Gilbert Abou Dagher

Use of Contrast-Enhanced Ultrasound for Confirmation of Central Venous Catheter Placement: Systematic Review and Meta-analysis

The purpose of this meta‐analysis was to determine the sensitivity, specificity, and positive and negative predictive values of contrast‐enhanced ultrasound (US) for confirming the tip location and placement of central venous catheters in adult patients.

Are patients with cancer with sepsis and bacteraemia at a higher risk of mortality? A retrospective chart review of patients presenting to a tertiary care centre in Lebanon

Objective Most sepsis studies have looked at the general population. The aim of this study is to report on the characteristics, treatment and hospital mortality of patients with cancer diagnosed with sepsis or septic shock. Setting A single-centre retrospective study at a tertiary care centre looking at patients with cancer who presented to our tertiary hospital with sepsis, septic shock or bacteraemia between 2010 and 2015. Participants 176 patients with cancer were compared with 176 cancer-free controls. Primary and secondary outcomes The primary outcome of this study was the in hospital mortality in both cohorts. Secondary outcomes included patient demographics, emergency department (ED) vital signs and parameters of resuscitation along with laboratory work. Results A total of 352 patients were analysed. The mean age at presentation for the cancer group was 65.39±15.04 years, whereas the mean age for the control group was 74.68±14.04 years (p<0.001). In the cancer cohort the respiratory system was the most common site of infection (37.5%) followed by the urinary system (26.7%), while in the cancer-free arm, the urinary system was the most common site of infection (40.9%). intravenous fluid replacement for the first 24 hours was higher in the cancer cohort. ED, intensive care unit and general practice unit length of stay were comparable in both the groups. 95 (54%) patients with cancer died compared with 75 (42.6%) in the cancer-free group. The 28-day hospital mortality in the cancer cohort was 87 (49.4%) vs 46 (26.1%) in the cancer-free cohort (p=0.009). Patients with cancer had a 2.320 (CI 95% 1.225 to 4.395, p=0.010) odds of dying compared with patients without cancer in the setting of sepsis. Conclusions This is the first study looking at an in-depth analysis of sepsis in the specific oncology population. Despite aggressive care, patients with cancer have higher hospital mortality than their cancer-free counterparts while adjusting for all other variables.

Discharge Against Medical Advice From the Emergency Department: Results From a Tertiary Care Hospital in Beirut, Lebanon.

AbstractPatients who leave the emergency department against medical advice are at high risk for complications. Against medical advice (AMA) discharges are also considered high-risk events potentially leading to malpractice litigation.Our aim was to characterize patients who leave AMA in a payment prior to service emergency department (ED) model and to identify predictors for return visits to ED after leaving AMA.We conducted a retrospective review study of charts of ED patients who were discharged AMA between January 1, 2012 and January 1, 2013 at a tertiary care center in Beirut Lebanon. We carried out a descriptive analysis and a bivariate analysis comparing AMA patients without and with return visit within 72 hours. This was followed by a Logistic regression to identify predictors of return visits after leaving AMA.A total of 1213 ED patients were discharged AMA during the study period. Mean age was 46.9 years (±20.9). There were 654 men (53.9%), 737 married (60.8%). The majority (1059 patients (87.3%)) had an emergency severity index of 3 or less (1 or 2). ED average length of stay was 3.8 hours (±6.8). Self payers accounted for 53.9%. Reasons for leaving AMA were: no reason mentioned (44.1%), incomplete workup (30.5%), refusing admission (12.4%), financial reasons (7.9%), long wait times (2.9%), and others (2.2%). Discharge diagnoses were mainly cardiac (23.4%), gastrointestinal (16.4%), infectious (10.1%), and trauma (9.8%).One hundred nineteen returned to ED within 72 hours (9.8%). Predictors of returning to ED after leaving AMA were: older age (OR 1.02 95% CI (1.01–1.03)), private insurance status (OR 4.64 95% (CI 2.89–7.47) within network insurance status (OR 7.20 95% CI (3.86–13.44), longer ED length of stay during the first visit (OR 1.03 95% CI (1.01–1.05).In our setting, the rate of return visit to ED after leaving AMA was 9.8%. Reasons for leaving AMA, high-risk discharge diagnoses and predictors of return visit were identified. Financial status was a strong predictor of return to ED after leaving AMA.

