Clinical assessment and short-term mortality prediction of older adults with altered mental status using RASS and 4AT tools.

BACKGROUND: Altered mental status (AMS) in older adults is a common reason for admission to emergency departments (EDs) and usually results from delirium, stupor, or coma. It is important to proficiently identify underlying factors and anticipate clinical outcomes for those patients. AIM: The primary objective of this study was to reveal and compare the clinical outcomes and etiologic factors of older patients with delirium, stupor, and coma. The secondary objective was to identify the 30-day mortality risk for those patients. METHOD: The study was conducted as prospective and observational research. We included patients aged 65 years and older who presented with new-onset neurological and cognitive symptoms or worsening in baseline mental status. Patients who presented no change in their baseline mental status within 48 h and those who needed urgent interventions were excluded. Selected patients were assessed using RASS and 4AT tools and classified into three groups: stupor/coma, delirium, and no stupor/coma or delirium (no-SCD). Appropriate statistical tests were applied to compare these 3 groups. The 30-day mortality risks were identified by Cox survival analysis and Kaplan-Meier curve. RESULTS: A total of 236 patients were eligible for the study. Based on their RASS and 4AT test scores: 56 (23.7%), 94 (40.6%), and 86 (36.4%) patients formed the stupor/coma, delirium and no-SCD groups, respectively. There was no statistical difference in the three groups for gender, mean age, and medical comorbidities. Neurological (34.7%), infectious (19.4%), and respiratory (19.0%) diseases were the leading factors for AMS. Post-hoc tests showed that CCI scores of the delirium (6, IQR = 3) and stupor/coma (7, IQR = 3) groups were not significantly different. The 30-day mortality rates of stupor/coma, delirium, and no-SCD groups were 42.%, 15.9%, and 12.8%, respectively (p < 0.005). The hazard ratio of the stupor/coma group was 2.79 (CI: 95%, 1.36-5.47, p = 0.005). CONCLUSION: AMS remains a significant clinical challenge in EDs. Using the RASS and 4AT tests provides benefits and advantages for emergency medicine physicians. Neurological, infectious, and respiratory diseases can lead to life-threatening mental deterioration. Our study revealed that long-term mortality predictor CCI scores were quite similar among patients with delirium, stupor, or coma. However, the short-term mortality was significantly increased in the stupor/coma patients and they had 2.8 times higher 30-day mortality risk than others.

Geriatric mortality risk factors in emergency department for non-traumatic abdominal pain.

OBJECTIVES: The study aimed to determine the factors affecting the mortality of geriatric patients presenting to the emergency department with non-traumatic abdominal pain, as well as the associations of these factors with mortality. BACKGROUND: With the increasing number of elderly patients, early recognition of patients with risk-bearing diagnoses is crucial. METHODS: This prospective cross-sectional study included 466 patients over 65 years of age who were admitted to THE emergency department of a tertiary hospital and consented to participate. Data was collected on patient demographics, vital signs, chronic diseases, laboratory investigations, diagnoses, disposition, and 30-day mortality. RESULTS: The results showed that the mean patient age was 74.42 years, with 47.4 % being male and 52.6 % female. 15.6 % of the patients had nonspecific causes. The risk of mortality within one month was 5.797 times higher in patients with neurological diseases and 5.183 times higher in those with a history of surgery. A one-unit decrease in hemoglobin increased the mortality risk by 0.656 times. CONCLUSION: This study highlights the importance of careful evaluation of elderly patients with neurological diseases, previous surgical history, and anemia in the emergency department with non-traumatic abdominal pain (Tab. 5, Ref. 18).

The Determining Factors for Outcome of Pediatric Intensive Care Admitted Children After Stem Cell Transplantation.

INTRODUCTION: Requiring pediatric intensive care unit (PICU) admission relates to high mortality and morbidity in patients who received hematopoietic stem cell transplantation (HSCT). In this study, we aimed to evaluate the indications for PICU admission, treatments, and the determining risk factors for morbidity and mortality in patients who had allogeneic HSCT from various donors. MATERIALS AND METHODS: In this retrospective study, we enrolled to patients who required the PICU after receiving allogeneic HSCT at our Pediatric Bone Marrow Transplantation Unit between 2005 and 2020. We evaluated to indication to PICU admission, applications, mortality rate, and the determining factors to outcomes. RESULTS: Thirty-three (7%) patients had 47 PICU admissions and 471 patients underwent bone marrow transplantation during 16-year study period. Also, 14 repeated episodes were registered in 9 different patients. The median age of PICU admitted patients was 4 (0.3 to 18) years and 29 (62%) were male. The main reasons for PICU admission were a respiratory failure, sepsis, and neurological event in 20, 8, and 7 patients, respectively. The average length of PICU stay was 14.5 (1 to 80) days, 14 (43%) of patients survived and the mortality rate was 57%. Multiple organ failure ( P =0.001), need for respiratory support ( P =0.007), inotrope agents ( P =0.001), and renal replacement therapy ( P =0.013) were found as significant risk factors for mortality. CONCLUSIONS: Allogeneic HSCT recipients need PICU admission because of its related different life-threatening complications. But there is a good chance of survival with quality PICU care and different advanced organ support methods.

