Early discharging patients with chest pain using EDACS-ADP and COMPASS-MI risk predictors.

Deciding on the early discharge of low-risk patients with chest pain is still controversial in emergency care. Beyond the validated tools for risk assessment, high sensitive troponin levels on admission, whether to take the next serial sampling or when to take are the main issues affecting the unnecessary follow-ups that lead to the emergency crowd. We aimed to investigate the prediction performance of emergency department assessment of chest pain score and accelerated diagnostic protocol (EDACS-ADP) and calculation of MI risk probabilities to manage patients with suspicion of myocardial infarction (COMPASS-MI). We conducted a prospective cross-sectional study that included patients with chest pain followed-up in the emergency department with a serial troponin sampling. We calculated the performance tests of the risk scores after recording the patients' risk factors, chest pain types, troponin levels as defined in the risk assessment tools. Nine hundred eleven patients were included in the study. Thirty-eight patients had significant adverse cardiovascular events (MACE) within 30 days. Patients with a not-low-risk score at EDACS-ADP had a 3.975 (95% CI 2.136-7.396) fold higher risk of MACE than the patients with low-risk EDACS-ADP, and the absolute risk increase was 7.3%. Patients with high-risk late-stage risk in COMPASS-MI had a 3.581 (95% CI 1.660-7.726) fold higher risk of MACE than those with low-risk late-stage risk in COMPASS-MI, and absolute risk increase was 4.6%. We found EDACS-ADP and COMPASS-MI at a late time point (2 h hsTnI) with a high negative predictive value as a risk assessment tool for discharging chest pain patients.

COVID-19 outbreak impact on discharge against medical advice from the ED: A retrospective study.

BACKGROUND: The COVID-19 pandemic has profoundly affected the habits of patients, as well as its negative effects on human health. The aim of this study is to investigate the factors associated with discharge against medical advice (DAMA) from the emergency department (ED) during the COVID-19 pandemic. METHODS: We conducted a retrospective study of the charts of DAMA cases (pandemic group) between May 1 and October 30, 2021 in a tertiary hospital in Istanbul, Turkey. Our data were compared with DAMA cases between May 1 and October 30, 2019 (pre-pandemic group-control group). RESULTS: During the pandemic period, DAMA cases increased by 24.5% in the ED compared to the previous period. Compared to the pre-COVID-19 period, among DAMA cases during the COVID-19 period, the rate of those arriving by ambulance (10.9 vs. 18.8%), those with one or more comorbid diseases (8.9 vs. 18.4%), those with a high triage level (4.0 vs. 7.4%), those with health tourism or refugee/asylum insurance (2.9 vs. 6.1%), those with trauma (11.5 vs. 19.9%) or alcohol/drug abuse (2.7 vs. 4.0%) increased significantly (p < 0.001). It was observed that DAMA cases' waiting times for total ED and from the door to doctor decreased during the pandemic period compared to the pre-pandemic period. CONCLUSION: During the COVID-19 pandemic period, it was observed that the rate of those with severe disease increased among DAMA cases. Necessary precautions should be taken for all patients, especially seriously ill patients, to feel safe in the hospital and to be treated, and the negative consequences that may develop should be prevented by addressing the concerns of the patients and their relatives.

An extremely rare complication of acute pancreatitis: Intraventricular thrombus.

Acute pancreatitis is a frequent reason for emergency admission, which has seen its numbers increase over the years. This condition has systemic, local, and vascular complications. A 73-year-old male patient presented to our emergency department complaining of abdominal pain, nausea, and vomiting. During imaging, intraventricular thrombus was discovered, and following completion of diagnostic testing, he was diagnosed with acute pancreatitis. Herein, we present the first case of intraventricular thrombus related to acute pancreatitis prothrombotic process in the literature.

Lung ultrasound for the diagnosis of pneumonia in adults.

