Attitude is everything: keep probe pitch neutral during side-fire prostate biopsy. A simulator study.

OBJECTIVES: To develop and validate on a simulator a learnable technique to decrease deviation of biopsied cores from the template schema during freehand, side-fire systematic prostate biopsy (sPBx) with the goal of reducing prostate biopsy (PBx) false-negatives, thereby facilitating earlier sampling, diagnosis and treatment of clinically significant prostate cancer. PARTICIPANTS AND METHODS: Using a PBx simulator with real-time three-dimensional visualization, we devised a freehand, pitch-neutral (0°, horizontal plane), side-fire, transrectal ultrasonography (TRUS)-guided sPBx technique in the left lateral decubitus position. Thirty-four trainees on four Canadian and US urology programmes learned the technique on the same simulator, which recorded deviation from the intended template location in a double-sextant template as well as the TRUS probe pitch at the time of sampling. We defined deviation as the shortest distance in millimeters between a core centre and its intended template location, template deviation as the mean of all deviations in a template, and mastery as achieving a template deviation ≤5.0 mm. RESULTS: All results are reported as mean ± sd. The mean absolute pitch and template deviation before learning the technique (baseline) were 8.2 ± 4.1° and 8.0 ± 2.7 mm, respectively, and after mastering the technique decreased to 4.5 ± 2.7° (P = 0.001) and 4.5 ± 0.6 mm (P < 0.001). Template deviation was related to mean absolute pitch (P < 0.001) and increased by 0.5 mm on average with each 1° increase in mean absolute pitch. Participants achieved mastery after practising 3.9 ± 2.9 double-sextant sets. There was no difference in time to perform a double-sextant set at baseline (277 ± 102 s) and mastery (283 ± 101 s; P = 0.39). CONCLUSION: A pitch-neutral side-fire technique reduced template deviation during simulated freehand TRUS-guided sPBx, suggesting it may also reduce PBx false-negatives in patients in a future clinical trial. This pitch-neutral technique can be taught and learned; the University of Florida has been teaching it to all Urology residents for the last 2 years.

Do carboxyhaemoglobin and methaemoglobin levels predict the return of spontaneous circulation and prognosis of cardiac arrest patients?

BACKGROUND: Early prediction of return of spontaneous circulation (ROSC) for cardiac arrest (CA) patients is a major challenge. Different biomarkers have been studied as an early predictor for ROSC, but a consensus has not been achieved in this regard. This study's goal was to investigate the value of the carboxyhaemoglobin (COHb) and methaemoglobin (MetHb) levels as a predictive marker for ROSC and prognostic marker for patients who achieve ROSC. METHODS: A total of 241 adult patients (109 female, 132 male) diagnosed as non-traumatic CA were included in the study. The patients were divided into two groups based on whether they achieved ROSC. The ROSC group was divided into two sub-groups: survivors and non-survivors. Complete blood count parameters, routine biochemistry measurements, coagulation parameters, and blood gas analysis, and cardiac markers values were compared between the groups. RESULTS: COHb levels were significantly lower in the non-ROSC group than in the ROSC group (P = .002). Urea, creatinine, potassium and cTn (cardiac troponin) levels in the non-ROSC group were significantly higher than in the ROSC group (P < .001, .001, .014, and .005, respectively). COHb levels were significantly lower in the non-survivor group than in the survivor group (P = .022). Urea, creatinine, potassium, lactate dehydrogenase, and cTn levels were significantly higher in the non-survivor group than the survivor group (P = .001, .005, .001, .010 and .008, respectively). There was no significant difference between the ROSC and non-ROSC groups and survivor group and non-survivor groups in terms of MetHb levels (P = .769 and .668, respectively). Moreover, CPR duration is significantly shorter in the survivor group than the non-survivor group (P Ë‚ .001). CONCLUSION: COHb levels in the blood gas analysis at the time of admission could be used as a predictive marker for ROSC and prognostic marker for the patients who achieved ROSC.

Concomitant hypertriglyceridemia-induced pancreatitis in pregnant monozygotic twin siblings.

Hypertriglyceridemia-induced pancreatitis (HTIP) is the third most common cause of pancreatitis. Hypertriglyceridemia shows familial transition and pregnancy increases the risk of HTIP. The treatment of HTIP is initiated with supportive treatment and continues with specific treatments including plasmapheresis, insulin, heparin infusion, and hemofiltration. The current study reports monozygotic twins who are pregnant at the same time having concurrent HTIP attack.

