A Rare Cause of Coagulopathy in the Emergency Department: Cefoperazone Use.

Cefoperazone (CPZ) is an antibiotic widely used for moderate to severe infections, especially in countries where resources are difficult to access. This case report aimed to draw attention to coagulopathy, a potential side effect of CPZ. This side effect can cause high mortality and morbidity in patients. In the mechanism of CPZ causing coagulopathy, it is reported that effects such as binding to vitamin K, disrupting vitamin K metabolism, and preventing platelet aggregation are responsible. In this presentation, a case who came to the emergency department with the complaint of hematuria caused by coagulopathy after the use of CPZ-containing antibiotics (CPZ + sulbactam) is presented.

Combined Use of Serum N-terminal Pro-B-Type Natriuretic Peptide and Glypican-6 in the Diagnosis of Heart Failure.

OBJECTIVE: The aim of this study was to investigate the efficacy of serum glypican-6 (GPC-6) levels and the combination of N-terminal pro-B-type natriuretic peptide (NT-ProBNP) and GPC-6 in the diagnosis of heart failure (HF). METHODS: In this prospective study, patients older than 18 years of age, admitted to the emergency department of our hospital between December 2021 and April 2022, diagnosed with heart failure (patient group), and healthy volunteers with similar sociodemographic characteristics (control group) were included. The disease severity classification of the patient group was made according to the 2021 ESC guidelines, using echocardiographic findings. Serum GPC-6 and NT-ProBNP levels were measured by the enzyme-linked immunosorbent assay (ELISA) method, which determines the antigen-antibody relationship. Optimal GPC-6 and NT-ProBNP levels for the diagnosis of HF were determined by receiver operating characteristic (ROC) analysis. The patients were divided into three groups according to these levels. Group 1 consisted of patients with both markers below the cutoff values, Group 2 consisted of patients with either of these markers above the cutoff values, and Group 3 consisted of patients with both markers above the cutoff values. RESULTS: The study included 65 heart failure patients and 20 healthy volunteers. When the patient and control groups were compared in terms of serum GPC-6 and serum NT-ProBNP levels, both parameters were evaluated as significantly higher in the patient group (p=0.038 and p<0.001; respectively). In the ROC analysis, it was determined that GPC-6 indicated HF with 58.46% sensitivity and 75% specificity for an optimal cutoff value of 390 pg/ml. In the ROC analysis, it was determined that serum NT-ProBNP indicated HF with 89.23% sensitivity and 70% specificity for an optimal cutoff value of 122 pg/ml. When the groups were compared according to the rate of HF, it was found to be higher in Group 3 compared to Group 2 (97.1% vs. 70.3%, p<0.002) and Group 1 (97.1% vs. 38.5%, p<0.001). This rate was seen to be significantly higher in Group 2 compared to Group 1 (70.3% vs. 38.5%, p=0.042). CONCLUSION: The combination of GPC-6 and NT-ProBNP may help diagnose HF patients admitted to the emergency department.

Evaluation of Serum Secretoneurin Levels in Patients With Ischemic Stroke Who Underwent Mechanical Thrombectomy.

Background Ischemic stroke is a focal or global cerebral dysfunction of vascular origin; its treatment aims to provide reperfusion. Secretoneurin is a hypoxia-sensitive biomarker found in high concentrations in brain tissue. We aim to determine secretoneurin levels in patients with ischemic stroke, examine how secretoneurin levels change in the mechanical thrombectomy group, and evaluate the correlation with disease severity and prognosis. Methods Twenty-two patients diagnosed with ischemic stroke in the emergency department underwent mechanical thrombectomy, and twenty healthy volunteers were included in the study. Serum secretoneurin levels were measured by the enzyme-linked immunosorbent assay (ELISA) method. Secretoneurin levels were measured at the 0th hour, 12th hour, and 5th day in patients who underwent mechanical thrombectomy. Results Serum secretoneurin levels were found to be statistically significantly higher in the patient group (7.43 ng/mL) compared to the control group (5.90 ng/mL) (p=0.023). The secretoneurin levels of the patients who underwent mechanical thrombectomy were 7.43 ng/mL, 7.04 ng/mL, and 8.65 ng/mL, measured at the 0th hour, 12th hour, and 5th day, respectively, and no significant difference was detected in all three time periods (p=0.142). Conclusion Secretoneurin appears to be a useful biomarker in the diagnosis of stroke. However, it was found that there was no prognostic value in the mechanical thrombectomy group, and it was not correlated with the severity of the disease.

