Factors affecting seizure recurrence in the emergency department.

Background: Information on Emergency Department (ED) follow-up of patients presenting with epileptic seizures is limited. Objectives: It was planned to investigate the factors affecting the recurrence of epileptic seizures in the follow-up of patients presenting to the ED with the complaint of epileptic seizures. Materials and methods: This prospective, observational, single-center study was carried out in an adult population presenting to the ED. The study included patients older than 18 years of age presenting to the ED with the complaint of epileptic seizures. Results: Of the 205 patients included in the study, 68 (33.2%) had seizure recurrence during the 6 h. In the univariable analysis, advanced age, prolonged post-ictal duration, increased seizure duration, generalized tonic clonic seizure, alcohol consumption within past 24 h, hypertension, coronary artery disease, Alzheimer's disease, prior ischemic cerebrovascular disease, low Glascow Coma Scale (GCS), high glucose, high C-Reactive Protein, high phosphorus, low potassium, high blood urea nitrogen, high lactate, increased anion gap, high osmolarity were statistically significant in predicting recurrent seizure recurrence within 6 h. According to the logistic regression, postictal duration, GCS score, and age were independent predictors in our model. The cut-off value of postictal duration in predicting seizure recurrence at the highest sensitivity (66.2%) and specificity (89.8%) was 22.5 min. Conclusion: A prolonged postictal state, low GCS score, advanced age may be an indication of seizure recurrence. Therefore, patients with a long postictal duration, low GCS score, advanced age should be followed up more carefully in terms of recurrent seizures in the ED.

Investigating the association between various platelet indices and different clinical sub-groups of severe malaria.

Aim: To evaluate the ability of platelet count, mean platelet volume, platelet distribution width, and platelet mass index to predict the severity of malaria. Materials and Methods: This study was conducted as a retrospective cohort study at a tertiary hospital in Somali. Patients grouped as severe and non-severe malaria. We compared groups in terms of platelet count, mean platelet volume, platelet distribution width, and platelet mass index. Results: A total of 131 patients were included in the final analysis. Of the patients, 77 (58.7%) had non-severe malaria, and 54 (41.3%) had severe malaria. The multivariate analysis revealed that there was no significant difference between the groups in terms of platelet count, mean platelet volume, platelet distribution width, and platelet mass index (p: 0.183, 0.323, 0.204, and 0.139, respectively). In the receiver operating characteristic analysis, the area under the curve values for platelet count, mean platelet volume, platelet distribution width, and platelet mass index were 0.699, 0.619, 0.504, and 0.675, respectively. Conclusion: Of the platelet indices, platelet count, mean platelet volume, platelet distribution width, and platelet mass index were not clinically significant markers that could be used to predict the severity of malaria.

Effect of the COVID-19 Pandemic on Emergency Department Presentations with Mushroom Poisoning: A Report from Turkey.

Background In this study, we investigated the effect of the coronavirus disease 2019 (COVID-19) pandemic on emergency department admissions with mushroom poisoning in a tertiary hospital in Turkey. Materials and Methods This study was conducted as a retrospective cohort study to evaluate the data of patients admitted to the emergency department between January 1, 2018, and December 31, 2020. The patients diagnosed with the International Classification of Diseases-10 code T62.0 concerning the toxic effect of ingested mushrooms were identified through the computerized medical and laboratory record system of the hospital. The patients' demographic data, presentation seasons, laboratory findings, emergency department outcomes, and mortality due to mushroom poisoning were obtained. To reveal the effect of COVID-19 pandemic on emergency department presentations with mushroom poisoning, the means of the pre-pandemic period (2018-2019) and the pandemic period (2020) were compared. Results The data of a total of 171 patients were included in the final analysis. The number of patients diagnosed with the toxic effect of ingested mushrooms was 96 in 2018, 61 in 2019, and 14 in 2020. There was a 5.6-fold decrease during pandemic period in the number of patients presenting to the emergency department with mushroom poisoning. Conclusion The decrease in mushroom poisoning cases may be related to the changes in the eating habits of individuals during the pandemic and our study being conducted in a metropolitan city. We recommend that multicenter studies be performed to verify the data obtained from our study and increase their generalizability.

Characteristics of School Injuries Presenting to the Emergency Department.

