Necrotizing pneumonia due to Aspergillus and Salmonella after immune checkpoint inhibitor treatment: An unusual case and review of the literature.

BACKGROUND: Immune checkpoint inhibitors (ICIs) are a promising new treatment for different types of cancer. The infectious complications in patients taking ICIs are rare. CASE REPORT: A 58-year-old male who received chemotherapy consisting of pembrolizumab (PD-1 inhibitor) for esophagus squamous cell carcinoma one month before was admitted to the emergency room with shortness of breath soon after fiberoptic bronchoscopy, which was done for the inspection of the lower airway. A computed tomography of the chest revealed a progressive consolidation on the right upper lobe. Salmonella group D was isolated from the bronchoalveolar lavage (BAL) fluid culture. The fungal culture of the same clinical sample yielded Aspergillus niger; furthermore, a high titer (above the cut-off values) of Aspergillus antigen was found both in the BAL fluid and serum of the patient. Despite the effective spectrum and appropriate dose of antimicrobial treatment, the patient died due to disseminated intravascular coagulopathy. CONCLUSIONS: Awareness of unusual pathogens in the etiology of pneumonia after ICI treatment may help to avoid underdiagnosis.

Necrotizing pneumonia due to Aspergillus and Salmonella after immune checkpoint inhibitor treatment: An unusual case and review of the literature / Neumonía necrotizante por Aspergillus y Salmonella tras tratamiento con un inhibidor de puntos de control inmunitario: un caso inusual y revisión de la literatura

Background: Immune checkpoint inhibitors (ICIs) are a promising new treatment for different types of cancer. The infectious complications in patients taking ICIs are rare. Case report: A 58-year-old male who received chemotherapy consisting of pembrolizumab (PD-1 inhibitor) for esophagus squamous cell carcinoma one month before was admitted to the emergency room with shortness of breath soon after fiberoptic bronchoscopy, which was done for the inspection of the lower airway. A computed tomography of the chest revealed a progressive consolidation on the right upper lobe. Salmonella group D was isolated from the bronchoalveolar lavage (BAL) fluid culture. The fungal culture of the same clinical sample yielded Aspergillus niger; furthermore, a high titer (above the cut-off values) of Aspergillus antigen was found both in the BAL fluid and serum of the patient. Despite the effective spectrum and appropriate dose of antimicrobial treatment, the patient died due to disseminated intravascular coagulopathy. Conclusions: Awareness of unusual pathogens in the etiology of pneumonia after ICI treatment may help to avoid underdiagnosis.(AU)

Antecedentes: Los fármacos inhibidores de puntos de control inmunitario (ICI) son una nueva y prometedora opción de tratamiento para diferentes tipos de cáncer. Las complicaciones infecciosas en pacientes que toman ICI son poco frecuentes. Caso clínico: Un varón de 58 años que recibió quimioterapia con pembrolizumab (inhibidor de PD-1) para un carcinoma de células escamosas de esófago hacía un año, ingresó en Urgencias por dificultad respiratoria poco después de realizarse una broncoscopia de fibra óptica para una inspección de las vías aéreas inferiores. La tomografía computarizada de tórax reveló una consolidación progresiva en el lóbulo superior derecho. Se aisló Salmonella grupo D en el cultivo del líquido de lavado broncoalveolar (LBA). En el cultivo de hongos de la misma muestra creció Aspergillus niger; además, se detectó antígeno (por encima de los valores de corte) de Aspergillus tanto en la muestra del LBA como en el suero del paciente. A pesar del espectro eficaz y la dosis adecuada del antifúngico utilizado, el paciente falleció debido a una coagulopatía intravascular diseminada. Conclusiones: El conocimiento de patógenos inusuales en la etiología de la neumonía tras el tratamiento con ICI puede ayudar a evitar el infradiagnóstico.(AU)

NEDOCS: is it really useful for detecting emergency department overcrowding today?

