Evaluation of the Blood Urea Nitrogen-to-Left Ventricular Ejection Fraction Ratio in Predicting Mortality in Patients Presenting to the Emergency Department with Heart Failure Symptoms

Heart failure is a clinical syndrome. In this study, the significance of the blood urea nitrogen-to-left ventricular ejection fraction (BUNLVEF) ratio in predicting short-term mortality in patients with heart failure symptoms was evaluated. This retrospectively designed study was conducted by evaluating the records of patients with a history of heart failure who presented to the emergency department with heart failure symptoms and signs from 01 January 2018 to 01 January 2020. One hundred and seventy-three patients were included in the sample within the last six months presented to the emergency department with the symptoms of acute heart failure. Blood urea nitrogen (BUN) and the BUNLVEF ratio had a significant relationship with mortality (p=0.004 and <0.010, respectively). In patients with a known history of heart failure presenting to the emergency department with heart failure symptoms, it would be more appropriate to evaluate poor outcomes with the BUNLVEF ratio rather than the LVEF or BUN value alone. Key Words: Blood urea nitrogen, Prognosis, Left ventricular dysfunction.

Predictors of 7-day symptomatic hemorrhagic transformation in patients with acute ischemic stroke and proposal of a novel screening tool: A retrospective cohort study

OBJECTIVES

Hemorrhagic transformation (HT) is significantly related to poor neurological outcomes and mortality. Although variables and models that predict HT have been reported in the literature, the need for a model with high diagnostic performance continues. We aimed to propose a model that can accurately predict symptomatic HT within 7 days of acute ischemic stroke (AIS).

METHODS

Patients with AIS admitted to the emergency department of a tertiary training and research hospital between November 07, 2021, and August 26, 2022, were included in this single-center retrospective study. For the model, binary logistics with the forced-entry method was used and the model was validated with 3-fold cross-validation. After the final model was created, the optimal cutoff point was determined with Youden's index. Another cut-off point was determined at which the sensitivity was the highest.

RESULTS

The mean age of the 423 patients included in the study was 70 (60-81) and 53.7% (n = 227) of the patients were male. Symptomatic HT was present in 31 (7.3%) patients. Mechanical thrombectomy, atrial fibrillation, and diabetes mellitus were the independent predictors (P < 0.001, P = 0.003, P = 0.006, respectively). The mean area under the curve of the receiver operating characteristics of the model was 0.916 (95% confidence interval [CI] = 0.876-0.957). The sensitivity for the optimal cut-off point was 90.3% (95% CI = 74.3%-97.9%) and specificity was 80.6% (95% CI = 76.4%-84.4%). For the second cutoff point where the sensitivity was 100%, the specificity was 60.5% (95% CI = 55.4%-65.3%).

CONCLUSION

The diagnostic performance of our model was satisfactory and it seems to be promising for symptomatic HT. External validation studies are required to implement our results into clinical use.

Emergency Medicine Association of Turkey Disaster Committee Summary of Field Observations of February 6th Kahramanmaraş Earthquakes

An earthquake measuring 7.7 magnitude on the Richter scale occurred at 04:17am on February 6, 2023 in the Pazarcık district of Kahramanmaraş province Turkey. In the hours following the 7.7 magnitude event in Kahramanmaraş, a second 7.6 magnitude earthquake struck the region and a third 6.4 magnitude earthquake struck Gaziantep, causing extensive damage and death. A total of ten provinces directly experienced the earthquake, including Kahramanmaraş, Hatay, Gaziantep, Osmaniye, Malatya, Adana, Diyarbakır, Şanlıurfa, Adıyaman, and Kilis. The official figures indicate 31,643 people were killed, 80,278 were injured, and 6,444 buildings were destroyed within seven days of the earthquakes (as of 12:00pm/noon on Monday, February 13th). The area affected by the earthquake has been officially declared to be 500km in diameter. This report primarily relies on observations made by pioneer Emergency Physicians (EPs) who went to the disaster areas shortly after the first earthquake (in the early stages of the disaster). According to their observations: (1) Due to winter conditions, there were transportation problems and a shortage of personnel reaching disaster areas on the first day after the disaster; (2) On the second day of the disaster, health equipment was in short supply; (3) As of the third day, health workers were unprepared in terms of knowledge and experience for the disaster; and (4) The subsequent deployment of health personnel to the disaster area was uncoordinated and unplanned on the following days, which resulted in the health personnel working there not being able to meet even their basic needs (such as food, heating, and shelter). During the first week, coordination was most frequently reported as the most significant problem.