OBJECTIVE: To investigate the value of chest ultrasound in the diagnosis of pneumonia in adults. METHODS: The prospective observational cohort study was conducted at Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey, from December 1, 2015,to March 1, 2016, and comprised suspected pneumonia patients aged >18 years. Sonographic pneumonia was defined as lung consolidation with air bronchograms. Treating clinicians were blinded to lung ultrasound results. All patients who were advised to undergo thoracic computerised tomography after physical examination were subjected to posteroanterior chest X-ray before the scan. Patients in whom pneumonia was detected in the scan underwent thorax ulstasonography according to Bedside Lung Ultrasound in Emergency protocol. Follow-up was done with medical record review to obtain the final diagnosis and antibiotic usage. Data was analysed using SPSS 22. RESULTS: Of the 125 patients, 61(48.8%) were male. The overall mean age was 73.9±14.6 years. In 97(77.6%) patients, pneumominal infiltration was detected by thorax ultrasound, and in 57(45.6%) the infiltration was detected with chest X-ray. CONCLUSIONS: Thorax ultrasound was found to be a helpful diagnostic method when performed according to the Bedside Lung Ultrasound in Emergency protocol.

Serum Levels and Urinary Excretion of Tenascin-C and TIMP-1 in Acute Kidney Injury.

BACKGROUND: Both the extracellular matrix molecule tenascin-C (Tn-C) and tissue inhibitors of metalloproteinases (TIMPs) have a role in tissue injury, inflammation, and remodeling. In this pilot study, we tried to evaluate the role of these markers in acute kidney injury (AKI). METHODS: A total of 52 subjects were enrolled in this study. Group 1 consisted of 27 patients with AKI (stage 1, 2, and 3), and Group 2 consisted of 25 age- and gender-matched healthy subjects. Serum and urine samples (to determine Tn-C and TIMP-1) were obtained from the participants at the beginning of the study. Second samples were obtained from Group 1 patients when renal function improved (at discharge). RESULTS: Serum TIMP-1 concentrations (admission and discharge) were higher in Group 1 than Group 2 (p = 0.0001 for both comparisons). Tn-C excretion in spot urine was significantly higher in healthy controls than at the admission levels of the patient group (p = 0.036). However, TIMP-1 excretion in spot urine was lower in healthy controls than in admission and discharge levels of the patient group (p = 0.0001 for both comparisons). CONCLUSIONS: Our results show that these biomarkers (especially TIMP-1) may have a role in the pathophysiology of AKI. Further studies are needed in this field.

Novel complication of Flakka: Stevens-Johnson syndrome/Toxic epidermal necrolysis overlap.

Flakka, as the newest member of the synthetic cathinone group, is a substance with serious cardiovascular, neurological, psychiatric, infectious effects and addictive potential. There are only a few case reports and laboratory studies in the literature and there is no dermatological side effects reported yet. We present the first Stevens-Johnson syndrome/Toxic epidermal necrolysis (SJS/TEN) overlap case after Flakka use.

Early effect of the fear of terrorism on a hospital's emergency department use and on the incidence of cardiovascular events: A Turkish multicenter study.

BACKGROUND: To our knowledge, the early effect of the fear caused by terrorism on human health, especially its effect on the number of visits to medical emergency departments (EDs), has not yet been studied. OBJECTIVES: To observe the effect of fear from terrorist alerts on the use of EDs and on the rate of cardiovascular (CV) and/or cerebrovascular events. SETTING: In Istanbul, Turkey, there was a terror alert on the weekend of 19 and 20 March 2016. In this multicenter retrospective study, we compared the data of patients from that weekend with those from the preceding and following weekends. PATIENTS: A total of 12 324 adult patients' records were included in this study: 4562 patients in the first weekend, 3627 patients in the second, terror alert weekend, and 4135 patients in the third weekend. MEASUREMENTS: The ED, CV, and cerebrovascular incidence rates of the above three groups were compared. RESULTS: The rate of ED use was the least in the weekend of the terror alert; the highest rate occurred during the weekend prior to it (female applications decreased more [P = 0.03]). The medical center that was the farthest from the crowded central places of the city and from the place where suicide bombing occurred was less affected by the decrease in use. CONCLUSIONS: Fear associated with terrorism may affect human health indirectly by preventing patients from reaching the necessary emergency healthcare facilities. This finding may be a pathfinder to decision-makers in such extraordinary emergency conditions. Further studies are needed in this field.