Background School injuries account for approximately one-fifth of pediatric injuries. We aimed to investigate the frequency and severity of school injuries among school-aged children and determine clinical diagnoses and surgery requirement data. Methods In this prospective study, children who were admitted to the emergency department due to school accidents over a 5-month period were included. Demographics, activity during trauma, mechanism of trauma, nature, severity, emergency department outcomes, and surgery requirement were evaluated. Results The study included a total of 504 school-aged children, of whom 327 (64.9%) were male and 177 (35.1%) were female. Of the children, 426 (84.5%) had no evidence of injury or minor injury, while 78 (15.5%) had moderate or severe injury. There was a statistically significant difference between these two groups in terms of gender ( p = 0.031). Of the 78 children with moderate or severe injuries, 45 had extremity fractures, 18 had lacerations, 5 had maxillofacial injuries, 4 had cerebral contusion, 1 had lung contusion, and 1 had cervical soft-tissue damage. Two patients with fractures and two with eyelid lacerations were treated surgically, and four patients with brain contusion were hospitalized for a close follow-up. Conclusion This study revealed that the most common moderate or severe injuries in school accidents referred to emergency department were distal radius fractures and lacerations.

Predictive Ability of the MEWS, REMS, and RAPS in Geriatric Patients With SARS-CoV-2 Infection in the Emergency Department.

BACKGROUND: The aim of this study was to compare the ability of the Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) to predict 30-d mortality in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection aged 65 y and over. METHODS: This prospective, single-center, observational study was carried out with 122 volunteers aged 65 y and over with patients confirmed to have SARS-CoV-2 infection according to the reverse transcriptase-polymerase chain reaction (RT-PCR) test, who presented to the emergency department between March 1, 2020, and May 1, 2020. Demographic data, comorbidities, vital parameters, hematological parameters, and MEWS, REMS, and RAPS values of the patients were recorded prospectively. RESULTS: Among the 122 patients included in the study, the median age was 71 (25th-75th quartile: 67-79) y. The rate of 30-d mortality was 10.7% for the study cohort. The area under the receiver operating characteristic curve values for MEWS, RAPS, and REMS were 0.512 (95% confidence interval [CI]: 0.420-0.604; P = 0.910), 0.500 (95% CI: 0.408-0.592; P = 0.996), and 0.675 (95% CI: 0.585-0.757; P = 0.014), respectively. The odds ratios of MEWS (≥2), RAPS (>2), and REMS (>5) for 30-d mortality were 0.374 (95% CI: 0.089-1.568; P = 0.179), 1.696 (95% CI: 0.090-31.815; P = 0.724), and 1.008 (95% CI: 0.257-3.948; P = 0.991), respectively. CONCLUSIONS: REMS, RAPS, and MEWS do not seem to be useful in predicting 30-d mortality in geriatric patients with SARS-CoV-2 infection presenting to the emergency department.

Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Renal Colic in the ED: A Randomized, Double-Blind, Placebo-Controlled Trial.

STUDY OBJECTIVE: To determine the analgesic efficacy of TENS treatment in patients with renal colic in the emergency department (ED). METHODS: This double-blind, randomized controlled trial was conducted in a tertiary care ED. Patients with a definitive diagnosis of renal colic were assigned (1:1) as randomized to receive the real TENS with frequency 100 Hz, pulse width 200 microseconds, voltage 2 mA, or placebo with sham TENS. Pain intensity was measured using visual analog scales (VAS) at baseline, after 15 and 30th minutes. RESULTS: A total of 100 patients were included in the final analysis: 50 patients treated with real TENS and 50 patients treated with sham TENS. VAS scores in both groups were similar at baseline. The mean reduction in VAS score at 15 min was 33.3 ± 17.6 (95% Confidence interval (CI): 28.3 to 38.3) for the real TENS group and 14.9 ± 11.6 (95% CI 11.6 to 18.2) for the sham TENS group (mean difference: 18.4 (95% CI: 12.5 to 24.4, P < 0.0001). The mean reduction in VAS score at 30 min was 63.7 ± 21.1 (95% CI: 57.7 to 69.7) for the real TENS group and 14.9 ± 16.2 (95% CI: 19.5 to 10.3) for the sham TENS group (mean difference: 48.8, 95% CI: 41.4 to 56.3, P < 0.0001). Four patients (8%) in the real TENS group and 24 patients (48%) in the sham TENS group required the rescue medication after 30th minutes. CONCLUSIONS: TENS is effective for acute pain treatment in renal colic patients in the ED. TENS therapy could be a treatment option for renal colic.

