Effect of access block on emergency department crowding calculated by NEDOCS score.

OBJECTIVE: Emergency department (ED) crowding poses a significant challenge in healthcare systems globally, leading to delays in patient care and threatening public health and staff well-being. Access block, characterized by delays in admitting patients awaiting hospitalization, is a primary contributor to ED overcrowding. To address this issue, the National Emergency Department Overcrowding Study (NEDOCS) score provides an objective framework for assessing ED crowding severity. This study aims to evaluate the impact of access block on ED crowding using the NEDOCS score and to explore strategies for mitigating overcrowding through scenarios over a 39-day period. METHODS: A single-center, prospective, observational study was conducted in an urban tertiary care referral center. The NEDOCS score was collected six times daily, including variables like total ED patients, ventilated patients, boarding patients, the longest waiting times, and durations of boarding patients. NEDOCS scores were recorded, and calculations were performed to assess the potential impact of eliminating access block in scenarios. RESULTS: NEDOCS scores ranged from 62.4 to 315, with a mean of 146, indicating consistent overcrowding. Analysis categorized ED conditions into different levels, revealing that over 81.2% of the time, the ED was at least overcrowded. The longest boarding patient's waiting duration was identified as the primary contributor to NEDOCS (48.8%). Scenarios demonstrated a significant decrease in NEDOCS when access block was eliminated through timely admissions. Shorter boarding times during non-working hours suggest the potential mitigating effect of external factors on the access barrier. Additionally, daytime measurements were associated with lower patient admissions and shorter wait times for initial assessment. CONCLUSION: Although ED crowding is a multifactorial problem, our study has shown that access block contribute significantly to this problem. The study emphasizes that eliminating access block through timely admissions could substantially alleviate crowding, highlighting the importance of addressing this issue to enhance ED efficiency and overall healthcare delivery.

Prediction of nipple involvement in breast cancer after neoadjuvant chemotherapy: Should we rely on breast MRI to preserve the nipple?

BACKGROUND: Indications for nipple sparing mastectomy (NSM) is extending to post-neoadjuvant chemotherapy (NAC) setting. Eligibility for NSM with an optimum tumor-nipple distance (TND) after NAC is unclear. We examined predictive factors for nipple tumor involvement in patients undergoing total mastectomy following NAC. METHODS: Clinical and pathological data from prospectively collected medical records of women with invasive breast carcinoma, who were undergone NAC and total mastectomy with sentinel lymph node biopsy and/or axillary lymph node dissection were analyzed. PreNAC and postNAC magnetic resonance imaging (MRI) views were examined and a cut-off TND value for predicting the negative nipple tumor status was determined. RESULTS: Among 180 women, the final mastectomy specimen analysis revealed that 12 (7%) had nipple involvement as invasive carcinoma. Patients with nipple involvement had more postNAC multifocal/multicentric tumors (p: 0.03), larger tumors on preNAC and postNAC images (p: 0.002 and p < 0.001), shorter median TNDs on preNAC and postNAC images (7 mm-IQR 1.5-14, p: 0.005 and 8.5 mm-IQR 3-15.5, p < 0.001, respectively), more nipple retraction on preNAC and postNAC images (p: 0.007 and p: 0.006) and more nipple areola complex skin thickening (> 2mm) on preNAC and postNAC images (p < 0.001 and p: 0.01). The best likelihood ratios (LR) belonged to the postNAC positivity of the < 20 mm TND, with a + LR of 3.40, and - LR of 0.11 for nipple involvement. PreNAC positivity of the < 20 mm TND also had a similar - LR of 0.14. CONCLUSION: A TND-cut-off  ≥ 2 cm on preNAC and postNAC MRI was shown to be highly predictive of negative nipple tumor involvement.

Isopropyl alcohol nasal inhalation for nausea in the triage of an adult emergency department.

