Yalcin Golcuk

Predictive cutoff point of admission N-terminal pro–B-type natriuretic peptide testing in the ED for prognosis of patients with acute heart failure ☆

OBJECTIVE The main objective of this study was to determine a cutoff level of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) that could successfully predict the short- and long-term prognosis of patients with acute heart failure at the time of admission to the emergency department. The results of our study are presented in context with previously published literature. We believe that the present study will be useful and salutary for the progress of literature. METHODS N-terminal pro-B-type natriuretic peptide plasma levels were obtained from 100 patients with shortness of breath and left ventricular dysfunction upon admission to the emergency department. All patients underwent follow-up evaluations 30 days and 1 year after admission. The end point was defined as all-cause mortality. RESULTS The mean age of the patients in this study was 70.8 ± 11.6 years, and 51% were female. All-cause mortality at the 30-day and 1-year follow-up evaluations was 21.2% and 53.5%, respectively. We determined that the optimal NT-proBNP cutoff point for predicting 30-day mortality at the time of admission was 9152.4 pg/mL, with a 71.4% sensitivity and an 81.3% specificity (95% confidence interval, area under the curve: 0.726; P = .002). The optimal NT-proBNP cutoff point for predicting 1-year mortality at the time of admission was 3630.5 pg/mL, with an 83.0% sensitivity and a 52.2% specificity (95% confidence interval, area under the curve: 0.644; P = .014). CONCLUSION Elevated NT-proBNP levels at the time of admission are a strong and independent predictor of all-cause mortality in patients with acute heart failure at 30 days and 1 year after admission. Furthermore, the optimal cutoff level of NT-proBNP used to predict 30-day and 1-year mortality had high sensitivity.

Combination of mean platelet volume and the CURB-65 score better predicts 28-day mortality in patients with community-acquired pneumonia.

OBJECTIVE This study aims to investigate whether mean platelet volume (MPV) is correlated with the CURB-65 (Confusion, Urea, Respiratory rate, Blood pressure, >65 years of age) score, and whether a combination of the CURB-65 score with MPV could better predict the 28-day mortality in patients with community-acquired pneumonia (CAP). METHODS This prospective, observational, single-center, and cross-sectional study was conducted at emergency department (ED) between September 1, 2013, and July 31, 2014. All patients underwent follow-up evaluations 28 days after admission. The end point was defined as all-cause mortality. RESULTS A total of 174 patients (mean age, 66.7 ± 15.8 years; 66.1% men) with CAP were enrolled in this study. All-cause mortality at the 28-day follow-up evaluation was 16.1%. A significant and inverse correlation between MPV and CURB-65 score was found (R = -.58, P < .001). We determined that the optimal MPV cutoff for predicting 28-day mortality at the time of ED admission was 8.55 fL, with a 75.0% sensitivity and a 75.3% specificity. For the prediction of 28-day mortality, the area under the receiver operating characteristic curve was 0.819 (95% confidence interval [CI], 0.740-0.898; P < .001) when the CURB-65 score was used alone, whereas it increased to 0.895 (95% CI, 0.819-0.936; P < .001) with the addition of MPV to the score. CONCLUSIONS Mean platelet volume level is valuable for predicting mortality and the severity of disease among patients with CAP at ED admission. Furthermore, a combination of CURB-65 score and MPV can enhance the predictive accuracy of 28-day mortality.

Determination of a predictive cutoff value of NT-proBNP testing for long-term survival in ED patients with acute heart failure☆

OBJECTIVE The main objective of this study was to determine a predictive cutoff value for plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) that could successfully predict the long-term (4-year) survival of patients with acute heart failure (HF) at the time of admission to the emergency department (ED). To our best knowledge, our study is the first research done to identify a predictive cutoff value for admission NT-proBNP to the prescriptive 4-year survival of patients admitted to ED with acute HF diagnosis. METHODS NT-proBNP levels were measured in plasma obtained from 99 patients with dyspnea and left ventricular dysfunction upon admission to the ED. The end point was survival from the time of inclusion through 4 years. RESULTS The mean age of the patients in this study was 71.1 ± 10.3 years; 50 of these patients were female. During the 4-year follow-up period, 76 patients died; survivors were significantly younger than non-survivors (64.26 ± 11.42 years vs 72.83 ± 11.07 years, P = .002). The optimal NT-proBNP cutoff point for predicting 4-year survival at the time of admission was 2300 pg/mL, which had 85.9% sensitivity and 39.1% specificity (95% confidence interval, area under the curve: 0.639, P = .044). CONCLUSION Elevated NT-proBNP levels at the time of admission are a strong and independent predictor of all-cause mortality in patients with acute HF 4 years after admission. Furthermore, the optimal cutoff level of NT-proBNP used to predict 4-year survival had high sensitivity. However, especially in the case of long-term survival, additional prospective, large, and multicenter studies are required to confirm our results.