Viral prevalence, clinical profiles and comparison of severity scores for predicting the mortality of adults with severe acute respiratory infections

Background/aim: The aim of this study was to determine the accuracy of severity scores for predicting the 28-day mortality among adults with severe acute respiratory infection (SARI) admitted to the emergency department. Materials and methods: This study included 159 consecutive adult patients with SARI admitted to the emergency department of a tertiary hospital. A standard form was filled out in order to record demographic information, clinical parameters, laboratory tests, and radiographic findings of the patients. CURB-65, PSI, SIRS, qSOFA, SOFA and APACHE II scores were compared between the survivor and nonsurvivor groups. Results: Of 159 patients included in the study, 38.4% were positive for respiratory viruses and 28.3% were positive for influenza viruses. 35.8% of the patients were admitted to an intensive care unit (ICU) and the mortality rate was 36.5%. The area under the receiver operating characteristic curve of CURB-65, PSI, SIRS criteria, qSOFA, SOFA and APACHE II scores were 0.717, 0.712, 0.607, 0.683, 0.755, and 0.748, respectively in predicting mortality and 0.759, 0.744, 0.583, 0.728, 0.741, and 0.731, respectively in predicting ICU admission. Conclusion: SOFA and APACHE II were more accurate than SIRS in predicting the 28-day mortality among adults with SARI. There was no significant difference among these scores in terms of other multivariate comparisons.

Diagnostic value of pulsed wave doppler in pneumothorax: a prospective study.

BACKGROUND: The diagnosis of pneumothorax is usually made through clinical examination and radiography. Pulsed wave (PW) Doppler mode has not previously been used in the diagnosis of pneumothorax on chest USG. AIMS: The aim of this study is to present, for the first time, a new finding demonstrating pleural movements using PW Doppler mode and to examine the value of the new sonographic finding in the diagnosis of pneumothorax. METHODS: We investigated the presence of PW artifact in patients with and without pneumothorax using the high-frequency probe in PW Doppler. The Dogan's sign, defined as the absence of PW artifact, was then compared with lung sliding and the barcode sign in pulsed wave Doppler for the diagnosis of pneumothorax. RESULTS: Of the 141 patients, 39 were in the pneumothorax group. The sensitivity and specificity of the Dogan's sign in the diagnosis of pneumothorax were 95.12% and 99.3%, respectively, in this study. The sensitivity and specificity of lung sliding were 95.12% and 98.08%, respectively; the sensitivity and specificity of the barcode sign were 92.86% and 98.08%, respectively, in the diagnosis of pneumothorax by ultrasonography in this study. CONCLUSION: PW Doppler is a useful tool in the diagnosis of pneumothorax. It has a high sensitivity and specificity for the detection of pneumothorax. It is also superior to both lung sliding and the barcode sign in detecting pneumothorax. The Dogan's sign can be used safely in the diagnosis of pneumothorax, together with lung sliding and the barcode sign.

The Prognostic Accuracy of Get With The Guidelines-Heart Failure Score Alone and with Lactate Among Acute Symptomatic Heart Failure Patients: A Retrospective Cohort Study.