OBJECTIVES: Nausea and vomiting (N&V) are among the most common complaints in the emergency department (ED). However, low acuity is assigned to most of these patients at the triage, and waiting for long hours without medication decreases patient safety and satisfaction. We aimed to compare the inhalation of isopropyl alcohol (IPA) with placebo (P) to treat nausea at the triage area of an ED. METHODS: In this prospective, randomized and placebo-controlled trial, we used a convenience sample of consecutive adult (ages 18-65) patients presented to the triage area of the ED with the complaint of N&V, and we randomized them to inhale IPA or P embedded gauzes. We used an 11-point (0-10) numeric rating scale (NRS) to evaluate the degree of N&V before the inhalation, at the baseline, and at 2, 4 and 10 min after the inhalation. RESULTS: We randomized 118 patients (IPA, n = 62; P, n = 56, intent-to-treat), three patients left the ED without being seen, and 115 patients completed the study. IPA and P groups were similar according to age, sex, comorbidities, and vital signs. We found that patients in the IPA group had significantly lower mean NRS starting with the 2nd minute (robust two-way mixed ANOVA between-subjects, p = 0.008). We also observed a significant within-subjects effect in the IPA group. The mean NRS value was decreased at each consecutive time point in the IPA group (all pairwise comparisons, p < 0.001). CONCLUSION: In this study, IPA was significantly more effective than P for N&V at the triage. Moreover, patients in the IPA group had less need for rescue treatment.

The middle cerebral artery density and ratio for the diagnosis of acute ischaemic stroke in the Emergency Department.

PURPOSE: Non-contrast computed tomography (ncCT) is the first-line imaging modality for acute ischaemic stroke diagnosis. Recognition of the early diagnostic signs of a stroke on computed tomography (CT) is crucial. The hyperdense middle cerebral artery (MCA) sign is one of these findings. We investigated the diagnostic utility of absolute MCA density (MCAD) in patients with acute MCA stroke confirmed with diffusion-weighted magnetic resonance imaging (dwMRI). METHODS: We retrospectively included all patients who presented to the Emergency Department with symptoms related to an acute stroke and confirmed with a dwMRI and ncCT to this diagnostic case-control study. An expert radiologist with more than four years of experience in neuroradiology re-evaluated all ncCT images. The evaluation of MCAD and ratio were measured on axial images in Hounsfield units (HU). RESULTS: We included 407 patients in our study (MCA infarction: 55%, n = 225; Control: 45%, n = 182). We calculated the threshold for the highest sensitivity (20%) and specificity (94%) as 49 HU with the Youden J index test for MCAD and as 1.1 for MCAD ratio (sensitivity 20% and specificity 95%). MCAD >49 HU or MCAD ratio >1.1 alone or joint use of MCAD >47 HU and MCAD ratio >1.1 are useful markers to confirm the diagnosis of MCA AIS with a specificity of at least 94%. Higher MCAD values are associated with larger infarction volumes. CONCLUSION: MCAD and MCAD ratio can be used to identify patients who need early treatment, especially in situations where computed tomography angiogram or dwMRI are not readily available.

The Diagnostic Accuracy of Ultrasonography for the Diagnosis of Rib Fractures in Patients Presenting to Emergency Department With Blunt Chest Trauma.

BACKGROUND: Rib fractures are the most common complications of blunt chest trauma (BCT). Computed tomography (CT) is the modality of choice for BCT, but with several disadvantages. Ultrasonography (US) is an inexpensive, readily available, and relatively harmless imaging alternative. However, a direct comparison of the sonographic evaluation of the rib as a whole with CT as a reference has not been performed to date. OBJECTIVE: This study aimed to compare the diagnostic accuracy of US with CT for the detection of rib fractures in patients who presented to emergency department (ED) with BCT. METHODS: We included a convenience sample of adult patients who presented to the ED with thoracic pain after BCT in the last 24 h in this prospective, observational, diagnostic accuracy study. The diagnostic utility of US performed by an emergency physician was compared with thorax CT. RESULTS: The final study population included 145 patients. The diagnostic accuracy of US was 80% with a sensitivity of 91.2% and specificity of 72.7% for the detection of any rib fracture (positive likelihood ratio 3.4 and negative likelihood ratio 0.12). If we considered each rib separately, the sensitivity of US decreased to 76.7% and specificity increased to 82.7% (81.3% accuracy). CONCLUSIONS: A negative US of the site of the highest tenderness and neighboring ribs in a patient with BCT who presented to the ED with lateralizing pain decreases the possibility of a rib fracture significantly. However, a positive US performs poorly to specify the exact location and number of the fractured ribs.

Association of acute phase reactants with prognostic scores in community acquired pneumonia.