Acute toxic fulminant myocarditis after a black widow spider envenomation: case report and literature review.

A 15-year-old boy with no medical history was bitten by a black spider on his right shoulder while sleeping indoors. The spider was killed and brought to the emergency department (ED) and later identifi ed as Latrodectus tredecimguttatus . Twenty min later, he felt chills, headache, and severe pain in the extremities: generalized itching, nausea, vomiting, and dizziness. On admission to the ED, approximately an hour after the spider bite, he was diaphoretic and he had a painless priapism. There was a red spot on his right shoulder (Fig. 1A). Arterial blood pressure and heart rate were 125/85 mmHg and 106 beats per min, respectively. Electrocardiography (ECG) was normal except mild sinus tachycardia. The chest radiography was unremarkable. Laboratory fi ndings (complete blood count and electrolytes) were within the normal range. During the ED course, the patient received intravenous 5 mg midazolam, 100 μ g fentany l, 45.5 mg feniramin male at, 100 mg ranitidine, and 125 mg methylprednisolone. Approximately fi ve h after the spider bite, the patient developed chest pain and shortness of breath with a respiratory rate of 32 breaths per min and oxygen (O 2 ) saturation of 80% on room air. Arterial blood pressure and heart rate were 160/100 mmHg and 104 beats per min, respectively. Physical examination revealed prevalent fi ne crackling rales in both the lungs. ECG revealed ST-segment elevation in leads DI, aVL, and ST-segment depression in leads DII, III, aVF, and V4 – V6 (Fig. 1B). Chest X-ray showed the classic appearance of interstitial pulmonary edema. Transthoracic echocardiography (TTE) revealed global hypokinesis of left ventricle with an ejection fraction of 30%. Serum biomarkers of myocardial injury were also elevated, and measuring troponin I was 1.4 ng/dL (0 – 0.04 ng/dL). The patient was transferred to the intensive coronary care unit, and he was initiated on standard acute decompensated heart failure medication (2.5 mg ramipril and 50 mg metoprolol succinate once a day; intravenous furosemide infusion (0.6 mg/kg/h) over three h with a noninvasive ventilation). Antivenom was not administered, because it is not available in Turkey. Following the supportive therapy, his symptoms resolved completely within 48 h, and he was discharged from the hospital after ten days without any complaints. ECG obtained two weeks later showed normal sinus rhythm with no ST – T wave changes. TTE obtained four weeks later revealed normal LV size with the recovery of systolic function (EF, 60%). Latrodectus tredecimguttatus or BWS is a member of the arthropod family which is widely distributed on earth and usually emerges between April and November. The major component of the venom is α -latrotoxin which can cause a wide variety of symptoms including dyspnea, severe muscle cramps, myalgia, weakness, sweating, headache, dizziness, vomiting, diarrhea, diaphoresis, priapism and hypoor hypertension. 1 Cardiovascular manifestations are relatively rare except hypertension and tachycardia, but in our case, the main clinical presentations of the BWS bite were associated with cardiovascular complaints. Myocardial involvement after a scorpion sting has been well described, but so far, only a few cases of myocarditis associated with BWS envenomation have been reported, and clinical experience with such cases is indeed limited. 2 – 8 Clinical Toxicology (2013), 51, 191–192 Copyright

Tirofiban-induced acute profound thrombocytopenia: What is the optimal approach to treatment?

A 40-year-old man without previous medical history presented to the emergency department with chest pain and diagnosed with acute coronary syndrome (ST segment elevation myocardial infarction). After the loading dose of clopidogrel (600 mg) and acetylsalicylic acid (300 mg), he was taken to the catheterization laboratory for urgent coronary angiography. Angiography demonstrated a 95% thrombotic stenosis at proximal portion of the left anterior descending artery (LAD) and plaques in circumflex and right coronary arteries without significant stenosis. Therefore, we decided to primary intervention to LAD lesion and after the bolus dose (10mg/kg) of intravenous tirofiban baloon angioplasty (Simpass 2 15 mm, 12 atm, AlviMedica, Istanbul, Turkey) with stenting (bare metal stent, Ephesus 3 18 mm, 12 atm, Medtronic, Minneapolis, MN) was successfully performed. The

Caffeine-induced rhabdomyolysis

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Acute myocardial infarction associated with thinner abuse: Case report and literature review

