Comparison of Bedside Index for Severity in Acute Pancreatitis and Emergency Department SpO2, Age and Systemic Inflammatory Response Syndrome Scores in Predicting Severe Acute Pancreatitis in Patients with Acute Pancreatitis in the Emergency Department.

BACKGROUND: As the mortality of severe acute pancreatitis (SAP) is significantly higher than those with mild or moderate severity, it is of clinical significance to identify patients most likely to develop SAP at the time of emergency department (ED) presentation. OBJECTIVES: The aim of this study was to compare the performance of the Bedside Index for Severity in Acute Pancreatitis (BISAP) and the Emergency Department SpO2, Age and SIRS (ED-SAS) scoring systems as early risk assessment tools for identifying patients at high-risk of developing SAP. METHODS: We retrospectively reviewed adult patients with AP presented to ED between January 2019-September 2022. We calculated the scores of each patient with the parameters of the initial data. The primary outcome was SAP. The secondary outcomes were 30-day mortality, intensive care admission, and identifying low-risk patients without complications. RESULTS: Of 415 patients, 34 (8.2%) developed SAP and 15 (3.6%) died. With regard to predicting SAP, BISAP and ED-SAS scores had similar discriminative ability with area under the curves (AUCs) of 0.84 (95% confidence interval [CI]:0.80-0.88) and 0.83 (95% CI:0.79-0.86), respectively (p = 0.642). At a cut-off score of ≥2 for SAP, sensitivity/specificity values were 73.5%/82.4% for BISAP, 76.5%/83.2% for ED-SAS. BISAP and ED-SAS scores of ≥3, yielded sensitivity/specificity values of 50%/95.8% and 35.3%/95.5%, respectively. BISAP and ED-SAS were also similar in predicting mortality (AUCs of 0.92 vs. 0.90, respectively) and intensive care unit admission (AUCs 0.91 vs. 0.91). CONCLUSION: The BISAP and ED-SAS scores performed similarly in predicting SAP, mortality, and intensive care unit admission. As an easily calculated tool early in the ED, ED-SAS may be helpful in disposition decisions for emergency physicians.

Prognostic value of early warning scores in patients presenting to the emergency department with exacerbation of COPD.

OBJECTIVE: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a condition that frequently presents to the emergency department (ED) and its prognosis is not very well understood. Risk tools that can be used rapidly in the ED are needed to predict the prognosis of these patients. METHODS: This study comprised a retrospective cohort of AECOPD patients presenting to a single center between 2015 and 2022. The prognostic accuracy of several clinical early warning scoring systems, Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), NEWS­2, Systemic Inflammatory Response Syndrome (SIRS) and the quick Sepsis-related Organ Failure Assessment (qSOFA), were compared. The outcome variable was determined as one-month mortality. RESULTS: Of the 598 patients, 63 (10.5%) had died within 1 month after presenting to the ED. Patients who died had more often congestive heart failure, altered mental status, and admission to intensive care, and they were older. Although the MEWS, NEWS, NEWS­2, and qSOFA scores of those who died were higher than those who survived, there was no difference between the SIRS scores of these two groups. The score with the highest positive likelihood ratio for mortality estimation was qSOFA (8.5, 95% confidence interval [CI] 3.7-19.6). The negative likelihood ratios of the scores were similar, the NEWS score had a negative likelihood ratio of 0.4 (95% CI 0.2-0.8) with the highest negative predictive value of 96.0%. CONCLUSION: In AECOPD patients, most of the early warning scores that are frequently used in the ED were found to have a moderate ability to exclude mortality and a low ability to predict mortality.

Scholarly impact of the dissertation requirement for postgraduate medical education and factors affecting transformation into publication: A bibliometric analysis of 2434 dissertations in the field of emergency medicine.