Can lactate levels and lactate kinetics predict mortality in patients with COVID-19 with using qCSI scoring system?

INTRODUCTION: In this study, we aimed to investigate the relationship between blood lactate levels and lactate kinetics (lactate clearance and Δ lactate) for predicting mortality in patients with COVID-19 admitted to the emergency department. METHODS: This study was performed as a retrospective study that included patients admitted to the emergency department between March 1st, 2020, and January 1st, 2022. Lactate levels were recorded at the first admission (0 h lactate) and the highest blood lactate levels in the first 24 h of follow-up (2nd highest lactate). Lactate kinetics were calculated. Clinical severity was determined according to the quick COVID Severity Index (qCSI). RESULTS: 300 patients were included in the study. Lactate levels at admission were similar in groups with or without mortality, but 2nd highest lactate levels were found to be significantly higher in the group with mortality (p < 0.001). Lactate clearance and ∆ lactate levels were also found to be lower in the mortality group (p < 0.001). Lactate kinetics in patients in the clinically low severity group were lower in the mortality group (p = 0.02 and p = 0.039, respectively). In the low-intermediate and high-intermediate groups, 0-h lactate and 2nd highest lactate levels were found to be higher in the mortality group, and lactate kinetics were similar in the groups with and without mortality. In the group with high clinical severity, 2nd highest lactate levels were found to be higher in the group with mortality (p = 0.010). Lactate kinetics were also found to be significantly lower in the mortality group (p < 0.001). In the high qCSI group, based on ROC analysis, the AUC for 2nd highest lactate levels predicting mortality was 0.642 (95% CI: 0.548-0.728). The optimal cut-off value for mortality was greater than >2.4 mmol/L (60.6% sensitivity, 67.4% specificity). The AUC for lactate clearance was 0.748 (95% CI: 0.659-0.824). The lactate clearance cut-off value was ≤ -177.78% (49.3% sensitivity, 100% specificity). The AUC for ∆ lactate was 0.707 (95% CI: 0.616-0.787). The optimal ∆ lactate cut-off was ≤ -2 mmol/L (45.1% sensitivity, 93.5% specificity). CONCLUSION: In COVID-19, 2nd highest blood lactate and lactate kinetics were found to be prognostic indicators of the disease. High 2nd highest lactate levels and low lactate kinetics in patients with high clinical severity were guiding physicians regarding the outcome of the disease.

The Role of Serum Secretoneurin Levels in Patients with Traumatic Brain Injury.

BACKGROUND: Secretoneurin is a neuropeptide expressed from endocrine, neuroendocrine, and neural tissues. Our study aimed to investigate whether there was a relationship between secretoneurin levels and the severity of traumatic brain injury (TBI). METHODS: Ninety patients aged over 18 years who were admitted to the emergency department with head trauma between April 2020 and October 2020 and 20 healthy volunteers (control group) were included in the study. Patients were divided into three groups according to Glasgow Coma Scale scores: Mild TBI (n=33), moderate TBI (n=28), and severe TBI (n=29). The final status of the patients was evaluated in three groups: exitus, discharge with Glasgow Outcome Scale (GOS) ≤ 3 and discharge with GOS >3. RESULTS: The median secretoneurin levels of patients with severe TBI 31.71 (14.21-70.95) were found to be significantly higher than in those with moderate TBI [17.30 (10.71-69.27) (P=0.025), and patients with moderate TBI had a substantially higher level of secretoneurin than those with mild TBI 11.70 (6-16.25) (P<0.001). There was no statistically significant difference between the median secretoneurin levels in patients with mild TBI and the control group 10.73 (5.33-13.18) (P=0.999). The secretoneurin cut-off value of >18.13 ng/mL had a sensitivity of 83.87% and a specificity of 77.97% for poor neurologic outcomes (AUC 0.86, 95% CI: 0.77- 0.92). The secretoneurin cut-off value of >20.67 ng/mL had a sensitivity of 90.91% and a specificity of 74.68% for mortality (AUC 0.85, 95% CI: 0.76-0.92). CONCLUSION: Secretoneurin can be a useful biomarker in diagnosing patients with moderate-tosevere TBI. It may also guide physicians in predicting the clinical outcome of patients with TBI.