Trauma-related oral lesions; Angina bullosa haemorrhagica: a rare case presentation

Angina bullosa haemorrhgica is a relatively uncommon condition characterized by blood-filled subepithelial lesions in the oral mucosa that is idiopathic and not caused by a systemic disease or a hemostatic abnormality. Middle-aged and elderly patients are usually affected and lesions heal spontaneously without scarring. A rapidly expanding hemorrhagic blister in the oropharynx can induce upper airway obstruction, so recognizing the lesion as soon as possible is essential. Because of its rarity, we wanted to highlight a 42-year-old male patient who presented with hemorrhagic bullae associated with insignificant local trauma in the oral mucosa and to emphasize that Angina bullosa haemorrhagica is a rare but recognizable lesion that clinicians should be aware of.

Posterior Reversible Encephalopathy Syndrome Presented with Typical Radiological Findings

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The role of a noninvasive index 'Spo2/ Fio2' in predicting mortality among patients with COVID-19 pneumonia

INTRODUCTION

Noninvasive risk assessment is crucial in patients with COVID-19 in emergency department. Since limited data is known about the role of noninvasive parameters, we aimed to evaluate the role of a noninvasive parameter 'SpO2/FiO2' in independently predicting 30-day mortality in patients with COVID-19 and its prognostic utility in combination with a noninvasive score 'CRB-65'.

METHODS

A retrospective study was performed in a tertiary training and research hospital, which included 272 patients with COVID-19 pneumonia diagnosed with polymerase chain reaction in emergency department. Data on characteristics, vital signs, and laboratory parameters were recorded from electronic medical records. The primary outcome of the study was 30-day mortality, and we assessed the discriminative ability of SpO2/FiO2 in predicting mortality in patients with COVID-19 pneumonia and its prognostic utility in combination with conventional pneumonia risk assessment scores.

RESULTS

Multivariate analysis revealed that only SpO2/FiO2 level was found to be an independent parameter associated with 30-day mortality (OR:0.98, 95% CI: 0.98-0.99, p = 0.003). PSI and CURB-65 were found to be better scores than CRB-65 in predicting 30-day mortality (AUC: 0.79 vs 0.72, p = 0.04; AUC: 0.76 vs 0.72, p = 0.01 respectively). Both SpO2/FiO2 combined with CRB-65 and SpO2/FiO2 combined with CURB-65 have good discriminative ability and seemed to be more favorable than PSI in predicting 30-days mortality (AUC: 0.83 vs 0.75; AUC: 0.84 vs 0.75), however no significant difference was found (p = 0.21 and p = 0.06, respectively).

CONCLUSION

SpO2/FiO2 is a promising index in predicting mortality. Addition of SpO2/FiO2 to CRB-65 improved the role of CRB-65 alone, however it performed similar to PSI. The combined noninvasive model of SpO2/FiO2 and CRB-65 may help physicians quickly stratify COVID-19 patients on admission, which is expected to be particularly important in hospitals still stressed by pandemic volumes.

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.

A Rare Cause of ST-Segment Elevation Myocardial Infarction in COVID-19: MINOCA Syndrome

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is defined as having a stenosis of less than 50% or no stenosis in coronary angiography in a patient diagnosed with myocardial infarction.