OBJECTIVES: In Turkey, conducting research for a dissertation is necessary to obtain a specialist degree, but publication of this research is not mandatory. Previous studies have shown a low rate of publication for dissertation-derived research. The aim of this study was to determine publication rates, factors affecting the transformation of the dissertations into high-quality publications, and bibliometric analysis of published articles in the field of emergency medicine (EM). METHODS: This was a retrospective bibliometric study of EM dissertations submitted between 1998 and 2021 to the National Thesis Center. Research characteristics, publication status, journal characteristics, indexing, citation analysis, and institution characteristics were recorded. Journals indexed in the web of science (WOS) were defined as high-quality journals. A logistic regression was performed to identify factors affecting publication in high-quality journals. RESULTS: A total of 2434 dissertations were included. Of these, 864 (35.5%) were published and 474 (54%) were published in WOS-indexed journals. The most common area of research was trauma (n = 150, 17%), and the most common journal was the American Journal of EM (n = 74, 8%). Prospective data collection (odds ratio [OR] = 2.5, 95% confidence interval [CI] = 1.8-2.5), experimental design (OR = 2, 95%, CI = 1.3-3), university-type residency program (OR = 1.4, 95% CI = 1.02-2.1), and duration between year of graduation and publication (OR = 0.9, 95% CI = 0.84-0.95) were associated with publishing in WOS-indexed journals. CONCLUSION: EM is a relatively successful specialty for publishing dissertation-derived studies. Prospective and experimental research design, graduation from a university-type residency program, and shorter duration between the graduation and publication may increase the chance of publishing in high-quality journals.

Adherence to Clinical Practice Guidelines for Non-ST Elevation Acute Coronary Syndrome in the Emergency Department: Exploring the Role of Social, Healthcare-system, and Clinical Determinants.

OBJECTIVES: The aim of this study was to assess adherence to the European Society of Cardiology 2020 non-ST elevation acute coronary syndrome (NST-ACS) guidelines, identify factors affecting this compliance, and explore the link between adherence and adverse cardiac outcomes. METHODS: This prospective cohort study was conducted in a tertiary-level academic hospital between January 2022 and January 2023. Patients diagnosed with NST-ACS in the emergency department (ED) were included. The primary outcome measured was the rate of adherence to the guidelines, and secondary outcomes were factors affecting this adherence in the ED and its association with 28-day adverse cardiac outcomes. RESULTS: Of the 298 patients included, guideline adherence was achieved in 32.2% in the ED. The highest compliance was observed in performing a 12-lead electrocardiogram (ECG) within 10 minutes (99.7%), while the lowest was found for obtaining additional right and posterior ECG leads when ongoing ischemia was suspected (42.3%). Factors associated with better adherence included the experience level of the treating physician, the presence of cardiac-quality chest pain, initial ischemic ECG findings, higher initial troponin levels, and advanced history, electrocardiogram, age, risk factors, and troponin score and Charlson comorbidity index. Complete guideline adherence over 28 days was achieved in 19.1% of patients and was found to be significantly associated with lower rates of adverse cardiac outcomes. CONCLUSIONS: Adherence to NST-ACS guidelines was generally low but was associated with improved patient outcomes. This study highlighted the importance of various factors associated with guideline adherence. Future research should explore further barriers to guideline adherence and develop targeted interventions.

Performance of emergency triage prediction of an open access natural language processing based chatbot application (ChatGPT): A preliminary, scenario-based cross-sectional study.

