Management and Morbidity of Major Pelvic Hemorrhage in Complex Abdominopelvic Surgery.

INTRODUCTION: Hemorrhage is a challenging complication of pelvic surgery. This study aimed to analyze the causes, management, and factors associated with morbidity in patients experiencing major pelvic hemorrhage during complex abdominopelvic surgery. METHODS: Patients who had major intraoperative pelvic hemorrhage during complex abdominopelvic surgery at 11 tertiary referral centers between 1997 and 2017 were included. Patient characteristics, management strategies to control bleeding, short- and long-term postoperative outcomes were evaluated retrospectively. RESULTS: There were 120 patients with a mean age of 56.6 ± 2.4 years and a mean BMI of 28.3 ± 1 kg/m2. While 104 (95%) of the patients were operated for malignancy, 16 (5%) of the patients had surgery for a benign disease. The most common bleeding site was the presacral venous plexus 90 (75%). Major pelvic hemorrhage was managed simultaneously in 114 (95%) patients. Electrocauterization 27 (23%), pelvic packing 26 (22%), suturing 7 (6%), thumbtacks application 7 (6%), muscle welding 4 (4%), use of energy devices 2 (2%), and topical hemostatic agents 2 (2%) were the management tools. Combined techniques were used in 43 (36%) patients. Short-term morbidity and mortality rates were 48 (40%) and 2 (2%), respectively. High preoperative CRP levels (p = 0.04), history of preoperative radiotherapy (p = 0.04), longer bleeding time (p = 0.006), and increased blood transfusion (p = 0.005) were the factors associated with postoperative morbidity. CONCLUSION: Postoperative morbidity related to major pelvic hemorrhage can be reduced by optimizing the risk factors. Prehabilitation prior to surgery to moderate inflammatory status and prompt action with proper technique to control major pelvic hemorrhage can prevent excessive blood loss in complex abdominopelvic surgery.

Immature Granulocyte Count and Percentage as New Predictors of Mortality in Patients with Upper Gastrointestinal Bleeding.

AIMS: Early identification of patients at risk of adverse outcomes may increase the survival rates in patients with upper gastrointestinal bleeding (UGIB), but this can be difficult to predict in emergencies. The aim of the study is to evaluate immature granulocyte (IG), which can be obtained from simple hemogram tests in patients with UGIB, in terms of clinical use and as a mortality marker. MATERIALS AND METHODS: The patients diagnosed with UGIB between March 1, 2019, and September 30, 2019, were evaluated retrospectively. Demographic characteristics, causes of hemorrhage, clinical presentations, hemogram, and biochemistry values at ED admission and 30-day mortality status of the patients were examined. We divided the patients into groups according to their mortality status, and the groups were compared among themselves in terms of parameters. RESULTS: A total of 213 patients who met the inclusion criteria were included in the study. Of these patients, 139 (65.3%) were male and the mean age was 65.05 ± 16.7 years. Fifteen (7%) of them were in the nonsurvival group, while 198 (93%) were in the survival group. The efficacy of both the IG count (IGC) and IG% in predicting mortality was statistically significant (p = 0.002, p = 0.008, respectively). The sensitivity and specificity for the IGC were found as 60% and 84.4; for the IG%, they were found as 66.7% and 75.7%, respectively. CONCLUSION: IGC and IG% are independent risk factors for the 30-day mortality status. These measurements are obtained from simple hemogram tests and may be useful for the evaluation of mortality in patients with UGIB. HOW TO CITE THIS ARTICLE: Bedel C, Korkut M, Avci A, Uzun A. Immature Granulocyte Count and Percentage as New Predictors of Mortality in Patients with Upper Gastrointestinal Bleeding. Indian J Crit Care Med 2020;24(9):794-798.

A dermatologic emergency; Sweet's syndrome.