The Effect of the COVID-19 Pandemic on Urine Culture Results and Resistance to Antibiotics in the Emergency Department.

BACKGROUND: This study aimed to investigate the effect of the COVID-19 pandemic on urine culture results and antibiotic sensitivities in patients with suspected urinary tract infections (UTI) admitted to the emergency department (ED) and determine more accurate treatment modalities for patients. The primary endpoint of our study was to determine the change in antibiotic resistance of UTI agents in the pre-and post-COVID period. METHODS: In the study, urine samples were sent from ED to the microbiology laboratory with a preliminary diagnosis of UTI between June 1, 2019, and July 1, 2021. Urine samples with the growth of 105 cfu/mL and above in urine cultures or with the growth of 103 cfu/mL and above in urine sample cultures taken from catheters were examined. At the end of the exclusions, the results of a total of 1,090 patients were evaluated. Urine cultures and an-tibiotic susceptibility tests of the patients included in the study were examined in two periods (pre-pandemic and post-pandemic). RESULTS: A total of 1,090 aerobic urine cultures sent from the ED between June 2019 and June 2021 were finalized in the microbiology laboratory. Of the 1,090 urine cultures sent from the ED within the 24 months included in the study, 497 (45.59%) were sent eight months before the COVID-19 pandemic. Growth was detected in 33 (6.63%) cultures. In the 16 months after the pandemic, 593 (54.41%) urine cultures were sent. Growth was seen in 69 (11.6%) cultures. The positivity rate obtained from urine cultures sent after the COVID-19 pandemic was significantly higher than those sent before the COVID-19 pandemic (p = 0.005). According to cultures and antibiogram results, resistance to ampicillin, cefuroxime, cefuroxime axetil, cefoxitin, cefixime, ceftazidime, ceftriaxone, and amoxicillin-clavulanic acid decreased significantly compared with pre-COVID-19 (p < 0.05). In addition, Extended Spectrum Beta-Lactamase (ESBL) resistance decreased significantly compared with the prepandemic period (p = 0.012). CONCLUSIONS: In this study, we found that the susceptible to antibiotics increased significantly in the post-COVID-19 period compared to the pre-COVID-19 period.

The Value of Serum I-FABP Level in the Diagnosis of Acute Appendicitis.

BACKGROUND: Acute appendicitis is one of the most common abdominal emergencies worldwide. Biomarkers and imaging are valuable adjuncts to history and examination. Differentiating complicated and uncomplicated appendicitis is essential. Our aim is to investigate whether serum I-FABP could be a suitable diagnostic biomarker in diagnosing acute appendicitis in which inflammation and ischemia play a role in the pathophysiology. METHODS: Sixty-six patients with histopathologically confirmed acute appendicitis were included in the study. Blood samples were taken from the patient and control groups to examine serum I-FABP, white blood cell (WBC) counts, C-reactive protein (CRP), and procalcitonin (PCT) levels. RESULTS: Twenty-six patients (39.3%) had complicated appendicitis. When the patient and control groups were compared in terms of I-FABP, WBC, neutrophil-lymphocyte ratio, (NLR) CRP, and PCT values, a significant difference was found in all biochemical parameters (p < 0.001). We compared the levels of patients with uncomplicated and complicated appendicitis in terms of serum I-FABP, WBC, NLR, CRP, and PCT levels and found that only the I-FABP level was significantly different (p < 0.001), and the diagnostic sensitivity was higher in patients with complicated appendicitis compared with uncomplicated patients (AUC; 0.89 for I-FABP, 0.55, 0.57, 0.61, and 0.59 for WBC, NLR, CRP, and PCT respectively). CONCLUSIONS: I-FABP has no diagnostic advantage over WBC, CRP, and PCT to diagnose acute appendicitis. However, it is more sensitive than other biomarkers in differentiating complicated from uncomplicated appendicitis.

Diagnostic and Prognostic Value of Serum Endocan Levels in Patients With COVID-19.

