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.

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.

Efficacy of Serum Angiotensin II Levels in Prognosis of Patients With Coronavirus Disease 2019.

OBJECTIVES: We aimed to determine serum angiotensin II levels in patients with coronavirus disease 2019 infection and to investigate the effect of these levels on the prognosis of the disease. DESIGN: The study was planned prospectively and observationally. SETTING: The study was conducted in a tertiary university hospital. PATIENTS: Coronavirus disease 2019 patients older than 18 years old, polymerase chain reaction test positive, with signs of pneumonia on tomography, and hospitalized were included in the study. ICU need, development of acute respiratory distress syndrome, and in-hospital mortality were considered as primary endpoints. INTERVENTIONS: Blood samples were taken from patients three times for angiotensin II levels. MEASUREMENTS AND MAIN RESULTS: Angiotensin II levels were studied by enzyme-linked immunosorbent assay method. The SPSS 24.0 program (Statistics Program for Social Scientists, SPSS, Chicago, IL) was used to analyze the data. A total of 112 patients were included in the study, of which 63.4% of the patients were men. The serum angiotensin II levels were statistically significantly lower in the patients with coronavirus disease 2019 compared with the healthy control group (p < 0.001). There was no statistical significance between the serum angiotensin II levels measured at three different times (p > 0.05). The serum angiotensin II levels of the patients with acute respiratory distress syndrome were found to be statistically significantly lower than those without acute respiratory distress syndrome in three samples collected at different clinical periods (p < 0.05). The angiotensin II levels of the patients who required admission to the ICU at all three times of blood sample collection were found to be statistically significantly lower than those who did not (p < 0.05). Although the serum angiotensin II levels of the patients who died were low, there was no statistically significant difference in mortality at all three times (p > 0.05). CONCLUSIONS: The serum angiotensin II levels decrease significantly in patients with coronavirus disease 2019, and this decrease is correlated with lung damage.

Chest Computed Tomography Findings of Eight Patients With Covid-19 Diagnosis: Case Series.

COVID-19 is an infectious disease caused by the virus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and declared a pandemic on March 11, 2020, by the world health organization. In Turkey, the first cases began to appear on March 11, 2020. After the cases in China, the appearance of ground glass with or without consolidation in the posterior and periphery of the bilateral lung is determined as the main finding of COVID-19. In this article, we wanted to share the tomography findings of eight patients who were diagnosed with COVID-19 in our emergency department and who had lung involvement.

Tacrolimus-Induced Vision Loss in a Renal Transplant Patient: Posterior Reversible Encephalopathy Syndrome.

Posterior reversible encephalopathy syndrome is a rare and serious neurologic adverse effect of calcineurin inhibitors. The pathophysiology of this clinical entity is still unclear. Impaired cerebral autoregulation and endothelial dysfunction are thought to be the main pathologic processes. Imaging shows the syndrome to be characterized by vasogenic edema or cytotoxic edema in parietal and occipital areas of the brain. With regard to clinic presentation, headache, diminished visual acuity, cortical blindness, altered consciousness, seizures, and hallucinations can be seen. It is known that the clinical presentation is improved when calcineurin inhibitors are stopped early. Here, we present and evaluate a case of a cortical blindness that developed in a 36-year-old patient who had been using tacrolimus after renal transplant and who returned to health after 1 week of hospitalization.