Clinical assessment and short-term mortality prediction of older adults with altered mental status using RASS and 4AT tools.

BACKGROUND: Altered mental status (AMS) in older adults is a common reason for admission to emergency departments (EDs) and usually results from delirium, stupor, or coma. It is important to proficiently identify underlying factors and anticipate clinical outcomes for those patients. AIM: The primary objective of this study was to reveal and compare the clinical outcomes and etiologic factors of older patients with delirium, stupor, and coma. The secondary objective was to identify the 30-day mortality risk for those patients. METHOD: The study was conducted as prospective and observational research. We included patients aged 65 years and older who presented with new-onset neurological and cognitive symptoms or worsening in baseline mental status. Patients who presented no change in their baseline mental status within 48 h and those who needed urgent interventions were excluded. Selected patients were assessed using RASS and 4AT tools and classified into three groups: stupor/coma, delirium, and no stupor/coma or delirium (no-SCD). Appropriate statistical tests were applied to compare these 3 groups. The 30-day mortality risks were identified by Cox survival analysis and Kaplan-Meier curve. RESULTS: A total of 236 patients were eligible for the study. Based on their RASS and 4AT test scores: 56 (23.7%), 94 (40.6%), and 86 (36.4%) patients formed the stupor/coma, delirium and no-SCD groups, respectively. There was no statistical difference in the three groups for gender, mean age, and medical comorbidities. Neurological (34.7%), infectious (19.4%), and respiratory (19.0%) diseases were the leading factors for AMS. Post-hoc tests showed that CCI scores of the delirium (6, IQR = 3) and stupor/coma (7, IQR = 3) groups were not significantly different. The 30-day mortality rates of stupor/coma, delirium, and no-SCD groups were 42.%, 15.9%, and 12.8%, respectively (p < 0.005). The hazard ratio of the stupor/coma group was 2.79 (CI: 95%, 1.36-5.47, p = 0.005). CONCLUSION: AMS remains a significant clinical challenge in EDs. Using the RASS and 4AT tests provides benefits and advantages for emergency medicine physicians. Neurological, infectious, and respiratory diseases can lead to life-threatening mental deterioration. Our study revealed that long-term mortality predictor CCI scores were quite similar among patients with delirium, stupor, or coma. However, the short-term mortality was significantly increased in the stupor/coma patients and they had 2.8 times higher 30-day mortality risk than others.

Geriatric mortality risk factors in emergency department for non-traumatic abdominal pain.

OBJECTIVES: The study aimed to determine the factors affecting the mortality of geriatric patients presenting to the emergency department with non-traumatic abdominal pain, as well as the associations of these factors with mortality. BACKGROUND: With the increasing number of elderly patients, early recognition of patients with risk-bearing diagnoses is crucial. METHODS: This prospective cross-sectional study included 466 patients over 65 years of age who were admitted to THE emergency department of a tertiary hospital and consented to participate. Data was collected on patient demographics, vital signs, chronic diseases, laboratory investigations, diagnoses, disposition, and 30-day mortality. RESULTS: The results showed that the mean patient age was 74.42 years, with 47.4 % being male and 52.6 % female. 15.6 % of the patients had nonspecific causes. The risk of mortality within one month was 5.797 times higher in patients with neurological diseases and 5.183 times higher in those with a history of surgery. A one-unit decrease in hemoglobin increased the mortality risk by 0.656 times. CONCLUSION: This study highlights the importance of careful evaluation of elderly patients with neurological diseases, previous surgical history, and anemia in the emergency department with non-traumatic abdominal pain (Tab. 5, Ref. 18).

Assessment of the role of neutrophil extracellular traps in SARS-CoV-2 pneumonia.

