Point-of-care Lung Ultrasound, Lung CT and NEWS to Predict Adverse Outcomes and Mortality in COVID-19 Associated Pneumonia.

Introduction: The appraisal of disease severity and prediction of adverse outcomes using risk stratification tools at early disease stages is crucial to diminish mortality from coronavirus disease 2019 (COVID-19). While lung ultrasound (LUS) as an imaging technique for the diagnosis of lung diseases has recently gained a leading position, data demonstrating that it can predict adverse outcomes related to COVID-19 is scarce. The main aim of this study is therefore to assess the clinical significance of bedside LUS in COVID-19 patients who presented to the emergency department (ED). Methods: Patients with a confirmed diagnosis of SARS-CoV-2 pneumonia admitted to the ED of our hospital between March 2021 and May 2021 and who underwent a 12-zone LUS and a lung computed tomography scan were included prospectively. Logistic regression and Cox proportional hazard models were used to predict adverse events, which was our primary outcome. The secondary outcome was to discover the association of LUS score and computed tomography severity score (CT-SS) with the composite endpoints. Results: We assessed 234 patients [median age 59.0 (46.8-68.0) years; 59.4% M), including 38 (16.2%) in-hospital deaths for any cause related to COVID-19. Higher LUS score and CT-SS was found to be associated with ICU admission, intubation, and mortality. The LUS score predicted mortality risk within each stratum of NEWS. Pairwise analysis demonstrated that after adjusting a base prediction model with LUS score, significantly higher accuracy was observed in predicting both ICU admission (DBA -0.067, P = .011) and in-hospital mortality (DBA -0.086, P = .017). Conclusion: Lung ultrasound can be a practical prediction tool during the course of COVID-19 and can quantify pulmonary involvement in ED settings. It is a powerful predictor of ICU admission, intubation, and mortality and can be used as an alternative for chest computed tomography while monitoring COVID-19-related adverse outcomes.

Comparison of different risk stratification systems for prediction of acute pancreatitis severity in patients referred to the emergency department of a tertiary care hospital.

BACKGROUND: Prognostic prediction and estimation of severity at early stages of acute pancreatitis (AP) are crucial to reduce the complication rates and mortality. The objective of the present study is to evaluate the predicting ability of different clinical and radiological scores in AP. METHODS: We retrospectively collected demographic and clinical data from 159 patients diagnosed with AP admitted to Canakkale Onsekiz Mart University Hospital between January 2017 and December 2019. Bedside index for severity AP (BISAP), and acute phys-iology and chronic health evaluation II (APACHE II) score at admission, Ranson and modified Glasgow Prognostic Score (mGPS) score at 48 h after admission were calculated. Modified computed tomography severity index (CTSI) was also calculated for each patient. Area under the curve (AUC) was calculated for each scoring system for predicting severe AP, pancreatic necrosis, length of hospital stay, and mortality by determining optimal cutoff points from the (ROC) curves. RESULTS: mGPS and APACHE II had the highest AUC (0.929 and 0.823, respectively) to predict severe AP on admission with the best specificity and sensitivity. In predicting mortality BISAP (with a sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of 75.0%, 70.9%, 98.2%, and 12.0%, respectively, [AUC: 0.793]) and APACHE II (with a sensitivity, specificity, NPV and PPV of 87.5%, 86.1%, 99.2%, and 25.0%, respectively, [AUC: 0.840]). CONCLUSION: mGPS can be a valuable tool in predicting the patients more likely to develop severe AP and maybe somewhat better than BISAP score, APACHE II Ranson score, and mCTSI.

The Effectiveness of National Early Warning Score, Quick Sequential Organ Failure Assessment, Charlson Comorbidity Index, and Elixhauser Comorbidity Index Scores in Predicting Mortality Due to COVID-19 in Elderly Patients.