BACKGROUND: Sweet's syndrome (SS), also known as acute febrile neutrophilic dermatosis, is a rare condition characterized by recurrent erythematous skin lesions. Skin lesions appear as papules, nodules and plaques located on the upper extremity, trunk, neck and face. CASE REPORT: A 72-year-old male patient presented to the emergency department with a 10-day history of generalized rash, generalized muscle and joint pain and high fever. He had a history of upper respiratory tract infection. He presented with painful erythematous plaques on both lower and upper extremities and the trunk as well as serohemorrhagic bullous lesions on the feet. The laboratory results revealed WBC count of 20.6 × 103/mm3 (76.9% neutrophils), CRP (c-reactive protein) of 33 mg/L and erythrocyte sedimentation of 110/h. The patient was referred to a dermatologist with prediagnosis of SS due to the presence of typical painful skin lesions, high fever and neutrophilic leukocytosis. A systemic corticosteroid therapy was initiated. The diagnosis for SS was confirmed after the skin biopsy revealed the presence of dense dermal infiltrate of neutrophils and leukocytoclasis in the upper dermis. The patient responded rapidly to corticosteroids and the skin lesions improved. CONCLUSION: We reported this case as it was a rare life-threatening dermatosis diagnosed in the emergency department, which is generally difficult to diagnose therein, and the skin lesions appeared on the lower extremities.

Evaluation of Tpeak-end interval, Tpeak-end/QT, and Tpeak-end/Qtc ratio during acute migraine attack in the emergency department.

INTRODUCTION: During an acute migraine attack, changes in ventricular repolarisation parameters may occur due to an imbalance in the autonomic nervous system. Tpeak-tend (Tp-e) interval, Tp-e/QT ratio, and Tp-e/corrected QT (QTc) ratio are novel parameters of arrhythmogenesis and can be easily calculated in electrocardiography (ECG). The objective of this study is to demonstrate that novel ventricular repolarisation parameters can anticipate the risk of ventricular dysrhythmia in the migraine attack period. METHODS: This research was a prospective case-control study, which recruited a total of 144 participants, including 74 migraine patients and 70 healthy volunteers in the control group (CG) who met the criteria for migraine with or without aura. All participants underwent 12-lead ECG recordings, and the study compared the Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio with those of the CG. RESULTS: The average age of patients experiencing migraine attacks was 38.14 ± 10.82, with 58 (76%) of these patients being female. The Tp-e interval mean was higher in the migraine attack group than the CG, with a statistically significant difference discovered (74.22 ± 20.20 ms [ms] compared to 65.39 ± 11.33 ms, p = 0.001). However, there were higher mean Tp-e/QT and Tp-e/QTc ratios in the migraine attack group compared to the CG, and this difference was found to be statistically significant (0.20 ± 0.05 vs. 0.17 ± 0.03, p = 0.001, 0.18 ± 0.52 vs 0.16 ± 0.29, p = 0.003, respectively). CONCLUSION: Prolonged Tp-e interval and elevated Tp-e/QT and Tp-e/QTc ratios were observed in migraine patients who presented to the emergency department, indicating a potential risk of ventricular dysrhythmia.

The effect of indicators of CALLY index on survival in glioblastoma.

INTRODUCTION: Glioblastoma is the most common primary brain tumor in adults. Recently, research has been published on the potential prognostic indicators associated with different types of cancer. Due to the limited availability of data investigating the relationship between the CALLY index and glioblastoma patients, we aimed to conduct this study. MATERIALS AND METHODS: Between January 2017 and December 2023, we conducted a study on patients diagnosed with glioblastoma. We collected demographic data and routine laboratory tests at the time of admission. To calculate the CALLY index, we used the formula (albumin value × lymphocyte count) / CRP value × 104. Parameters were compared for in-hospital mortality across different groups. RESULTS: The study analyzed 202 patients who met the inclusion criteria. Of these, 165 (81.7%) were classified as "survivors" and 37 (18.3%) as "deceased." A comparison of hematologic parameters between the two groups showed a significantly lower CALLY index in the "deceased" group (3.05 (4.92)) compared to the "survivor" group (10.13 (13.69)) (p < 0.001). The study compared the parameters between groups with regard to in-hospital mortality. CONCLUSIONS: Based on the results of the study, we conclude that the CALLY index can be considered an easily applicable indicator for the mortality of glioblastoma patients.

Complicated Meckel's diverticulum and therapeutic management.