Pneumomediastinum, pneumocephalus, and bilateral pneumo-orbita in the same patient: a rare dangerous coexistence but a lucky prognosis.

Trauma is the leading cause of mortality and morbidity among young adults. In the emergency department, blunt and penetrating traumas must be evaluated carefully especially for life-threatening conditions. High-pressure air is a rare penetrating trauma type. Pneumomediastinum, pneumocephalus, and bilateral pneumo-orbita are all dangerous conditions and coexistence of them is extremely rare. There is no consensus for the treatment of this concurrence and, moreover, there is no opportunity for future randomized studies. Hence, in this study, we report a pneumomediastinum, pneumocephalus, and bilateral pneumo-orbita case after high-pressure air trauma and resolution with supportive care without any complication.

Assessment of endotracheal intubation procedures following inadvertent esophageal intubation. A randomized crossover manikin trial.

OBJECTIVE: To evaluate the success, degree of difficulty and completion time of endotracheal intubation without removing the endotracheal tube in the event of an oesophageal intubation.. METHODS: The prospective, randomised crossover study was conducted at Gulhane Training and Research Hospital, Ankara, Turkey, from July 1, 2018, to August 31, 2018, and used a manikin model. Endotracheal intubation was performed using Miller, Macintosh blades and a video laryngoscope. The procedures were randomised into two groups, with group E+ being subjected to it while an endotracheal tube ETT was placed in the oesophagus (E+) simulating the oesophageal intubation, and control group E- getting the standard procedure without the endotracheal tube in the oesophagus. All methods were evaluated for their success, completion time, and degree of difficulty. Data was analysed using SPSS 22. RESULTS: There were 120 manikins, with 60(50%) in each of the two groups. The mean completion time with Miller in E+ group was 19.05±9.65 and for E- it was 17.55±11.95 seconds. With Macintosh, E+ had a mean completion time of 19.85±12.66 seconds and E- had 16.75±8.66. With video laryngoscope, E+ group had a mean completion time of 16.75±8.66 seconds, while E- had it 14.60±8.17. No significant difference was found in the paired group comparisons in terms of the degree of task difficulty (p>0.05). CONCLUSIONS: In case of inadvertent oesophageal intubation condition, leaving the tube in the oesophagus and performing subsequent endotracheal intubation attempts was not found to decrease the rate of success regardless of the laryngoscope type.

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 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.

Development and Validation of a Mixed-Reality Simulator for Reducing Biopsy Core Deviation During Simulated Freehand Systematic Prostate Biopsy.

INTRODUCTION: We describe the development and validation of a mixed-reality prostate biopsy (PBx) simulator with built-in guidance aids and real-time 3-dimensional visualization. METHODS: We evaluated our simulator during one-on-one training sessions with urology residents and attendings from 2018 to 2022. Participants performed freehand, side-fire, double-sextant transrectal ultrasound-guided systematic prostate biopsy (sPBx). After a baseline assessment (first set of 12 biopsy cores), participants trained for 25 minutes with visualization and cognitive aids activated. Training was followed by an exit set of 12 biopsy cores without visualization or cognitive aids and afterward, subjective assessment by trainees of the simulator. Deviation is the shortest distance of the center of a core from its intended template location. RESULTS: Baseline deviations (mean ± SD) for residents (n = 24) and attendings (n = 4) were 13.4 ± 8.9 mm and 8.5 ± 3.6 mm ( P < 0.001), respectively. Posttraining deviations were 8.7 ± 6.6 mm and 7.6 ± 3.7 mm ( P = 0.271), respectively. Deviations between baseline and exit were decreased significantly for residents ( P < 0.001) but not for attendings ( P = 0.093). Overall feedback from participants was positive. Confidence in performing a PBx increased in novices after training ( P = 0.011) and did not change among attendings ( P = 0.180). CONCLUSIONS: A new PBx simulator can quantify and improve accuracy during simulated freehand sPBx while providing visualization and graphical feedback. Improved simulated sPBx accuracy could lead to more even distribution of biopsy cores within the prostate when performed in clinical settings, possibly reducing the high risk of missing an existing lesion and thus decreasing the time to initiating treatment, if indicated.

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.

Micro-Ultrasound Guided Transperineal Prostate Biopsy: A Clinic-Based Procedure.