INTRODUCTION: As the mortality rate in coronavirus disease 2019 (COVID-19) patients older than 65 years is considerable, evaluation of in-hospital mortality is crucial. This study aimed to evaluate in-hospital mortality in COVID-19 patients older than 65 years using the National Early Warning Score (NEWS), Quick Sequential Organ Failure Assessment (q-SOFA), Charlson Comorbidity Index (CCI), and Elixhauser Comorbidity Index (ECI). METHODS: This retrospective study included data from 480 patients with confirmed COVID-19 and age over 65 years who were evaluated in a university emergency department in Turkey. Data from eligible but deceased COVID-19 patients was also included. NEWS, q-SOFA, CCI, and ECI scores were retrospectively calculated. All clinical data was accessed from the information management system of the hospital, retrieved, and analyzed. RESULTS: In-hospital mortality was seen in 169 patients (169/480). Low oxygen saturation, high C-reactive protein (CRP) and urea levels, and high q-SOFA and ECI scores helped us identify mortality in high-risk patients. A statistically significant difference was found in mortality estimation between q-SOFA and ECI (p <0.001), respectively. CONCLUSION: Q-SOFA and ECI can be used both easily and practically in the early diagnosis of in-hospital mortality in COVID-19 positive patients over 65 years of age admitted to the emergency department. Low oxygen saturation, high CRP and urea levels, and high q-SOFA and ECI scores are helpful in identifying high-risk patients.

Diagnostic utility of hematological indices in predicting adverse outcomes and severity of acute pancreatitis based on BISAP and modified Glasgow score.

BACKGROUND: The neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte-ratio (PLR), and red blood cell distribution width (RDW) are simple indicators of inflammatory status previously established as a severity indicator in distinct disease states. This study aimed to determine the impact of these simple hematologic indices with conventional inflammation markers such as C-reactive pro-tein (CRP) and white blood cells in acute pancreatitis (AP) patients and their relationship with AP risk stratification scores including Bedside Index for Severity of Acute Pancreatitis (BISAP) and modified Glaskow Prognostic score (mGPS) scores. METHODS: This retrospective study was performed in the emergency department of Canakkale Onsekiz Mart University. A total of 171 patients (male/female: 68 [39.8%]/103 [60.3%]) with AP and 59 age and gender matched healthy subjects (male/female: 23 [39%]/36[61%]) as controls were enrolled in the present study. The patients were grouped according to severity and adverse outcomes according to BISAP and mGPS and a comparative analysis was performed to compare the NLR, PLR, and RDW between groups. RESULTS: The mean NLR values of AP patients and control group were 9.62±6.34 and 2.04±1.08, respectively (p<0.001), while the mean PLR values of AP patients and control group were 221.83±122.43 and 83.30±38.89, respectively (p<0.001). Except from RDW, all the other hematologic indices were found to be elevated (p<0.05 for WBC; NLR, PLR, and CRP) on both mild and severe disease at disease onset. NLR and PLR showed significant predictive ability for estimating serious complications associated with AP. CONCLUSION: The present study showed that NLR and PLR is increased in AP. Moreover, peripheral blood NLR and PLR values can predict disease severity and adverse outcomes associated with AP and can be used as an adjunctive marker for estimating disease severity.

Prediction of adverse outcomes using non-endoscopic scoring systems in patients over 80 years of age who present with the upper gastrointestinal bleeding in the emergency department.

BACKGROUND: The emergency department (ED) admission rate for elderly patients with non-variceal upper gastrointestinal bleeding (UGIB) is increasing. The AIMS65 and Glasgow-Blatchford score (GBS) are two distinct scoring systems proposed to predict in-hospital and post-discharge mortality, length of stay (LOS), and health-related costs in these patients. The objective of the present study is to evaluate the accuracy of these scoring systems, in conjunction with the Charlson comorbidity index (CCI), to predict 30-day mortality and LOS in UGIB patients who are 80 years of age or older METHODS: A retrospective analysis was undertaken of 182 patients with non-variceal UGIB who were admitted to the ED of Canakkale Onsekiz Mart University Hospital. The AIMS65, GBS, and CCI scores were calculated and adverse patient outcomes were assessed. RESULTS: The mean age of patients was 85.59±4.33 years, and 90 (49.5%) of the patients were males. The AIMS65 was superior to the GBS (area under the receiver operating characteristic curve [AUROC] 0.877 vs. 0.695, respectively) and CCI (AUROC 0.877 vs. 0.526, respectively) in predicting the 30-day mortality. All three scores performed poorly in predicting the LOS in hospital. The cutoff threshold that maximized sensitivity and specificity for mortality was three for the AIMS65 score (sensitivity, 0.87; specificity, 0.80; negative predictive values [NPV], 0.977; positive predictive values [PPV], 0.392), 14 for GBS (sensitivity, 0.83; specificity, 0.51; NPV, 0.923; PPV, 0.367), and 5 for CCI (sensitivity, 0.91; specificity, 0.22; NPV, 0.946; PPV, 0.145). CONCLUSION: The AIMS65 is a simple, accurate, and non-endoscopic scoring system that can be performed easily in ED settings. It is superior to GBS and CCI in predicting 30-day mortality in elderly patients with UGIB.