We aimed to evaluate whether there was a relationship between endocan (human endothelial cell-specific molecule-1) levels and disease prognosis in patients who presented to the emergency department with coronavirus disease 2019 (COVID-19). A total of 60 patients with COVID-19 who were hospitalized from the emergency department to clinical wards and a control group consisting of healthy adult individuals (n = 28), were included in the study. The majority (93.3%) of the patients were discharged after recovery; 6.7% died. The median endocan value was 243.5 ng/mL in the patient group versus 201.5 ng/mL in the control group (P = .002). The median endocan level was 240.5 ng/mL in those discharged with recovery and 558 ng/mL in those who died (P = .001). There was no significant relationship in hospitalization duration, sex, tomography findings, and clinical outcomes. A 202 ng/mL serum endocan level had 86.7% sensitivity and 50% specificity for COVID-19. Serum endocan levels may be a useful biomarker both for the diagnosis of COVID-19 and to predict mortality.

Determination of Serum Oxidative Stress, Antioxidant Capacity and Protein Profiles in Dogs Naturally Infected with Ehrlichia canis.

PURPOSE: Canine ehrlichiosis is an important tick-borne disease of dogs worldwide. In the present study, we aimed to determine the serum total antioxidant capacity (TAC), malondialdehyde (MDA), nitric oxide (NO), superoxide dismutase, (SOD), glutathione peroxidase (GSH-Px), adenosine deaminase (ADA) activity and serum protein profiles in dogs affected with naturally acquired ehrlichiosis. METHODS: The animal materials had been consisted of ten dogs naturally infected with Ehrlichia canis, and ten controls negative for Ehrlichia canis. TAC, MDA, NO, SOD, GSH-Px, ADA activity and TP, ALB, GLOB levels were measured in sera of the animals. The serum protein concentrations were measured by autoanalyzer. The electrophoretic profiles of serum total protein were determined by native polyacrylamide gel electrophoresis (Native-PAGE). RESULTS: In dogs with ehrlichiosis, decreased TAC (P < 0.05) and GSH-Px (P > 0.05) levels were determined. However, NO (P > 0.05), SOD (P < 0.05), ADA (P > 0.05), MDA (P > 0.05), TP (P < 0.05) and GLO (P < 0.05) levels were found as increased in the Ehrlichia positive dogs. ALB levels were decreased without a statistical significance (P > 0.05). ALB, α1 and ß2 globulin strip densities were found as decreased in native-PAGE, while ß1 and γ globulin strip densities were significantly increased in the E. canis positive group when compared to the control. CONCLUSION: It was determined that the oxidative stress decreased high antioxidant activity in dogs naturally infected with E. canis, and consequently, pro-oxidant and antioxidant defense and serum protein profiles were affected. It was thought that antioxidant supplementation could be beneficial to the treatment of the disease.

Influence of circadian blood pressure alterations on serum SCUBE-1 and soluble CD40 ligand levels in patients with essential hypertension.

BACKGROUND: Dipper and non-dipper hypertension are different clinical forms of essential hypertension. In this study, the effect of circadian blood pressure changes on serum SCUBE-1 and soluble CD40 ligand (sCD40L) levels was investigated in patients with hypertension. METHODS: A total of 100 participants aged 23-89 years were included in the study. Patients with essential hypertension were followed up by ambulatory blood pressure measurement. RESULTS: Serum SCUBE1 levels were significantly higher in the non-dipper group than in the normal group (P < 0.001). Dipper and non-dipper patients had significantly higher serum sCD40L levels when compared to the normal group (P = 0.048 and P = 0.035, respectively). We also found a positive correlation between SCUBE1, sCD40L levels and 24-hour mean systolic blood pressure levels (r: 0.232, p: 0.034 and r: 0.241, p: 0.027, respectively). CONCLUSION: Serum SCUBE1 and sCD40L levels were higher in hypertensive patients than normal participants. Serum SCUBE1 levels were higher in patients with non-dipper compared to other participants.

The Role of Lactate and Troponin-I Levels in Predicting Length of Hospital Stay in Patients with Carbon Monoxide Poisoning.

