Assessing the psychological impact of Beirut Port blast: A cross-sectional study

Beirut Port blast's magnitude is considered the third after Hiroshima and Nagasaki atomic bombings. This blast occurred in the densely populated section of Beirut, leaving more than six thousand injured patients. The psychological disturbances were assessed in the blast survivors who presented to the Emergency Department (ED) at the American University of Beirut Medical Center (AUBMC). This was a cross-sectional study at the ED of AUBMC. Identified patients were contacted and consented to participate in the study. Post-Traumatic Stress Disorder (PTSD) was selected as an outcome. Depression, PTSD, and concussion were assessed using patient health questionnaire (PHQ)-9, PTSD checklist for DSM-5 (PCL5), and brain injury symptoms (BISx) tools, respectively. The association of patients and injury characteristics with the study outcome was assessed using logistic regression. 145 participants completed the study procedures. The participants' average age was 39.8 ± 15.4 years, and 60% were males. Almost half of the participants showed depression on PHQ, and 2-thirds had PTSD. The participant's age was negatively associated with PTSD, whereas being a female, having depression, and having a concussion were positively associated with PTSD. The results of this study were in line with the previous literature report except for the association between younger age and PTSD, which warrants further investigations to delineate the reasons.

Two-point compression ultrasonography: Enough to rule out lower extremity deep venous thrombosis?

BACKGROUND

Deep venous thrombosis (DVT) is a major cause of morbidity and is a common presenting complaint to the emergency department (ED). Point-of-care two-point compression ultrasonography has evolved as a quick and effective way of diagnosing DVT. The purpose of this study is to validate the prevalence and distribution of venous thrombi isolated to proximal lower extremity veins, other than common femoral and popliteal veins in patients with DVT.

METHODS

This is a single-center retrospective study that looked at patients presenting to the ED of a tertiary care hospital between January 2014 and August 2018. The clinical presentation and laboratory and imaging results were obtained using the hospital's electronic medical record.

RESULTS

A total of 2,507 patients underwent a lower extremity duplex ultrasound during the study period. Among them, 379 (15%) were included in the study. The percentages of isolated thrombi to the femoral vein and deep femoral vein were 7.92% and 0.53%, respectively. When the patients were stratified into the two groups of isolated DVT and two-point compression DVT, there were no statistically significant differences in the laboratory results between both groups. However, immobilized patients and patients with recent surgeries were more likely to have an isolated DVT.

CONCLUSIONS

Thrombi isolated to proximal lower extremity veins other than the common femoral and popliteal veins make up 8.45% of DVTs. Given this significant number of missed DVTs, the authors recommend the addition of the femoral and deep femoral veins to the two-point compression exam.

Liver function tests as predictors of common bile duct stones in acute cholecystitis patients with a chronic history: A retrospective cohort study on the ACS-NSQIP database

Liver function tests (LFTs) use for common bile duct stone (CBDS) prediction in acute cholecystitis (AC) patients is challenging, especially in patients with chronic cholecystitis (CC) history.This study aims to describe characteristics of AC patients with CC history and assess LFTs' utility for CBDS prediction in these patients.A retrospective cohort study was conducted on adults with a diagnosis of AC and CC history included in the National Surgical Quality Improvement Program database from 2008 to 2016. Patients were categorized into CBDS- (without CBDS) and CBDS+ (with CBDS). Multivariate logistic regression was used to determine CBDS predictors.This study included 7458 patients, of which 40.2% were CBDS+. CBDS+ patients were more commonly females (64.4% vs 54.7%, P < .001). Mean levels of bilirubin (1.70 vs 0.90, P < .001), SGOT (105.9 vs 49.0, P < .001) and ALP (164.6 vs 103.8, P < .001) were significantly higher among CBDS+ patients.Significant positive predictors of CBDS were female gender, increased BMI, and abnormal bilirubin, ALP and SGOT. AC patients with CC history are more likely to have CBDS. Abnormal LFTs are significantly associated with CBDS in this patient population. Familiarity with these findings can help raise clinical suspicion of providers for earlier evaluation and management of CBDS.