OBJECTIVE: This study aimed to investigate the treatment options and compare patient management with the literature for patients operated on for an acute abdomen who had complications due to inflammation of the Meckel's diverticulum at our clinics. MATERIAL AND METHODS: This study retrospectively evaluated 14 patients who had been operated on for acute abdomen and had been diagnosed with Meckel's diverticulitis (MD) in Ege University Medical Faculty Department of General Surgery, between October 2007 and October 2012. RESULTS: Fourteen patients with a diagnosis of Meckel's diverticulitis (MD) were retrospectively analyzed. Radiologically, the abdominal computer tomography showed pathologies compatible with mechanical intestinal obstruction, Meckel's diverticulitis and peridiverticular abscess, as well as detection of free air within the abdomen on direct abdominal X-ray. Among patients diagnosed with complicated Meckel's diverticuli (obstruction, diverticulitis, perforation) 10 patients had partial small bowel resection and end-to-end anastomosis (71.5%), three patients underwent diverticulum excision (21.4%), and one patient underwent right hemicolectomy+ileotransversostomy (7.1%). CONCLUSION: Meckel's diverticulum is a vestigial remnant of an omphalomesenteric channel in the small bowel. It is a real congenital diverticular abnormality that contains all three layers of the small bowel. Surgical excision should be performed if Meckel's diverticulum is detected in order to avoid incidental complications such as ulceration, bleeding, bowel obstruction, diverticulitis or perforation. Meckel's diverticulitis does not have specific clinical and radiological findings. Delayed diagnosis can lead to lethal septic complications. Complications associated with Meckel's diverticulitis, especially if a definite diagnosis is not made during the preoperative period, should be considered in the differential diagnosis. In the presence of a complicated diverticulum the appropriate treatment should be emergent surgical intervention.

Spontaneous intestinal intramural hematoma: What to do and not to do.

OBJECTIVE: Spontaneous intestinal intramural hematoma is a rare complication of anticoagulant treatment. In this study, we retrospectively evaluated 14 patients with the diagnosis of intramural hematoma of the small intestine who were followed-up and treated in our clinic, and we aimed to determine current approaches in the diagnosis and treatment of intramural hematoma. MATERIAL AND METHODS: Between February 2010-October 2012, 14 patients diagnosed with small intestinal intramural hematoma were retrospectively analyzed. Nine patients were followed due to clinical findings and 5 patients underwent operation with a histopathological diagnosis of intramural hematoma. RESULTS: Abdominal computed tomography demonstrated ileal and jejunal wall thickening in 10 patients, while findings were consistent with mesenteric vascular disease in four. Five patients were operated due to mechanical bowel obstruction and acute abdomen. The other 9 patients were followed up with medical treatment and 8 of these patients were already using warfarin due to cardiac bypass and valve replacement. CONCLUSION: Spontaneous intestinal intramural hematoma is a rare cause of small bowel obstruction due to intramural hematoma, which is encountered even more rarely. An intramural hematoma should be considered among differential diagnosis of patients who present with abdominal pain and symptoms of obstruction with a history of anticoagulant drug use and elevated International Normalized Ratio (INR) levels. Early diagnosis and medical follow-up can provide a good response to treatment in the majority of patients without requiring surgery.

Abducens paralysis-a rare complication of spinal anesthesia at an emergency department: a case report.

The sixth cranial nerve (CN VI) is a rare site of complication associated with spinal anesthesia and can produce secondary symptoms of ocular muscle palsy. A 38-year-old man was admitted to the emergency department with complaint of diplopia and limited lateral gaze in the first week after endoscopic urological surgery under spinal anesthesia. Isolated unilateral CN VI palsy was considered after excluding differential diagnoses. Ocular palsy and diplopia regressed with conservative treatment during follow-up, and the patient was discharged. This article aims to show that CN VI palsy is a rare complication of spinal anesthesia, which can be observed in the emergency department.

Echocardiographic epicardial fat thickness and immature granulocyte are novel inflammatory predictors of acute ischemic stroke: a prospective study.

