Murat Pekdemir

Comparison of the Glasgow-Blatchford and AIMS65 Scoring Systems for Risk Stratification in Upper Gastrointestinal Bleeding in the Emergency Department

OBJECTIVES The aim of this study was to compare the performance of the Glasgow-Blatchford and the AIMS65 scoring systems as early risk assessment tools for accurately identifying patients with upper gastrointestinal (GI) bleeding who are at a low risk of requiring clinical interventions, including emergency endoscopy. The secondary objective was to compare their performance regarding relevant clinical outcomes. METHODS Data were collected prospectively over a 2-year period in the emergency department of a university hospital. Adult patients with upper GI bleeding from either variceal or nonvariceal sources were included. Composite clinical outcomes consisted of a need for surgical or endoscopic intervention, rebleeding, intensive care unit admission, or in-hospital mortality. Patients who required blood transfusions or suffered composite clinical outcomes were considered high-risk patients. Glasgow-Blatchford score (GBS) and AIMS65 score were calculated for each patient. The sensitivity and specificity of the scoring systems were calculated. The areas under the receiver-operating characteristic curve (AUC) of the scores were compared. RESULTS There were 254 patients in the study, of whom 163 (64.2%) were men. The median age was 61 years (interquartile range = 45 to 72 years). Among the patients, 211 (83.1%) underwent endoscopy, of whom 49 (19.3%) required endoscopic intervention to achieve hemostasis. Five (2%) patients required surgical intervention. Rebleeding was observed in 33 (13%) patients. A total of 143 (56.3%) patients received blood transfusions. A total of 152 (59.8%) were defined as high risk. Eighty-one (31.9%) experienced at least one component of the composite clinical outcomes, 18 (7.1%) of whom suffered in-hospital mortality. A GBS of 0 was observed in 16 patients (6.3%) in the study group. Two of these were high-risk patients. A total of 101 (39.8%) patients had AIMS65 scores of 0. Thirty-four of these were high-risk patients. A GBS of 0 had higher sensitivity than an AIMS65 score of 0 (98.68% vs. 77.6%). The negative predictive values of the GBS and AIMS65 of 0 were 87.5 and 66.3%, respectively. The GBS and AIMS65 were similar with regard to the composite outcome prediction, with AUCs of 0.795 (95% confidence interval [CI] = 0.74 to 0.843) and 0.746 (95% CI = 0.688 to 0.798), respectively (p = 0.137). The scores were also similar with respect to predicting in-hospital mortality (AUCs of 0.85 vs. 0.81; p = 0.342). The GBS was superior to the AIMS65 in identifying high-risk patients, with AUCs of 0.896 (95% CI = 0.85 to 0.93) and 0.771 (95% CI = 0.714 to 0.821; p < 0.001), respectively. The GBS was also more accurate than the AIM65 in predicting the need for blood transfusions (AUCs of 0.904 vs. 0.796; p < 0.001) and interventions (AUCs of 0.727 vs. 0.647; p = 0.05). CONCLUSIONS These results suggest that the GBS has superior sensitivity relative to the AIMS65 in identifying patients who were not likely to require interventions, including emergency endoscopy. Additional work to determine the use in real-time decision making may be warranted and helpful in providing guidance to clinicians.

Disparity Between Mainstream And Sidestream End Tidal Carbon Dioxide Values And Arterial Carbon Dioxide Levels

BACKGROUND: Measuring and monitoring end-tidal carbon dioxide (PETCO2) is an important aspect of caring for critically ill patients. The 2 methods used for PETCO2 measurement are the mainstream and sidestream methods. OBJECTIVE: To assess the agreement between PETCO2 measurements performed by mainstream and sidestream methods with the PaCO2 values. METHODS: This was a prospective observational study. A total of 114 subjects were enrolled in the study. PETCO2 measurements using mainstream and sidestream methods were performed simultaneously with the arterial blood sampling in subjects who were observed in the emergency department and required arterial blood gas analysis. Agreement between the PETCO2 measurements and the PaCO2 values obtained from arterial blood gas analysis were evaluated using the Bland-Altman method. RESULTS: Sixty subjects (52.6%) were female, and the mean age was 60.9 years (95% CI 58.3–63.6). The mean PaCO2 was 35.16 mm Hg (95% CI 33.81–36.51), the mainstream PETCO2 was 22.11 (95% CI 21.05–23.18), and the sidestream PETCO2 was 25.48 (95% CI 24.22–26.75). Bland-Altman analysis showed an average difference between mainstream PETCO2 and PaCO2 values of 13 mm Hg (95% limits of agreement −0.6 to 25.5) and moderate correlation (r = 0.55, P < .001). The average difference between the sidestream PETCO2 and PaCO2 values was 9.7 mm Hg (95% limits of agreement −5.4 to 24.7) and poor correlation (r = 0.41, P < .001). CONCLUSIONS: PETCO2 values obtained by mainstream and sidestream methods were found to be significantly lower than the PaCO2 values. There was essentially no agreement between the measurements obtained by 2 different methods and the PaCO2 values.