Haemogram indices are as reliable as CURB-65 to assess 30-day mortality in Covid-19 pneumonia.

Background Mortality due to Covid-19 and severe community-acquired pneumonia (CAP) remains high, despite progress in critical care management. We compared the precision of CURB-65 score with monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) in prediction of mortality among patients with Covid-19 and CAP presenting to the emergency department. Methods We retrospectively analysed two cohorts of patients admitted to the emergency department of Canakkale University Hospital, namely (i) Covid-19 patients with severe acute respiratory symptoms presenting between 23 March 2020 and 31 October 2020, and (ii) all patients with CAP either from bacterial or viral infection within the 36 months preceding the Covid-19 pandemic. Mortality was defined as in-hospital death or death occurring within 30 days after discharge. Results The first study group consisted of 324 Covid-19 patients and the second group of 257 CAP patients. The non-survivor Covid-19 group had significantly higher MLR, NLR and PLR values. In univariate analysis, in Covid-19 patients, a 1-unit increase in NLR and PLR was associated with increased mortality, and in multivariate analysis for Covid-19 patients, age and NLR remained significant in the final step of the model. According to this model, we found that in the Covid-19 group an increase in 1-unit in NLR would result in an increase by 5% and 7% in the probability of mortality, respectively. According to pairwise analysis, NLR and PLR are as reliable as CURB-65 in predicting mortality in Covid-19. Conclusions Our study indicates that NLR and PLR may serve as reliable predictive factors as CURB-65 in Covid-19 pneumonia, which could easily be used to triage and manage severe patients in the emergency department.

Evaluation of the factors predicting the need for intensive care of patients with COVID-19 aged above 65 years: data from an emergency department in Turkey

SUMMARY OBJECTIVE: Individuals aged ≥65 years are more susceptible to COVID-19 disease and admission to intensive care is most notable. The scoring systems (national early warning score, quick sequential organ failure assessment, shock index) are recommended for rapid assessment of patients in emergency room conditions. The goal of our study is to evaluate scoring systems in conjunction with predictive factors of need for admission to intensive care of patients ≥65 years old with a diagnosis of COVID-19 who applied to the emergency room. METHODS: Patients were divided into two groups according to evolution in the emergency room, being those who needed or not intensive care. National Early Warning Score, quick sequential organ failure assessment, shock index scores and serum biochemistry, blood count and blood gas values were evaluated from hospital information management system records. RESULTS: Of the patients included in the study, 80.8% were admitted to the ward and 14.5% to the unit of intensive care. Lymphocyte count, base deficit and bicarbonate levels were lower, and the levels of C-reactive protein, lactate, D-dimer, urea and lactate dehydrogenase were higher in patients who needed intensive care. Quick sequential organ failure assessment and shock index were considered significant in the group admitted to the intensive care unit. CONCLUSIONS: We recommend that quick sequential organ failure assessment and shock index be used quickly, practically and easily in predicting the need for intensive care unit in patients aged ≥65 years in emergency department diagnosed with COVID-19.

Prediction of mortality in COVID-19 through combing CT severity score with NEWS, qSOFA, or peripheral perfusion index.