Can 1st and 6th month pulmonary function test follow-ups give an idea about the long-term respiratory effects of COVID-19 pneumonia?

OBJECTIVE: The aim of this study was to ascertain the long-term respiratory effects of COVID-19 pneumonia through pulmonary function tests in follow-ups at 1 and 6 months. METHODS: Our study was conducted between August 1, 2020 and April 30, 2021. At 1 month after discharge, follow-up evaluations, PFTs, and lung imaging were performed on patients aged above 18 years who had been diagnosed with COVID-19 pneumonia. In the 6th month, the PFTs were repeated for those with pulmonary dysfunction. RESULTS: A total of 219 patients (mean age, 49±11.9 years) were included. Pathological PFT results were noted in the 1st month for 80 patients and in the 6th month for 46 (7 had obstructive disorder, 15 had restrictive disorder, and 28 had small airway obstruction) patients. A significant difference was found between abnormal PFT results and patient-described dyspnea in the 1st month of follow-up. The 6-month PFT values (especially those for forced vital capacity) were statistically significantly lower in the patients for whom imaging did not indicate complete radiological improvement at the 1-month follow-up. No statistically significant difference was found between the severity of the first computed tomography findings or clinical condition on emergency admission and pulmonary dysfunction (Pearson's chi-square test, P=0.904; Fisher's exact test, P=0.727). CONCLUSION: It is important that patients with COVID-19 pneumonia be followed up for at least 1 month after discharge to be monitored for potential long-term lung damage. PFTs should be administered to those in whom ongoing dyspnea, which started with COVID-19, and/or full recovery were not identified in pulmonary imaging.

Diagnostic performance of thorax CT in mildly symptomatic COVID-19 patients: The importance of atypical CT findings.

OBJECTIVE: Computed tomography of the thorax (Thorax CT) is frequently used to diagnose viral pneumonia in moderate to severe COVID-19 patients, but its diagnostic performance in mildly symptomatic COVID-19 patients is still unclear. Assessing the diagnostic performance of thorax CT in mildly symptomatic COVID-19 patients was the purpose of our study. METHODS: Mildly symptomatic and clinically stable, suspected COVID-19 patients scanned with Thorax CTs between March 11, 2020, and April 13, 2020, were included in this study. The sensitivity, specificity, positive and negative likelihood ratios, positive and negative predictive values, and the respective accuracies were calculated for diagnostic purposes. RESULTS: Among the 1119 patients enrolled in our study, abnormal thorax CT scans were 527 out of which 363/527 (68.9%) had typical CT features for COVID-19. According to analysis of typical COVID findings, sensitivity, specificity, positive predictive values, negative predictive value, and the accuracy of Thorax CTs with were 51.45%, 86.07%, 78.24%, 64.55%, and 68.99%, respectively. When typical CT findings and atypical CT findings were combined for the statistical analysis, the sensitivity, specificity, and accuracy observed 68.84%, 74%, and 71.49%. CONCLUSION: Diagnosing pneumonia can be challenging in mildly symptomatic COVID-19 patients since the Reverse Transcription Polymerase Chain Reaction test results, when compared with symptoms are not always evident. According to our study, thorax CT sensitivity was higher when atypical COVID-19 CT findings were included compared to those with typical COVID-19 CT findings alone. Our study which included the largest number of patients among all other similar studies indicates that not only typical but also atypical CT findings should be considered for an accured diagnosis of COVID-19 pneumonia.

Effectiveness of the rapid emergency medicine score and the rapid acute physiology score in prognosticating mortality in patients presenting to the emergency department with COVID-19 symptoms.