BACKGROUND: Abnormal neutrophil extracellular traps are associated with lung diseases, thrombosis, increased mucosal secretion in the airways. The aim of this study is to evaluate the possible place of the most specific NETosis marker Cit-H3 protein in diagnostic algorithms by revealing its relationship with the severity, mortality and prognosis of SARS-CoV-2 pneumonia. PATIENTS AND METHODS: Patients (n = 78) who applied to the Emergency Department between March 11, 2020 and June 10, 2020, with positive SARS-CoV-2 polymerase chain reaction (PCR) test and lung involvement were included in the prospective study. Serum Cit-H3 levels and critical laboratory parameters were measured at baseline on the day of clinical deterioration and before recovery/discharge/death. Cit-C3 levels were determined by enzyme immunassay method. RESULTS: Cit-H3 levels in patients with SARS-CoV-2 pneumonia during their first admission to the hospital were significantly higher compared to the healthy control group (p < 0.05). Repeated measurements of Cit-H3 levels of the patients significantly correlated with D-dimer, procalcitonin, Neutrophil/ Lymphocyte ratio, lymphocyte, CRP, and oxygen saturation. Cit-H3 levels of the patients who died were significantly higher than that of those who survived (p < 0.05). Cit-H3 levels were found to be statistically significantly higher in patients who developed acute respiratory distress syndrome, were admitted to the intensive care unit, and had mortality (p < 0.05). CONCLUSIONS: Cit-H3 plays a role in inflammatory processes in SARS-CoV-2 pneumonia, and changes in serum Cit-H3 levels of these patients can be used to determine prognosis and mortality (Tab. 5, Fig. 1, Ref. 21).

ACE2 and ANGII levels in patients with COVID-19 based on thoracic tomography findings and PCR test results.

INTRODUCTION: Reverse transcriptase polymerase chain reaction tests and thoracic tomography have been widely employed in the diagnosis of the disease, but doubts about their sensitivity still persist. Also there are controversial results about ACE2 and AngII levels according to the severity of disease. In this study, we aimed to analyze the ACE2 and AngII levels in patients with suspected COVID-19 based on polymerase chain reaction test results and thoracic tomography findings and to examine their relationship with disease severity. METHODOLOGY: Patients with suspected COVID-19 in the emergency department were divided into 4 groups according to thoracic tomography findings and PCR test results. The in-hospital mortality of patients was recorded. ACE2 and AngII levels in patients were analyzed according to groups and severity of the disease. RESULTS: ACE2 levels for the patients with suspected COVID-19 were significantly lower than in the control group, but AngII levels were higher (not statistically significant). The mean age and male sex ratio of patients who developed acute respiratory distress syndrome (ARDS) and died were significantly higher than those who survived. Whereas there was no difference in ACE2 levels in patients with severe diseases such as ARDS and mortality, their AngII levels were significantly lower. CONCLUSIONS: It can be suggested that decreased ACE2 levels combined with increased AngII levels are determinative at disease onset and in the development of lung damage. However, decreased AngII levels are more determinative in patients with severe diseases such as ARDS and mortality.

Role of plasma angiotensin II and angiotensin-converting enzyme 2 levels on prognosis and mortality in hypertensive patients with COVID-19.

Introduction: SARS-CoV-2 requires angiotensin-converting enzyme 2 (ACE2) to enter the cell. In our study, we aimed to investigate the role of angiotensin-converting enzyme 2 and angiotensin II plasma levels on prognosis and mortality in patients with isolated hypertension, patients with chronic diseases in addition to hypertension and patients with COVID-19 without comorbidities, in accordance with the use of renin-angiotensin-aldosterone system inhibitor. Materials & methods: In the study, patients diagnosed with COVID-19 were divided into three groups. Angiotensin II and ACE2 levels were compared by comorbidities, antihypertensive drugs used, intensive care hospitalization and termination of patients. The relationship between angiotensin II and ACE2 levels and service and intensive care times was investigated. Findings: A total of 218 patients were enrolled in our study, including 68 patients diagnosed with COVID-19 without comorbidities, 33 patients diagnosed with isolated hypertension and 117 patients with other chronic diseases in addition to hypertension. There was no statistically significant difference between the comorbid disease groups between angiotensin II and ACE2 levels of the patients enrolled in the study. The rate of patients admitted to the intensive care unit was 17.9%, and the mortality rate was 11.5%. Results: In our study, we did not obtain significant findings regarding angiotensin II and ACE2 levels on presentation that can be used in prognosis and mortality of COVID-19 patients and development of future treatment methods.