BACKGROUND: To evaluate the prognostic accuracy of the Get With The Guidelines-Heart Failure (GWTG-HF) score, Shock Index (SI), Modified Shock Index (MSI), and Age Shock Index (Age-SI) alone and with lactate in patients with acute symptomatic heart failure (HF). METHODS: A retrospective cohort study was conducted in the emergency department of a tertiary hospital between January 1, 2019, and December 31, 2019. Patients aged >18 years and diagnosed with acute symptomatic HF were consecutively included in the study. Patients referred from another center and missing medical records were excluded. Arrival type, vital parameters, demographic characteristics, comorbid diseases, consciousness status, laboratory results, and outcomes of the patients were recorded. The primary endpoint of the study was in-hospital mortality. RESULTS: A total of 368 patients were included in the final analysis. The in-hospital mortality rate of the patients was 7.6%. The GWTG-HF score outperformed other scores in predicting in-hospital, 24-hour, and 30-day mortality (area under the curve (AUC) = 0.807, 0.844, and 0.765, P <.001, respectively). The overall performance of the GWTG-HF score with lactate (GWTG-HF+L) was better in predicting in-hospital, 24-hour, and 30-day mortality than the original GWTG-HF score (AUC = 0.872, 0.936, and 0.801, P <.001, respectively). Adding lactate values to the SI, MSI, and Age-SI improved their overall performance for all 3 outcomes. CONCLUSION: Both the GWTG-HF and GWTG-HF+L scores have acceptable discriminatory power in patients with acute symptomatic HF. The GWTG-HF score, SI, MSI, and Age-SI can be used together with lactate to predict mortality in patients with acute HF.

The prognostic value of rapid risk scores among patients with community-acquired pneumonia : A retrospective cohort study.

BACKGROUND: Community-acquired pneumonia (CAP) is a frequent reason for emergency department (ED) presentations. Various risk scores have been validated in the management of CAP and are recommended for daily practice. OBJECTIVE: The aim of the study was to evaluate the performance of the rapid risk scores (the rapid acute physiology score (RAPS), the rapid emergency medicine score (REMS), the Worthing physiological scoring system (WPS), CURB-65 and CRB-65) among patients with CAP. METHODS: This retrospective cohort study was conducted in the ED of a tertiary hospital between 1 January 2019 and 31 December 2019. Patients aged ≥ 18 years and diagnosed with CAP were included. Patients who were transferred from another center or with missing records were excluded. Demographic information, vital signs, level of consciousness, laboratory results, and outcomes were recorded. RESULTS: A total of 2057 patients were included in the final analysis. The 30-day mortality of the patients was 15.2% (n = 312). The WPS achieved the most successful results for all three outcomes, 30-day mortality, intensive care unit (ICU) admission and mechanical ventilation (MV) needs (area under the curve, AUC 0.810, 0.918, and 0.910, respectively; p < 0.001). In the prediction of mortality, RAPS, REMS, CURB-65, and CRB-65 had a moderate overall performance (AUC 0.648, 0.752, 0.778, and 0.739, respectively). In the prediction of ICU admission and MV needs, RAPS, REMS, CURB-65, and CRB-65 had moderate to good overall performance (AUC at ICU admission 0.793, 0.873, 0.829, and 0.810; AUC for MV needs 0.759, 0.892, 0.754, and 0.738, respectively). Advanced age, lower levels of mean arterial pressure and peripheral oxygen saturation, presence of active malignancy and cerebrovascular disease, and ICU admission were associated with mortality (p < 0.05). CONCLUSION: The WPS outperformed other risk scores in patients with CAP and can be used safely. The CRB-65 can be used to discriminate critically ill patients with CAP due to its high specificity. The overall performances of the scores were satisfactory for all three outcomes.

Relationships of the frailty index and geriatric trauma outcome score with mortality in geriatric trauma patients.

BACKGROUND: We aimed to determine the relationships of the trauma-specific frailty index (TSFI) and the geriatric trauma out-come score (GTOS) with 30-day mortality among geriatric trauma patients aged 65 and older. METHODS: This prospective observational study included 382 patients aged 65 years and older who were admitted to a training and research hospital due to blunt trauma. Informed consent was obtained from them and/or their relatives. In addition to patients' vital signs, information about chronic diseases and drug use was obtained on admission to the emergency service and the results of labo-ratory examinations, radiological imaging, blood replacements, length of stay in the emergency room and hospital, and mortality were recorded in case forms. Glasgow coma scale, injury severity score, GTOS, TSFI, and body mass index (BMI) values were calculated by the researchers. Outcome information was obtained from the patient and/or relatives by phone 30 days later. RESULTS: When the patients who died and those who survived were compared at the 30th day after trauma, no significant difference was found in terms of BMI or TSFI (p>0.05). It was determined that patients with a GTOS of ≥95 at admission would have higher 30-day mortality (the sensitivity was 76%, and the specificity was 72.27% (p<0.001)). When correlations were evaluated according to mortality, a correlation was found between the presence of two or more comorbid diseases and mortality (p=0.001). CONCLUSION: We think that a more reliable frailty score can be obtained using these parameters as we have determined that the TSFI as calculated at admission to the emergency department is not sufficient on its own, while the lactate, GTOS, and the length of hospital stay are also effective in mortality. We suggest that it would be appropriate to use the GTOS in long-term follow-up as well as for predictive power for mortality within 24 h.

