Relative Hyperlactatemia in the Emergency Department.

Objective: The clinical interpretation of lactate ≤ 2.00 mmol/L in emergency department (ED) patients is not well-characterized. This study aims to determine the optimal cutoff value for lactate within the reference range that predicts in-hospital mortality among ED patients. Methods: This was a retrospective study of adult patients presenting to a tertiary ED with an initial serum lactate level of <2.00 mmol/L. The primary outcome was in-hospital mortality. Youden's index was utilized to determine the optimal threshold that predicts mortality. Patients above the threshold were labeled as having relative hyperlactatemia. Results: During the study period, 1,638 patients were included. The mean age was 66.9 ± 18.6 years, 47.1% of the population were female, and the most prevalent comorbidity was hypertension (56.7%). The mean lactate level at presentation was 1.5 ± 0.3 mmol/L. In-hospital mortality was 3.8% in the overall population, and 16.2% were admitted to the ICU. A lactate level of 1.33 mmol/L was found to be the optimal cutoff that best discriminates between survivors and non-survivors. Relative hyperlactatemia was an independent predictor of in-hospital mortality (OR 1.78 C1.18-4.03; p = 0.02). Finally, relative hyperlactatemia was associated with increased mortality in patients without hypertension (4.7 vs. 1.1%; p = 0.008), as well as patients without diabetes or COPD. Conclusion: The optimal cutoff of initial serum lactate that discriminates between survivors and non-survivors in the ED is 1.33 mmol/L. Relative hyperlactatemia is associated with increased mortality in emergency department patients, and this interaction seems to be more important in healthy patients.

Significance of Clostridium difficile in community-acquired diarrhea in a tertiary care center in Lebanon.

Clostridium difficile infection (CDI) is becoming a cause of community-acquired diarrhea. The aim is to describe (CDI) as a cause of acute diarrhea in patients presenting from the community to the Emergency Department (ED) of a tertiary care center in Lebanon. A retrospective study conducted in the ED at the American University of Beirut Medical Center (AUBMC). Adult patients presenting with the chief complaint of diarrhea and having positive CDI by stool laboratory testing (toxins A and B), during a three-year period were included. 125 patients with CDI were included. Average age was 61.43 (±20.42) with roughly equal sex prevalence. 30% (n = 36) of patients had neither antibiotic exposure nor recent hospitalization prior to current CDI. Mortality was 9.6% (n = 12), CDI was attributed as the cause in 16.7% (n = 2) and a contributing factor in 41.6% (n = 5). Recurrence within 3 months occurred in 9.6% (n = 11) in mainly those taking Proton Pump Inhibitors (PPIs) and having multiple co-morbidities. There is a high rate of community acquired CDI in Lebanon. Review of patients' medications (PPIs and antibiotics) is crucial. More studies are needed to assess mortality associated with CDI and the outcome of coinfection with other enteric pathogens.

Black Urine and Methemoglobinemia in the Setting of Sepsis Due to Clostridium Perfringens.

Clostridium Perfringens is an anaerobic gram-positive bacillus able to produce different types of toxins and can cause septicemia. The mechanism is through translocation from a previously colonized gastrointestinal or genital tract. Massive intravascular hemolysis induced by this bacterium is a rare presentation reported in only 7% to 15% of cases of Clostridium Perfringens bacteremia with a mortality rate reaching 90%.We present the case of a middle-aged man with metastatic melanoma having black-colored urine as the first sign of massive hemolysis along with mild methemoglobinemia. Despite timely management, the patient progressed into septic shock with severe hypoxia and passed away. Postmortem, blood cultures grew clostridium perfringens. Black-colored urine and blood samples, sepsis-induced mild methemoglobinemia and acute massive hemolysis should raise concern for Clostridium Perfringens sepsis in the appropriate clinical settings.

Impact of Ramadan on emergency department visits and on medical emergencies.

BACKGROUND: Fasting during Ramadan is important to Muslims. This study describes changes in emergency department (ED) visits and in frequencies of emergency conditions and impact on clinical outcomes during Ramadan in a tertiary care center in Beirut, Lebanon. PATIENTS AND METHODS: Patients presenting to ED during Ramadan 1 month before and 1 month after Ramadan over a 3-year period with specific conditions (acute coronary syndrome, stroke, seizure, diabetes, renal colic, headache or hypertension) were included. Clinical and sociodemographic characteristics, ED volume, diagnoses, and outcomes were examined during two periods (Ramadan vs. non-Ramadan). Multiple logistic regressions were performed to identify the impact of Ramadan on ED bounce-back and mortality at ED discharge. RESULTS: A total of 3536 patients were included. The daily average ED volume was higher during non-Ramadan months (145.65±22.14) compared with Ramadan (128.85±14.52). The average ED length of stay was higher during Ramadan (5.42±14.86 vs. 3.96±4.29 h; P=0.006). Frequencies and admission rates for the selected diseases were comparable during the two periods, except for patients with acute coronary syndrome or stroke who had lower admission rates during Ramadan.ED bounce-back rates and mortality at ED discharge were higher during Ramadan (odds=1.34, 95% confidence interval: 1.03-1.74 and odds ratio=2.88, 95% confidence interval: 1.01-8.27, respectively). CONCLUSION: EDs might experience a decrease in volumes, higher length of stay, and potentially worse outcomes during Ramadan. Changes in the frequencies of ED visits related to common conditions are not expected. Prospective studies documenting fasting status would clarify further the impact of Ramadan.