BACKGROUND: Acute ischemic stroke (AIS) is the most common type of stroke. Inflammation is the primary factor in the pathogenesis of atherosclerosis. Use of immature granulocytes (IGs) has been recommended as a new indicator of systemic inflammation. However, data on the association between echocardiographic epicardial fat tissue thickness (EFT) and IGs in patients with AIS are limited. OBJECTIVE: To evaluate the association between the presences of IGs, epicardial fat tissue and AIS. DESIGN AND SETTING: Prospective study in a tertiary-care university hospital in Antalya, Turkey. METHODS: Our study included 53 AIS patients and 41 healthy controls with age and gender compatibility. Blood samples and transthoracic echocardiography of all participants were compared. RESULTS: IG levels were significantly higher in patients with AIS than in controls (0.62 ± 0.36 versus 0.28 ± 0.02, P < 0.001). The mean EFT was 3.74 ± 0.61 mm in the control group and 6.33 ± 1.47 mm in the AIS patient group. EFT was significantly greater in AIS patients than in controls (P < 0.001). For the optimum cut-off value for IG (0.95), the area under the curve (AUC) was determined to be 0.840; sensitivity was determined to be 81.1% and specificity, 92.5%. For the optimum cut-off value for EFT (4.95 mm), the AUC was determined to be 0.953; sensitivity was determined to be 90.6% and specificity, 90%. CONCLUSIONS: IG and echocardiographic EFT are clinical markers that can be used to predict AIS risk.

The relationship between abnormal intracranial findings in brain computed tomography and antiplatelet or anticoagulant use in patients with nontraumatic headache: a prospective cohort study.

OBJECTIVE: This study aimed to investigate the relationship between abnormal intracranial findings on brain computed tomography and antiplatelet or anticoagulant use in patients with nontraumatic headache in the emergency department (ED). METHODS: This was a single-center prospective observational study of patients admitted to the tertiary ED with complaints of nontraumatic headache between May 1, 2016 and September 1, 2016. Anticoagulant or antiplatelet drug use by the patient was recorded. Brain computed tomography (CT) results were categorized into two groups, abnormal results (CT positive) and no pathologic results (CT negative), and compared. The CT positive group included any pathological signs in the brain and the negative group was considered a normal read. A logistic regression analysis was used for evaluating the association of antiplatelets and anticoagulants with abnormal CT findings. RESULTS: Of the 837 patients with nontraumatic headaches, 157 (18.8%) patients who underwent brain CT scanning were included. The mean age of the patients was 44.4±16.7 years. Eighty-eight (56.1%) of the patients were women. Of the 29 (18.4%) patients using antiplatelets or anticoagulants, 16 (55.2%) were in the CT positive group. There was a statistically significant difference between both groups in terms of drug use compared to the CT negative group (P<0.001). Factors affecting CT restuls were examined in logistic regression analysis and a statistically significant difference was found in the detection of positive results in antiplatelet or anticoagulant drug users (adjusted odds ratio, 2.478; 95% confidence interval, 1.006-6.102; P=0.048). CONCLUSION: The use of antiplatelets or anticoagulants in patients admitted to the ED with nontraumatic headache is associated with an increased risk of abnormal intracranial results in brain CT.

The prognostic value of sepsis scores and dichotomized triage score in patients presenting to the emergency department with fever: A prospective, observational study.

BACKGROUND: The performance of the Quick Sequential Organ Failure Assessment (qSOFA) score needs to be explored further in the emergency triage room. This study aims to explore the performance of triage (tqSOFA) versus the dichotomized triage score (DTS) in patients admitted to the emergency room triage with fever. METHODS: This research was designed as a prospective, observational study within a six-month period, including patients who presented to the emergency room triage with infrared fever ≥ 37.5 °C. RESULTS: 771 patients were analyzed.The highest sensitivity for predicting overall hospitalization and intensive care admission was seen for DTS (95.4 %, 100 %; p < 0.0001, p < 0.0001, respectively) (AUC:0.697, 95 % CI 0.663 to 0.730; AUC:0.684, 95 % CI 0.650 to 0.717, respectively). The highest sensitivity for predicting 1st week and 1st month mortality was found for DTS (100 %, 96.3 %; p < 0.0001, p < 0.0001, respectively). However, the highest specificity for predicting 1st week and 1st month mortality was observed in tqSOFA (94.1 %, 95.16; p = 0.0845, p < 0.0001, respectively) (AUC:0.658, 95 % CI 0.623 to 0.691; AUC:0.698, 95 % CI 0.664 to 0.730, respectively). CONCLUSION: We found DTS to be as effective as tqSOFA and SIRS in determining all hospitalization times and mortality.