Assessment of the role of neutrophil extracellular traps in SARS-CoV-2 pneumonia.

BACKGROUND: Abnormal neutrophil extracellular traps are associated with lung diseases, thrombosis, increased mucosal secretion in the airways. The aim of this study is to evaluate the possible place of the most specific NETosis marker Cit-H3 protein in diagnostic algorithms by revealing its relationship with the severity, mortality and prognosis of SARS-CoV-2 pneumonia. PATIENTS AND METHODS: Patients (n = 78) who applied to the Emergency Department between March 11, 2020 and June 10, 2020, with positive SARS-CoV-2 polymerase chain reaction (PCR) test and lung involvement were included in the prospective study. Serum Cit-H3 levels and critical laboratory parameters were measured at baseline on the day of clinical deterioration and before recovery/discharge/death. Cit-C3 levels were determined by enzyme immunassay method. RESULTS: Cit-H3 levels in patients with SARS-CoV-2 pneumonia during their first admission to the hospital were significantly higher compared to the healthy control group (p < 0.05). Repeated measurements of Cit-H3 levels of the patients significantly correlated with D-dimer, procalcitonin, Neutrophil/ Lymphocyte ratio, lymphocyte, CRP, and oxygen saturation. Cit-H3 levels of the patients who died were significantly higher than that of those who survived (p < 0.05). Cit-H3 levels were found to be statistically significantly higher in patients who developed acute respiratory distress syndrome, were admitted to the intensive care unit, and had mortality (p < 0.05). CONCLUSIONS: Cit-H3 plays a role in inflammatory processes in SARS-CoV-2 pneumonia, and changes in serum Cit-H3 levels of these patients can be used to determine prognosis and mortality (Tab. 5, Fig. 1, Ref. 21).

ACE2 and ANGII levels in patients with COVID-19 based on thoracic tomography findings and PCR test results.

INTRODUCTION: Reverse transcriptase polymerase chain reaction tests and thoracic tomography have been widely employed in the diagnosis of the disease, but doubts about their sensitivity still persist. Also there are controversial results about ACE2 and AngII levels according to the severity of disease. In this study, we aimed to analyze the ACE2 and AngII levels in patients with suspected COVID-19 based on polymerase chain reaction test results and thoracic tomography findings and to examine their relationship with disease severity. METHODOLOGY: Patients with suspected COVID-19 in the emergency department were divided into 4 groups according to thoracic tomography findings and PCR test results. The in-hospital mortality of patients was recorded. ACE2 and AngII levels in patients were analyzed according to groups and severity of the disease. RESULTS: ACE2 levels for the patients with suspected COVID-19 were significantly lower than in the control group, but AngII levels were higher (not statistically significant). The mean age and male sex ratio of patients who developed acute respiratory distress syndrome (ARDS) and died were significantly higher than those who survived. Whereas there was no difference in ACE2 levels in patients with severe diseases such as ARDS and mortality, their AngII levels were significantly lower. CONCLUSIONS: It can be suggested that decreased ACE2 levels combined with increased AngII levels are determinative at disease onset and in the development of lung damage. However, decreased AngII levels are more determinative in patients with severe diseases such as ARDS and mortality.

Evaluation of Oxidative Stress in Ectopic Pregnancies.

PURPOSE: The aim of the study is to show the relationship between oxidative stress and ectopic pregnancy. MATERIALS AND METHODS: A total of 62 patients, 31 in the ectopic pregnancy group (study group) and 31 in the first-trimester pregnancy (control group) were included in the study. Patients between 18-45 years of age who had tubal ectopic pregnancy diagnosed by transvaginal ultrasonography and serum ß-HCG values were included in the study group. Serum thiol- disulfide hemostasis were measured from venous blood. RESULTS: Between the control group and the ectopic pregnant group; there was no statistically significant difference in terms of age, total thiol, albumin, disulfide, index 1 (disulfide / total thiol), index 2 (disulfide / native thiol), and index 3 levels (p> 0.05). The area under the ROC curve for native thiol measurements was statistically significant in distinguishing the control group and the ectopic pregnant group [AUC = 0.657, 95% CI: 0.521-0.793, p = 0.034] Conclusion: This study shows that ectopic pregnancies may be associated with the presence of high oxidative stress. Especially in early stage suspected patients, demonstrating the presence of oxidative stress together with serial ß-HCG follow-up may be helpful in diagnosis.

Role of plasma angiotensin II and angiotensin-converting enzyme 2 levels on prognosis and mortality in hypertensive patients with COVID-19.