The diagnostic value of ischemia-modified albumin in a rat model of acute mesenteric ischemia.

OBJECTIVES Previous studies have demonstrated that ischemia-modified albumin (IMA) is a useful marker for the diagnosis of ischemic events. This study aimed to determine the value of ischemia-modified plasma albumin in the early diagnosis of acute mesenteric ischemia in an experimental model. METHODS The study was performed on 32 Wistar albino rats divided into control (n = 8), sham (n = 8), 2-hour (n = 8), and 6-hour (n = 8) ischemia groups. Mesenteric ischemia was created by arterial occlusion, and then blood samples (2 mL) were collected and centrifuged. Serum levels of IMA were measured by a rapid calorimetric test that determined the reduced cobalt binding to albumin. For histopathologic evaluation, samples of the small intestine were obtained from the animals after they were euthanized at the end of the experiment. RESULTS Histopathologic damage of the intestinal wall correlated with the duration of ischemia. While the mean pathology scores of the 2- and 6-hour ischemia groups were different from each other, IMA levels (mean ± SD) in the four groups were not significantly different from each other: 0.55 ± 0.07 absorbance units (ABSU) in the control group, 0.62 ± 0.09 ABSU in the sham group, 0.60 ± 0.07 ABSU in the 2-hour ischemia group, and 0.64 ± 0.12 ABSU in the 6-hour ischemia group (p = 0.153). CONCLUSIONS Serum IMA values were not useful in the early diagnosis of acute mesenteric ischemia. Further studies to investigate ischemic and nonischemic conditions that affect IMA levels are needed.

A rare cause of headache: cerebral venous sinus thrombosis due to hyperthyroidism

Headache represents up to 4% of all emergency department (ED) visits. Emergency physicians generally are concerned with identifying those patients whose headaches are caused by life-threatening conditions. Cerebral venous sinus thrombosis may be difficult to diagnose clinically because of its various and nonspecific manifestations. The most frequent but least specific symptom of sinus thrombosis is severe headache, which is present in more than 90% of adult patients. In the case report we present, a patient had severe headache and was diagnosed until third ED visit at different hospitals. He had one of the most unusual causes of headache, that is, cerebral venous sinus thrombosis due to hyperthyroidism.

Comparison of alprazolam versus captopril in high blood pressure: A randomized controlled trial

Abstract Objective. Anxiety is an important cause of acute blood pressure (BP) elevation. However, the role of anxiolysis in this situation is still controversial. In this study, the relationship of anxiety with BP and the effect of anxiolytic treatment on BP were investigated. Methods. Emergency department (ED) patients with an initial systolic BP (SBP) ≥ 160 mmHg or diastolic BP (DBP) ≥ 100 mmHg but no end organ damage were approached for inclusion in the study. In those consenting to participate, anxiety levels were measured using the State-Trait Anxiety Index (STAI) and Visual Analog Scale for Anxiety (VAS-A). Patients were randomly assigned to receive oral alprazolam 0.5 mg or captopril 25 mg. BP and anxiety levels were measured at baseline and at 1 and 2 h after administration of the study medication. Results. Of 133 patients meeting inclusion criteria, 53 patients agreed to participate. Of these, 27 patients (50.9%) received captopril and 26 patients (49.1%) received alprazolam. The majority of the patients had a high-level trait (96.2%, n = 51) and state anxiety (81.1%, n = 43). The mean SBP and VAS-A values of both patient groups dropped significantly over the 2 h, with no significant difference between the two groups. A significant association between SBP and VAS-A scores was found (F(2,50) = 6.27, p = 0.004). Conclusion: A significant association exists between the level of BP and anxiety in hypertensive ED patients. Alprazolam is as effective as captopril in lowering BP in ED patients with an initial SBP > 160 mmHg.