Usefulness of Immature Granulocytes as A Prognostic Factor in ST-Elevation Myocardial Infarction.

OBJECTIVE: ST-segment elevation myocardial infarction (STEMI) is a serious, life-threatening disease. Inflammatory markers have recently become the focus of attention in the assessment of severity in the early stages of STEMI. This study aimed to evaluate the importance of immature granulocytes (IG) as a prognostic marker in STEMI. METHODS: Patients admitted to the coronary care unit with a diagnosis of STEMI and who underwent primary percutaneous coronary intervention (pPCI) within the period from January 1, 2019 to January 1, 2020, were retrospectively scanned. A total of 146 patients were analised; of these, 112 (76.7%) were male and 34 (33.3) were female, with a mean age of 62.65±14.06 years. Patients' age, gender, haemogram, biochemistry, and mortality results were recorded. The patients were divided into two groups as low (<0.6) and high (≥0.6) IG levels and compared. RESULTS: The mean IG levels were significantly higher in the non-survivor group compared to the survivor group (1.12±0.22 vs. 0.50±0.28, P<0.001). Mortality rates were significantly higher in the high IG group compared to the low IG group (26.9% vs. 9.6%, P=0.006). IG was shown to predict mortality with a sensitivity of 72.2% and a specificity of 77.8% at a cut-off value of 0.65 (area under the curve: 0.740, 95% CI: 0.635-0.846, P<0.001). CONCLUSION: High IG values in the blood collected at the time of admission to the emergency department are a marker of mortality in patients with STEMI.

Functional outcomes of intersphincteric resection in low rectal tumors.

Objectives: Currently, sphincter-saving procedures are increasingly performed in the treatment of low rectal cancers. This study aimed to evaluate the outcomes of patients who underwent intersphincteric resection. Material and Methods: This was a single-center, retrospective, cross-sectional study. We evaluated the electronic data files of 29 patients who had intersphincteric resections at our institute between 2008 and 2018. Bowel function outcomes were assessed prospectively using Wexner incontinence score. Histopathological, surgical and functional outcomes were analyzed. Results: Mean age of nine female and 20 male patients included in the study was 55.8 ± 12.8 (30-76) years. A tumor-free surgical margin was achieved in all patients. Anastomotic leakage was detected in two patients. Mean Wexner incontinence score of 20 patients who still had functional anastomosis was 8.35, whereas 65% of the patients (n= 13) had a good continence status. There was no relationship between the continence status and sex, tumor distance from anal verge, T stage, distal surgical margin, and lymph node involvement. Twenty-one patients underwent primary coloanal anastomosis and eight patients underwent two-stage coloanal anastomosis. Conclusion: In the treatment of distal rectal cancer, adequate oncological surgery and relatively acceptable functional outcomes can be obtained with intersphincteric resection technique in suitable patients.

Foreign bodies in the rectum: an analysis of 30 patients.

PURPOSE: A foreign body in the rectum is a rare clinical entity. These foreign bodies can be classified under two major groups: the ones that are inserted from the anus and the ones that are swallowed and thereafter become stuck in the rectum. METHODS: Data of patients admitted with a foreign body in the rectum between 1988 and 2008 were retrospectively analyzed. A total of 30 patients were reviewed. RESULTS: The most common reason for a foreign body in the rectum was insertion for erotic purposes, which was seen in 19 of the 30 patients. All these patients were male. The remaining 11 patients reported nonerotic causes. The most efficient and implemented therapeutic method was simple extraction during the first examination. CONCLUSIONS: The most common reason for a foreign body in the rectum is insertion for erotic purposes. The first target of therapy should be extraction of the foreign body using the simplest method possible. Meanwhile, protecting the integrity of the intestine is of the utmost importance. The care for maintaining the integrity of the rectum should include an evaluation of the patient's psychological status.

Can NLR, PLR and LMR be used as prognostic indicators in patients with pulmonary embolism? A commentary.