CHAMPS score in predicting mortality of patients with acute nonvariceal upper gastrointestinal bleeding.

OBJECTIVE: The aim of this study was to evaluate the performance of the Charlson Comorbidity Index ≥2, in-hospital onset, albumin <2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥2, steroid use score in predicting mortality in patients with nonvariceal upper gastrointestinal bleeding and compare it with the Glasgow-Blatchford score; the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score; the age, blood tests, and comorbidities score; and Complete Rockall score. METHODS: The data of patients with acute upper gastrointestinal bleeding who visited the emergency department during the study period were obtained from the hospital automation system by using the classification of disease codes and analyzed in this retrospective study. Adult patients with endoscopically confirmed nonvariceal upper gastrointestinal bleeding were included in the study. Patients with bleeding from the tumor, bleeding after endoscopic resection, or missing data were excluded. The prediction accuracy of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score was calculated using the area under the receiver operating characteristic curve and compared with that of Glasgow-Blatchford score, the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score, the age, blood tests, and comorbidities score, and Complete Rockall score. RESULTS: A total of 805 patients were included in the study, and the in-hospital mortality rate was 6.6%. The performance of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score (area under the receiver operating characteristic curve 0.812, 95%CI 0.783-0.839) was better than Glasgow-Blatchford score (area under the receiver operating characteristic curve 0.683, 95%CI 0.650-0.713, p=0.008), and similar to the the age, blood tests, and comorbidities score (area under the receiver operating characteristic curve 0.829, 95%CI 0.801-0.854, p=0.563), the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score (area under the receiver operating characteristic curve 0.794, 95%CI 0.764-0.821, p=0.672), and Complete Rockall score (area under the receiver operating characteristic curve 0.761, 95%CI 0.730-0.790, p=0.106). CONCLUSION: The performance of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score in predicting in-hospital mortality for our study population is better than Glasgow-Blatchford score and similar to the the age, blood tests, and comorbidities score, the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score, and Complete Rockall score.

Elderly trauma patients and the effect of trauma scores on hospitalization decision.

Objectives: Hospitalization, mortality and trauma scores are important in trauma patients aged ≥65 years. The present study aimed to investigate the use of trauma scores in the prediction of hospitalisation and mortality in trauma patients aged ≥65 years. Material and Methods: Patients aged ≥65 years who presented to the emergency department with trauma over a one-year period were included in the study. Baseline data of the patients together with their Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Injury Severity Score (ISS), hospitalisation and mortality were analysed. Results: A total of 2264 patients were included in the study, of whom 1434 (63.3%) were women. The most common mechanism of trauma was simple falls. Mean GCS scores, RTSs and ISSs of the inpatients were 14.87 ± 0.99, 6.97 ± 0.343 and 7.22 ± 5.826, respectively. Furthermore, a significant negative correlation was found between the duration of hospitalisation and GCS scores (r= -0.158, p <0.001) and RTSs (r= -0.133, p <0.001), whereas a positive significant correlation with ISSs (r= 0.306, p <0.001) was observed. The ISSs (p <0.001) of the deceased individuals were significantly elevated, whereas their GCS scores (p <0.001) and RTSs (p <0.001) were significantly decreased. Conclusion: All trauma scoring systems can be used to predict hospitalisation, but the results of the present study suggest that the use of ISS and GCS in making the decision regarding mortality is more appropriate.

The predictive value of modified risk scores in patients with acute exacerbation of COPD: a retrospective cohort study.