OBJECTIVE: We investigated the effectiveness of the Rapid Emergency Medicine Score and the Rapid Acute Physiology Score in identifying critical patients among those presenting to the emergency department with COVID-19 symptoms. MATERIAL AND METHODS: This prospective, observational, cohort study included patients with COVID-19 symptoms presenting to the emergency department over a two-month period. Demographics, clinical characteristics, and the data of all-cause mortality within 30 days after admission were noted, and the Rapid Emergency Medicine Score and the Rapid Acute Physiology Score were calculated by the researchers. The receiver operating characteristic curve analysis was performed to determine the discriminative ability of the scores. RESULTS: A total of 555 patients with a mean of age of 49.4 ± 16.8 years were included in the study. The rate of 30-day mortality was 3.9% for the whole study cohort, 7.2% for the patients with a positive rt-PCR test result for SARS-CoV-2, and 1.2% for those with a negative rt-PCR test result for SARS-CoV-2. In the group of patients with COVID-19 symptoms, according to the best Youden's index, the cut-off value for the Rapid Emergency Medicine Score was determined as 3.5 (sensitivity: 81.82%, specificity: 73.08%), and the area under curve (AUC) value was 0.840 (95% confidence interval 0.768-0.913). In the same group, according to the best Youden's index, the cut-off value for the Rapid Acute Physiology Score was 2.5 (sensitivity: 90.9%, specificity: 97.38%), and the AUC value was 0.519 (95% confidence interval 0.393-0.646). CONCLUSION: REMS is able to predict patients with COVID-19-like symptoms without positive rt-PCR for SARS-CoV-2 that are at a high-risk of 30-day mortality. Prospective multicenter cohort studies are needed to provide best scoring system for triage in pandemic clinics.

Early predictors of mortality for moderate to severely ill patients with Covid-19.

BACKGROUND: Determining the factors affecting the mortality and clinical conditions of the patients with Covid-19 are indispensable needs in developing patient treatment algorithms. We aimed to determine the parameters that can predict the mortality of moderate to severely ill patients with laboratory confirmed Covid-19. METHODS: Moderate to severely ill, Covid-19 patients older than 18 years were included. Mild Covid-19 patients and the ones with negative polymerase chain reaction test results were excluded from the study. The primary outcome of the study was 30-day mortality rate and we aimed to determine the factors affecting mortality in moderate to severely ill Covid-19 patients. RESULTS: 168 patient results were analyzed. Median age of the patients was 59.5 (48.3 to 76) and 90 (53.6%) were male. According to multivariate regression analysis results, the presence of any comorbid disease (p = 0.027, HR = 26.11 (95%CI: 1.45 to 471.31)), elevated C-reactive protein levels (CRP) (p < 0.001, HR = 1.24 (95%CI: 1.11 to 1.38)) and presence of dyspnea (p = 0.026, HR = 4.26 ((95%CI: 1.19 to 15.28)) were found to significantly increase the mortality, while high pulse O 2 saturation level (p < 0.001, HR = 0.90 (95%CI: 0.82 to 0.99) was found to decrease. When receiver operating characteristic curve was created for laboratory tests, it was determined that white blood cell counts, neutrophil counts, CRP levels and neutrophil/lymphocyte ratio predicted mortality while Lymphocyte levels did not. CONCLUSION: Dyspnea, the presence of any comorbid disease, elevated CRP levels, and low pulse O 2 saturation levels predict mortality in moderate to severely ill Covid-19 patients.

Treatment of migraine attacks by transcutaneous electrical nerve stimulation in emergency department: A randomize controlled trial.

PURPOSE: The primary purpose of this trial is to evaluate the effectiveness of Transcutaneous Electrical Nerve Stimulation (TENS) therapy application in the emergency department. METHODS: The patients were divided into 2 groups: a sham group, and a verum group. Patients in the verum group include those who use the device for the first time. Both groups were connected to visually indistinguishable devices. Both groups underwent therapy for a total of 20 min. Using the Visual Analog Scale (VAS), the patients' perceived changes in pain intensity were recorded at the 20th and 120th minutes after initiation therapy. After the 120th minute, patients' individual needs for additional treatment were assessed. Additionally, their self-reported well-being was assessed using a Likert-type verbal scale. RESULTS: In total 151 patients that were admitted to the emergency ward were assessed, with the sham and verum group being assigned 39 patients each from this pool. For the verum group the VAS change from 0 to 120 min was -65 ± 25 and for the sham group it was -9 ± 2 (p < 0.001). Verbal scores in the 120th minute were found to be 1.2 for sham group and 4.5 in the verum group (p < 0.001). Thirty patients (76.92%) in the sham group and 1 (2%) in the verum group had additional analgesic requirement after 120 min. CONCLUSION: TENS therapy is a fast-acting, effective therapy for the treatment of acute migraine in the emergency department.