Role of urine studies in asymptomatic febrile neutropenic patients presenting to the emergency department

BACKGROUND

The role of urine studies in the detection of urinary tract infection (UTI) in febrile neutropenic patients with urinary symptoms (having a urinary catheter or having a positive urine analysis) is inarguable. However, the evidence is scarce regarding the indication for urine studies in asymptomatic (i.e., without urinary symptoms) patients with febrile neutropenia (FN) presenting to the emergency department (ED). The aim of this study is to evaluate the need for obtaining urine studies in asymptomatic febrile neutropenic patients.

METHODS

This was a retrospective cohort study conducted on adult cancer patients who presented to the ED with FN and had no urinary symptoms. We included all ED presentations of eligible patients between January 2013 and September 2018. Student's t-test and Wilcoxon rank-sum test were used for continuous data, while Chi-square and Fisher's exact tests were used for categorical data. Participants were divided into two groups based on their urine culture (UC) results: negative and positive UCs. Two cut-offs were used for positive UC results: ≥10⁵ cfu/mL and ≥10⁴ cfu/mL.

RESULTS

We included 284 patients in our study. The age of our patient population was 48.5±18.5 years. More than two-thirds (68.7%) of patients had severe neutropenia, while only 3.9% and 9.9% of the patients had positive UCs at ≥10⁵ cfu/mL and ≥10⁴ cfu/mL, respectively. UCs were expectedly positive in most patients with urinalysis (UA) abnormalities. However, 27.3% and 32.1% of patients with positive UCs at ≥10⁵ cfu/mL and ≥10⁴ cfu/mL respectively had a normal UA.

CONCLUSIONS

In our study, the incidence of UTI in adult febrile neutropenic cancer patients who present to the ED without urinary symptoms is low. Consequently, routine urine testing may not be warranted in this population, as it adds unnecessary financial burdens on the patients and delays timely management.

The utility of chest X-ray vs. computed tomography in febrile neutropenia patients presenting to the emergency department

Introduction: Pulmonary infections are not uncommon in patients with febrile neutropenia. Physicians have agreed to perform a chest X-ray (CXR) for all febrile neutropenic patients presenting with respiratory signs/symptoms. Nevertheless, they were divided into two groups when it came to asymptomatic febrile neutropenic patients (i.e. without respiratory signs/symptoms). A superior alternative to CXR is Computed Tomography (CT). CT, in comparison to CXR, was shown to have better sensitivity in detecting pulmonary foci. The aim of our study is to compare the diagnostic performance of CT and CXR in febrile neutropenic patients presenting to the emergency department, regardless of their clinical presentation. We are also interested in the predictors of pneumonia on chest imaging. Methodology: This is a retrospective cohort study conducted on febrile neutropenic adult cancer patients presenting to the emergency department of the American University of Beirut Medical Center. Results: 11.4% of 263 patients had pneumonia although 27.7% had respiratory signs/symptoms. 17.1% of those who were symptomatic and did a CXR were found to have pneumonia. 41.7% of those who were symptomatic and did a CT were found to have pneumonia. 30% had negative findings on CXR but pneumonia on CT. Conclusion: Patients with positive findings of pneumonia on chest imaging mainly had solid tumors, profound neutropenia, a higher CCI and a longer LOS. The presence of respiratory signs is the main predictor of positive pneumonia on chest imaging. CT is superior to CXR in detecting pulmonary foci in the population studied.

Effectiveness and outcomes of 2 therapeutic interventions for cardiac tamponade: A retrospective observational study

Pericardial effusions can either be drained by percutaneous pericardiocentesis (PCC) or by surgical pericardiotomy (SP), with limited evidence of superiority for the management of cardiac tamponade (CTa).This study uses the US Nationwide Emergency Department Sample database to investigate the effectiveness of SP and PCC in patients with CTa in terms of clinical outcomes and healthcare costs.Retrospective observational study conducted on the US Nationwide Emergency Department Sample 2014 dataset CTa patients. Descriptive and multivariate logistic regression analyses were done to assess the impact of different procedures (none, SP, PCC, SP, and PCC) on mortality.A total of 10,410 CTa patients were included, of which 28.9% underwent no procedure, 32.9% underwent SP, 30.2% underwent PCC and 8.0% underwent SP and PCC. Mortality rates were highest in patients undergoing no procedure (22.3%) followed by PCC (15.0%), SP and PCC (11.5%), and then SP (9.6%) (P < .001). SP patients had longer length of stay (11.65 vs 8.16 days, P < .001) and higher total charges ($162,889.1 vs $100,802, P < .001) compared to PCC patients. Undergoing any procedure for CTa reduced the rate of mortality compared to no procedure with SP being the most effective (OR = 0.323, 95%CI 0.244-0.429), followed by SP & PCC (OR = 0.387, 95% CI 0.239-0.626), and then PCC (OR = 0.582, 95% CI 0.446-0.760).Adult CTa patients treated with SP had lower mortality rates but longer length of stay and higher healthcare expenses. This SP associated benefit remained consistent across different subpopulations after stratifying by age and potential disease etiology.