A 40-year-old homeless man without previous medical history presented to the emergency department with chest pain 2 h after he had inhaled thinner for the fi rst time. On admission, his arterial blood pressure was 145/95 mmHg and his heart rate was 106 beats/min. Electrocardiography (ECG) revealed mild sinus tachycardia with poor R-wave progression in leads V1 – V6 (Fig. 1). His serum biomarkers of myocardial injury were elevated and his Troponin I, CK, and CK-MB levels were 41.6 ng/dl (0 – 0.04 ng/ dL), 383 U/L, and 93 U/L, respectively. Other routine laboratory results including platelet count, electrolyte levels, renal function, liver function, and coagulation tests [i.e., INR, PT, aPTT, and bleeding time were 0.9 (0.8 – 1.2), 11 s (9.7 – 14 s), 29 s (16 – 36 s), and 3.4 min (2 – 5 min), respectively] were normal. Following the administration of a loading dose of clopidogrel (600 mg) and acetylsalicylic acid (300 mg), he was immediately taken to the catheterization laboratory for urgent angiography and was diagnosed with acute anterior myocardial infarction. Coronary angiography revealed critical thrombotic stenosis at the proximal segment of the left anterior descending artery (LAD) (Fig. 2A and B, Supplementary Movies 1 and 2 to be found online at http://informahealthcare.com/doi/abs/10.3109/15563650.2013. 818683). Nonstenotic atherosclerotic plaques in the circumfl ex and right coronary arteries were also noted. Because of extensive thrombus burden, the patient was given 25 μ g/kg Tirofi ban over 3 min by intravenous bolus, which was followed by an infusion of 0.15 μ g/kg Tirofi ban per minute for 24 h. After 3 days, repeated coronary angiography demonstrated patent LAD with no residual stenosis (Fig. 2C and D, Supplementary Movies 3 and 4 to be found online at http://informahealthcare.com/doi/abs/10. 3109/15563650.2013.818683). The patient ’ s in-hospital course was uneventful and he was discharged from the hospital after 7 days without any complaints. Paint thinner, which is commonly used as a cleaning agent to dilute household paints, ink, and adhesives, contains a mixture of various halogenated and aromatic hydrocarbons (e.g., toluene, xylene, N-hexane, and benzene). 1,2 Recent studies suggest that the prevalence of volatile substance abuse to achieve a euphoric state was 73% among homeless children in Istanbul, Turkey. 3 Following skin contact or inhalation of thinner, hydrocarbon ingredients, especially toluene, rapidly diffuse into the blood because of their lipophilic properties and easily penetrate tissues that are rich in lipids (e.g., the central nervous system, lung, kidney, liver, and adrenal gland). In target tissues, toluene is oxidized by monooxidase enzymes, and as a result of this oxidation, extensive free radicals are released, causing tissue damage. 4 Toluene is one of the most important components of paint thinner, and it can cause dyspnea, tachypnea, central nervous system toxicity (euphoria, ataxia, convulsions, tremor, and coma), renal tubular acidosis, and electrolyte abnormalities (especially hypophosphatemia). Acute coronary syndrome (ACS) is relatively very rare when compared to other cardiovascular manifestations such as atrial or ventricular arrhythmias (by effecting myocardial sodium channels), sudden cardiac death, myocarditis, and dilated cardiomyopathy (by causing hypophosphatemia). In our case, the main clinical presentation of thinner intoxication was associated with acute myocardial infarction. Thus far, only a few cases of acute myocardial infarction associated with thinner (toluene) abuse have been reported (Table 1), and therefore clinical experience with such cases is limited. 5 – 8 The exact mechanism of ACS due to thinner inhalation is not well known. However, possible mechanisms include coronary vasospasm caused by an increased sensitivity to catecholamines, a decrease in cardiac output, nonperfusing arrhythmias, and the development of severe renal tubular acidosis, which effects platelet function and the coagulation cascade. 6,8 Based on what we saw in our case, coronary thrombus formation may also be one of the possible mechanisms. The management of thinner-induced acute myocardial infarction should be no different from the management of classical acute myocardial infarction. Percutaneous coronary intervention could serve as a basic treatment for cases with hemodynamic instability, the development of life-threatening arrhythmias, or with ST segment elevation myocardial infarction. In the absence of these conditions, anticoagulant or antiaggregant treatment such as glycoprotein IIb/IIIa inhibitors could be performed, particularly in the ACS cases with massive thrombus burden. In conclusion, myocardial infarction associated with thinner abuse is very rare and may be life-threatening. Therefore, followup with ECG and cardiac enzymes should be considered for the early detection of coronary events in a patient with thinner intoxication. In such cases, coagulation and platelet function tests should also be performed.