OBJECTIVES: Artificial intelligence companies have been increasing their initiatives recently to improve the results of chatbots, which are software programs that can converse with a human in natural language. The role of chatbots in health care is deemed worthy of research. OpenAI's ChatGPT is a supervised and empowered machine learning-based chatbot. The aim of this study was to determine the performance of ChatGPT in emergency medicine (EM) triage prediction. METHODS: This was a preliminary, cross-sectional study conducted with case scenarios generated by the researchers based on the emergency severity index (ESI) handbook v4 cases. Two independent EM specialists who were experts in the ESI triage scale determined the triage categories for each case. A third independent EM specialist was consulted as arbiter, if necessary. Consensus results for each case scenario were assumed as the reference triage category. Subsequently, each case scenario was queried with ChatGPT and the answer was recorded as the index triage category. Inconsistent classifications between the ChatGPT and reference category were defined as over-triage (false positive) or under-triage (false negative). RESULTS: Fifty case scenarios were assessed in the study. Reliability analysis showed a fair agreement between EM specialists and ChatGPT (Cohen's Kappa: 0.341). Eleven cases (22%) were over triaged and 9 (18%) cases were under triaged by ChatGPT. In 9 cases (18%), ChatGPT reported two consecutive triage categories, one of which matched the expert consensus. It had an overall sensitivity of 57.1% (95% confidence interval [CI]: 34-78.2), specificity of 34.5% (95% CI: 17.9-54.3), positive predictive value (PPV) of 38.7% (95% CI: 21.8-57.8), negative predictive value (NPV) of 52.6 (95% CI: 28.9-75.6), and an F1 score of 0.461. In high acuity cases (ESI-1 and ESI-2), ChatGPT showed a sensitivity of 76.2% (95% CI: 52.8-91.8), specificity of 93.1% (95% CI: 77.2-99.2), PPV of 88.9% (95% CI: 65.3-98.6), NPV of 84.4 (95% CI: 67.2-94.7), and an F1 score of 0.821. The receiver operating characteristic curve showed an area under the curve of 0.846 (95% CI: 0.724-0.969, P < 0.001) for high acuity cases. CONCLUSION: The performance of ChatGPT was best when predicting high acuity cases (ESI-1 and ESI-2). It may be useful when determining the cases requiring critical care. When trained with more medical knowledge, ChatGPT may be more accurate for other triage category predictions.

Relationship between clinical anxiety and patient outcomes in patients with chronic obstructive lung disease exacerbation in the emergency department.

PURPOSE: Anxiety is a comorbidity that is not routinely addressed in patients with chronic obstructive lung disease (COPD) exacerbation in the emergency department (ED). Anxiety in patients with COPD exacerbation can be related with negative outcomes. The Generalized Anxiety Disorder 7 (GAD-7) score is an easy-to-use tool to determine anxiety. This study aimed to investigate the relationship between GAD­7 score and patient outcomes in patients with COPD exacerbation in the ED. METHODS: A prospective, cross-sectional study was conducted in a tertiary academic ED between July 2019 and January 2021. Patients admitted to the ED with COPD exacerbation were included. A GAD­7 score of ≥ 10 was defined as clinically significant anxiety. Negative outcomes were defined as a composite outcome that included recurrent ED visits, intensive care unit admission, and mortality. The relationship between clinically significant anxiety and negative outcomes within 30 days was determined. RESULTS: A total of 92 patients were assessed for eligibility and 80 were included in the study. Thirty-seven patients (46.3%) experienced negative outcomes. Although no significant difference was detected in median GAD­7 scores between patients with positive and negative outcomes, negative outcomes were significantly higher in patients who had a GAD­7 score of ≥ 10 (n = 25, p = 0.03). A sensitivity of 43.2%, specificity of 79.1%, positive likelihood ratio of 2.1 and negative likelihood ratio of 0.7 were determined for GAD­7 score in predicting negative outcome. CONCLUSION: In patients with COPD exacerbation in the ED, a GAD­7 score of ≥ 10 was associated with 30-day negative outcomes.

Comparison of PECARN clinical decision rule and clinician suspicion in predicting intra-abdominal injury in children with blunt torso trauma in the emergency department.

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) developed a clinical decision rule to identify children at low risk for intra-abdominal injury requiring acute intervention (IAI-I) for reducing unnecessary radiation exposure of ab-dominal computed tomography (CT) after blunt torso trauma. This study aimed to compare the PECARN decision rule with clinician suspicion in identifying children at low risk of intra-abdominal injuries that an abdominal CT scan can be safely avoided. METHODS: This study is a retrospective review of children with blunt torso trauma in an academic emergency department (ED) between 2011 and 2019. Patients were considered positive for the PECARN rule if they exhibited any of the variables. Clinician suspi-cion was defined as actual CT ordering of the treating physician. The primary outcome was IAI-I detected by imaging or surgery within 1 month after the trauma, and the secondary outcome was any intra-abdominal injury (IAI) presence. RESULTS: Among the 768 children included, 48 (6.25%) had intra-abdominal injuries and 21 (2.73%) of whom underwent acute in-tervention. Four hundred and fifty-three (59%) children underwent abdominal CT scanning. If the PECARN rule had been applied, 232 patients would have undergone abdominal CT. The rule revealed 90.48% (95% CI=68.17-98.33%) sensitivity for IAI-I and 81.25% (95% CI=66.9-90.56%) for IAI. Clinician suspicion revealed sensitivities of 100% (95% CI=80.76-00%) and 93.75% (95% CI=81.79-98.37%) for IAI-I and IAI, respectively. Sensitivities of the rule and clinician suspicion were statistically similar for both IAI-I (p=0.5) and IAI (p=0.146). CONCLUSION: In this study, the PECARN abdominal rule and clinician suspicion performed similarly in identifying intra-abdominal injuries in children with blunt torso trauma. However, our study supports the use of PECARN abdominal rule in addition to clinical judgment to limit unnecessary abdominal CT use in pediatric patients with blunt torso trauma in the ED.