Pulmonary Embolism Can Be Nauseous: A Case Report and Review of D-Dimer Use in Pediatric Oncology Patients

BACKGROUND

Pulmonary embolism (PE) is a very common presentation in the emergency department (ED). Despite being life-threatening, PE is preventable if diagnosed and managed early, especially in high-risk patients like pediatric oncology patients. A negative d-dimer has a high negative predictive value and can rule out PE in low-risk patients; however, it does not lower post-test probability enough and should be coupled with further diagnostics in high-risk patients.

CASE REPORT

We describe the case of a 14-year-old girl known to have acute lymphoblastic leukemia and presented to the ED with persistent nausea and vomiting only, which was exacerbated by exertion. She had previously presented to the ED 1 week earlier for the same complaint, with a nonrevealing physical examination. At that time, the patient was worked up for nausea and vomiting and received symptomatic treatment. An electrocardiogram (ECG) during that presentation showed normal sinus rhythm. During this presentation, ECG showed new ST segment depressions from V1 to V6 in addition to an S1Q3T3 pattern. This, coupled with the exacerbation of her initial symptoms, triggered further investigations. Computed tomography angiography (CTA) of the chest was performed and showed a right lower lobe segmental pulmonary artery embolus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the importance of having a high level of suspicion for PE, especially in pediatric oncology patients and specifically in hematologic malignancies. Although our patient's presentation, examination, and laboratory results were not concerning initially, CTA of the chest showed a PE. We are addressing this particular topic to increase the awareness of emergency physicians of cases like this, as PE can have an unusual presentation and missing such a diagnosis can be fatal.

Retrospective cohort study on clinical predictors for acute abnormalities on CT scan in adult patients with abdominal pain

PURPOSE

Identification of clinical predictors of acute and surgical pathologies on abdominal CT in patients with non-traumatic abdominal pain (NTAP).

METHODS

Retrospective chart review cohort study of adults who had abdominal CT scans for investigation of NTAP in the Emergency Department in a tertiary care center in Lebanon. Multivariate analyses were performed to identify predictors of pathologies on CT scan.

RESULTS

This study included 147 patients who had abdominal CT scans for NTAP. Mean age was 39.8 ± 15.1 years and 58.5 % of patients were females. Less than half (44.9 %) had normal scans. Women had significantly higher rates of normal scans compared to males. Right lower quadrant (RLQ) tenderness was associated with significantly higher odds of having acute abnormalities on CT and of having surgical diagnoses, while epigastric tenderness was negatively associated with these two outcomes. Right and left upper quadrants and diffuse abdominal tenderness, and an abnormal neutrophil count were found to be associated with surgical diagnoses on CT.

CONCLUSIONS

Women are less likely to have acute and surgical pathologies on CT ordered for non traumatic abdominal pain. Epigastric tenderness is negatively associated with abnormal and surgical CT results while RLQ tenderness is associated with an abnormal CT that is likely surgical in nature. These findings should help improve diagnostic accuracy of ordering providers and improve resource utilization.

Utility of liver function tests in acute cholecystitis

Backgrounds/Aims

Common bile duct stones (CBDS) affect the management of acute cholecystitis (AC). This study aims to investigate the utility of liver function tests (LFTs) in predicting the presence of CBDS in AC patients.

Methods

Retrospective cohort study of adult patients with AC found in the American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2016. Patients were classified into two groups, without CBDS (AC⁻) and with CBDS (AC⁺). LFT results namely total bilirubin, SGOT and ALP were collected and categorized into normal and abnormal with the cut-offs of 1.2 mg/dl for total bilirubin, 40 U/L for SGOT and 120 IU/L for ALP. Measures of diagnostic accuracy for individual and combinations of LFTs were computed.