Characteristics of injuries among infants who fall from bed.

INTRODUCTION: Accidental falls are the most common causes of injury among infants. Due to their limited ability to move independently, falling from bed or other types of furniture (such as sofas or armchairs) is considered the most common reason for such injury. However, little is known about the frequency and types of injury associated with this type of fall among infants. This study aimed to determine the incidence and characteristics of injury among infants presented at emergency departments (ED) after falling from bed or similar furniture. METHODS: The retrospective analysis of infants under one year old presenting at ED after falling from bed (or similar furniture) was performed over a four-year period (2016-2019). Patient demographics, incidence and patterns of injury, outcomes, and ED resources use were evaluated as part of the study. RESULTS: In total, 1,439 infants were included in the study, of whom 782 (54.3%) were male and 657 (45.7%) female. The median age of the patients was 7 months (interquartile range [IQR]: 6-9 months). More than half the infants (n = 812, 56.4%) had minor injuries, such as abrasions, bruising, contusions, and lacerations. There were significant injuries for 135 (9.4%) infants. The most common fracture was skull fracture (n = 59, 4.1%), followed by proximal fracture of the upper extremities (n = 26, 1.8%). Six (0.4%) patients had radial head subluxation. Traumatic brain injury featured for 30 (2.1%) infants (intracranial hemorrhage/cerebral contusion). While the majority of patients (n = 1352, 94%) were discharged from ED, 86 (6%) infants were hospitalized, all due to head injuries. A neurosurgical intervention was performed with three (0.2% of all patients) of the hospitalized patients. CONCLUSION: Falling from bed causes skull fractures, traumatic brain injury, and long bone fractures among infants. Therefore, campaigns should be organized to raise awareness of these risks among parents and caregivers of infants. In addition, the use of safety equipment (such as bed rails) and creating a safe environment can help prevent significant injuries.

Tension gastrothorax secondary to trauma in the emergency room: A case report.

In tension gastrothorax, the abdominal contents are displaced into the thorax, leading to a mediastinal shift that arises from the pressure placed on the intrathoracic region. This condition is often due to a congenital or acquired (secondary to surgery) diaphragmatic defect and is rarely seen secondary to trauma. A 40-year-old man presented to the emergency department after an in-vehicle traffic accident. He had no active complaint other than mild chest pain. On auscultation, breath sounds were audible in the left lung base and bowel sounds were heard. Computed tomography of the thorax revealed left-sided diaphragmatic hernia. The jugular vein was distended, and the patient became desaturated in the emergency room. Nasogastric decompression was performed, and the saturation improved. The patient underwent open surgery. Traumatic tension gastrothorax should be considered in the differential diagnosis of acute-onset severe respiratory failure. It can be diagnosed by rapid clinical and radiological evaluation.

A Rare Case of Metformin Intoxication with Mortal Course.

Metformin-associated lactic acidosis is a rare side effect in metformin poisoning. There is conflicting data about mortality rates changing from 3% to 83%. We aimed to discuss a case that developed lactic acidosis and acute renal failure progressing to mortality due to metformin intoxication. A 33 year-old female patient was admitted to the emergency department, with nausea and vomiting after taking 30 tablets of 1000 mg metformin. In the 2nd hour of follow-up, patient was observed to develop lactic acidosis which did not recover despite the infusion replacement treatments and hemodialysis. Following the development of respiratory failure, under mechanical ventilation, the patient developed cardiac arrest at the 48th hour of her admission. In metformin intoxications, it should be remembered that acidosis deepens very quickly and can progress with mortality despite optimal supportive therapy. More specific recommendations and further studies are required for the management and treatment of acute metformin-associated lactic acidosis.

WhatsApp as an Emergency Teleradiology Application for Cranial CT Assessment in Emergency Services.