The Emergency Department (ED) overcrowding is an ongoing problem all over the world. The scoring systems are available for the detection of this problem. This study aims to test the applicability of the National Emergency Department Overcrowding Study (NEDOCS) scoring system, one of the scoring systems that evaluate the ED overcrowding.In this prospective observational study, the survey was applied on on-duty doctors, nurses, paramedics, intern doctors, and ward persons working in a University Adult Emergency Department and agreed to participate in the study, between certain hours during the day and the NEDOCS score was calculated simultaneously. The demographic characteristics of the on-duty staff, overcrowding of ED, and the number of the on-duty staff members were recorded in the questionnaires.During the study, 153 measurements were performed, and 3221 questionnaires were filled. The NEDOCS mean score was determined as 101.59 and the most reached result was "extremely busy but not overcrowded" (32%). The ED was rated mostly as "busy" (33.7%) by the on-duty staff. A significant difference was found between ED overcrowding and NEDOCS score. There is a significant difference between ED overcrowding and on-duty emergency nurse and intern doctor count.The NEDOCS score is not suitable for evaluating ED overcrowding. Accurate determination of the ED overcrowding is very important to avoid the negative consequences of the ED overcrowding. Increasing emergency nurse and intern doctor count will decrease ED overcrowding. Also, there is an urgent need to constitute local hospitals and also public health policies to satisfy the increasingly ED's presentations.

The determinants of neurological phenotypes during acute hypertensive crises - a preliminary study.

Background and Purpose: Acute blood pressure elevations lead to wide spectrum of neurologic manifestations, ranging from no overt neurologic symptoms to catastrophic events like ICH. Little is known regarding the determinants of this clinical variability. We determined clinical and imaging features of hypertensive crisis patients with normal neurological examination, ICH and posterior reversible encephalopathy syndrome (PRES).Methods: Cranial MRI was performed in patients with hypertensive urgency or emergency but normal neurological examination. Their clinical characteristics, and imaging features regarding cerebral small vessel disease were compared to ICH and PRES patients.Results: Hypertensive ICH patients (n = 58) were older, less likely to have hyperlipidemia, less commonly used calcium channel blockers, and had higher burden of chronic cSVD features in comparison to hypertensive crisis patients with normal neurological findings (n = 51). Multivariate analyses revealed cSVD burden score (p = 0.003) to be related with ICH, while higher admission blood pressure levels (p < 0.001), hyperlipidemia (p = 0.006) and calcium channel blocker usage (p = 0.005) were more common in patients with normal neurological examination. The PRES (n = 9) group was comprised of younger patients with recent history of hypertension and low burden of cSVD.Conclusions: Hypertensive surge is associated with ICH when cSVD burden is high, probably caused by microvascular dysfunction secondary to long-standing hypertension, while the episode causes no structural damage if this burden is less. Although our observations are exploratory, short term but severe hypertension manifests with PRES possibly due to the absence of adaptive changes.

Evaluation of gunshot wounds in the emergency department.

BACKGROUND: This study aimed to evaluate injury patterns of patients admitted to the emergency department with gunshot wounds, results of imaging studies, treatment modalities, outcomes, mortality ratios, and complications. METHODS: A retrospective descriptive study was carried out including a total number of one hundred and forty-two patients admitted to Hacettepe University Emergency Department with gunshot injuries between January 1, 1999 and December 31, 2013. The Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Injury Severity Score (ISS), and the Trauma and Injury Severity Score (TRISS) probability of survival for penetrating trauma were calculated for all patients. RESULTS: Among the one hundred and forty-two patients in the study, one hundred and twenty-eight (90.1%) were male. Mean age was 36 years. On admission, the average GCS score was 13, mean RTS was 6.64, median ISS was 5 and median TRISS probability for survival was 99.4% for penetrating trauma. Fluid was detected in three (13%) patients in FAST, whereas intra-abdominal solid organ injury and bowel injury were detected in 11 (58%) patients in abdominal CT. The pneumothorax, hemothorax and lung injuries were detected in 10 (40%) patients, whereas hemothorax was detected only in one patient with thoracic injury by chest X-ray. Twenty four (16.9%) patients died; eighteen patients (75%) had isolated severe intracranial injuries, two (8.3%) had thoracic injuries with head and neck injuries, and four (16.7%) patients had intra-abdominal organ injuries (one with concomitant head injury). Ten patients were brought to the ED in cardiopulmonary arrest. In dead patients, GCS, RTS and TRISS were significantly lower, and ISS were significantly higher than in surviving patients. Twenty three (95.8%) patients were in critical injury level (ISS 25-75, actually ISS >50) in the exitus group. CONCLUSION: Mortality rates in gunshot wound patients with cranial injuries are very high. Spontaneous return is not seen in patients brought to the ED in arrest state. Bullets can cause internal organ injuries which can be greater than expected. In thoracoabdominal gunshot wound injuries, conventional X-ray and bedside FAST can be ineffective in detecting the whole extent of intrathoracic and intra-abdominal injuries. Thus, thoracic and abdominal CT should be planned early for hemodynamically stable patients in order to eliminate causes of fatality and make a timely and correct diagnosis. ISS, RTS and GCS are useful in predicting prognosis and mortality. Especially in patients with ISS scores >50, the mortality rate can be as high as 96%.