OBJECTIVE: To investigate the association of C-reactive protein and procalcitonin with commonly used prognostic scoring systems, hospitalisation and mortality in cases of community-acquired pneumonia. METHODS: The prospective study was conducted from April 2014 to April 2015 at the emergency department of Marmara University Pendik Research and Training Hospital, Turkey, and comprised community-acquired pneumonia patients diagnosed according to the British Thoracic Society criteria. Prognosis was estimated using confusion, urea, respiratory rate, blood pressure and age >65, Pneumonia Severity Index-Pneumonia Patient Outcome Research Team score, and severe community-acquired pneumonia scores. Data was analysed using MedCalc 15.8. RESULTS: Of the 203 patients assessed, community-acquired pneumonia was confirmed in 152(74.8%). Procalcitonin had moderate correlation with the three scales used (p<0.001), while C-reactive protein had weak correlation with them (p<0.004). CONCLUSIONS: Both procalcitonin and C-reactive protein levels were found to be correlated with prognostic risk scores.

Initial and Sustained Response Effects of 3 Vagal Maneuvers in Supraventricular Tachycardia: A Randomized, Clinical Trial.

BACKGROUND: For acute termination of supraventricular tachycardia (SVT), vagal maneuvers, including the standard Valsalva maneuver (sVM), modified Valsalva (mVM) maneuver, and carotid sinus massage (CSM), are first-line interventions. There is no criterion standard technique. OBJECTIVE: This prospective, randomized study was aimed at analyzing the success rates of these 3 vagal maneuvers as measured by sustaining sinus rhythm at the fifth minute and SVT termination. METHODS: We conducted this prospective, randomized controlled study in an emergency department (ED). We enrolled all the patients who were admitted to the ED and diagnosed with SVT. We randomly assigned them to 3 groups receiving sVM, mVM, and CSM and recorded the patients' responses to the vagal maneuvers and SVT recurrence after vagal maneuvers. RESULTS: The study was completed with 98 patients. A total of 25 (25.5%) instances of SVT were initially treated successfully with vagal maneuvers. The success rate was 43.7% (14/32 cases) from mVM, 24.2% (8/33) for sVM, and 9.1 % (3/33) for CSM (p < 0.05). At the end of the fifth minute, only 12.2% (12/98) of all patients had sinus rhythm. Sinus rhythm persisted in 28.1% (9/32) of patients in the mVM group, 6.1% (2/33) of patients in the sVM group, and 3% (1/33) in the CSM group at the fifth minute (p < 0.05). CONCLUSION: mVM is superior to the CSM maneuver in terminating SVT and maintaining rhythm. We conclude that it is beneficial to use mVM, which is more effective and lacks side effects.

Diagnostic accuracy of the Extended Focused Abdominal Sonography for Trauma (E-FAST) performed by emergency physicians compared to CT.

INTRODUCTION: The diagnostic accuracy of the FAST exam performed by EM residents were shown to be similar to radiology residents. However, in the last 2 decades, an extended-FAST (E-FAST) protocol including thoracic examination to exclude pneumo- and hemothorax was introduced. The accuracy of emergency physicians (EPs) while performing E-FAST is a less studied area, especially in Europe. The aim of this study was to compare the diagnostic accuracy of the E-FAST exam performed by EM residents with the results of CT scan as a gold standard. METHODS: This was a prospective, observational, diagnostic accuracy study conducted at the ED of a Level 1 Trauma Center. All consecutive adult multiple trauma patients were eligible, and any patient in whom thoraco-abdominal CT was ordered were recruited. Unstable and unavailable patients were excluded. E-FAST examination was performed by EPs as the index test, and CT examinations reported by a blinded academic radiology faculty was the gold standard. RESULTS: A total of 140 patients were recruited from eligible 144 patients. The final study population was 132 for abdominal and 130 for thorax examinations. In this study, AUC of E-FAST was 0.71 for abdominal free fluid, 0.87 for pneumothorax and 1.00 for pleural effusion. The sensitivity was 42.9% and specificity was 98.4%. The +LR for abdominal free fluid was 26.8 and -LR was 0.58. CONCLUSION: E-FAST examination has an excellent specificity. However, the sensitivity of the test is not high enough to rule-out thoraco-abdominal injuries in trauma patients when performed by EPs.

Diagnostic utilities of tracheal ultrasound and USB-endoscope for the confirmation of endotracheal tube placement: A cadaver study.