Comparison of Short‐term Infusion Regimens of N‐Acetylcysteine Plus Intravenous Fluids, Sodium Bicarbonate Plus Intravenous Fluids, and Intravenous Fluids Alone for Prevention of Contrast‐induced Nephropathy in the Emergency Department

BACKGROUND There is no evidence regarding the several short-term prophylaxis protocols for contrast-induced nephropathy (CIN) that may be most feasibly convenient in emergency settings. OBJECTIVES The purpose of this study was to compare the efficacies of short-term CIN prophylaxis protocols of normal saline, N-acetylcysteine (NAC) plus saline, and sodium bicarbonate plus saline in emergency department (ED) patients at moderate or high risk of CIN after receiving intravenous (IV) contrast agent. METHODS This single-center, randomized, nonblinded clinical trial was conducted in the ED with adult patients requiring contrast-enhanced computed tomography (CT). Patients with moderate to high risk of CIN according to the Mehran risk score, who consented to participate, were eligible. Patients with continuous renal replacement therapy or who reported contrast allergy were excluded. Enrolled patients were randomly assigned to receive 150 mg/kg NAC in 1000 mL of 0.9% sodium chloride (NaCl), 150 mEq of sodium bicarbonate in 1000 mL of 0.9% NaCl, or 1000 mL of IV saline infusion, all given at 350 mL/hr for 3 hours. All of the patients were administered less than 100 mL of nonionic, low-osmolality contrast agent. The primary outcome of CIN was defined as a 25% increase or a greater than 0.5 mg/dL increase in the serum creatinine level 48 to 72 hours later compared with the baseline measurement. RESULTS A total of 107 patients were randomized to NAC (n = 36), sodium bicarbonate (n = 36), and saline prophylaxis (n = 35). The mean age of the patients was 71 years (95% confidence interval [CI] = 65 to 77 years), and 58 (54.2%) were male. The groups were similar regarding baseline characteristics and nephropathy risks. Of the 16 (14.9%) patients who eventually developed CIN, seven (19.4%) were in the NAC plus saline group, four (11.1%) were in the sodium bicarbonate plus saline group, and five (14.2%) were in the saline group. There were no significant differences between the groups in terms of the prevention of CIN (p = 0.60). CONCLUSIONS None of the short-term protocols with normal saline, NAC, or sodium bicarbonate was superior in ED patients requiring contrast-enhanced CT who had a moderate or high risk of CIN.

Intranasal Lidocaine in Acute Treatment of Migraine: A Randomized Controlled Trial

Study objective: The study aims to evaluate the efficacy and safety of intranasal lidocaine administration for migraine treatment. Methods: This single‐center, double‐blind, randomized, controlled trial was conducted in a tertiary care emergency department. Included patients met the migraine criteria of the International Headache Society. Patients were randomized to intranasal lidocaine or saline solution; all participants received 10 mg of intravenous metoclopramide. Patient pain intensity was assessed with an 11‐point numeric rating scale score. The primary outcome measure was the change in pain scores at 15 minutes; secondary outcomes were changes in pain intensity after pain onset and need for rescue medication. Results: Patients (n=162) were randomized into 2 groups with similar baseline migraine characteristics and numeric rating scale scores. The median reduction in numeric rating scale score at 15 minutes was 3 (interquartile range [IQR] 2 to 5) for the lidocaine group and 2 (IQR 1 to 4) for the saline solution group (median difference=1.0; 95% confidence interval 0.1 to 2.1). The reduction in pain score at 30 minutes was 4 (IQR 3 to 7) for the lidocaine group and 5 (IQR 2 to 7) for the saline solution group (median difference=1.0; 95% confidence interval 0.1 to 2.1). Need for rescue medication did not differ between the groups, and local irritation was the most common adverse event in the lidocaine group. Conclusion: Although intranasal lidocaine was found no more efficacious than normal saline solution in our study, future studies should focus on patients who present earlier after headache onset.