Because of its thrombogenic predisposition in COVID-19, the diagnosis of MINOCA syndrome is rarely thought in the patients with ST-segment elevation myocardial Infarction on electrocardiogram. In this case report, we discuss a 47-year-old male patient diagnosed with MINOCA who was followed up with respiratory failure due to COVID-19 viral pneumonia in intensive care unit. His 12-lead electrocardiogram showed “inferior STEMI”. A 30-40% stenosis was also shown in the midportion of left anterior descending artery in emergency coronary angiography. The patient had a normal computed tomographic pulmonary angiography and was discharged with a full recovery.

MINOCA may be triggered by hyperinflammation or various processes due to COVID-19. To explain these processes associated with MINOCA syndrome, further clinical trials are needed.

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.

Prolongation of QT interval due to hydroxychloroquine overdose used in COVID-19 treatment

Hydroxychloroquine is one of the most commonly used drugs in COVID-19 treatment. In this case report, we aimed to present a young patient whose QT interval was prolonged due to hydroxychloroquine overdose which was given for COVID-19 treatment. This is the first reported case of QT interval prolongation at a low dose of 1.600 mg in the literature. A 28-year-old male patient was admitted to the emergency department with the complaints of nausea, diarrhea, and weakness. The patient was diagnosed with COVID-19 a day prior and home isolation was recommended with hydroxychloroquine and oseltamivir P. O. treatment. His complaints started 6 h after accidentally taking 1.600 mg of hydroxychloroquine P. O. at the same time. On physical examination, the Glasgow Coma Scale was 15, and neurological, respiratory, and abdominal examinations were normal. His pulse was 54 beats/min, oxygen saturation was 99%, arterial blood pressure was 122/82 mmHg, and fever was 36.5°C. Electrocardiography (ECG) showed sinus bradycardia and corrected QT interval was calculated as 510 ms. The QT interval prolongation and bradycardia persisted, and the patient was hospitalized for follow-up and treatment. He was discharged on the 3rd day of his hospitalization after the corrected QT interval was detected to be 420 ms and his bradycardia improved. Due to the potential cardiac side effects, patients who are sent to home isolation with treatment should be educated about the use, dosage, and possible side effects of this medicine, and serial ECG monitoring should be provided to patients who are hospitalized.

Is potassium thiosulfate a poison? Is it safe? A case series

Potassium Thiosulfate is a liquid substance used for producing fertilizers. In this case series, we present five patients who have been exposed to potassium thiosulfate inhalation. Three of them were intubated in the scene by paramedics because of confusion and respiratory depression. They had refractory status epilepticus. The other two were exposed during trying to help the others for getting out, they presented to ED with nausea, vomiting and headache. One of the intubated patients died on the 4th day of his follow-up at ICU. Others were sent home after few days with no complication. Potassium thiosulfate is not a substance documented for poisoning and it is assumed to be a safe and stable solution. Although, it was assumed to be a safe substance there are risks of metabolic acidosis, resistant generalized seizures, and death due to disturbance of oxidative reactions with potassium thiosulfate.

Social media, FOAMed in medical education and knowledge sharing: Local experiences with international perspective

Social media, through the Internet and other web-based technologies, have become a means of communication and knowledge-sharing. In this article, we provide details about the social media traffic of various scientific activities, the organizations of which we have played an active role in. We also provide information in our native language through our FOAMed website, which has been published for about 30 months, with us acting as editors. We are comparing these local and limited ventures with examples from the world and aim to remind that social media sources play a very important role in sharing knowledge in medical training and encouraging local initiatives, like ours, with limited resources.

Spinal Trauma is Never without Sin: A Tetraplegia Patient Presented Without any Symptoms

Spinal cord injuries are amongst the most dangerous injuries, leading to high mortality and morbidity. Injured patients are occasionally faced with life-threatening complications and quality-of-life changing neurological deficits. Thoracic and cervical spinal segments are the most effected sites of injury and a wide range of complications including paraplegia, respiratory and cardiovascular compromise secondary to autonomic dysfunction or tetraplegia may ensue. We aim to draw attention to the progressive nature of the neurological deficits in a patient admitted asymptomatically. Also, we would like to discuss the importance of swift diagnosis and management in such patients. In asymptomatic patients in whom no fractures are diagnosed with CT scans, a neurological examination should be repeated several times to exclude any neurological injuries that were missed. MRI should be ordered in an emergency setting even though it is not frequently used as a diagnostic modality. This should be done especially in patients without any fractures on CT but with neurological signs.