We read with great interest the article "Prognostic role of NLR, PLR, and LMR in patients with pulmonary embolism" by Köse et al.[1]. They found that the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and lymphocyte-monocyte ratio (LMR) were related to the prognosis and clinical severity of patients with pulmonary embolism (PE). First of all, we congratulate the authors for their invaluable contribution to literature. However, we think that some points should be discussed regarding the use of these laboratory parameters. White blood cell subtypes NLR, PLR, and LMR, have been associated with many inflammatory diseases, including PE [2,3]. These parameters, which can be easily determined by simple and easy measurement of systemic inflammation, maintain their importance today. However, these parameters are affected by many factors such as trauma, local or systemic infection, acute coronary syndromes, and malignancy [3-5]. For these reasons, it would be better for the authors to mention these factors and exclude them from the tables that included malignancy and trauma patients in the study. It is known that drugs, including steroids, can increase neutrophils and decrease lymphocytes and therefore affect NLR, PLR, and LMR values [6]. Consequently, it will be more valuable to exclude patients who use drugs that may affect laboratory parameters. Besides, plasma inflammatory biomarkers are time-dependent variables. The time of sample collection and the time from the onset of the symptom to the sampling may impact the parameters [3-6]. Therefore, it is essential to identify the time from the first symptom to sample collection and the factors that may affect it. In conclusion, because NLR, PLR, and LMR can be affected by many factors, prospective studies with large populations are needed to show the accuracy of use in critically ill patients.

NLR, d-NLR and PLR can be affected by many factors.

We have read the article by Yang et al, entitled "The diagnostic and predictive role of NLR, d-NLR and PLR in COVID-19 patients" with great interest. The authors emphasized that the NLR (Neutrophil to lymphocyte ratio) is an independent prognostic biomarker for COVID-19 patients. First of all, we congratulate the authors for their valuable contribution to the literature in these difficult conditions. However, we would like to add on a few cases that need more attention.

A new extraction technique for rectal foreign bodies with a rubber band ligation device.

Foreign bodies in the rectum are a rare clinical condition that should be noted. The most frequently encountered cause is erotic activity. The first goal of the therapy is extraction of the foreign body using the simplest method possible while protecting the integrity of the intestine. Many instruments and methods have been suggested for this purpose. This report discusses a new management strategy for these patients along with a review of the literature.

Aortic dissection or spontaneous renal artery dissection, a rare diagnosis?

Spontaneous renal artery dissection (SRAD) is a rare entity causing muscle spasm due to acute low back pain, back pain, or flank pain symptoms or misleading clinical diagnosis such as renal colic. A 25-year-old Syrian male refugee presented to the emergency department with sudden onset of left-sided flank pain in the evening. Physical examination results were normal except left-sided costovertebral angle sensitivity. Abdominal, pelvic and thoracic contrast computed tomography angiography (CTA) was performed to evaluate aortic dissection, which was our urgent preliminary diagnosis. Left renal artery dissection was detected in CTA. The patient was treated with medical conservative treatment and spontaneous recovery was observed during the follow-up period. Early detection of SRAD in the emergency department can be difficult due to the fact that the clinical presentation is misleading.

Usefulness of Immature Granulocytes to Predict High Coronary SYNTAX Score in Acute Coronary Syndrome; a Cross-sectional Study.

INTRODUCTION: Immature granulocytes (IG) in peripheral blood indicate increased bone marrow activation and inflammation, and SYNTAX score (SS) is an anatomical scoring system based on coronary angiogram. This study, aimed to evaluate the relationship between IG and SS, as a new inflammatory marker in patients with acute coronary syndrome (ACS). METHODS: Patients aged >18 years who were diagnosed with ACS in the emergency department were included in this study, which was planned as a cross-sectional study. Patients were divided into two groups of patients with high and low SSs according to coronary angiography results. Demographic and laboratory parameters were compared between the groups. RESULTS: Our study consisted of 78 patients diagnosed with ACS, who met the inclusion criteria. The average age of the study group was 59 years, and 67.9% of the patients were male. 21 patients (26.9%) had high SSs and 57 patients (73.1%) had low SSs. Mean IG% was significantly higher in high SS group compared to low SS group (0.71±0.25 vs 0.44±0.21 mg/dl, p<0.001). IG% can present a high SS with 76.2% sensitivity and 75.4% specificity at a cut-off value of 0.7. CONCLUSION: IG was significantly higher in ACS patients with high SSs. It seems that IG can be used as a parameter, which is quickly accessible and cheap, in order to predict high SS in ACS patients in daily clinical practice.