OBJECTIVES: Confirmation of the endotracheal tube placement (CoETP) has the utmost importance in the management of an airway. Visualization of tracheal rings or carina with a fiber-optical bronchoscope (FOB) has considered to be a reliable method for the CoETP. However, FOB is expensive, time-consuming, and not always practical. Inexpensive endoscopic USB-cameras were shown to aid intubation successfully and reliably. On the other hand, there have been no studies investigating their use for the CoETP. Tracheal ultrasonography (TUS) is also a new, inexpensive and widely available alternative. A cadaver study has planned to evaluate the diagnostic utility of TUS and a USB-camera. METHODS: This study was conducted in the Anatomy Lab of a University on a fresh frozen female cadaver. Three senior Emergency Physicians have intubated the cadaver, and performed TUS or USB-endoscopy. We have prepared a randomized intubation list (n=96) in three blocks (3 times 32) as to include equal number of esophageal and tracheal intubations (48 for each). Each EP is performed all three interventions (intubation, TUS and USB-endoscopy) in consecutive blocks of 32 intubations, in turn. The position of the tube has been verified from a 2cm wide ostium on the proximal trachea. RESULTS: In this study, all intubations (n=96, 100%) were correctly identified as tracheal or esophageal with both TUS and USB-camera. Both the sensitivity and specificity of TUS and USB-endoscopy for the CoETP were 100.0%. CONCLUSION: The perfect accuracy of TUS and USB-endoscopy, have placed those techniques in a unique position as an alternative in resource-poor situations.

Predictors of false negative diffusion-weighted MRI in clinically suspected central cause of vertigo.

INTRODUCTION: Vertigo is classified as peripheral and central. Differentiation of stroke mimics is the most important diagnostic challenge. There is no clinical guidance for the indications of neuroimaging in isolated vertigo patients. The primary aim of this study is to test the diagnostic value of a DWI-MRI protocol to rule-out a central cause in patients with acute isolated vertigo in the ED. METHODS: We prospectively enrolled 144 patients who were presented with isolated vertigo to the ED. A detailed neurological examination and maneuvers were performed for differential diagnosis. All patients underwent CT and/or DW-MRI either during ED visit or at the follow-up, if necessary. Out-patient follow-up exams and evaluations were repeated until all patients had a definitive diagnosis. RESULTS: In the study, 137 of the 144 patients completed the follow-up period, and 34 of 137 patients were diagnosed with central vertigo. Six of 34 central vertigo patients had normal DW-MRI findings. One was diagnosed with migraine headache and five with vertebra-basilar insufficiency during the out-patient follow-up. One of the 28 patients with a pathological MRI was diagnosed with mass and the rest was stroke. The utility of DW-MRI in vertigo patients was moderately high (sensitivity: 82%, specificity: 100%). We found that age, history of HT, history of CAD and vertigo unresponsive to ED treatment were significantly associated with a central cause of vertigo. CONCLUSION: We suggest that unresponsiveness to ED treatment, especially in patients with a history of HT and CAD, should alert physicians for central causes and warrant DW-MRI imaging.

Which is more effective for the treatment of Acute Migraine Attack: Dexketoprofen, Ibuprofen or Metoclopramide?

OBJECTIVE: The aim of this study was head-to-head comparison of the efficacy and rate of adverse events of metoclopramide, ibuprofen and dexketoprofen for the acute treatment of migraine attack in the real-life conditions of a busy emergency department (ED). METHODS: This was a prospective, observational, cross-sectional study. All patients who presented to the ED with a headache fulfilling the inclusion criteria were enrolled. All patients were treated by the attending emergency physicians in their daily routine. If an IV treatment in the ED was found indicated by the EP, they selected one of the options in the written departmental migraine treatment protocol. RESULTS: During the study period, 54 patients met the inclusion criteria. The median change in the pain score was significantly different among treatment options (p<0.0001). The median pain score change at the end of the 30 minutes for treatment groups were 7.5 mm (IQR: 7.0-8.0), 5.0 mm (IQR: 4.75-7.0), and 7.0 mm (IQR: 6.0-7.25), respectively (p=0.0002). All three groups were found to be significantly different from each other in the post-hoc analysis. CONCLUSION: All drugs compared in this study are effective in the relief of migraine headache. However, IV dexketoprofen seems to be faster and more effective than metoclopramide and ibuprofen.

Prognostic value of 2-hour lactate level and lactate clearance for 30-day mortality and comparison with trauma scores in multi-trauma patients.