BACKGROUND: Carbon monoxide (CO) is one of the most common causes of unintentional poisonings resulting in death. Patients with more severe findings such as loss of consciousness and persistent neurological or cardiovascular dysfunction require hospitalization. Although there are clinical findings which determine hospitalization criteria in patients presenting with CO poisoning, there is some ambiguity regarding laboratory biomarkers which determine length of hospital stay (LOS) in these patients. In this study, we aimed to identify the effectiveness of initial blood gases and biochemical parameters in predicting LOS in patients presenting to the emergency department with CO poisoning by retrospective analysis of medical records. METHODS: This study was conducted in the Emergency Department (ED) of Samsun Training and Research Hospital by analyzing from medical records retrospectively of 275 patients who were admitted to the hospital following acute CO poisoning between January 2014 and July 2017. The patients were divided into 3 groups according to LOS: Group I, patients with LOS < 24 hours; group II, those with LOS > 24 hours and < 3 days; and group III, those with LOS > 3 days. RESULTS: In comparisons regarding lactate and troponin-I, it was found that there were significant differences in both parameters among the three groups (p = 0.000) and that both lactate and troponin-I levels were higher in group III than groups I and II, with group I being lowest (group III > group II > group I). While there was a mod¬erate positive statistically significant correlation between LOS and lactate (r: 0.43, p = 0.001) and troponin (r: 0.31, p = 0.001), a weak positive correlation was determined with CK (r: 0.19, p = 0.04). In this study, it was found that lactate and troponin-I values were more effective in predicting LOS when compared to carboxyhemoglobin levels and other biochemical parameters. CONCLUSIONS: The results of this study may guide clinicians to predict LOS in patients who present with CO poi-soning and have high troponin-I and lactate levels at the time of admission to EDs.

How Prepared Are We for Possible Bioterrorist Attacks: An Approach from Emergency Medicine Perspective.

Preparedness for bioterrorist attacks and early recognition of specific agents are essential for public health. Emergency departments may play an important role in this field. The large spectrum of bioterrorism involves not only disastrous terrorism with mass casualties, but also microevents using low technology but producing civil unrest, disruption, disease, disabilities, and death. It aims not only to cause mortality and morbidity, but also to lead to social and political disruption. Preparedness appears to be the most potent defense against possible bioterrorist events. In this article, we aim to create awareness against biological agents and underline the importance of emergency departments in this public health problem.

Acute ischemic stroke and severe multiorgan dysfunction due to multiple bee stings.

Various manifestations after bee sting have been described. Local reactions, such as pain, wheal, flare, edema and swelling, are common and generally self-limiting. Uncommonly manifestations like vomiting, diarrhea, dyspnea, generalized edema, acute renal failure, anaphylactic shock, myocardial infarction, hypotension, collapse, pulmonary hemorrhage, acute hemorrhagic pancreatitis, and atrial fibrillation may occur. We report a 59 year-old man who sustained ischemic stroke and multi-organ dysfunction following multiple bee stings.

A study to develop clinical decision rules for the use of radiography in wrist trauma: Karadeniz wrist rules.

INTRODUCTION: The aim of this study was to evaluate patients presenting to the emergency department (ED) with wrist trauma using physical examination findings and functional tests and to identify findings with high sensitivity and specificity among the parameters assessed in patients with fracture in the wrist. The ultimate objective was thus to establish a reliable and widely usable clinical decision rule for determining the necessity of radiography in wrist trauma. METHODS: This prospective, multicenter study was performed in 8 hospitals. The relation between radiologically determined fracture and clinical findings consisting of physical examination findings and functional tests was assessed in terms of whether or not these were markers of radiography requirement, with the aim of identifying predictive values for fracture. RESULTS: A total of 603 eligible trauma patients presented to the participating EDs during the study period. Fracture was identified in 24.5% of patients (n = 148). The 4-way combination with the highest sensitivity was identified as axial compression and the positive distal radioulnar drawer test, and pain with radial deviation and dorsal flexion. Sensitivity at distal ulna palpation was added as a fifth parameter, and sensitivity and negative predictive value thus increased to 100%. CONCLUSION: With their 100% sensitivity and 100% negative predictive values, the Karadeniz wrist rules may represent a clinical decision rule that can be used in practice in EDs. If all 5 findings are negative, there is no indication for wrist radiography.

Investigation of the 8-hydroxy-2'-deoxyguanosine, total antioxidant and nitric oxide levels of serum in dogs infected with Babesia vogeli.