Prostate cancer is the most common solid malignancy in men and requires a biopsy for diagnosis. This manuscript describes a freehand micro-ultrasound guided transperineal technique performed under local anesthesia, which maintains accuracy, keeps patients comfortable, has low adverse events, and minimizes the need for disposables. Prior micro-ultrasound-guided transperineal techniques required general or spinal anesthesia. The key steps described in the protocol include (1) the placement of the local anesthesia, (2) micro-ultrasound imaging, (3) and the visualization of the anesthetic/biopsy needle while uncoupled from the insonation plane. A retrospective review of 100 patients undergoing this technique demonstrated a 68% clinically significant cancer detection rate. Pain scores were prospectively collected in a subset of patients (N = 20) and showed a median procedural pain score of 2 out of 10. The 30 day Grade III adverse event rate was 3%; one of these events was probably related to the prostate biopsy. Overall, we present a simple, accurate, and safe technique for performing a micro-ultrasound-guided transperineal prostate biopsy.

Can mainstream end-tidal carbon dioxide measurement accurately predict the arterial carbon dioxide level of patients with acute dyspnea in ED.

OBJECTIVE: This study was designed to determine whether the mainstream end-tidal carbon dioxide (ETCO2) measurement can accurately predict the partial arterial carbon dioxide (Paco2) level of patients presented to emergency department (ED) with acute dyspnea. METHODS: This prospective, observational study was conducted at a university hospital ED, which serves more than 110 000 patients annually. Nonintubated adult patients presented with acute dyspnea who required arterial blood gas analysis were recruited in the study for a 6-month period between January and July 2010. Patients were asked to breathe through an airway adapter attached to the mainstream capnometer. Arterial blood gas samples were obtained simultaneously. RESULTS: We included 162 patients during the study period. The mean ETCO2 level was 39.47 ± 10.84 mm Hg (minimum, 19 mm Hg; maximum, 82 mm Hg), and mean Paco2 level was 38.95 ± 12.27 mm Hg (minimum, 16 mm Hg; maximum, 94 mm Hg). There was a positive, strong, statistically significant correlation between ETCO2 and Paco2 (r = 0.911, P < .001). The Bland-Altman plot shows the mean bias ± SD between ETCO2 and Paco2 as 0.5 ± 5 mm Hg (95% confidence interval, -1.3165-0.2680) and the limits of agreement as -10.5 and +9.5 mm Hg. Eighty percent (n = 129) of the ETCO2 measurements were between the range of ±5 mm Hg. CONCLUSION: Mainstream ETCO2 measurement accurately predicts the arterial Paco2 of patients presented to ED with acute dyspnea. Further studies comparing mainstream and sidestream methods in these patients are required.

Features of patients with upper gastrointestinal bleeding and factors affecting the re-bleeding risk.

BACKGROUND: The risk of re-bleeding in upper gastrointestinal bleeding (UGIB) is a major complication that can be mortal. In this study, we aimed to determine the factors that can predict the risk of re-bleeding in UGIB patients. METHODS: We retrospectively screened UGIB patients admitted in adult intensive care. Along with age and gender, complaints of admission, vital signs, comorbidities, laboratory findings, medications, endoscopy status, and re-bleeding status were recorded. According to these findings, Glasgow-Blatchford and AIMS65 scores of the patients were calculated. All statistical tests were performed with the Predictive Analytics Software (PASW®, version 18, SPSS Inc., Chicago, IL). RESULTS: A total of 241 patients were included in the study. Mean age of patients was 57.58±19.31, years and 176 (73.0%) of them were male. A total of 117 (48.5%) patients were Helicobacter pylori positive and re-bleeding occurred in 77 (32.0%) patients. Sclerotherapy was applied in 103 (42.7%) patients, while 5 (2.1%) underwent electrocoagulation, and 4 (1.7%) underwent hemoclips. There was a significant difference between patients with and without endoscopic intervention for re-bleeding (p<0.001). Hematocrit, urea values, Glasgow-Blatchford, and AIMS65 scores were statistically significant different between the groups with and without re-bleeding (p=<0.001, <0.001, <0.001, and 0.008, respectively). In the ROC analysis of Glasgow-Blatchford and AIMS65 scoring systems area, under the curve values were 0.700 (p=<0.001, 95% CI: 0.626-0.775), and 0.557 (p=0.194, CI 95%: 0.469-0.645), respectively. Mortality rate was 2.1% (n=5) among study population. CONCLUSION: Hematocrit and urea values seem beneficial among studied laboratory values, however, Glasgow-Blatchford scoring system performed better than AIMS65 in the prediction of re-bleeding risk in UGIB. The authors concluded that more specific predictive markers may be useful for clinicians.