Introduction: SARS-CoV-2 requires angiotensin-converting enzyme 2 (ACE2) to enter the cell. In our study, we aimed to investigate the role of angiotensin-converting enzyme 2 and angiotensin II plasma levels on prognosis and mortality in patients with isolated hypertension, patients with chronic diseases in addition to hypertension and patients with COVID-19 without comorbidities, in accordance with the use of renin-angiotensin-aldosterone system inhibitor. Materials & methods: In the study, patients diagnosed with COVID-19 were divided into three groups. Angiotensin II and ACE2 levels were compared by comorbidities, antihypertensive drugs used, intensive care hospitalization and termination of patients. The relationship between angiotensin II and ACE2 levels and service and intensive care times was investigated. Findings: A total of 218 patients were enrolled in our study, including 68 patients diagnosed with COVID-19 without comorbidities, 33 patients diagnosed with isolated hypertension and 117 patients with other chronic diseases in addition to hypertension. There was no statistically significant difference between the comorbid disease groups between angiotensin II and ACE2 levels of the patients enrolled in the study. The rate of patients admitted to the intensive care unit was 17.9%, and the mortality rate was 11.5%. Results: In our study, we did not obtain significant findings regarding angiotensin II and ACE2 levels on presentation that can be used in prognosis and mortality of COVID-19 patients and development of future treatment methods.

Tocilizumab in COVID-19: The Cerrahpasa-PREDICT score.

BACKGROUND: Cytokine release syndrome (CRS), characterized by overproduction of proinflammatory cytokines in the course of severe coronavirus disease 2019 (COVID-19), has been suggested as the major cause of mortality. Tocilizumab, a recombinant humanized monoclonal antibody against human IL-6 receptor, poses a therapeutic option for the treatment of CRS leading to severe acute respiratory syndrome in coronavirus-2 (SARS-CoV-2) infection. METHODS: We performed a single-center retrospective study to reveal the outcome of COVID-19 patients on tocilizumab and proposed "the Cerrahpasa-PREDICT score", a new clinical scoring system using clinical and laboratory parameters that would help predicting the 28-day mortality of COVID-19 patients receiving tocilizumab. RESULTS: Eighty-seven patients (median age: 59 years) were included of whom 75.8% were male. Tocilizumab use significantly improved clinical and laboratory parameters. The 28-day mortality rate on tocilizumab was 16.1%. The Cerrahpasa-PREDICT score, consisting of platelet counts, procalcitonin, D-dimer levels, SO2R and the time from symptom onset to tocilizumab administration had a positive predictive value of 94.5% and negative predictive value of 92.9% for anticipating 28-day mortality. CONCLUSIONS: Severe COVID-19 should closely be monitored for the signs of hyperinflammation. We showed that administration of tocilizumab early in the course of the disease (prior to ICU admission) resulted in a favorable outcome. Close monitoring usually aids identifying patients who would benefit from tocilizumab. In this regard, the Cerrahpasa-PREDICT score might serve as a practical tool for estimating the 28-day mortality in COVID-19 patients who received tocilizumab and would facilitate timely recognition of fatal cases to be evaluated for other therapeutic options.

Transition from pandemic to infodemic: an analysis of Turkishlanguage COVID-19 YouTube videos.

BACKGROUND: YouTube can be a powerful educational tool for the dissemination of health information. However, if uploaded health-related videos are inaccurate, it can mislead, create confusion and generate panic. AIMS: This study aimed to determine the success of the most-watched Turkish-language COVID-19 YouTube videos regarding information and guidance on the disease for the public. The secondary aim of this study was to evaluate the accuracy and quality of such video content. METHODS: The study was conducted during May 2020 and analysed 133 videos. The length of the videos, the number of likes and dislikes, comments and views, how long they have been on YouTube, Medical Information and Content Index (MICI) Score, mDISCERN scores, global quality scores, and the source and target audiences of the videos were all determined. RESULTS: The average MICI Scores of videos was 2.48±3.74 and the global quality scores was 1.27±0.64. When MICI Scores were compared between video sources, the scores of academic hospitals and government videos were significantly higher. The global quality scores of videos from news agencies and independent users was significantly lower ( < 0.001). The mDISCERN score of the videos uploaded by news agencies and categorized as useful was higher than the others (P < 0.001). Among the targeted videos, only the global quality scores of the videos made for health-care workers were found to be significantly higher. CONCLUSION: Health-care professionals should upload more videos to improve the quality of health-related video content available on YouTube. Accompanied by evidence-based information, the issues of diagnosis, ways of transmission, prevention and treatment of diseases should be emphasized.

Vitamin D Poisoning; Hypercalcemia in a Case with Richter Transformation.

In addition to modern medicine, the search for complementary and alternative medicine has been present for malignancy patients in every period. Confusion, polyuria, polydipsia, anorexia, vomiting, and muscle weakness are symptoms of acute poisoning and are related to hypercalcemia. In our case, a 52-year-old male patient applied to the Emergency Department(ED) with abdominal pain and weakness for two days. In this article, we wanted to present a case with vitamin D poisoning that occurs after the phytotherapy in a patient who developed chronic lymphocytic leukemia (CLL) to Richter transformation. In some patients, especially at ED, taking a high dose of vitamin D history can be challenging. In patients with hypercalcemia, a careful history should be taken, and it should be questioned as "Vitamin D use" rather than "Drug use" since families do not accept the vitamins as drugs.