Medical Response to the February 6, 2023, Earthquakes in Hatay: Challenges Faced in the Deadliest Disaster in the History of Türkiye.

OBJECTIVE: The Kahramanmaras earthquakes struck the north-eastern part of Türkiye and Syria on February 6, 2023. It is well known that timely coordination and provision of emergency medical care in the field is particularly important to save lives after earthquakes. This study aimed to identify the challenges faced by medical responders on the ground. METHODS: This exploratory-descriptive qualitative study was conducted in Hatay, the province most affected by the earthquakes. Data were collected through in-depth semi-structured interviews and field observations, and then analyzed using thematic analysis approach. RESULTS: The study was carried out with 15 first responders from the medical profession. The study revealed 9 themes of challenges faced by medical responders: providing safety and security, human resources management, meeting personal needs, recording data, communication, patient transport, burial procedures, psychological acumen, and logistical problems. Some problems were resolved after 72 h and some continued until day 7. CONCLUSIONS: Inadequate organization of volunteer health workers, communication breakdowns, and logistical problems are some of the main challenges. To address these issues, satellite phones and radio systems can be promoted, as well as disaster-resilient logistical planning and better coordination of volunteers.

Developing and Validating a New Model to Predict In-Hospital Mortality in Patients with Acute Myocardial Infarction.

OBJECTIVE: To derive and validate a regression model that can successfully and robustly predict in-hospital mortality of patients who underwent percutaneous coronary intervention (PCI) after admission to the Department of Emergency Medicine (ED) with acute myocardial infarction (AMI). STUDY DESIGN: Cohort study. Place and Duration of the Study: ED of University of Health Sciences, Sancaktepe Training and Research Hospital, that worked as a PCI centre between January and March 2022. METHODOLOGY: Patients older than 18 years of age, diagnosed with acute ST elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) in the ED, and consequently underwent PCI were included. Patients with missing information of the outcome were excluded. For the regression model, backward stepwise logistic regression was utilised. The non-random split-sample development and validation method was used for the internal and external validation of the model. Ejection fraction, diastolic blood pressure, haemoglobin A1c, and haemoglobin were selected as the predictors. RESULTS: A total of 279 patients were included in the analysis. The area under the curve (AUC) of the final model in the derivation cohort was 0.982 (95% CI = 0.956-1.0). The sensitivity was 92.3% (95% CI = 64-99.8) and the specificity was 96.2% (95% CI = 92.3-98.4). The AUC of the final model in the validation cohort was 0.956 (95% CI = 0.904-1.0). The sensitivity was 80% (95% CI = 28.3-99.5) and the specificity was 92.3% (95% CI = 84-97.1). CONCLUSION: The suggested model generated results that can be utilised as a screening tool for predicting in-hospital mortality in patients diagnosed with STEMI or NSTEMI who are admitted to PCI in emergency medicine settings. Nonetheless, it is essential to validate the model in different populations. KEY WORDS: Percutaneous coronary intervention, Mortality, In-hospital mortality, Prediction model, Logistic regression.

Strategies for Strengthening the Resilience of Public Health Systems for Pandemics, Disasters, and Other Emergencies.

OBJECTIVE: The aim of this study was to identify and prioritize strategies for strengthening public health system resilience for pandemics, disasters, and other emergencies using a scorecard approach. METHODS: The United Nations Public Health System Resilience Scorecard (Scorecard) was applied across 5 workshops in Slovenia, Turkey, and the United States of America. The workshops focused on participants reviewing and discussing 23 questions/indicators. A Likert type scale was used for scoring with zero being the lowest and 5 the highest. The workshop scores were analyzed and discussed by participants to prioritize areas of need and develop resilience strategies. Data from all workshops were aggregated, analyzed, and interpreted to develop priorities representative of participating locations. RESULTS: Eight themes emerged representing the need for better integration of public health and disaster management systems. These include: assessing community disease burden; embedding long-term recovery groups in emergency systems; exploring mental health care needs; examining ecosystem risks; evaluating reserve funds; identifying what crisis communication strategies worked well; providing non-medical services; and reviewing resilience of existing facilities, alternate care sites, and institutions. CONCLUSIONS: The Scorecard is an effective tool for establishing baseline resilience and prioritizing actions. The strategies identified reflect areas in most need for investment to improve public health system resilience.