Assessment of Sepsis in a Developing Country: Where do We Stand?

Abstract: Sepsis affects millions of people worldwide every year. The majority of sepsis research arises from developed countries. This large gap in medical advancement between the developed and developing world leaves us pondering over crucial questions that must be tackled: Are developing countries able to implement the standards of care set by the developed world? Do they have access to the ongoing medical innovations? Is there global equality of medical care? Is the burden and toll of sepsis heavier in the developing world? To answer all these questions, the starting point is to assess the impact of sepsis on developing countries. Literature about Sepsis in Lebanon, a developing country in the Middle East Region, is scarce. This review article sheds light on the burden of sepsis in Lebanon and the Middle East as well as shares our personal research experiences.

An insidious presentation of thrombotic thrombocytopenic purpura: A case report and brief literature review

Abstract Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy with an estimated incidence of 11 cases/million population per year. Early treatment is essential and is curative in this disease where lack of treatment results in 90% mortality. We describe an atypical case of a patient with TTP who presented to the Emergency Department for headache, and was found to have thrombocytopenia but only mild anemia that was explained by another disease process. Case: A 44-year-old female presented to the Emergency Department for worsening headache and weakness over the last week. She had no fever and no focal neurological deficits but was pale and complained of severe headache. A blood test showed her to be anemic and thrombocytopenic. She explained that she had been having prolonged heavy menses over the last year. She was treated with blood and platelet transfusions, and seen by the Gynecology service who treated her for uterine fibroids after which she was discharged. She returned 1 week later with the same complaint, and was found to have a stable hemoglobin level but recurrence of thrombocytopenia. A TTP diagnosis was entertained and the workup confirmed it. The patient was treated with plasmapheresis and discharged home with no sequalae. Conclusion: Emergency physicians should keep TTP in mind when approaching cases of thrombocytopenia with mild anemia, even if an alternative diagnosis exists.

Outcomes of patients with systolic heart failure presenting with sepsis to the emergency department of a tertiary hospital: a retrospective chart review study from Lebanon

Objectives Patients with congestive heart failure (CHF) may be at a higher risk of mortality from sepsis than patients without CHF due to insufficient cardiovascular reserves during systemic infections. The aim of this study is to compare sepsis-related mortality between CHF and no CHF in patients presenting to a tertiary medical centre. Design A single-centre, retrospective, cohort study. Setting Conducted in an academic emergency department (ED) between January 2010 and January 2015. Patients’ charts were queried via the hospital’s electronic system. Patients with a diagnosis of sepsis were included. Descriptive analysis was performed on the demographics, characteristics and outcomes of patients with sepsis of the study population. Participants A total of 174 patients, of which 87 (50%) were patients with CHF. Primary and secondary outcomes The primary outcome of the study was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital lengths of stay, and differences in interventions between the two groups. Results Patients with CHF had a higher in-hospital mortality (57.5% vs 34.5%). Patients with sepsis and CHF had higher odds of death compared with the control population (OR 2.45; 95% CI 1.22 to 4.88). Secondary analyses showed that patients with CHF had lower instances of bacteraemia on presentation to the ED (31.8% vs 46.4%). They had less intravenous fluid requirements in first 24 hours (2.75±2.28 L vs 3.67±2.82 L, p =0.038), had a higher rate of intubation in the ED (24.2% vs 10.6%, p=0.025) and required more dobutamine in the first 24 hours (16.1% vs 1.1%, p<0.001). ED length of stay was found to be lower in patients with CHF (15.12±24.45 hours vs 18.17±26.13 hours, p=0.418) and they were more likely to be admitted to the ICU (59.8% vs 48.8%, p=0.149). Conclusion Patients with sepsis and CHF experienced an increased hospital mortality compared with patients without CHF.