Manual Conservation of Supplemental Oxygen in Low-Resource Settings During the COVID-19 Pandemic.

SUMMARY STATEMENT: Using a simulated adult COVID-19 patient with hypoxemia, we investigated whether caregivers interrupting oxygen flow by manually occluding oxygen tubing with pliers during exhalation can conserve oxygen while maintaining oxygenation. Oxygen pinching reduced oxygen use by 51% to 64%, maintained simulated oxygen saturation between 88% and 90%, and increased simulated average alveolar partial pressure of oxygen from a room air baseline of approximately 131 to 294-424 mm Hg compared with 607 mm Hg with 10 liters per minute (LPM) continuous oxygen flow. Simulation provided a methodology to rapidly evaluate a technique that has begun to be used with COVID-19 patients in low-resource environments experiencing an acute oxygen shortage.

[Contribution of Turkish Emergency Medicine to the international literature: evaluation of 15 years]. / Türk acil tibbinin uluslararasi literatüre katkisi: 15 yilin degerlendirilmesi.

BACKGROUND: The aim of this study was to present characteristics of internationally published articles originating from Turkish Emergency Medicine (EM) departments over the last 15 years. METHODS: The PubMed database was searched for all articles published from 1995 to 2010 that originated from Turkish EM departments. RESULTS A total of 514 articles were included. Of all articles, 77% (n=396) were published in the last five years. Publications were detected to increase at a rate of 6.2 articles per year. 58.7% (n=302) of the articles were published in non-EM journals. Advances in Therapy in the non-EM group, with 27 articles, and the Turkish Journal of Trauma & Emergency Surgery in the EM group, with 48 articles, were the preferred journals. The most popular subjects were toxicology, at 26% (n=134), followed by trauma, at 16% (n=86). 7.7% (n=40) of all articles were animal studies and 6% (n=31) were randomized controlled trials. CONCLUSION: Significant publication growth was detected related with the development of EM in Turkey. The preference for non- EM journals, toxicology as the most popular subject and the effect of university hospitals were the interesting results of this study. The low number of multicenter, randomized controlled trials and of published articles in high impact factor journals have led us to consider the importance of publication quality, which requires additional effort.

Investigation of the Value of T peak to T end and QTc Intervals as Electrocardiographic Arrhythmia Susceptibility Markers in Acute Ischemic Stroke.

INTRODUCTION: Arrhythmias are one of the most common causes of mortality in patients with acute ischemic stroke (AIS). This study aimed to investigate the relationships of arrhythmia susceptibility markers (QT, QTc, Tpe, Tpe-D, Tpe/QT, and Tpe/QTc) with the localization and volume of the ischemic area, the National Institutes of Health Stroke Scale (NIHSS) scores, and troponin levels in AIS. METHODS: Patients diagnosed with AIS in the emergency department in the period from 01 November 2016 to 31 March 2019 were retrospectively reviewed. Patients admitted to the emergency department with no pathological ECG findings were included. The measurements of QT, QTc, Tpe, Tpe-D, Tpe/QTc, and Tpe/QT were performed under a digital microscope. The NIHSS scores, troponin values, and the ischemic area volume based on the diffusion-weighted magnetic resonance imaging findings at the time of admission were found. RESULTS: A total of 135 patients, comprising 70 AIS patients and 65 individuals as controls, were included in the study. The male/female ratio was 73/62 and the mean age was 68.51±10.80 years. All of the ECG parameters in the AIS group and the control group were statistically significantly different between the groups except Tpe-D (p=0.454) (For QT, QTc, Tpe, Tpe/QTc, and Tpe/QT; p=0.003, 0.022, <0.001, 0.001, 0.001; respectively). QT, QTc, Tpe, Tpe/QTc, and Tpe/QT values were not significantly different between the groups with a NIHSS score of ≤5 and >5 (p=0.480, 0.688, 0.663, 0.512, 0.333, respectively). CONCLUSIONS: Arrhythmia susceptibility markers including QT, QTc, Tpe, the values of Tpe-D, Tpe/QT, and Tpe/QTc are different in AIS patients compared to the individuals in the control group; therefore, these parameters can be included among the other parameters of close cardiac monitoring.