Transition from pandemic to infodemic: an analysis of Turkishlanguage COVID-19 YouTube videos.

BACKGROUND: YouTube can be a powerful educational tool for the dissemination of health information. However, if uploaded health-related videos are inaccurate, it can mislead, create confusion and generate panic. AIMS: This study aimed to determine the success of the most-watched Turkish-language COVID-19 YouTube videos regarding information and guidance on the disease for the public. The secondary aim of this study was to evaluate the accuracy and quality of such video content. METHODS: The study was conducted during May 2020 and analysed 133 videos. The length of the videos, the number of likes and dislikes, comments and views, how long they have been on YouTube, Medical Information and Content Index (MICI) Score, mDISCERN scores, global quality scores, and the source and target audiences of the videos were all determined. RESULTS: The average MICI Scores of videos was 2.48±3.74 and the global quality scores was 1.27±0.64. When MICI Scores were compared between video sources, the scores of academic hospitals and government videos were significantly higher. The global quality scores of videos from news agencies and independent users was significantly lower ( < 0.001). The mDISCERN score of the videos uploaded by news agencies and categorized as useful was higher than the others (P < 0.001). Among the targeted videos, only the global quality scores of the videos made for health-care workers were found to be significantly higher. CONCLUSION: Health-care professionals should upload more videos to improve the quality of health-related video content available on YouTube. Accompanied by evidence-based information, the issues of diagnosis, ways of transmission, prevention and treatment of diseases should be emphasized.

Vitamin D Poisoning; Hypercalcemia in a Case with Richter Transformation.

In addition to modern medicine, the search for complementary and alternative medicine has been present for malignancy patients in every period. Confusion, polyuria, polydipsia, anorexia, vomiting, and muscle weakness are symptoms of acute poisoning and are related to hypercalcemia. In our case, a 52-year-old male patient applied to the Emergency Department(ED) with abdominal pain and weakness for two days. In this article, we wanted to present a case with vitamin D poisoning that occurs after the phytotherapy in a patient who developed chronic lymphocytic leukemia (CLL) to Richter transformation. In some patients, especially at ED, taking a high dose of vitamin D history can be challenging. In patients with hypercalcemia, a careful history should be taken, and it should be questioned as "Vitamin D use" rather than "Drug use" since families do not accept the vitamins as drugs.

Efficacy of Serum Angiotensin II Levels in Prognosis of Patients With Coronavirus Disease 2019.

OBJECTIVES: We aimed to determine serum angiotensin II levels in patients with coronavirus disease 2019 infection and to investigate the effect of these levels on the prognosis of the disease. DESIGN: The study was planned prospectively and observationally. SETTING: The study was conducted in a tertiary university hospital. PATIENTS: Coronavirus disease 2019 patients older than 18 years old, polymerase chain reaction test positive, with signs of pneumonia on tomography, and hospitalized were included in the study. ICU need, development of acute respiratory distress syndrome, and in-hospital mortality were considered as primary endpoints. INTERVENTIONS: Blood samples were taken from patients three times for angiotensin II levels. MEASUREMENTS AND MAIN RESULTS: Angiotensin II levels were studied by enzyme-linked immunosorbent assay method. The SPSS 24.0 program (Statistics Program for Social Scientists, SPSS, Chicago, IL) was used to analyze the data. A total of 112 patients were included in the study, of which 63.4% of the patients were men. The serum angiotensin II levels were statistically significantly lower in the patients with coronavirus disease 2019 compared with the healthy control group (p < 0.001). There was no statistical significance between the serum angiotensin II levels measured at three different times (p > 0.05). The serum angiotensin II levels of the patients with acute respiratory distress syndrome were found to be statistically significantly lower than those without acute respiratory distress syndrome in three samples collected at different clinical periods (p < 0.05). The angiotensin II levels of the patients who required admission to the ICU at all three times of blood sample collection were found to be statistically significantly lower than those who did not (p < 0.05). Although the serum angiotensin II levels of the patients who died were low, there was no statistically significant difference in mortality at all three times (p > 0.05). CONCLUSIONS: The serum angiotensin II levels decrease significantly in patients with coronavirus disease 2019, and this decrease is correlated with lung damage.