Reliability of smartphone measurements of peripheral oxygen saturation and heart rate in hypotensive patients measurement of vital signs with smartphones.

Objective: With the increasing use of wearable technologies (smartphones and smartwatches), it has become possible to measure vital signs outside healthcare institutions without the need for an additional medical device. With the advancement in technologies, the accuracy of vital signs measured by smartphones and smartwatches has also increased. In this study, the accuracy of smart devices in the measurement of heart rate and saturation, which are two vital signs that are difficult to detect in conditions such as hypotension were investigated. Materials and methods: The study was prospectively conducted in a tertiary healthcare center. In hypotensive patients who presented to the emergency department (ED) and required an arterial blood gas evaluation, oxygen saturation and heart rate values measured by a smartphone, those measured with a vital signs monitor (VSM) at the time of admission to the ED and oxygen saturation values measured by a blood gas analyzer (BGA) were compared. Results: A total of 200 patients, 117 women and 83 men, were included in the study. It was determined that the correlation coefficients of the heart rate values measured by the vital signs monitor and smartphone were in a high statistical agreement. When the saturation values measured by the vital signs monitor, smartphone, and blood gas analyzer were compared, it was found that the intra-class correlation coefficients of the saturation values measured by the smartphone with reference to the blood gas analyzer and vital signs monitor were 0.957 and 0.949, respectively, indicating an excellent agreement. Conclusion: Smartphones have as high efficiency as reference devices in measuring heart rate and saturation in hypotensive patients. In this way, hypotensive patients who need medical help can also have the opportunity to measure their vital parameters with their smartphones, without the need for any other medical device, before applying to the hospital or emergency health system. This may contribute to the improvement of the quality of life of the patients and the early and accurate information of the health care providers about the patient's health parameters.

Predictors of mortality in patients less than 50 years old with coronavirus disease 2019: a multicenter experience in Istanbul.

OBJECTIVE: The objectives of this study were to identify predictors of mortality in young adult patients with coronavirus disease 2019 and to assess the link between blood type and mortality in those patients. METHODS: This multicenter retrospective study, which was conducted in seven training and research hospitals in Istanbul, involved young adults who aged ≥18 and <50 years and hospitalized with coronavirus disease 2019. RESULTS: Among 1,120 patients, confusion at admission (p<0.001) and oxygen saturation (p<0.001) were significantly predictive factors of mortality. Blood type O was significantly associated with mortality compared to those discharged from the hospital (p<0.001). Among co-morbidities, the most reliable predictive factors were cerebral vascular disease (p<0.001) and chronic renal failure (p=0.010). Among laboratory parameters, high C-reactive protein (p<0.001) and low albumin (p<0.001) levels were predictors of mortality in young adult patients with coronavirus disease 2019. CONCLUSIONS: SpO2 at admission was the best predictor of mortality in young adult patients with coronavirus disease 2019. The mortality rate was increased by cerebral vascular disease and chronic renal failure. Also, high C-reactive protein and low albumin levels were predictive factors of mortality. Moreover, blood type O was associated with a higher mortality rate than the other types.

Predictors of mortality in patients less than 50 years old with coronavirus disease 2019: a multicenter experience in Istanbul

SUMMARY OBJECTIVE: The objectives of this study were to identify predictors of mortality in young adult patients with coronavirus disease 2019 and to assess the link between blood type and mortality in those patients. METHODS: This multicenter retrospective study, which was conducted in seven training and research hospitals in Istanbul, involved young adults who aged ≥18 and <50 years and hospitalized with coronavirus disease 2019. RESULTS: Among 1,120 patients, confusion at admission (p<0.001) and oxygen saturation (p<0.001) were significantly predictive factors of mortality. Blood type O was significantly associated with mortality compared to those discharged from the hospital (p<0.001). Among co-morbidities, the most reliable predictive factors were cerebral vascular disease (p<0.001) and chronic renal failure (p=0.010). Among laboratory parameters, high C-reactive protein (p<0.001) and low albumin (p<0.001) levels were predictors of mortality in young adult patients with coronavirus disease 2019. CONCLUSIONS: SpO2 at admission was the best predictor of mortality in young adult patients with coronavirus disease 2019. The mortality rate was increased by cerebral vascular disease and chronic renal failure. Also, high C-reactive protein and low albumin levels were predictive factors of mortality. Moreover, blood type O was associated with a higher mortality rate than the other types.