This study aims to evaluate the performance of CREWS (Chronic Respiratory Early Warning Score), S-NEWS (Salford-National Early Warning Score), qNEWS (Quick National Early Warning Score), NEWS (National Early Warning Score), and qSOFA (Quick Sequential Organ Failure Assessment) scores in predicting mortality, intensive care unit (ICU) admission and the need for mechanical ventilation (MV) of patients presented with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). This retrospective cohort study was conducted in the emergency department of a tertiary hospital between January 1 and December 31, 2019. The patients with AECOPD and aged ≥ 18 were included. Patients who were transferred from another center and whose data could not be reached were excluded. Demographic information, comorbid diseases, variables of the scores, laboratory results, and outcomes were recorded. A total of 575 consecutive patients were included. The 30-day mortality, ICU admission, and MV need rate were 5.7% (n = 33), 9.6% (n = 55), and 13.7% (n = 79), respectively. Each score had moderate-to-excellent performance in predicting MV need and ICU admission, while their performance in predicting mortality was poor. CREWS is the most successful score in predicting 30-day mortality (AUC 0.695), ICU admission (AUC 0.841), and MV need (AUC 0.924). ICU admission, age, and creatinine levels were associated with mortality (p < 0.05). All scores have better performance in predicting ICU admission and MV need than mortality. ICU admission, age, and creatinine levels may be the predictors of mortality among AECOPD patients.

Evaluation of renal function in rats with moderate and mild brain trauma.

BACKGROUND: We aimed to diagnose possible acute kidney injury (AKI) with new early biochemical markers in patients who were admitted to the emergency department frequently with mild and moderate brain trauma, and to prevent possible complications, shorten the duration of treatment and hospital stay. With this purpose, we decided to reach our scientific target using the experimental rat model. METHODS: Wistar albino rats were included our experiment. Fifteen rats were randomly separated into three groups: Sham control (n=1: Underwent craniotomy alone), control (n=7: Without craniotomy), and trauma group (n=7: Underwent craniotomy followed by brain injury). RESULTS: There were no significant differences groups creatinine levels within 0 and 24 h (0.35±0.02 and 0.33±0.03, respectively, p>0.05). Plasma NGAL and KIM1 concentrations were statistically significant different in both control and trauma groups (Friedman p<0.05) and significant differences at both NGAL and KIM-1 concentrations at dual comparisons by means of all sampling time (0-2 h, 0-24 h, and 2-24 h) (Wilcoxon p<0.001, after Bonferroni correction). CONCLUSION: The presence of AKI in patients with mild-to-moderate brain trauma increases the risk of mortality. Early diagnosis of AKI reduces the hospitalization period and requiring of dialysis. Diagnosis of AKI within 24 h with early biomarkers and starting therapy is crucial issues.

COVID-19 outbreak impact on emergency trauma visits and trauma surgery in a level 3 trauma center.

BACKGROUND: This study aims to compare emergency trauma visits' severity, emergency surgical needs, and characteristics between the pandemic and pre-pandemic periods. METHODS: This retrospective observational study was conducted in a tertiary training and research hospital between 1 and 30 April 2020 (pandemic group) and compared with the previous year's same dates (pre-pandemic group). Trauma patients aged 18 and over were included in the study. Emergency Severity Index (ESI) levels, trauma surgery needs, and injury characteristics were compared. RESULTS: A total of 2097 patients (592 pandemic and 1505 pre-pandemic) were included. There was an approximately 60% reduction in total and daily visits. ESI levels 1 (0.2% vs. 1.4%) and 2 (0.8% vs. 1.9%) patients increased during pandemic period. Trauma surgery needs (1.6% vs. 2.2%), intensive care unit (ICU) admission (0.4% vs. 0.2%), and ward admission (6.3% vs. 7.9%) did not change during pandemic period. CONCLUSION: Despite the decrease in the visit frequency of adult trauma patients during the pandemic period, the needs for trauma surgery, ICU, and ward admission did not change. Trauma teams should continue their duties during the pandemic period.