OBJECTIVE: Trauma scores are prone to misreading. Therefore, a readily available, objective way to estimate the mortality of the trauma patients is needed. We aimed to evaluate the prognostic utility of lactate levels, and clearance for 30-days mortality, and compare with the physiological trauma scores. METHODS: All adult trauma patients (two hundred) admitted to ED were enrolled. Initial and 2-hour serum lactate levels were measured and components of GAP, MGAP, RTS, VIEWS and VIEWS-L trauma scores were calculated. RESULTS: Final study population was 200 patients with a median age of 33 years. Mortality was 7/200 (3.5%) in 30-days. Both initial (2.3 vs. 7.7 mmol/L) and 2h-lactate (1.7 vs. 8.4 mmol/L) levels were significantly lower, and lactate clearance was significantly higher (23.8% vs. -12.0%) in survivors. Also, the change in the lactate level from 0h to 2h (2.3 vs. 1.7mmol/L) was significant in survivors, contrary to non-survivors (7.7 vs. 8.4mmol/L). VIEWS-L, VIEWS, two hour-lactate level and EMTRAS showed high specificity at the 100% sensitivity cut-offs, therefore, were the most valuable prognostic parameters in this study. CONCLUSION: Calculation of 2h-lactate clearance and evaluation of a 2h-lactate level may not be needed to predict long-term mortality if the initial lactate level is below 2.8mmol/L.

Normal values of cervical vertebral measurements according to age and sex in CT.

INTRODUCTION: Atlantodental interval (ADI), basion-dental interval (BDI) and the thickness of prevertebral soft tissue (TOPST) measured in lateral cervical radiographs were reported to be useful indicators and indirect signs of underlying cervical spine injuries. However, cervical computed tomography (MDCT) is the first method of imaging used in all trauma patients and upper normal limits (UNLs) of cervical distances according to age and sex are undetermined. Therefore, we aimed to calculate these metrics. METHODS: 500 adult trauma patients with cervical MDCT at the time of admission were retrospectively selected. ADI, BDI, and TOPSTs were measured by two blinded researchers. RESULTS: 488 cervical spine CT scans were reported to be normal and 12 has pathological findings. Mean ADI, BDI and TOPST of C1, C2, C6 and C7 were statistically significantly wider in males. In females, ADI and BDI were significantly narrower with the increase in age. In males, only ADI was significantly narrower, and TOPST of C6 and C7 vertebra were significantly wider with the increase in age. We found the optimal UNLs as follows: ADI 2.5mm, BDI 8.5mm, C1 6.5mm, C2 5.7mm, C3 6.3mm (6mm for C1-3 for practical purposes), C4 11.7 and C5-7 17mm. DISCUSSION: We believe that the increase in distances with age may be affected by the height losses of discs and vertebral bodies, formation of anterior osteophytes and regional kyphosis by age. Those results were compatible with the previous reports.

Is potassium thiosulfate a poison? Is it safe? A case series.

Potassium Thiosulfate is a liquid substance used for producing fertilizers. In this case series, we present five patients who have been exposed to potassium thiosulfate inhalation. Three of them were intubated in the scene by paramedics because of confusion and respiratory depression. They had refractory status epilepticus. The other two were exposed during trying to help the others for getting out, they presented to ED with nausea, vomiting and headache. One of the intubated patients died on the 4th day of his follow-up at ICU. Others were sent home after few days with no complication. Potassium thiosulfate is not a substance documented for poisoning and it is assumed to be a safe and stable solution. Although, it was assumed to be a safe substance there are risks of metabolic acidosis, resistant generalized seizures, and death due to disturbance of oxidative reactions with potassium thiosulfate.

Determination of the chest wall thicknesses and needle thoracostomy success rates at second and fifth intercostal spaces: a cadaver-based study.