Does determination of drug level in intoxicated patients offer an advantage in diagnosis, treatment, and reducing complications?

OBJECTIVE: To investigate the effect of determining the drug type and level on emergency management in patients presenting with intoxication, and to identify the factors behind associated mortality. METHODS: The retrospective, observational, cross-sectional and single centre study was conducted at a large tertiary care teaching hospital in Istanbul, Turkey, between September and November 2016 using the hospital's toxicology registry. Data was extracted for patients who had presented to the emergency department from January 1, 2011, to February 28, 2013, and were found to have toxic doses of single active ingredients in the plasma. The patients were evaluated in terms of age, gender, demographic characteristics, time from ingestion to presentation, reason for drug ingestion, type of drug ingested, time elapsed before the emergency service was called, treatment given, drug level, hospitalisation and mortality. Data was analysed using SPSS 11.5. RESULTS: Of the 224 patients, 145(64.8%) were women. The overall mean age was 30.8±15.4 years. Drug ingestion was more common in women aged 18-30 years (p<0.0001). Besides, 215(96%) patients had ingested drugs with the intent to commit suicide. The minimum education level of 163(72.8%) patients was high school. The most frequently ingested drug was paracetamol 90(40.2%). Overall mortality was 4(1.8%) and all of them were brought to the emergency department after a delay of more than five hours (p<0.0001). CONCLUSIONS: Drug type and quantity were found to be of great importance in taking timely decisions while attending to patients with intoxication in an emergency setting. Delay in presentation was associated with mortality..

Escalator-related injuries in one of the deepest subway stations in Europe.

BACKGROUND: Escalator-related injuries (ERI) have emerged as a new injury type due to the frequent use of escalators in Metro stations. OBJECTIVES: Investigate ERI in the stations on the Marmaray metro line. DESIGN: Retrospective, observational study. SETTING: Patients admitted to the emergency department of a training and research hospital. PATIENTS AND METHODS: All patients with ERI were included in the study. We analyzed demographic characteristics, injury type and anatomical location of injury, Glasgow coma score, and body mass index (BMI). Patients were grouped by BMI: underweight (BMI less than 18.5 kg/m2), normal weight (BMI=18.5-24.9 kg/m2), overweight (BMI=25-29.9 kg/ m2) and obese (BMI greater than or equal 30kg/m2). MAIN OUTCOME MEASURES: Injury characteristics and BMI values of patients with ERI. SAMPLE SIZE: 82 patients. RESULTS: The mean age was 45.1 (15.5) years (range:14-77 years). Forty-two were women (52.5%). The mean BMI was 26.7 (2.2) kg/m2 (range: 22.1-33.3 kg/m2)]. Most of the patients who were injured due to escalators were older than 50 years (n=39, 47.6%) and 77.5% (n=62) of all patients were overweight. There was a significant relationship between increased BMI and serious ERI (P=.010, OR: 1.85, 95% C.I: 1.132.65). The most frequent mechanism of injuries was a fall (97.6%). The majority of injuries were the head (42%) and extremity injuries (33%). The major type of ERI was soft tissue injuries (41.3%), followed by lacerations (20.7%), closed head injuries (18.5%), fractures (15.2%) and serious injuries (4.4%). Serious injuries were more prevalent in patients aged older than 50 years (P less than .05), and in overweight and obese individuals (P less than .001) CONCLUSION: Novel protective measures against ERI should be developed for crowded subway stations. LIMITATIONS: The small sample size and retrospective nature. CONFLICT OF INTEREST: None.

Reliability of smartphone measurements of vital parameters: A prospective study using a reference method.