Chest Computed Tomography Findings of Eight Patients With Covid-19 Diagnosis: Case Series.

COVID-19 is an infectious disease caused by the virus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and declared a pandemic on March 11, 2020, by the world health organization. In Turkey, the first cases began to appear on March 11, 2020. After the cases in China, the appearance of ground glass with or without consolidation in the posterior and periphery of the bilateral lung is determined as the main finding of COVID-19. In this article, we wanted to share the tomography findings of eight patients who were diagnosed with COVID-19 in our emergency department and who had lung involvement.

Distribution and cost of Syrian refugees operated on in Southeastern Anatolia, Turkey.

BACKGROUND: As a result of the Syrian civil war, > 5 million Syrian citizens have fled to neighbouring countries, particularly Turkey, under refugee status. AIMS: To analyse the cost and justification for surgery of Syrian refugees treated in a secondary care hospital in Sanliurfa, Southeastern Turkey, close to the Syrian border. METHODS: We enrolled 1458 Syrian refugees who were operated upon between 2012 and 2015. The data were obtained through a retrospective search of the hospital information system. Patients were divided into traumatic and nontraumatic cases. Injured body regions, anaesthetic technique, duration of operation, length of hospital stay, sociodemographic features and treatment cost were recorded and analysed. RESULTS: Length of the hospital stay was 7.66 (0.31) days for all 1458 patients. The most common operations were orthopaedic, urological and cranial surgery. The total healthcare costs while patients stayed in hospital was ~US$ 2 million, and cost per patient was US$ 1400. CONCLUSIONS: The number of trauma operations performed has declined between 2012 and 2015. Health spending on refugees is an indicator of the economic burden on the country.

Tacrolimus-Induced Vision Loss in a Renal Transplant Patient: Posterior Reversible Encephalopathy Syndrome.

Posterior reversible encephalopathy syndrome is a rare and serious neurologic adverse effect of calcineurin inhibitors. The pathophysiology of this clinical entity is still unclear. Impaired cerebral autoregulation and endothelial dysfunction are thought to be the main pathologic processes. Imaging shows the syndrome to be characterized by vasogenic edema or cytotoxic edema in parietal and occipital areas of the brain. With regard to clinic presentation, headache, diminished visual acuity, cortical blindness, altered consciousness, seizures, and hallucinations can be seen. It is known that the clinical presentation is improved when calcineurin inhibitors are stopped early. Here, we present and evaluate a case of a cortical blindness that developed in a 36-year-old patient who had been using tacrolimus after renal transplant and who returned to health after 1 week of hospitalization.

Bleeding Complications in Warfarin-Treated Patients Admitted to the Emergency Department.

BACKGROUND: Increased use of warfarin for the treatment and prophylaxis of many diseases has increased the frequency of adverse events. Emergency departments (EDs) are the first places where early interventions for bleeding and other complaints related to warfarin use are performed. This study assessed the characteristics of patients receiving warfarin and the risk factors for bleeding complication among those admitted to the ED. METHODS: Patients admitted to the ED for any reason other than trauma during a 1-year period were retrospectively reviewed. The study population consisted of 96 patients who had received warfarin and had an international normalized ratio (INR) ≥ 3. Patient demographics and medical history were recorded. RESULTS: The mean age of the patients (female, 52.1%) was 64.9 ± 14.5 years. Fatigue was the most common presenting complaint (61%). At least one major and/or minor bleeding event had occurred in 32 (33.3%) of the patients. Patients with (n = 32) and without (n = 64) bleeding complications did not significantly differ with respect to age, sex, reason for warfarin initiation, duration of warfarin use, concomitant diseases, and concurrent medications. There were also no significant differences in the distribution of patient admissions in terms of season at presentation, INR level, and weekly warfarin dose. CONCLUSIONS: While the parameters evaluated in this study did not significantly differ among warfarin-treated patients, they may nonetheless pose a risk of bleeding. Further large-scale and long-term studies that take into account biological variation are required to precisely identify the risk factors for bleeding.

Beware Postpartum Shortness of Breath.