Use of ABCD2 risk scoring system to determine the short-term stroke risk in patients presenting to emergency department with transient ischaemic attack

OBJECTIVE

To determine the 3-day stroke risk of patients presenting to emergency department with transient ischaemic attack, and to evaluate the predictive value of ABCD(2) (Age, Blood pressure, Clinical features, Duration of symptoms and Diabetes) score for these patients.

METHODS

The prospective study was conducted on patients with diagnosis of transient ischaemic attack who were divided into low (0-3 points), medium (4-5 points) and high (6-7 points) risk groups according to their ABCD(2) scores. The sensitivity of the scoring system on estimation of the risk of stroke in 3 days was evaluated through receiver operating characteristic curve. SPSS 15 was used for data analysis.

RESULTS

Of the 64 patients in the study, none of the low-risk group had stroke. Stroke was present in 4 of 33 (12.12%) medium-risk patients, while there were 4 in 18 (22.22%) in the high-risk group. Sensitivity and specificity of each ABCD(2) score for 3rd day stroke risk was calculated. In the receiver operating curve generated by these calculations, the c statistics was determined as 0.76 (95% CI: 0.64, 0.86; p < 0.01) and the most appropriate cut-off score to dichotomise the study group was determined as 4.

CONCLUSIONS

In transient ischaemic attack patients with an ABCD(2) score of four or higher had a markedly increased short-term stroke risk, while those with a lower score were quite safe. It is appropriate to hospitalise patients with a score of four or more and investigate for underlying cause and initiate treatment.

Determination of the appropriate catheter length and place for needle thoracostomy by using computed tomography scans of pneumothorax patients

INTRODUCTION

The primary goal of this study was to compare the chest wall thicknesses (CWT) at the 2nd intercostal space (ICS) at the mid-clavicular line (MCL) and 5th ICS at the mid-axillary line (MAL) in a population of patients with a CT confirmed pneumothorax (PTX). This result will help physicians to determine the optimum needle thoracostomy (NT) puncture site in patients with a PTX.

MATERIALS AND METHODS

All trauma patients who presented consecutively to A&E over a 12-month period were included. Among all the trauma patients with a chest CT (4204 patients), 160 were included in the final analysis. CWTs were measured at both sides and were compared in all subgroup of patients.

RESULTS

The average CWT for men on the 2nd ICS-MCL was 38mm and for women was 52mm; on the other hand, on the 5th ICS-MAL was 33mm for men and 38mm for women. On the 2nd ICS-MCL 17% of men and 48% of women; on the 5th ICS-MAL 13% of men and 33% of women would be inaccessible with a routine 5-cm catheter. Patients with trauma, subcutaneous emphysema and multiple rib fractures would have thicker CWT on the 2nd ICS-MCL. Patients with trauma, lung contusion, sternum fracture, subcutaneous emphysema and multiple rib fractures would have thicker CWT on the 5th ICS-MAL.

CONCLUSIONS

This study confirms that a 5.0-cm catheter would be unlikely to access the pleural space in at least 1/3 of female and 1/10 of male Turkish trauma patients, regardless of the puncture site. If NT is needed, the 5th ICS-MAL is a better option for a puncture site with thinner CWT.

An Unusual Complication following Unconventional Use of High Pressure Injector

High pressure injection injuries most commonly occur in industrial accidents. In accident due to high pressure gun injuries, the nature of injected materials, the degree of toxicity, and the amount injected will affect the clinical outcome. Early vigorous treatment is essential to reduce morbidity. We reported a case of hand injuries due to inadvertent use of a high pressure injector device for haemostasis. 46-year-old male technician tried to stop bleeding from his injured hand by directing air jet from a high pressure injector to the wound resulting in significant subcutaneous emphysema. Adequate training and knowledge on occupational safety should be reinforced to avoid similar accidents.