OBJECTIVE: To evaluate the diagnostic agreement of transmitted images of cranial CT due to trauma, through WhatsApp software compared to workstation image-based diagnosis. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Emergency Medicine, Adiyaman University Training and Research Hospital, from January 2017 to May 2018. METHODOLOGY: A total of 94 cases that presented to the Emergency Department and underwent cranial CT were included in the study. CT images were video-recorded by the emergency physician using an Apple iPhone 7. The images were evaluated by two different radiologists using Samsung Galaxy Edge 7 and Samsung Note 8 mobile phones. Later, the radiological images were reviewed by two different radiologists at the PACS workstation. Then, the WhatsApp-mediated and final diagnoses were compared for various lesions to evaluate the interobserver agreement and diagnostic success of the use of WhatsApp software. RESULTS: In the assessment of the interobserver agreement, the kappa values were found to be 0.89 for normal findings, 0.84 for subdural hematoma, 0.73 for subarachnoid hemorrhage, 0.81 for epidural hematoma, 0.85 for fractures, 1 for parenchymal hematoma, and 0.68 for parenchymal contusion. CONCLUSION: Although WhatsApp can be used in the evaluation of emergency cranial CT images, it is essential to note that some findings, especially those indicating fractures, subdural hematoma, and parenchymal contusion, can be overlooked. Key Words: Teleradiology, PACS, Medical software, Computed tomography, WhatsApp, Instant Messenger.

Cardiac compression of a hepatic cyst in polycystic liver disease: A rare cause of hemodynamic instability.

Polycystic liver disease (PLD) develops due to embryonic ductal plate malformation of intrahepatic bile ducts. Cysts in the liver can range from a simple compression effect to severe liver failure. The most common complication is rupture and inflammation of cyst. It can sometimes progress to the extent of pushing the heart to the left or compressing the inferior vena cava, thereby reducing the venous return. Here, we present a case with giant liver cyst-related symptoms that caused external compression of the right ventricle and atrium. A 71-year-old female patient was admitted to our emergency department with increasing dyspnea, chest pain, and abdominal distension. Her vital signs were as follows: temperature 38°C, pulse 140 beats/min, and blood pressure 70/40 mmHg. Her abdomen was distended, and there was minimal epigastric tenderness. Hepatomegaly was also present. Posteroanterior chest radiography revealed opacity that erased the right diaphragm contour at the right inferior hemithorax. In thoracoabdominal computed tomography, the heart was deviated toward the left due to the compression of a large cystic formation located in the hepatic right lobe, pushing the diaphragm to the superior. Piperacillin/tazobactam 3 g × 4.5 g treatment was initiated, and external drainage was performed by interventional radiology. Following this procedure, significant improvement was observed in the patient's condition. Her symptoms significantly improved, and the drainage catheter was removed on the seventh day. Hepatic cysts in patients with PLD may compress adjacent structures, and cardiac compression can be life-threatening if hemodynamic instability occurs.

Evaluation of the Relationship between Early Troponin Clearance and Short-Term Mortality in Patients with Chronic Renal Failure.

OBJECTIVE: In patients with CKD, cTn concentrations may be elevated in the absence of AMI, which is a predicted finding caused by chronic structural heart disease rather than acute injury. The increase in troponin level observed in noncardiac conditions provides conflicting results when predicting mortality. Low lactate clearance was associated with increased mortality. Lactate clearance is calculated as follows: (early lactate - late lactate/early lactate) ∗ 100. We aimed to investigate whether troponin clearance calculated according to this formula had an effect on short-term mortality. METHODS: The study included 300 patients with chronic renal failure who had a sepsis-related organ failure assessment (SOFA) score ≥3. By taking the baseline troponin at the time of emergency presentation as reference and comparing them with the fourth-hour troponin values, troponin clearance was investigated in the evaluation of mortality among hospitalized patients with CKD within the first month after discharge. The data obtained were analyzed using the SPSS data analysis software version 20.0. Student's t-test was used for the parametric data, and the Chi-squared test for the nonparametric data. RESULTS: Of the 300 patients evaluated, 189 patients survived (mean age 66.20 ± 14.597 years), and 111 died (mean age 74.81 ± 12.916 years). Troponin clearance was detected in 40 of the 111 patients in the mortality group and 119 of the 189 patients in the survival group. Troponin clearance was significantly more frequent in surviving patients (P=0.0000083). CONCLUSION: Troponin clearance can be considered as a valuable leading indicator of survival, but higher levels of troponin clearance did not lead to higher survival rates.