Peripartum cardiomyopathy (PPCM) is one of the potentially life-threatening complications of pregnancy. We report a case of a 36-year-old female patient who presented with shortness of breath, swelling of feet after giving birth to triplets, and her tests revealed that left ventricle is dilated with its diameter on the borderline and she had EF 35% with advanced systolic dysfunction. Anterior wall and septum were severely hypokinetic. In the presence of these findings, the patient was evaluated as PPCM. PPCM must be considered in the differential diagnosis of a patient presenting with shortness of breath and swelling of feet, which are also common in pregnancy.

Importance of neutrophil gelatinase-associated lipocalin in differential diagnosis of acute and chronic renal failure.

BACKGROUND: Neutrophil Gelatinase-associated Lipocalin (NGAL) protein is easily detected in the blood and urine soon after acute renal injury. NGAL gains features of an early, sensitive and noninvasive biomarker for acute renal injury. Recent evidences suggest that its expression is also increased in CRF reflecting the severity of disease. OBJECTIVES: In the present study, we aimed to investigate whether blood NGAL level plays a role in the differential diagnosis of acute and chronic renal failure. PATIENTS AND METHODS: This was a prospective case-control study. Fifty patients presented to emergency department with acute renal failure (ARF), 30 with chronic renal failure (CRF) and 20 healthy individuals as control group were included in this study. Blood pH, HCO3(-), BUN, creatinine and potassium values were evaluated in all patients. Blood NGAL values were evaluated in all groups. BUN, serum creatinine and NGAL values were statistically compared between patients and controls. RESULTS: Median NGAL levels in patients was 304.50 (29), and 60 (0) in control, which was statistically significant between the two groups (Z = -6.477, P < 0.001). The median NGAL values were 261.50 ± 291 in ARF group and 428.50 ± 294 in CRF group. There was a significant difference in NGAL level between ARF and CRF groups (Z = -2.52, P = 0.012). Median BUN values were 153.46 ± 82.47 in ARF group and 169.40 ± 93.94 in CRF group. There was no significant difference in BUN value between ARF and CRF groups (P > 0.05). Median creatinine values were 2.84 ± 2.95 in ARF group and 4.78 ± 4.32 in CRF group. In serum creatinine values, a significant difference was found between ARF and CRF groups (P < 0.05). CONCLUSIONS: Serum NGAL levels of ARF and CRF patients were significantly higher than healthy individuals. In addition, NGAL values of patients with CRF were significantly higher than those of ARF. Serum NGAL values can be used to detect renal injury and differentiate ARF and CRF.

Contrast-induced nephropathy risk due to emergency contrast-enhanced computed tomography.

OBJECTIVE: In this study, we aimed to compare serum creatinine, blood urea, and glomerular filtration rate (GFR) levels of patients at baseline and 48 h after the administration of radiocontrast agent in the emergency department. METHOD: We prospectively enrolled 114 patients who underwent contrast-enhanced computed tomography scan and had a baseline creatinine level of 1.5 mg/dl or less. Serum creatinine and blood urea levels were measured at baseline and 48 h after the administration of radiocontrast agent. GFR and Mehran risk score were calculated at baseline and 48 h after the administration of radiocontrast agent. RESULTS: Baseline mean serum creatinine was 1.03±0.25 mg/dl. Forty-eight hours after the administration of radiocontrast agent, mean serum creatinine was 1.04±0.31 mg/dl, baseline mean blood urea was 8.14±4.04 mmol/l, mean blood urea was 8.42±4.42 mmol/l, baseline mean GFR was 76.74±27.08 ml/min, and mean GFR was 77.21±27.92 ml/min. There were no significant differences between baseline and 48 h after the administration of radiocontrast agent serum creatinine, blood urea levels, and GFR (P>0.05). CONCLUSION: There was no statistically significant difference between basal and 48 h after the administration of radiocontrast agent serum creatinine and GFR levels of patients who were enrolled in this study. Results had shown that administration of intravenous radiocontrast agent (≤100 ml) for emergency imaging in the emergency department did not produce a risk for contrast-induced nephropathy in patients with serum creatinine levels of 1.5 mg/dl or less.