INTRODUCTION: The purposes of this study were to measure the chest wall thicknesses (CWTs) at second intercostal space (ICS) mid-clavicular line (MCL) and fifth ICS MAL directly, and compare the actual success rates of needle thoracostomies (NTs) by inserting a 5-cm-long syringe needle. Predictive values of weight, body mass index (BMI) and CWT were also analyzed. MATERIALS AND METHODS: This study included 199 measurements of 50 adult fresh cadavers from both hemithoraces. Five-centimeter-long syringe needles were inserted and secured. Penetration into the pleural cavity was assessed, and CWTs at 4 locations were measured. Achieved power of this study for the primary aim of CWT comparison from 2nd and 5th ICSs was .94. RESULTS: Overall mean CWTs at 2nd ICS MCL and 5th ICS MAL were measured as 2.46 ± 0.78 and 2.89 ± 1.09, respectively, and 5th ICS MAL was found to be statistically thicker (P = .002). The success rate of NT at 2nd ICS MCL was 87% (95% CI, 80-94), and that at 5th ICS MAL was 78% (95% CI, 70-86; P = .3570). Only 6 (17.1%) of 35 failed NTs had a CWT greater than 5-cm. Needle thoracostomy has failed in 29 (14.9%) of 194 locations, despite a CWT less than 5-cm. Below a weight of 72 kg, BMI of 23 kg/m2, or CWT of 2.4 cm, all NTs were successful. DISCUSSION AND CONCLUSIONS: In this report, we present the largest cadaver-based cohort to date to the best of our knowledge, and we observed a statistically nonsignificant 9% more NT success rate at 2nd ICS at a power of 88% and statistically significant more success rate in males at 5th ICS was (47.7%). We also observed thinner CWTs and higher success rates than previous imaging-based studies. A BMI of 23 kg/m2 or less and weight of 72 kg or less seem to accurately rule-out NT failure in cadavers, and they seem to be better predictors at the bedside.

The utility of heart-type free fatty-acid binding-protein (HFABP) levels for differentiating acute ischemic stroke from stroke mimics.

BACKGROUND: Heart-type fatty acid-binding protein (HFABP) is found in the myocardium, brain, and some organs and is rapidly released from damaged cells into the circulation in case of ischemia. AIMS: We aimed to determine the diagnostic utility of HFABP levels in patients suggesting acute ischemic stroke (AIS). METHODS: This study was a prospective, single-center, observational diagnostic accuracy study with a nested cohort design. The estimated sample size was 126 patients, with a 1:1 case and control ratio. We included all consecutive patients with a lateralizing symptom (motor or sensory) or finding suggesting AIS (139 patients) who presented to ED within 24 h of their symptom onset and collected plasma at admission to the ED. After further evaluations, 111 patients (79.8%) were diagnosed with AIS and 28 with other neurological diseases (stroke-mimics). FINDINGS: In our study, the median HFABP levels of the cases and controls were 2.6 µg/ml and 2.2 µg/ml, respectively, without any statistically significant difference (p = 0.120). The diagnostic accuracy of HFABP for AIS was also insignificant at 0.60 (95% CI 0.51-0.68; p = 0.119). DISCUSSION: Plasma HFABP level is not a marker that can differentiate AIS from other neurological pathologies in patients presenting to the ED, with findings suggesting AIS.

Earliest electrocardiogram is golden for the diagnosis of Brugada syndrome.

Cardiac syncope can be classified as being either structural or dysrhythmogenic in origin, and it may be the only warning symptom of sudden cardiac death. One of the causes of dysrhythmic sudden cardiac death in young adults with structurally normal hearts is Brugada syndrome. Electrocardiogram (ECG) of Brugada syndrome is characterized by an ST-segment elevation in the right precordial leads. A 23-year-old man was presented to our emergency department (ED) with a history of syncope which has occurred 30 minutes before arrival and lasted for 10 minutes. Both physical and neurological examinations were unremarkable. Family history revealed coronary artery disease of his father and sudden death at 45. Initial ECG performed 3 minutes after his arrival showed a type 2 repolarization variant of Brugada syndrome. This pattern was reverted back to normal 5 minutes later and never showed up again on his future ECGs. In our case, it was only the earliest ECG that made the diagnosis possible since all future ECGs showed a perfectly normal pattern throughout the follow-up period. In all syncope patients, initial ECGs should be kept and filed to be reviewed again in case the primary physician is not competent enough for the evaluation of ECG.

Use of ABCD2 risk scoring system to determine the short-term stroke risk in patients presenting to emergency department with transient ischaemic attack.