Performance of qSOFA, SIRS, and the qSOFA + SIRS combinations for predicting 30-day adverse outcomes in patients with suspected infection.

BACKGROUND: The use of the quick sequential organ failure assessment score (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria to identify patients at high risk for adverse outcomes in the emergency department (ED) remains controversial due to their low predictive performance and lack of supporting evidence. This study aimed to determine the predictive performance of qSOFA, SIRS, and the qSOFA + SIRS combinations for adverse outcomes. METHODS: All adult patients admitted to the ED with suspected infection were prospectively included. qSOFA scores ≥ 2, SIRS score ≥ 2 were defined as risk-positive for adverse outcome. Furthermore, combination­1, which was defined as either qSOFA or SIRS positivity, and combination­2, which was defined as both qSOFA and SIRS positivity, were also considered as risk-positive for adverse outcome. The predictive performance of qSOFA, SIRS, combination­1, and combination­2 for a composite adverse outcome within 30 days, including mortality, intensive care unit (ICU) admission, and non-ICU hospitalization, were determined. RESULTS: A total of 350 patients were included in the analysis. The composite outcome occurred in 211 (60.3%) patients within 30 days: mortality in 84 (24%), ICU admission in 78 (22.3%), and non-ICU hospitalization in 154 (44%). The sensitivity and specificity, respectively, were determined in predicting composite outcome as 0.34 and 0.93 for qSOFA, 0.81 and 0.31 for SIRS, 0.84 and 0.28 for combination­1, and 0.31 and 0.96 for combination­2. CONCLUSION: The study results suggest that qSOFA and combination­2 could be a useful tool for confirming patients at high risk for adverse outcomes. Although SIRS and combination­1 could be helpful for excluding high-risk patients, the requirement of white blood cell counts limits their utilization for screening.

Acute Psychosis in COVID-19: Is It Due to Favipiravir Treatment or Acute Viral Illness?

In this report, we present a case of acute psychosis that occurred after the loading dose of favipiravir, one of the most prescribed antiviral drugs in many countries, in a patient with COVID-19. A 31-year-old female was readmitted to the emergency department after 3 days of sleep disturbance, intermittent paranoid delusions, auditory hallucinations, and agitation that started after the favipiravir treatment was initiated. A physical examination revealed disorganized speech, distorted orientation, and agitation. All laboratory tests, including drug screening and cerebrospinal fluid analysis, were normal. After excluding all the other causes of acute psychosis, favipiravir treatment was discontinued, antipsychotic treatment was started, and the patient was admitted to the psychiatric ward. The symptoms resolved on the second day of hospitalization. Although acute viral illness does seldomly cause psychosis in patients with increased inflammatory response, in the presented case, none of the inflammatory markers were positive, and acute psychosis was attributed to the loading dose of favipiravir. In conclusion, clinicians should be aware of this rare adverse effect and prescribe cautiously to patients at a high risk of psychosis.

Delayed Parosmia Following SARS-CoV-2 Infection: a Rare Late Complication of COVID-19.

In this report, we present two cases of delayed parosmia, a rare complication that occurs in the late period after COVID-19. A 28-year-old male and a 32-year-old female, found to be positive in rRT-PCR tests for SARS-CoV-2, had a loss of taste and smell, respectively. Following the regaining of their ability to smell after 87 and 72 days, respectively, the male patient reported that the smell he perceived felt the smell of burnt rubber, while the female patient stated that it was similar to the smell of onion. As a result of evaluations, a diagnosis of delayed parosmia was made occurring in the late period secondary to SARS-CoV-2 infection. Although anosmia is a common symptom in the early phase of COVID-19, olfactory damage due to Sars-CoV-2 can be persistent, and distorted sense of smell can be prolonged.