Emergency admissions due to swallowed foreign bodies in adults.

AIM: To study a retrospective analysis of patients who presented to the emergency departments (ED) with complaints related to foreign body ingestions. METHODS: Patients older than 16 years of age who presented to the ED between January 1(st) and December 31(st) of 2010 with complaints related to swallowed foreign bodies were identified from electronic health records and patient charts. RESULTS: A total of 100 patients presented with a complaint of foreign body ingestion during the study period. Overall, an X-ray was performed on 75 patients, and a fiberoptic evaluation was performed on 45 patients. A foreign body was detected in 46 (46%) patients. The diagnostic yield of the X-ray was 27 (36%) out of 75 patients, while the diagnostic yield of the fiberoptic evaluations was 21 (47%) out of 45 patients. The detected foreign bodies were mostly located in the esophagus (17 out of 46 foreign bodies detected). When the types of ingested foreign bodies were evaluated, 52 (52%) patients reported ingesting food, and 19 (19%) patients reported swallowing pins. An X-ray was performed on 33 patients with accidental food ingestions but yielded a positive result in only two cases. In 12 out of 21 patients with accidental food ingestion who underwent fiberoptic evaluation, the foreign material was detected and removed. CONCLUSION: Plain radiography is helpful in the localization of radiopaque swollen foreign bodies, while fiberoptic methods are useful as both diagnostic and therapeutic tools, regardless of radiopacity.

A model of complaint based for overcrowding emergency department: Five-Level Hacettepe Emergency Triage System.

BACKGROUND: To compare ESI Five-Level Triage System with 5-Level Hacettepe Emergency Triage System (HETS), which was developed for Overcrowded EDs in our country. METHODS: Over a period of six days, patients were assessed by a different ED staff everyday using HETS, then re-evaluated blindly by an emergency physician using HETS. Then patients were evaluated blindly for a third time by an independent, ESI-using emergency physician. RESULTS: Of the patients in the study, 133 were men, 175 were women and the average age was 44.41±18.033. Inter-rater agreement was 97.40% (Kappa=0.963) between HETS and HETS-Blind, 74.35% (Kappa=0.646) between HETS and ESI-Blind, 74.67% (Kappa=0.652) between HETS-Blind and ESI-Blind. Inter-observer agreement between the second emergency physician performing HETS-Blind and the first emergency physician, resident, or nurse was very good (Kappa=1.0). Intern doctor, non-medical secretary and paramedic were found to have almost very good agreement (Kappa=0.971; 0.935; 0.864, respectively). An overtriage of 7.25% and undertriage of 1.08% were found in HETS. CONCLUSION: Complaint-based HEST developed for overcrowded Eds is a triage system with a very good agreement between observations and observers. Low undertriage and overtriage ratios, and easy application by all staff from a non-medical secretary to the emergency physician.

Cardiac monitoring in patients with electrocution injury.

BACKGROUND: The necessity of admitting patients exposed to electrocution injuries for monitoring and observation in the emergency department (ED) remains controversial. METHODS: We evaluated the medical records of 102 patients (86 male, 16 female; median age 29.5; range 18 to 68 years) admitted to the adult ED with electrocution injuries over the past 20 years. RESULTS: Only 9 deaths were reported: 3 as a result of contact with low-voltage electricity and 6 after contact with high-voltage electricity. With the exception of a case of sepsis, all deaths were related to early rhythm abnormalities immediately following the incident. The ECG findings of surviving patients in the study group were as follows: 70 normal, 8 sinus tachycardia, 3 sinus bradycardia, 4 ST-T wave changes, and 1 ventricular extrasystole. ECG recordings of 7 patients could not be found. 72 cases had been followed up with repeat ECG recordings. There were no observed ECG changes requiring any medical or electrical therapies in the surviving patients. CONCLUSION: Cardiac rhythm abnormalities related to electrocution injuries are usually observed at the time of the incident. If the patient's overall clinical condition is good and they have a normal ECG at the time of admission to the ED, the probability of observing any delayed serious dysrhythmia is unlikely.