry. Flow cytometry was used to assess mitochondrial membrane potential (Ψm) in PBMCs. One-way analysis of variance and Pearson correlations were performed. RESULTS: Mitochondrial oxygen consumption decreased in all tissues, including PBMCs, following decompensated HS, severe HS, and resuscitation. However, the degree of impairment varied significantly across tissues during hemorrhagic shock and resuscitation. Of the tissues investigated, PBMC mitochondrial oxygen consumption and Ψm provided the closest correlation to kidney mitochondrial function during HS (complex I: r = 0.65; complex II: r = 0.65; complex IV: r = 0.52; P < 0.05). This association, however, disappeared with resuscitation. A weaker association between PBMC and heart mitochondrial function was observed, but no association was noted between PBMC and liver mitochondrial function. CONCLUSIONS: All tissues including PBMCs demonstrated significant mitochondrial dysfunction following hemorrhagic shock and resuscitation. Although PBMC and kidney mitochondrial function correlated well during hemorrhagic shock, the variability in mitochondrial response across tissues over the spectrum of hemorrhagic shock and resuscitation limits the usefulness of using PBMCs as a proxy for tissue-specific cellular respiration.