Use of noninvasive volume assessment methods to predict acute blood loss in spontaneously breathing volunteers.

OBJECTIVE: The use of noninvasive volume assessment methods to predict acute blood loss in spontaneously breathing patients remains unclear. We aimed to investigate changes in the pleth variability index (PVI), vena cava collapsibility index (VCCI), end-tidal carbon dioxide (EtCO2), pulse pressure (PP), and mean arterial pressure (MAP) in spontaneously breathing volunteers after acute loss of 450 mL blood and passive leg raise (PLR). METHODS: This prospective observational study enrolled healthy volunteers in the blood donation center of an academic hospital. We measured the PVI, EtCO2, VCCI, MAP, and PP before blood donation; at the 0th and 10th minute of blood donation; and after PLR. The primary outcome was the changes in PVI, EtCO2, VCCI, MAP, and PP. RESULTS: We enrolled thirty volunteers. There were significant differences among the four obtained measurements of the PVI, EtCO2, and MAP (P<0.001, P<0.001, P<0.001, respectively). Compared to the predonation values, post-hoc analysis revealed an increase in the PVI at the 0th min postdonation (mean difference [MD], 5.4±5.9; 95% confidence interval [CI], -7.6 to -3.1; P<0.001); a decrease in the EtCO2 and MAP at the 0th and 10th minute postdonation, respectively (MD, 2.4±4.6; 95% CI, 0.019 to 4.84; P=0.008 and MD, 6.4±6.4; 95% CI, 3 to 9.7; P<0.001, respectively). Compared with EtCO2 at the 10th minute, the value increased after PLR (MD, 1.8±3.2; 95% CI, 0.074 to 4.44; P=0.006). CONCLUSION: The PVI and EtCO2 could detect early hemodynamic changes after acute blood loss. However, it remains unclear whether they can determine volume status in spontaneously breathing patients.

Contribution of caval index and ejection fraction estimated by e-point septal separation measured by emergency physicians in the clinical diagnosis of acute heart failure.

OBJECTIVES: Although the reliability of e-point septal separation (EPSS) and caval index (CI) is proven in the diagnosis of acute heart failure (AHF), how much they contribute to the initial clinical impression is unclear. This study aimed to determine the diagnostic contribution of EPSS and CI to the initial clinical impression of AHF. METHODS: This is a prospective observational study conducted in an academic emergency department (ED). The patients admitted to the ED with acute undifferentiated dyspnea were included. Primary diagnosis was made after an initial clinical evaluation, and a secondary diagnosis was made after EPSS and CI measurements. Independent cardiologists made the final diagnosis. The primary outcome was the diagnostic contribution of EPSS and CI to the primary diagnosis. RESULTS: A total of 182 patients were included in the study. The primary diagnosis was found with a sensitivity of 0.55 and specificity of 0.84 and the secondary diagnosis was determined with a sensitivity of 0.78 and specificity of 0.83 in predicting the final diagnosis. The agreement coefficient between the primary and final diagnosis was 0.44 and between the secondary diagnosis and the final diagnosis was 0.61. When the primary diagnosis was coherent with secondary diagnosis, sensitivity and specificity were found to be 0.74 and 0.90, respectively. CONCLUSION: Although a detailed history and physical examination are the essential factors in shaping clinical perception, CI and EPSS combined significantly contribute to the initial clinical impression.

Reliability of chest pain risk scores in cancer patients with suspected acute coronary syndrome.