Corrected carotid flow time and passive leg raise as a measure of volume status

BACKGROUND The aim of this study was to investigate the value of corrected carotid flow time (FTc) with passive leg raise (PLR) as a non-invasive marker of volume status in end stage renal disease (ESRD) patients. METHODS Prospective observational study of ESRD patients presenting to the Emergency department requiring hemodialysis. The common carotid artery was evaluated in long axis. Flow time measurements pre- and post-dialysis as well as before and after PLR were recorded. RESULTS 54 patients were enrolled, of which, 30 (55%) were male. The mean age was 47.4 years. The mean volume of fluid removed was 3.89 ± 0.91 L. In the pre-dialysis cohort, the mean FTc was 340.16 ms (95% CI, 330.36-349.95). Following PLR, the mean FTc was 341.34 ms (95% CI 331.74-350.94). In the post hemodialysis cohort, the mean FTc was 302.48 ms (95% CI, 293.63-311.32). Following the PLR maneuver, the mean FTc was 340.49 ms (95% CI 331.97-349.02). The mean decrease in corrected carotid flow time was 19.15 ms (95% CI, 22.86-41.17), 32.02 ms (95% CI 4.05-34.25) and 41.17 ms (95% CI, 36.47-54.76) for patients who had <3 L, 3-4 L and >4 L removed, respectively. In patients without CHF, the mean decrease in FTc after hemodialysis was 38.80 ms (95% CI, 30.12-47.49) whereas for CHF patients the mean decrease was 35.60 ms (95% CI, 25.05-46.15). CONCLUSION Corrected flow time in conjunction with passive leg raise seem to correlate with volume status in hemodialysis patients.

Dual defibrillation in patients with refractory ventricular fibrillation

ABSTRACT In the setting of cardiac arrest, refractory ventricular fibrillation (VF) is difficult to manage, and mortality rates are high. Double sequential defibrillation (DSD) has been described in the literature as a successful means to terminate this malignant rhythm, after failure of traditional Advanced Cardiac Life Support (ACLS) measures. The authors herein present a case of refractory VF in a patient with cardiac arrest, on whom DSD was successful in reversion to sinus rhythm, and provide a thorough review of similar cases in the literature.

Atypical presentation of gangrenous cholecystitis: A case series

ABSTRACT Gangrenous cholecystitis (GC) is a serious complication of acute cholecystitis that has been associated with increased morbidity. Patient with GC can present with a wide variety of non‐specific clinical, laboratory, and imaging characteristics, making the diagnosis challenging. This disease requires emergent treatment, which is why a quick and reliable diagnosis is essential for the wellbeing of the patient. The authors herein present a case of GC in a patient whose initial complaint was intractable hiccups, and provide a thorough review of the literature of cases of GC with atypical presentations.

Primary Spontaneous Pneumothorax, an Era of Fresh Air

Background. There are no rigid guidelines for the management of primary spontaneous pneumothorax. Although there seems to be a consensus between several medical societies regarding the management of an asymptomatic small pneumothorax, the approach toward a moderate to large symptomatic primary spontaneous pneumothorax is unclear and is not substantiated by well-designed research studies. Objectives. Our aim is to shed some light on the role of observation alone in the setting of moderate to large primary spontaneous pneumothorax and to report the different medical societies’ views on the treatment of a primary spontaneous pneumothorax. Case report. We report a case of a 26-year-old man who presented to our emergency department with shortness of breath and was found to have a symptomatic moderate-size pneumothorax that was successfully treated with oxygen therapy and supportive care. Conclusion. We hope that this case will stimulate further research in the field of primary spontaneous pneumothorax manageme...