Endotracheal Intubation by Paramedics Using Neodymium Magnet and Modified Stylet in Simulated Difficult Airway: A Prospective, Randomized, Crossover Manikin Study.

BACKGROUND: The present study evaluates the success and efficacy of endotracheal intubation (ETI) using a modified intubation stylet and a magnet system to direct the stylet into the trachea. The system was developed by the researchers in an attempt to increase the success and efficacy of ETI. METHODS: ETI procedures were performed on an airway management manikin by emergency medical technicians with at least four years of experience in ETI. The technicians used a stylet modified with an iron ball affixed to the tip and a neodymium magnet, designed specifically for the study. The intention was to guide the endotracheal tube into the trachea at the level of the thyroid and cricoid cartilages on the manikin with the aid of the modified stylet and the magnetic force of the neodymium magnet. The success rate, completion time, and degree of difficulty of two procedures were compared: magnetic endotracheal intubation (METI) and classic ETI (CETI). RESULTS: The success rate was 100% in both groups. The mean completion times for the METI and CETI procedures were 18.31 ± 2.46 s and 20.01 ± 1.95 s, respectively. There were significant differences in completion time and degree of difficulty between the METI and CETI procedures (both p=0.001). CONCLUSIONS: We found the use of a neodymium magnet and modified stylet to be an effective method to guide the endotracheal tube into the trachea. The present study may provide a basis for future studies.

Using Standardized Checklists Increase the Completion Rate of Critical Actions in an Evacuation from the Operating Room: A Randomized Controlled Simulation Study.

INTRODUCTION: Hospital evacuations of patients with special needs are extremely challenging, and it is difficult to train hospital workers for this rare event.Hypothesis/Problem:Researchers developed an in-situ simulation study investigating the effect of standardized checklists on the evacuation of a patient under general anesthesia from the operating room (OR) and hypothesized that checklists would improve the completion rate of critical actions and decrease evacuation time. METHODS: A vertical evacuation of the high-fidelity manikin (SimMan3G; Laerdal Inc.; Norway) was performed and participants were asked to lead the team and evacuate the manikin to the ground floor after a mock fire alarm. Participants were randomized to two groups: one was given an evacuation checklist (checklist group [CG]) and the other was not (non-checklist group [NCG]). A total of 19 scenarios were run with 28 participants. RESULTS: Mean scenario time, preparation phase of evacuation, and time to transport the manikin down the stairs did not differ significantly between groups (P = .369, .462, and .935, respectively). The CG group showed significantly better performance of critical actions, including securing the airway, taking additional drug supplies, and taking additional equipment supplies (P = .047, .001, and .001, respectively). In the post-evacuation surveys, 27 out of 28 participants agreed that checklists would improve the evacuation process in a real event. CONCLUSION: Standardized checklists increase the completion rate of pre-defined critical actions in evacuations out of the OR, which likely improves patient safety. Checklist use did not have a significant effect on total evacuation time.

Comparison of the efficacy of ShotBlocker and cold spray in reducing intramuscular injection-related pain in adults. A prospective, randomized, controlled trial.

OBJECTIVES: To compare the efficacy of ShotBlocker and cold spray in reducing intramuscular (IM) injection-related pain in adults. Methos: A prospective, randomized, controlled study carried out between January 2018 and March 2018 at the Department of Emergency Medicine, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey. Adult patients receiving IM injection of diclofenac sodium (75 mg/3 ml) were included. The patients were randomized into 3 groups: ShotBlocker, cold spray, and control. Each group comprised 40 patients. Patients were instructed to rate the intensity of IM injection-related pain using a 100-mm visual analog scale (VAS). Visual analog scale scores of the patients were statistically analyzed. Results: Visual analog scale scores were lower in the ShotBlocker (11 mm) and cold spray (10 mm) groups than in the control group (31 mm) (p=0.001). There were no significant differences in VAS scores between the ShotBlocker and cold spray groups. The operators' responses revealed that ShotBlocker was more difficult to administer than cold spray. Conclusion: ShotBlocker is an effective non-pharmacological method that reduces IM injection-related pain and is similar in efficacy, to cold spray.