Main reasons and predictive factors of cancer-related emergency department visits in a Hungarian tertiary care center.

BACKGROUND: Identifying the reasons for the Emergency Department (ED) visit of patients with cancer would be essential for possibly decreasing the burden of ED use. The aim of our study was to analyze the distribution of the demographic and clinical parameters of patients with cancer based on the reasons for the ED visits and to identify possible predictive factors for their visits. METHODS: This retrospective study, carried out at a large, public tertiary hospital in Hungary, involved all patients 18 years or over, who had received a cancer diagnosis latest within five years of their visit to the ED in 2018. Demographic and clinical characteristics were collected partly via automated data collection and partly through the manual chart review by a team of experts, including six emergency physicians and an oncologist. Five main reasons for the ED visit were hypothesized, pilot-tested, then identified, including those with cancer-related ED visits (whose visit was unambiguously related to their cancer illness) and those with non-cancer-related ED visits (whose visit to the ED was in no way associated with their cancer illness.) A descriptive approach was used for data analysis and binary logistic regression was used to determine predictive factors for patients with cancer visiting the ED. RESULTS: 23.2% of the altogether 2383 ED visits were directly cancer-related, and these patients had a significantly worse overall survival than patients with non-cancer related ED visits. Age 65 or below (Odds Ratio: 1.51), presence of two more comorbidities (OR: 7.14), dyspnea as chief complaint (OR: 1.52), respiratory cancer (OR: 3.37), any prior chemotherapy (OR: 1.8), any prior immune/biological treatment (OR: 2.21), any prior Best Supportive Care/palliative care (OR: 19.06), or any prior hospice care (OR: 9.43), and hospitalization (OR:2.88) were independent risk factors for the ED visit to be cancer-related. CONCLUSIONS: Our study is the first to identify independent predictive factors of ED use by patients with cancer based on the chief cause of their visit in the Central and Eastern European region. These results may provide important information for the development of algorithms intended to identify the needs of care of patients with cancer at the ED.

Successful management of zinc phosphide poisoning-a Hungarian case.

BACKGROUND: Zinc phosphide (ZnP) is the basic component of several insecticides easily accessible worldwide. Intentional or accidental intoxication may lead to severe complications and multiple organ failure, resulting in high mortality. No known antidote is currently available. The iron-chelation and the antioxidative effects are well-known features of alpha-lipoic acid (ALA), although its use in the treatment of ZnP poisoning has not been documented previously. We describe the case of a patient with serious ZnP poisoning with multiple organ failure, where ALA was also included in the patient's supportive therapy. CASE PRESENTATION: A 65-year-old man ingested 125 g of Arvalin® (containing 5 g ZnP) and presented to the Emergency Department, with respiratory insufficiency and decreased consciousness. He developed hypokalemia, hypocalcemia, low white blood cell count, elevated C-reactive protein level, mixed acidosis, hepatic and kidney damage, thickening of the jejunal wall, and lung atelectasis, which served as a basis for the ensuing bacterial pneumonia. Antibiotics and adequate supportive therapy were provided. Laboratory tests indicated liver damage (slightly increased liver enzymes, low pseudocholinesterase levels; 706 U/L on day 2), possibly caused by the patient's chronic alcoholism or the ZnP poison itself, therefore, hepatoprotective agents, ALA (Thiogamma Turbo-Set®) with N-acetylcysteine were administered for six consecutive days. Pseudocholinesterase values increased sixfold until the end of the second week of care. Fifteen days after admission, the patient was relocated to the department of psychiatry with stable vital functions, clear consciousness, declining inflammatory markers, and improved liver function. He was discharged 1 month later, fully recovered. CONCLUSIONS: Our case is the first documented voluntary and severe ZnP poisoning in Hungary. Our patient developed multiple organ failure and atelectasis, possibly resulting in the observed respiratory infection. The development of bacterial pneumonia highlighted the dangers of phosphine-induced atelectasis. The use of ALA in our patient's case, as an antioxidant and agent for metal chelation, suggested that this agent could be a promising tool in the prevention and treatment of ZnP-induced hepatic damage.

Extending knowledge of the clinical picture of Balkan adder (Vipera berus bosniensis) envenoming: The first photographically-documented neurotoxic case from South-Western Hungary.

We report a severe envenoming associated with minimal local symptoms following a Balkan adder (Vipera berus bosniensis) bite in South-Western Hungary. A 63-year-old male with a history of hypertension and sinus bradycardia (45/min) was bitten by a sub-adult specimen of V. b. bosniensis in Somogy County on 04 May 2017. The patient was transported to and treated at the Emergency Department of "Moritz Kaposi" General Hospital, Kaposvár. Locally only pain and minimal swelling with a small haematoma developed on the bitten finger. The abdominal muscles were very tender and guarding was detected upon palpation on the way to hospital. The patient, who had taken his telmisartan (80 mg) tablet in that morning, complained of nausea and dizziness during the first medical examination. The systemic signs included fluctuations in blood pressure (115/85-165/105 mmHg), ECG changes (transient horizontal ST depression in V5-6, and sinus tachycardia (90/min)), severe diarrhoea and vomiting (in 7 episodes). Descending neuromuscular paralysis appeared in the next morning, including complete bilateral ptosis with external ophthalmoplegia, and binocular diplopia. Single-fiber electromyography confirmed the neuromuscular block in the frontalis muscle innervated by the facial nerve. Intense dizziness with uncoordinated movement emerged on the 3rd day. The laboratory findings were mild, including anaemia, hypokalaemia, elevated glutamic-pyruvic transaminase and C-reactive protein levels. The absolute neutrophil count remained almost completely normal. Supportive care and monovalent antivenom (Viper Venom Antitoxin®, Biomed, Warsaw) were applied. The patient was discharged from hospital on the 4th day, although recovery was not complete until 9 days after the bite. This is the first photographically-documented case of neurotoxic envenoming from the South-Western Hungarian distribution range of V. b. bosniensis.