Results

A total of 32,839 patients were included in the study, with 8,801 (26.8%) AC⁺ and 24,038 (73.2%) AC⁻ patients. Their mean age was 52.4 (±18.6) years and over half (59.1%) were females. Mean LFT results were significantly higher in the AC⁺ group for total bilirubin (1.82 vs 0.97), SGOT (110.9 vs 53.3) and ALP (164.4 vs 102.3) (p<0.0001). The proportions of abnomal LFTs were significantly higher in the AC⁺ group for total bilirubin (47.7% vs 20.2%), SGOT (62.8% vs 27.1%) and ALP (56.6% vs 21.0%) (p<0.0001). Among AC⁺, the odds of having abnormal results for bilirubin, SGOT and ALP were found to be 3.61, 4.54 and 4.90 times higher than among AC⁻, respectively.

Conclusions

Abnormal LFTs are strong predictors for the presence of CBDS in patients with AC. Normal LFTs should be interpreted with caution as some patients with AC and CBDS might not present with characteristic abnormalities in results.

Gunshot Injuries in Lebanon: Does Intent Affect Characteristics, Injury Patterns, and Outcomes in Victims?

Introduction:

Lebanon lacks a national database of gunshot injuries (GSIs), which limits injury prevention initiatives.

Objectives:

This study examines patient characteristics, injury patterns, and clinical outcomes in GSI victims and evaluates the impact of intent on clinical outcomes with the aim of improving awareness among emergency department (ED) physicians about the importance of inquiring about intent to predict prognosis.

Materials and Methods:

We conducted a retrospective cohort study of GSI victims presenting to the ED of a tertiary care center in Beirut, Lebanon. Descriptive and bivariate analyses were done to identify differences based on intent.

Results:

A total of 83 patients were included, 59% with intentional GSI, 22% with unintentional GSI, and 19% with unspecified intent. They were mostly males (89.2%), with a mean age of 31.7 years, and mostly presenting during summer seasons. Females were more commonly victims of unintentional GSI. All victims sustaining multiple GSIs were in the intentional group. When compared to unintentional GSI, intentional and unspecified GSIs were found to result in more ICU admissions (46.9%, 31.3%, and 16.7%, P = 0.096), significantly longer hospital stays (18.2, 26.3, and 5.6 days; P = 0.001) and higher mortality (11.6%, 18.2%, and 6.7%; P = 0.747). The rates of surgical procedures were similar between the three groups although more victims of intentional and unspecified GSI underwent multiple surgeries.

Conclusion:

GSIs have different features, resource utilization, and clinical outcomes depending on the intentionality of injuries. All GSI victims suffer from substantial morbidity and mortality, but intentionally harmed victims sustain more severe injuries with worse outcomes.

Description of blast injuries and predictors of admission to hospital in blast victims in an urban civilian setting

INTRODUCTION

Blast injuries characteristics and outcomes are not well described in urban civilian settings.

OBJECTIVES

To describe blast injuries characteristics and to identify predictors of hospital admission after sustaining a blast injury.

METHODS

Retrospective chart review study of blast victims who presented to the Emergency Department (ED) of a tertiary care center in Beirut, Lebanon, over 8 years. The authors conducted a descriptive analysis, followed by a multivariate analysis to identify predictors.

RESULTS

A total of 59 patients were included. They were mostly males (81.4 percent) with a mean age of 35.4 (± 15) years with high rate of admission to the hospital (71.2 percent). Surface injury (mainly open wounds) was most common (91.5 percent). Injuries involved mainly the face (45.8 percent) and thigh/knee (33.9 percent). Significant associations were identified between different injury locations. Significant predictors of hospital admission in blast victims were internal injury (odds ratio [OR] = 11.6, 95% confidence interval [CI; 1.7, 79.9]), orthopedic injury (OR = 41.1, 95% CI [3.4, 496.2]), and undergoing a chest X-ray in the ED (OR = 14.3, 95% CI [2.2, 93.3]).

CONCLUSION

Blasts in a civilian setting result in a wide range of injuries. Facial injuries were most common in our setting with close associations between injuries of different organ systems. Identified predictors of hospital admission can help guide disposition decision for blast victims in the ED.