Ketoprofen gel improves low back pain in addition to IV dexketoprofen: a randomized placebo-controlled trial

OBJECTIVE Oligoanalgesia is common in emergency departments (EDs), and pain management is of concern for ED physicians. The aim of this study was to reveal the effect of ketoprofen gel in patients presenting with mechanical low back pain to the ED. METHOD All the study patients received intravenous dexketoprofen additional to study drugs. After dexketoprofen, 2 g of 2.5% ketoprofen gel or placebo was administered to the site with pain and tenderness. Pain relief at 15 and 30 minutes was measured by visual analog scale scores. Rescue drug need and adverse effects were also recorded. RESULTS A total of 140 patients were enrolled into the study. The mean age of the study patients was 35±12, and 56% (n=79) of them were male. The mean pain reduction at 30 minutes was 52±18 for ketoprofen gel and 37±17 for placebo, and ketoprofen gel was better than placebo at 30 minutes (mean difference, 16 mm; 95% confidence interval, 10-21). Ten patients (14%) in the placebo group and 2 patients (3%) in the ketoprofen gel group needed rescue drug (P=.35). CONCLUSION Ketoprofen gel improves pain in patients presenting with mechanical low back pain to ED at 30 minutes in addition to intravenous dexketoprofen when compared to placebo.

Prognostic value of serum pregnancy-associated plasma protein A level at the initial ED presentation in elderly patients with CAP

OBJECTIVE This study aims to compare serum pregnancy-associated plasma protein A (PAPP-A) levels in surviving and nonsurviving elderly patients with community-acquired pneumonia (CAP), investigating whether PAPP-A is correlated with CAP prediction scores and whether PAPP-A can successfully predict 28-day mortality rates in elderly patients. METHODS This prospective, observational, single-center, cross-sectional study was conducted at the emergency department (ED) of Celal Bayar University Hospital in Manisa, Turkey, between January and September 2014. All patients underwent follow-up evaluations 28 days after admission. The end point was defined as all-cause mortality. RESULTS A total of 100 elderly patients (mean age, 77.3 ± 7.6 years [range, 65-94 years]); 60% men) with CAP were enrolled in this study. All-cause mortality at the 28-day follow-up evaluation was 22%. Admission PAPP-A levels were significantly higher in nonsurvivors compared with 28-day survivors (10.3 ± 4.5 vs 3.8 ± 2.6 ng/mL, P < .001). A significant and positive correlation between admission PAPP-A levels and pneumonia severity index; confusion, oxygen saturation, respiratory rate, blood pressure, and age 75 years or older; and confusion, urea, respiratory rate, blood pressure, and age older than 65 years scores was found (r = .440, P < .001; r = .395, P < .001; and r = .359, P < .001, respectively). Moreover, we determined that the optimal PAPP-A cutoff for predicting 28-day mortality at the time of ED admission was 5.1 ng/mL, with 77.3% sensitivity and 77.9% specificity. CONCLUSIONS Serum PAPP-A level is valuable for predicting mortality and the severity of the disease among elderly patients with CAP at ED admission. Thus, PAPP-A might play a further role in the clinical assessment of the severity of CAP.

Effect of renal failure on N-terminal Pro-Brain natriuretic peptide in patients admitted to emergency department with acute dyspnea.

OBJECTIVE Preexisting renal failure diminishes the excretion of N-Terminal Pro-Brain Natriuretic Peptide (NT-proBNP), therefore limits the diagnostic value of this peptide for concomitant heart failure. The aim of this study was to evaluate the association between NT-proBNP and the stages of renal dysfunction in a typical population attended to emergency department with acute dyspnea. METHODS In this cross-sectional study, all consecutive patients with acute dyspnea underwent clinical evaluation, laboratory assessment of NT-proBNP, and echocardiographic examinations. Among subjects, 54.5% were diagnosed as heart failure. Grouping variables according to renal function capacity and ejection fraction, independent variables were compared with Kruskal-Wallis or ANOVA with posthoc tests. Correlation and linear regression analysis were done to analyze the variables associated with NT-proBNP. The diagnostic performance of NT-proBNP was evaluated by receiver-operating characteristic (ROC) curve. RESULTS Serum median NT-proBNP level in patients with severe renal impairment was significantly higher than moderate and mildly decreased renal functions (p=0.001). In patients with moderate and severe left ventricular failure, NT-proBNP was significantly higher compared with normal subjects (LVEF>50%) (p=0.040, and 0.017, respectively). Renal dysfunction was associated in 56% of patients with heart failure. The area under the ROC curve of NT-proBNP for identifying left ventricular failure in patients with renal failure (eGFR<90 mL/min/1.73 m2) was 0.649 and reached significant difference (95% CI:0.548-0.749, p=0.005). CONCLUSION In addition to NT-proBNP measurement in clinical judgement of heart failure, renal functions have to be taken into consideration to avoid misdiagnosis.