OBJECTIVE: The history, electrocardiogram, age, risk factors, troponin (HEART), the thrombolysis in myocardial infarction (TIMI), and Global Registry of Acute Coronary Events (GRACE) scores are useful risk stratification tools in the emergency department (ED). However, the accuracy of these scores in the cancer population is not well known. This study aimed to compare the performance of cardiac risk stratification scores in cancer patients with suspected acute coronary syndrome (ACS) in the ED. METHODS: This prospective cohort study recruited patients with cancer who visited the ED because of suspected ACS. The development of any major adverse cardiac events (MACE) within 6 weeks was recorded, with the study outcome being a MACE within 6 weeks of ED admission. RESULTS: A total of 178 patients participated in this study, of whom 5.6% developed a MACE. Statistically significant differences were found between the mean HEART and TIMI scores in predicting MACE. The HEART score had the highest area under the curve (0.64; 95% confidence interval, 0.48-0.81), highest sensitivity (80%), and highest negative predictive value (97.5) in patients with cancer. CONCLUSION: We found a similar rate of MACE in cancer patients with low-risk chest pain compared to that in the general population. However, the HEART, TIMI, and GRACE scores had a lower performance in cancer patients with MACE compared to that in the general population.

Myopericarditis caused by severe acute respiratory syndrome coronavirus 2.

A 25-year-old man presented to the emergency department with acute-onset chest pain and shortness of breath. A physical examination revealed coarse crackles in the both lower lungs. Consolidation and ground-glass opacities suggesting viral infection were detected in the right lower lobe on chest computed tomography. Laboratory findings revealed elevated troponin, leukocytosis, and lymphopenia. Electrocardiography revealed ST segment elevation with PR depression in leads I, aVL, V5, and V6, and ST depression and PR elevation in aVR. Echocardiography revealed diffuse cardiac hypokinesia and a decreased left ventricular ejection fraction. Suspecting coronavirus disease 2019 (COVID-19)-related myopericarditis, the patient was hospitalized. After one week of empirical antibiotics, antivirals, and supportive therapy, his condition improved. Antibody testing for COVID-19 was positive on hospitalization day 8. The presentation of myopericarditis can be vague and mislead physicians during the COVID-19 pandemic. Myopericarditis should be included as a differential diagnosis for patients with suspected COVID-19.

Determination of carboxyhemoglobin half-life in patients with carbon monoxide toxicity treated with high flow nasal cannula oxygen therapy.

Background: Acute carbon monoxide poisoning is a common environmental emergency worldwide. Treatment options are limited to normobaric oxygen therapy with a nonrebreather face mask or endotracheal tube and hyperbaric oxygen. The aim of this study is to determine the half-life of carboxyhemoglobin (COHb) in adult patients admitted to the emergency department with acute carbon monoxide poisoning receiving high flow nasal cannula (HFNC) oxygen. Device tolerability and patient comfort with the high flow nasal cannula were also evaluated. Methods: This study was conducted between January 2017 and February 2018 in two academic emergency departments. Venous blood samples were obtained at 10 minute intervals to determine the rate of elimination of COHb. Patient comfort was evaluated by a verbal numeric rating scale. The primary outcome was the determination of the half-life of COHb. The secondary outcome was device tolerability and patient comfort with the high flow nasal cannula oxygen delivery system. Results: A total of 33 patients were enrolled in the study. The mean baseline COHb level of the patients was 22.5% (SD 8%). The mean half-life of carboxyhemoglobin was determined as 36.8 minutes (SD 9.26 min) with high flow nasal cannula oxygen. COHb levels were halved during the first 40 minutes in 22 (67%) of the study patients. Twenty of the patients receiving HFNC oxygen did not report intolerance or discomfort. Among the 11 patients who requested a change in the flow rate, the median verbal numeric rating score was 7. After decreasing the flow rate, the median verbal numeric rating score was 9. Conclusion: High flow nasal cannula oxygen is an easy, safe, comfortable and effective method to reduce COHb. HFNC may be a promising alternative method if it is validated as effective in future studies with clinical outcomes.

Factors predicting the need for tube thoracostomy in patients with iatrogenic pneumothorax associated with computed tomography-guided transthoracic needle biopsy.