OBJECTIVE: In this study, we aimed to evaluate the accuracy of HR and SaO2 data obtained using a smartphone compared with the measurements of a vital signs monitor (VSM) and an arterial blood gas (ABG) device, respectively. MATERIAL AND METHODS: In this single-center prospective study, the HR and SaO2 measurements were performed using the built-in sensor and light source of a Samsung Galaxy S8 smartphone and compared to the results of VSM and ABG device. The Bland-Altman analysis was used to evaluate and visualize the agreement between the methods. RESULTS: The data of 101 patients were analyzed. There was a high correlation between HR measured by smartphone and HR measured by VSM [P < 0.0001; 0.9918 (95% CI = 0.987-0.994)]. In addition, the SaO2 values obtained by smartphone were highly correlated with those by ABG (P < 0.0001; 0.968 (95% CI = 0.952-0.978)). CONCLUSION: The HR and SaO2 values obtained by smartphone were found to be consistent with the measurements of the reference devices. With the growing use of smartphone technology in the health field, we foresee that patients will be able to make their own triage assessment before presenting to the hospital.

Healthcare Service Access and Utilization among Syrian Refugees in Turkey.

Background Aim: Many Syrian civil war refugees are housed in carefully designed camps, however 60% of all refugees in host countries reside outside of specifically designated camps. Turkey hosts the largest number of refugees displaced in the civil war of Syria. In the present study, we aimed to illustrate healthcare services provided to Syrian refugees in Turkey. METHOD: Data presented in this retrospective observational registry study was obtained from multiple sources including official websites and written communications contributed by Turkish Disaster and Emergency Management Agency(AFAD), Turkish Ministry of Health and Turkish Red Crescent as well as the United Nations High Commissioner for Refugees(UNHCR). The number of refugee camps, total number of refugees housed in these camps, the demographic characteristics of the refugees and a breakdown of social and healthcare services provided in the camps including the number of healthcare professionals serving in the refugee camps were analyzed. RESULTS: According to data from UNHCR as of January 12, 2017, there are 4,904,021 registered refugees from Syria of which 2,854,968 (58.2%) are residing in Turkey. Organized health care services specifically for Syrian refugees in Turkey was first established in April 29, 2011 in Hatay. Preventative health services are also provided for Syrian refugees. Among refugees living in the camps 25% and 33% were not vaccinated for polio and measles respectively. The percentage of unvaccinated refugees living outside the camps were even higher for these viruses (45% for polio and 41% for measles). This poses a public health threat for the population where these refugees reside. CONCLUSION: One of the major concerns for countries hosting refugees from Syria is the introduction of infectious diseases. Of the major deficiencies in refugee health care has been preventative services. Within refugee camps, preventative services for pregnant woman, newborns and young children as well as family planning services are not at optimal levels. These services are even more restricted for refugees living outside of established camps. There have also been shortcomings in the care of the elderly and those with chronic health problems.

Comparison of the Effects of Metoclopramide and Ondansetron on Emergency Service Observation Times in Acute Gastroenteritis-Related Nausea and Vomiting Cases.

OBJECTIVES: The aim of the present study was to compare the effect of metoclopramide and ondansetron treatments on the emergency department observation time in acute gastroenteritis-related nausea and vomiting (NV). METHODS: The study was conducted retrospectively on 297 patients diagnosed with acute gastroenteritis in a training and research hospital's emergency service observation unit within 6 months. Patients with gastroenteritis who were diagnosed with NV were divided into two groups according to the treatment they received in the observation unit. Patients who received 4 mg ondansetron slow infusion therapy were classified as Group 1, and patients who received 10 mg metoclopramide slow infusion therapy were classified as Group 2. RESULTS: The average age of the patients was 39.57±18.75 years. Of the 297 participants, 56.6% (168) were female. Among them, 51.5% (153) received ondansetron (Group 1), and 48.5% (144) received metoclopramide (Group 2). 6.9% weakness-numbness and 4.9% akathisia were detected due to metoclopramide use. There were no adverse effects related to ondansetron use. The duration of observation ranged from 19 to 75 min in Group 1 and from 42 to 122 min in Group 2. Nineteen (13.2%) patients in Group 2 and 5 (3.3%) patients in Group 1 revisited the emergency department within 24 h due to ongoing complaints. CONCLUSION: In conclusion, side effects of weakness and akathisia due to metoclopramide use were observed. However, no side effects were observed due to ondansetron use. Additionally, the use of ondansetron showed a shorter observation time and less recurrent admission to the emergency department. Therefore, ondansetron is a more effective drug in the treatment of NV associated with acute gastroenteritis.