INTRODUCTION: The assessment of disease severity and the prediction of clinical outcomes at early disease stages can contribute to decreased mortality in patients with Coronavirus disease 2019 (COVID-19). This study was conducted to develop and validate a multivariable risk prediction model for mortality with using a combination of computed tomography severity score (CT-SS), national early warning score (NEWS), and quick sequential (sepsis-related) organ failure assessment (qSOFA) in COVID-19 patients. METHODS: We retrospectively collected medical data from 655 adult COVID-19 patients admitted to our hospital between July and November 2020. Data on demographics, clinical characteristics, and laboratory and radiological findings measured as part of standard care at admission were used to calculate NEWS, qSOFA score, CT-SS, peripheral perfusion index (PPI) and shock index (SI). Logistic regression and Cox proportional hazard models were used to predict mortality, which was our primary outcome. The predictive accuracy of distinct scoring systems was evaluated by the receiver-operating characteristic (ROC) curve analysis. RESULTS: The median age was 50.0 years [333 males (50.8%), 322 females (49.2%)]. Higher NEWS and SI was associated with time-to-death within 90-days, whereas higher age, CT-SS and lower PPI were significantly associated with time-to-death within both 14 days and 90 days in the adjusted Cox regression model. The CT-SS predicted different mortality risk levels within each stratum of NEWS and qSOFA and improved the discrimination of mortality prediction models. Combining CT-SS with NEWS score yielded more accurate 14 days (DBA: -0.048, p = 0.002) and 90 days (DBA: -0.066, p < 0.001) mortality prediction. CONCLUSION: Combining severity tools such as CT-SS, NEWS and qSOFA improves the accuracy of predicting mortality in patients with COVID-19. Inclusion of these tools in decision strategies might provide early detection of high-risk groups, avoid delayed medical attention, and improve patient outcomes.

Accidental Hypothermia and Transcranial Doppler Sonography: Case Report.

We present a patient who was diagnosed with hypothermia in the emergency department and the changes in bedside transcranial Doppler (TCD) measurements during and immediately after the diagnoses were recorded. To the best of our knowledge, this is the first case report in the literature in which TCD data were shared in an accidental hypothermia patient in the emergency department. A 78-year-old male patient was brought to the emergency department with the complaint of speech impairment. The respiratory rate was 24 bpm, pulse rate 40 bpm, body temperature 25.6°C, blood pressure 80/50 mmHg, and glasgow coma scale 11. On electrocardiography, sinus bradycardia (40 bpm) and a small deflection (J wave) at the end of the QRS complex were observed. Immediately after the patient's admission, right middle cerebral artery end diastolic velocity (EDV) was 13.42 cm/s, peak systolic velocity (PSV) was 40.25 cm/s, and pulsatile index (PI) was 1.26 cm/s. After 1 hour, her body temperature was 34.5°C. Measurements with TCD were repeated 1 hour later at the same point and EDV was found to be 26.12 cm/s, PSV 84.02 cm/s, and PI 1.33. At the fourth hour, the patient's body temperature was 36.4°C, he was normothermic, and his mental status completely normalized. The patient was hospitalized for follow-up and treatment. This case supports that it can be used in the evaluation of cerebral perfusion and improvement during treatment in patients with accidental hypothermia in their admission to the emergency department.

Evaluation of the factors predicting the need for intensive care of patients with COVID-19 aged above 65 years: data from an emergency department in Turkey.

OBJECTIVE: Individuals aged ≥65 years are more susceptible to COVID-19 disease and admission to intensive care is most notable. The scoring systems (national early warning score, quick sequential organ failure assessment, shock index) are recommended for rapid assessment of patients in emergency room conditions. The goal of our study is to evaluate scoring systems in conjunction with predictive factors of need for admission to intensive care of patients ≥65 years old with a diagnosis of COVID-19 who applied to the emergency room. METHODS: Patients were divided into two groups according to evolution in the emergency room, being those who needed or not intensive care. National Early Warning Score, quick sequential organ failure assessment, shock index scores and serum biochemistry, blood count and blood gas values were evaluated from hospital information management system records. RESULTS: Of the patients included in the study, 80.8% were admitted to the ward and 14.5% to the unit of intensive care. Lymphocyte count, base deficit and bicarbonate levels were lower, and the levels of C-reactive protein, lactate, D-dimer, urea and lactate dehydrogenase were higher in patients who needed intensive care. Quick sequential organ failure assessment and shock index were considered significant in the group admitted to the intensive care unit. CONCLUSIONS: We recommend that quick sequential organ failure assessment and shock index be used quickly, practically and easily in predicting the need for intensive care unit in patients aged ≥65 years in emergency department diagnosed with COVID-19.