OBJECTIVES: Traumatic iatrogenic pneumothorax occurs most often after a transthoracic needle biopsy. Since this procedure has become a common outpatient intervention, emergency department admissions of post-biopsy pneumothorax patients have increased. The aim of this study was to determine the factors that predict the need for tube thoracostomy in patients with post-biopsy pneumothorax in the emergency department. METHODS: A retrospective cross-sectional study was conducted on 191 patients with post-biopsy pneumothorax who were admitted to the emergency department between 2010 and 2017. Patient characteristics, clinical findings at the emergency department presentation, and procedural and radiological features were reviewed. A multivariate logistic regression model was constructed using the variables from univariate comparisons to determine the need for tube thoracostomy in patients with iatrogenic pneumothorax, and the effect sizes were demonstrated with odds ratios. RESULTS: Tube thoracostomies were performed on 69 out of 191 patients (36.1%). A total of 122 patients (63.9%) were treated with supplemental oxygen therapy without any other intervention, and 126 patients (66.0%) were hospitalized. In the multivariate model, the variables predicting the need for a tube thoracostomy were decreased breath sounds, dyspnea, decreased systolic blood pressure, decreased oxygen saturation and increased pleura-lesion distance. A distance of 19.7 mm predicted the need with a sensitivity of 69.6% and a specificity of 62.3%. CONCLUSION: Decreased breath sounds, dyspnea, decreased systolic blood pressure, decreased oxygen saturation, and increased pleura-lesion distance may predict the need for a tube thoracostomy in patients with post-biopsy pneumothorax.

Alpha lipoic acid intoxication: An adult.

INTRODUCTION: Alpha lipoic acid (ALA) is a potent antioxidant used to treat a variety of disorders. Although ALA is considered a very safe supplement and intoxication is very rare, acute high-dose ingestions can cause mortality. In this report, we discuss a very rare case of ALA intoxication to increase awareness of this issue. CASE REPORT: A 22-year-old female was referred to our emergency department with ALA intoxication after ingesting a total of 18g of ALA with a suicidal intention. The patient was found in an altered mental state and confused. During the physical examination, the patient's Glasgow Coma Scale was 13 (E4M6V3); however, she was neither alert nor oriented. Vital signs revealed a mildly decreased blood pressure, tachycardia, and an increased respiratory rate. Cranial nerve examination was normal except a horizontal gaze nystagmus. Laboratory testing showed a decompensated metabolic acidosis. T wave inversions were seen in the electrocardiography (EKG). The patient was treated with supportive treatment and discharged within three days of intensive care unit (ICU) admission. CONCLUSION: ALA is a very common supplement that is easily accessible worldwide. Although ALA intoxication is very rare, it is sometimes seen after accidental or suicidal acute ingestion. Neurologic effects, metabolic acidosis, and t wave inversions in the EKG are observed when this acute poisoning occurs. Supportive treatment should be the main therapy.

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 7days 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 -0.6cm (95% CI: -1.7-0.5) difference in abscess diameter compared to the I&D group. There was also a reduction in cellulitis diameter (-1.3cm, 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).

Distributive Shock in the Emergency Department: Sepsis, Anaphylaxis, or Capillary Leak Syndrome?

BACKGROUND: Distributive shock is a hyperdynamic process resulting from excessive vasodilatation. Impaired blood flow causes inadequate tissue perfusion, which can lead to end-organ damage. Although the most common etiology is septic shock, anaphylactic and other etiologies should be considered. CASE REPORT: We report the case of a 30-year-old female who presented to the emergency department with nonspecific symptoms and hypotension after a viral upper respiratory infection. Her physical examination revealed mild edema and rebound tenderness in the right upper and bilateral lower quadrants. She also presented with hypotension concomitant with hypoperfusion symptoms, which were manifested by the loss of consciousness in the hour after her presentation. Neither etiologic agent nor drug use history was provided at the presentation; these may have caused anaphylaxis; however, she later reported that she took a propolis extract 1 day earlier. The hypotensive state was refractory to large amount of crystalloid infusion and a series of examinations were performed to determine the shock etiology. Computed tomography images showed pneumonic infiltrates in the lower zone of the right lung, an enlarged liver, a thickened gallbladder wall, and an extensive amount of free fluid in the perihepatic and retroperitoneal areas. All radiologic changes were thought to be due to a secondary condition that triggers them, none were considered as septic focus. Capillary leak syndrome was considered in differential diagnosis and 3 days after her presentation, her hypotension improved and she was discharged in a healthy state. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Capillary leak syndrome is a variant of distributive shock. After assessing other etiologies for this condition, emergency physicians should focus on a triggering event that may have caused hypoalbuminemia and a fluid shift.