An unusual complication of posterior packing in epistaxis.

Endonasal or transnasal procedures are sometimes necessary in patients with head trauma. Before these procedures, the integrity of the skull base must be considered to avoid penetration of the cranial vault. A 54-year-old man was taken to a district hospital following a car accident. After the initial assessment and emergency treatment, he was transferred to our emergency clinic for further examination. The patient had massive nasal bleeding, though a Foley catheter had been inserted to control posterior bleeding. Computed tomography (CT) revealed that the catheter was not positioned correctly and was in the cranial vault. Several fractures of the maxillofacial and cranial bones and cervical vertebrae were detected on CT. He also had right hemothorax and bilateral brain contusions. Endonasal insertion of catheters or tubes in trauma patients without a complete assessment of the skull base can cause serious complications.

Diagnostic Accuracy of InitiaI Chest X-Rays in Thorax Trauma.

OBJECTIVE: To evaluate the efficacy, sensitivity and specificity of chest x-ray as a diagnostic imaging tool in management of thorax traumas. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey, between December 2014 and December 2015. METHODOLOGY: Case records of patients admitted to the emergency department with thoracic trauma were retrospectively analysed through the hospital database. Plain postero-anterior chest X-rays and thorax computerised tomography (CT) scans were evaluated seperately by same radiologist. Accurcy of signs of thoracic trama was determined using CT scan as gold standard. RESULTS: Nine of 23 pneumothorax patients were diagnosed by chest X-ray. Sensitivity and specificity of PA chest X-ray in the diagnosis of pneumothorax was 39.1% and 100%, respectively. Positive predictive values of chest X-ray for diagnosis of pneumothorax was 100% and negative predictive value was 97.1%. Twenty-four patients had pleural effusions on CT scans, while only 15 could be diagnosed in chest X-rays. Chest X-rays were 62.5% sensitive and 100% specific with positive and negative predictive values of 100% and 98.1%, respectively. Twenty of 41 rib fractures were diagnosed with X-rays. Chest x rays had a 48.8% sensitivity and 100% specificity, and positive and negative predictive values were 100% and 95.6%, respectively. CONCLUSION: Chest X-ray should not be used as a sole diagnostic imaging tool for exclusion of pneumothorax, hemothorax, and lung contusion. Due to high predictive values of chest X-rays, they can be used for follow-up.

CPR-related thoracic injuries: comparison of CPR guidelines between 2010 and 2015

Background/aim: This study aimed to evaluate traumatic thorax complications in post-CPR patients and to investigate whether or not there has been a decrease in these complications since the adoption of current chest compression recommendations. Materials and methods: Post-CPR patients with return of spontaneous circulation (ROSC) were admitted between January 2014 and January 2016 were analyzed retrospectively. Patients admitted to the ED in 2014 were resuscitated according to 2010 AHA CPR guidelines, while those admitted to the ED in 2015 were resuscitated according to current ERC CPR guidelines. Results: The study population comprised 48 male and 35 female patients. Of the 2010 AHA guideline patients, 39.21% experienced pulmonary contusion, while 54.83% of 2015 ERC guideline patients had pulmonary contusion. It was found that 11.76% of 2010 AHA guideline patients and 3.22% of 2015 ERC guideline patients had pneumothorax, while 9.8% of 2010 AHA guideline patients and 12.9% of 2015 ERC guideline patients experienced hemothorax. Incidence rates of lung contusion, pneumothorax, and hemothorax were higher in patients with rib fractures. Conclusion: In this study, traumatic thoracic complications were investigated in patients with ROSC after CPR. The incidence of CRP-related injuries did not decrease on application of the new 2015 ERC CPR guideline recommendations. The most common injury in this study was rib fracture, followed by sternal fracture, lung contusion, hemothorax, and pneumothorax. Statistically, rib fracture had a positive relationship with lung contusion, hemothorax, and pneumothorax.

Health results of a coup attempt: evaluation of all patients admitted to hospitals in Istanbul due to injuries sustained during the July 15, 2016 coup attempt.