Oxidative stress was defined as corruption of balance between oxidant-antioxidant states in favor of oxidants. In this study, it was aimed to determine oxidative stress in naturally infected dogs with Babesia vogeli. The 8-hydroxy-2'-deoxyguanosine (8-OHdG), nitric oxide (NO) and total antioxidant capacity (TAC) levels in the sera were analyzed by ELISA. 8-OHdG levels increased in B. vogeli infected dogs compared to control group (P<0.05). Also, NO levels increased while TOC levels decreased in B. vogeli infected dogs but these variations were not found as statistically important (P>0.05).

Omentin and chemerin and their association with obesity in women with polycystic ovary syndrome.

We aimed to investigate whether overweight/obesity is associated with omentin and chemerin. The study group consisted of 81 women with Polycystic ovarian syndrome (PCOS) (41 lean, BMI < 25 kg/m² and 40 overweight or obese, BMI > 25 kg/m²) and 61 healthy subjects (31 lean, BMI < 25 kg/m² and 30 overweight or obese, BMI > 25 kg/m²; control group). The clinical, endocrine, metabolic parameters, plasma omentin and chemerin levels were measured in patients and compared to control. In all subjects with PCOS (n = 80), serum chemerin levels were higher compared with those of the controls (n = 58) (7.71 ± 1.78 ng/mL versus 6.94 ± 0.82 ng/mL, p = 0.003). However, serum omentin levels were not significantly different between the PCOS subjects and the controls (1.55 ± 0.43 ng/mL versus 1.69 ± 0.37 ng/mL, p = 0.056). The mean chemerin concentrations were significantly elevated in the obese PCOS group compared with the obese control subjects (8.98 ± 1.45 ng/mL versus 7.02 ± 0.67 ng/mL, p = 0.000) and the nonobese PCOS group compared with the obese control subjects (6.57 ± 1.17 ng/mL versus 7.02 ± 0.67 ng/mL, p = 0.000). In conclusion, fat mass seems to be the main determinant factor of increased chemerin and decreased omentin in women with PCOS.

Value of the serum I-FABP level for diagnosing acute mesenteric ischemia.

PURPOSE: This study examined the feasibility of using the serum intestinal fatty acid binding protein (I-FABP) level for the early diagnosis of acute mesenteric ischemia, and investigated whether it contributes to the clinical decision-making process. METHOD: Thirty patients diagnosed with acute mesenteric ischemia, 27 patients with other types of acute abdomen who presented with acute abdomen symptoms but were not diagnosed with acute mesenteric ischemia, and 20 healthy people were included in the study. Mesenteric ischemia was confirmed by a pathological evaluation in patients who underwent intestinal resection due to detection of mesenteric ischemia during surgery. RESULTS: There was no significant difference in the leukocyte counts and D-dimer levels between subjects with mesenteric ischemia and acute abdomen due to other causes (p > 0.05). There was a significant difference in the serum I-FABP level between these groups (p < 0.001). CONCLUSION: The I-FABP level is a more reliable parameter for diagnosing acute mesenteric ischemia compared to leukocytosis and D-dimer elevation.

Reasons for Overcrowding in the Emergency Department: Experiences and Suggestions of an Education and Research Hospital.

OBJECTIVES: In this study, we aimed to determine the causes of overcrowding in the Emergency Department (ED) and make recommendations to help reduce length of stay (LOS) of patients in the ED. METHODS: We analyzed the medical data of patients admitted to our ER in a one-year period. Demographic characteristics, LOS, revisit frequency, and consultation status of the patients were determined. RESULTS: A total of 163,951 patients were admitted to our ED between January 1, 2013, and December 31, 2013. In this period 1,210 patients revisited the ED within 24 hours. A total of 38,579 patients had their treatment in the observation room (OR) of the ED and mean LOS was found to be 164.1 minutes. Cardiology was the most frequently consulted specialty. Mean arrival time of the consultants in ED was 64 minutes. CONCLUSIONS: Similar to EDs in other parts of the world, prolonged length of stay in the ED, delayed laboratory and imaging tests, delay of consultants, and lack of sufficient inpatient beds are the most important causes of overcrowding in the ED. Some drastic measures must be taken to minimize errors and increase satisfaction ratio.