Comparison of loop and primary incision & drainage techniques in adult patients with cutaneous abscess: A preliminary, randomized clinical trial

Objectives The aim of this study is to compare efficacy of loop drainage and standard incision & drainage (I&D) in adult patients with cutaneous abscess in the emergency department. Methods This study is an interventional, parallel group, randomized clinical trial. Adult patients with cutaneous abscess were randomized into loop drainage and standard I&D groups. The primary outcome was defined as change in diameter of abscess and cellulitis 7 days after procedure. Secondary outcome measures were pain intensity at the end of the procedure and procedure duration. Also patient satisfaction, need for antibiotics and repetitive drainage were recorded. Results A total of 46 patients were included in the study (23 in each group). Both groups had similar baseline characteristics. Median abscess diameters were 3.2 (1.9–4.0) cm and 3.0 (2.4–4.8) cm in loop drainage and I&D groups respectively. In the loop drainage group there was a − 0.6 cm (95% CI: − 1.7–0.5) difference in abscess diameter compared to the I&D group. There was also a reduction in cellulitis diameter (− 1.3 cm, 95% CI: − 3.4–0.8). No statistically significant difference was found between groups in patient satisfaction, use of antibiotics or need for repetitive drainage. Conclusion This preliminary study revealed that, loop drainage technique is similar to standard I&D technique in abscess resolution and complications. (Clinical Trials Registration ID: NCT02286479)

Comparison of diagnostic and prognostic utility of lactate and procalcitonin for sepsis in adult cancer patients presenting to emergency department with systemic inflammatory response syndrome.

Objectives Differentiating sepsis from other noninfectious causes of systemic inflammatory response syndrome (SIRS) in cancer patients is often challenging. Although lactate and procalcitonin have been studied extensively regarding sepsis management, little is known about their utility in cancer patients. This study aimed to compare the diagnostic and prognostic utility of lactate and procalcitonin for sepsis in cancer patients. Material and methods This prospective case-control study was conducted with adult cancer patients presenting to emergency department (ED) with at least two SIRS criteria. The infection status of each patient was determined retrospectively. Main diagnostic variables were calculated for diagnostic and prognostic utilities of lactate and procalcitonin. Results Among 86 patients, mean age was 61. Twenty-two (25.6%) were determined in the sepsis group. In the ROC analysis, a lactate value of 1 mmol/L predicted sepsis with 86.36% (95%CI: 65.1%–97.1%) sensitivity and 28.12% (95%CI: 17.6%–40.76%) specificity. A procalcitonin value of 0.8 ng/mL yielded a sensitivity of 63.64% (95%CI: 40.7%–82.8%) and 76.56% (95%CI: 63.4%–86.2%) specificity for differential diagnosis of sepsis in cancer patients. Lactate and procalcitonin showed similar abilities in differentiating sepsis from non-infective SIRS in cancer patients [AUROCs of 0.638 (95%CI:0.527–0.739) vs 0.637 (95%CI:0.527–0.738), respectively. p = 0.994]. They were also similar in predicting poor clinical outcome with AUROCs of 0.629 (95%CI:0.518–0.731) and 0.584 (95%CI: 0.473–0.69), respectively (p = 0.577). Conclusions The results of this study indicated that, none of the lactate and procalcitonin can be recommended alone to differentiate sepsis from non-infectious SIRS and to predict the poor clinical outcomes in adult cancer patients with SIRS in the ED.

Asymptomatic Chronic Epidural Hematoma in a Child As a Result of Extracranial Decompression

BACKGROUND Epidural hematoma (EDH) in children is a diagnostic challenge due to its nonspecific clinical presentation. Asymptomatic chronic epidural hematoma is a very rare entity. Reports of spontaneous decompression into the subgaleal spaces are limited with acute epidural hematomas in the literature. OBJECTIVE We report a child presenting with chronic epidural hematoma at 15 days after a head trauma. She remained asymptomatic, owing to spontaneous decompression via a skull fracture. We intend to remind emergency physicians to be alert about epidural hematomas in asymptomatic children in the presence of a history of, even minor and distant, trauma. CASE PRESENTATION An 8-year-old girl presented to the Emergency Department with a swelling in the right parietal region. She had fallen at the playground and struck her head on the ground 15 days prior. Computed tomography showed a mixed-density subacute-chronic parietal epidural hematoma with a linear fracture overlying it. There was no evidence of midline shift or ipsilateral ventricular compression. CONCLUSION An initially minimal but expanding EDH in a child can remain asymptomatic even in the later phases, owing to the spontaneous decompression through a skull fracture.