The effect of meteorological variables on spontaneous pneumothorax in two regions with different altitudes.

Spontaneous pneumothorax (SP) is defined as the presence of free air inside the pleural space. Many studies have reported that meteorological variables may trigger SP, but the mechanism is unknown. The aim of this study was to compare the effects of meteorological variables on the development of SP in two regions with different altitudes. The study was conducted in the Çanakkale (2 m above sea level) and the Erzurum region (1758 m). A total of 494 patients with SP who presented to the hospitals of the two regions between January 2011 and December 2016 were included in the study. The meteorological variables used included ambient temperature, atmospheric pressure, relative humidity, precipitation amount, wind speed, and wind direction (as north and south). The total 2192 days were divided into two as days with and without an SP case presentation. A 4-day period prior to the day a case presented was compared with the other days without any cases to investigate the presence of any lagged effect. Statistical significance was accepted at p < 0.05. Comparison of these two regions showed a significant difference between them. The meteorological variables of the regions that affect SP development were found to be low mean minimum temperature, high daily temperature change, low precipitation, low wind speed and north winds for Erzurum, and only rainy days for Çanakkale. The results have demonstrated that cold weather, sudden temperature changes, north winds, and low wind speed are risk factors for the development of SP at high altitudes.

Prognostic performance of peripheral perfusion index and shock index combined with ESI to predict hospital outcome.

INTRODUCTION: Peripheral perfusion index (PPI) and shock index (SI) are considered valuable predictors of hospital outcome and mortality in various operative and intensive care settings. In the present study, we evaluated the prognostic capabilities of these parameters for performing emergency department (ED) triage, as represented by the emergency severity index (ESI). METHODS: This prospective cross-sectional study included 367 patients aged older than 18 years who visited the ED of a tertiary referral hospital. The ESI triage levels with PPI, SI, and other basic vital sign parameters were recorded for each patient. The hospital outcome of the patients at the end of the ED period, such as discharge, admission to the hospital and death were recorded. RESULTS: A total of 367 patients (M/F: 178/189) admitted to the ED were categorized according to ESI and included in the study. A decrease in diastolic BP, SpO2 and PPI increased the likelihood of hospitalization and 30-day mortality. Based on univariate analysis, a significant improvement in performance was found by using age, diastolic BP, mean arterial pressure, SpO2, SI and PPI in terms of predicting high acuity level patients (ESI < 3). In the multivariable analysis only SpO2 and PPI were found to predict ESI < 3 patients. CONCLUSION: Peripheral perfusion index and SI as novel triage instruments might provide useful information for predicting hospital admission and mortality in ED patients. The addition of these parameters to existing triage instruments such as ESI could enhance the triage specificity in unselected patients admitted to ED.

Transient ST Segment Elevation Caused by Intracoronary Thrombus after Acute Carbon Monoxide Poisoning.

Carbon monoxide (CO) poisoning is the most common cause of death and injury among all poisonings. Myocardial injury is detected in one-third of CO poisonings. In this Case Report, a previously healthy 41-year-old man was referred for CO poisoning. The initial electrocardiogram (ECG) showed 1mm ST segment elevation in leads DII, DIII, and aVF. As the patient did not describe chest pain and had no cardiac symptoms, ECG was repeated 10 minutes later and it was seen that ST segment elevation disappeared. As the patient had a transient ST segment elevation and elevated high-sensitive Tn-T (HsTn-T), the patient was transferred to the coronary angiography laboratory. The patient's left coronary system was normal, but a thrombus image narrowing the lumen by approximately 60% was observed in the right coronary artery. Intravenous tirofiban was administered for 48 hours. Control coronary angiography showed continuing thrombus formation and a bare metal stent was successfully implanted. This is the first reported case with transient ST segment elevation associated with acute coronary thrombus caused by CO poisoning. It may be recommended that patients with CO poisoning should be followed-up with a 12-lead ECG monitor or 24-hour ECG Holter monitoring, even if they show no cardiac symptoms and echocardiography shows no wall motion abnormality. Early coronary angiography upon detection of such dynamic ECG changes in these recordings as ST segment elevation can reduce the risk of myocardial infarction (MI) and mortality in these patients.