BACKGROUND: A coup attempt against the government took place in Turkey on July 15, 2016. This attempt caused serious injuries and deaths in the country. In this study, the data of patients referred to all hospitals in Istanbul during the attempt were evaluated, and differences between natural disasters, other terrorist actions, and coup attempts were analyzed. METHODS: In total, 1104 patients were injured in the abovementioned coup attempt. In this study, the demographic and health information of 882 coup victims who were admitted to all hospitals (state and private) in Istanbul on July 15 and 16, 2016 and registered at the Crisis Center of Istanbul Provincial Health Directorate was analyzed. RESULTS: Of the 882 patients evaluated, 97.27% were male and 2.73% were female. The mean age of the patients was 34.12 years. Most (82.43%) patients were admitted to state hospitals, and 17.57% were admitted to private hospitals. The total mortality rate due to the abovementioned coup attempt was 10.4% (9.76% in state hospitals and 13.54% in private hospitals). Of the 882 patients evaluated, 65.07% had gunshot injuries, 11.11% had been assaulted, 7.70% had experienced tank/motor vehicle accidents, 5.44% had other penetrating injuries, 5.32% had soft-tissue trauma, 2.83% had experienced falls (including falls from heights), 0.33% had psychiatric disorders, and 2.15% were admitted for other reasons. CONCLUSION: The patterns of injury and mortality resulting from the July 15, 2016 coup attempt differed from those resulting from natural disasters and terrorist acts and were similar to those encountered during wars: the victims were predominantly male, similar to those in wars. Following a coup attempt, an increase in the number of patients with post-traumatic stress disorder can be expected. Further studies focusing on the incidence of this disorder due to the abovementioned coup attempt in Turkey are needed. Hospital disaster plans need to include information and plans related to terrorist acts, such as coup attempts.

Asymmetric dimethylarginine contributes to airway nitric oxide deficiency in patients with COPD.

INTRODUCTION: Asymmetric dimethylarginine (ADMA) and nitric oxide (NO) show their mechanism of action reciprocally, the balance between these molecules contributes to the tight regulation of airways tone and function. OBJECTIVES: The aim of this study to determine the serum levels of ADMA and NO in patients with chronic obstructive pulmonary disease (COPD) and establish whether their level vary in relation to forced expiratory volume in 1s (FEV1 ), to assess their role in pathophysiology of COPD. MATERIALS AND METHODS: This study consisted of 58 patients with COPD and 30 healthy subjects. Serum ADMA and NO levels were measured using enzyme-linked immunosorbent assay and the colorimetric method, respectively. RESULTS: Serum ADMA levels were significantly higher, however, NO levels were lower in patients with COPD compared with controls. ADMA levels were inversely correlated with NO levels. Serum ADMA and NO were significantly correlated with FEV1 . Multivariable logistic regression analysis revealed that serum ADMA and NO were independently and significantly associated with the presence of COPD. Multiple linear regression analysis showed that COPD was positively associated with ADMA, additionally COPD and ADMA were independently and inversely associated with NO. NO levels were decreased, ADMA levels were increased compliant with progression of COPD stages. CONCLUSION: While circulating ADMA is higher, NO is lower in COPD and both show a strong correlation to the degree of airflow limitation. ADMA seems to be a possible new marker of prognosis of COPD and can be a novel therapeutic target for the treatment of COPD.

Neuropsychiatric side effects due to a transdermal fentanyl patch: hallucinations.

Opioid analgesics are used commonly in end-stage cancer patients for pain treatment. Central nervous system adverse effects are rare. A73-year-old female patient was admitted to the emergency department for auditory and visual hallucinations. The patient had been receiving palliative treatment for liver, cervical, and lumbar bone metastases from an unknown origin. The patient used a transdermal fentanyl patch for palliative pain management and metoclopramide hydrochloride for nausea and vomiting. The patient had suffered weight loss of 10 kg within 5 months, and laboratory findings revealed hypoalbuminemia. The patient was considered to have experienced a fentanyl overdose, and the transdermal fentanyl patch treatment was stopped. The hallucinations improved during follow-up, and the patient was discharged with a dose adjustment. End-stage cancer patients with weight loss and hypoalbuminemia may be more prone to opioid adverse effects, such as hallucinations. The dose of fentanyl must be adjusted for weight loss, and correction of hypoalbuminemia may also lower the incidence of such adverse effects.