OBJECTIVE: To determine the 3-day stroke risk of patients presenting to emergency department with transient ischaemic attack, and to evaluate the predictive value of ABCD(2) (Age, Blood pressure, Clinical features, Duration of symptoms and Diabetes) score for these patients. METHODS: The prospective study was conducted on patients with diagnosis of transient ischaemic attack who were divided into low (0-3 points), medium (4-5 points) and high (6-7 points) risk groups according to their ABCD(2) scores. The sensitivity of the scoring system on estimation of the risk of stroke in 3 days was evaluated through receiver operating characteristic curve. SPSS 15 was used for data analysis. RESULTS: Of the 64 patients in the study, none of the low-risk group had stroke. Stroke was present in 4 of 33 (12.12%) medium-risk patients, while there were 4 in 18 (22.22%) in the high-risk group. Sensitivity and specificity of each ABCD(2) score for 3rd day stroke risk was calculated. In the receiver operating curve generated by these calculations, the c statistics was determined as 0.76 (95% CI: 0.64, 0.86; p < 0.01) and the most appropriate cut-off score to dichotomise the study group was determined as 4. CONCLUSIONS: In transient ischaemic attack patients with an ABCD(2) score of four or higher had a markedly increased short-term stroke risk, while those with a lower score were quite safe. It is appropriate to hospitalise patients with a score of four or more and investigate for underlying cause and initiate treatment.

Endoscopic gastrostomy, nasojejunal and oral feeding comparison in aspiration pneumonia patients.

BACKGROUND: Aspiration pneumonia is a potentially preventable illness requiring attention to small details of patient care. The type, management, and care of feeding should be carried out properly. MATERIALS AND METHODS: This is a prospective clinical study of enteral feeding on patients admitted to hospital with aspiration pneumonia. The known enteral nutritional methods, advantages, and disadvantages were told to the patient or proxy. If they didn't accept Percutaneous endoscopic gastrostomy (PEG), nasojejunal tube (NJT) was advised. If they denied all of the procedures, oral feeding education was given. A total of 94 patients were enrolled to the study, 29 of them accepted PEG, 42 preferred NJT, and 23 preferred oral route. RESULTS: A total of 94 patients with a mean age of 77.84, standard deviation 10.784; 95% confidence interval (CI) 75.63-80.03 were enrolled to the study of which 27 (28.7%) patients had a history of aspiration pneumonia. Oral feeding was prominently preferred for patients nursed by a relative (15; 65.2% of Oral feeding group and 16% of total) or a caregiver (7; 30.4% of Oral feeding group and 7.4% of total) while only 1 (4.3% of Oral feeding group and 1.1% of total) with a health-care worker (P = 0.001). Overall re-aspiration rates at the 6(th) month were 58%, 78%, 91% in EG, NJT, oral groups, respectively. Sixth months' survival rates of the different feeding groups were not significantly divergent from each other. History of aspiration was also found to be a significant contributor of mortality. CONCLUSION: In aspiration pneumonia patients' long-term survival rates of the different feeding groups were not significantly divergent from each other.

Comparison of the Analgesic Effects of Low-Dose Ketamine Versus Fentanyl in Patients With Long Bone Fractures in the Emergency Department: A Prospective Observational Study.

Aim and background In most emergency departments (ED), opioids are the primary analgesic agents for trauma patients. However, safe alternative drugs are required because of possible adverse effects. Ketamine, an anesthetic agent, provides satisfactory analgesia at low doses and is an alternative drug that has begun to be used in numerous areas with fewer side effects. This study aimed to compare low-dose ketamine and fentanyl infusions in terms of their pain-relieving effects and observed adverse effects in patients presenting to the ED with isolated long bone fractures. Materials and methods This single-center observational study was conducted in the ED of the Marmara University Pendik Training and Research Hospital between August 2018 and December 2019. Patients diagnosed with isolated long bone fractures who were administered low-dose ketamine or fentanyl rapid infusions for pain relief were included in the study. Patient pain scores were evaluated using the visual analog scale (VAS) with a standard horizontal 10-centimeter line. The primary outcome of the study was to compare the changes in pain at 30 and 60 min after medication administration for each group. Results A total of 100 patients were included in the study. Ketamine infusion was administered to 48% (n=48) of the patients as a pain reliever. After 60 min of observation, pain was significantly reduced in both study groups. However, the pain scores at baseline (p=0.319), 30 min (p=0.631), and 60 min (p=0.347) after treatment were similar in both groups. In terms of the observed adverse effects, dizziness was more common in the ketamine group (p=0.010). Conclusion The results of this study showed that low-dose ketamine infusion (0.3 mg/kg/h) had a similar effect to fentanyl infusion (1 mcg/kg/h) as a pain reliever in patients with isolated long bone fractures in the ED.