Pulse deficit in atrial fibrillation - a different perspective on rhythm or rate control strategy.

BACKGROUND: Pulse deficit (PD) is a frequently unused but crucial clinical finding in atrial fibrillation (AF) diagnosis. AIMS: We aimed to investigate the relationship between PD and exercise intolerance in AF patients to remodel the treatment in case of a favorable outcome. METHODS: This prospective study was conducted with 273 permanent AF patients between September 2019 and October 2020. An exercise stress test stratified by age and sex-matched was performed to determine exercise intolerance, and the patients were divided into 2 groups based on physical capacity: low (<75 percentile as Group 1) (n = 160; 58.6%) and adequate (≥75 percentile as Group2) (n = 113; 41.4%). RESULTS: The mean (standard deviation [SD]) PD of exercise intolerance patients was significantly higher than patients with adequate exercise capacity (17 [4] vs. 12 [2]; P <0.001). Moreover, PD was independently associated with exercise intolerance after adjusting for potential covariates (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.51-0.69; P <0.001). In both univariate and multivariable analyses, higher heart rates had a stronger relationship with exercise intolerance (mean [SD], 107 [11] vs. 99 [10]; P <0.001; OR, 0.92; 95% CI, 0.89-0.96; P <0.001). Also, there was a positive correlation between heart rate and PD (r = 0.431; P <0.001). CONCLUSIONS: Increased PD was associated with decreased exercise capacity in persistent AF patients. Rhythm control strategy should be considered to increase left ventricular filling pressures in AF patients with high PD and exercise intolerance.

A 4-Year Retrospective Analysis of Patients Presenting at the Emergency Department With Synthetic Cannabinoid Intoxication in Turkey.

PURPOSE/BACKGROUND: The number of patients with acute synthetic cannabinoid intoxication (SCI) has increased in recent years although the prohibition of its legal sale and use in Turkey despite other countries allowing to some extent sale and use. The reported clinical findings of acute SCI are similar to the symptoms of several diseases. The first case of acute SCI seen in our hospital was in 2014. The aim of this study was to share the data of synthetic cannabinoid use in a research hospital in Turkey and to contribute the epidemiologic data globally betwen 2014 and 2017. METHODS/PROCEDURES: A retrospective evaluation was made of patients who presented at emergency department (ED) because of SCI between January 2014 and December 2017. The initial diagnosis of the patients was done either via their self-report or clinician's clinical observation (family history with hallucination, lethargy, convulsions, dizziness, etc.). Totally, 352 patients were included to the study whose cannabioid use was proven with their urine drug analysis. FINDINGS/RESULTS: Men were predominantly high (93.8%). Nearly all patients (93.5%) were followed up and discharged in 24 hours. Among them, 21 (5.9%) patients were admitted for hospitalization, and mortality was seen in 2 (0.6%). The mean number of previous presentations at ED with a similar diagnosis was 8.6 ± 10.31. IMPLICATIONS/CONCLUSIONS: Great care must be taken in respect of complications related to SCI, which can even result in death. Patients have a tendency to not disclose the substance they have taken because it is illegal. Patients presenting at ED with recurrent symptoms must be referred to relevant legal authorities. For patients presenting with different clinical effects, SCI must be considered.

A novel hemostatic scaffold material and the importance of scaffold formation on ending hemorrhage: An experimental rat study.

BACKGROUND: Different pharmacological agents are developed to control bleeding. However, it is critical for these agents to induce thrombin formation and have an effect on vasoconstriction, coagulation, and scaffold. In this study, we aimed to demonstrate the agents' ability to stop bleeding properties on minor and major open bleedings after skin clefts, extracorporal injuries, traumatic cuts, spontaneous or surgical intervention besides scaffold properties. For this purpose, a new and authentic hemostatic agent, processed diatomite (PD) and the most preferred chitosan in the medical area were used to test blood stopping and scaffold effects in a rat femoral bleeding model. The samples were examined by scanning electron microscopy (SEM), and the results on blood stopping were shared. METHODS: The current experimental study was conducted on rats. The effects of hemostatic agents on our femoral bleeding model were determined. In this study, 22 male Wistar albino rats weighing 158-215 g, were used. The rats were assigned randomly to three groups: control group (n=6), chitosan group (n=8), and PD group (n=8). Bleeding time, scaffold formation, weight differences, histopathological effect and scanning electron microscope (SEM) analyses were performed. RESULTS: In our experimental model, weight loss was 5.0±1.3 g for the control group, 2.9±1.1 g for the chitosan group, and 2.7±1.0 g for the PD group, respectively. When weighed before and after the experiment, there was a significant change in weights of rats in chitosan, and PD groups regarding scaffold formation: it was complete for six rats (75%) and weak for two (25%) rats in chitosan group; however, it was complete for seven rats (87.5%) and weak for one (12.5%) rat in the PD group. Scaffold formation was significant for the chitosan and PD groups versus the control group (p=0.002). CONCLUSION: In our study, the scaffold formed by PD exerts appropriate porousness and contributes to fibrin formation and prevent re-bleeding. PD had a strong and significant scaffold effect. The effectiveness of PD to stop bleeding was equal to chitosan. Besides being natural, hemostatic agents should not induce cellular damage. We histopathologically demonstrated that PD was harmless for the natural structure of cells and vessels in the femoral site.

Physical abuse of the elderly: a 4-year retrospective evaluation in the emergency department.

AIM: Elderly physical abuse (EPA) is defined as injury or assault to or the restriction of an elderly person. Although EPA is an important social problem, its diagnosis is difficult because of tendency to cover up the event. In this study, patients aged 65 years and over who presented at the emergency department (ED) for forensic reasons and in whom physical abuse was suspected were examined. The aim of this study was to raise ED awareness of EPA and thereby to contribute to treatment plans for these patients in the ED. METHODS: The study was conducted over a 4-year period between January 2013 and January 2017. Patients were selected retrospectively from the hospital information system according to the following criteria: (i) admission to ED with trauma; (ii) aged 65 and older; and (iii) evaluated as having forensic trauma by an ED specialist based on either the patient's history or the specialist's observations and suspicions. RESULTS: The patients included 80 men (69%) and 36 women (31%), with a mean age of 73.92 ± 7.08 years. The length of ED stay was 0-1 h in 27.6% of patients and 1-6 h in 46.6%. When the causes of physical trauma were examined, general assault was seen as the most prevalent, occurring in nearly 63% of the patients. CONCLUSIONS: There may be three conclusions for the current study: First, although EPA is a rare problem for patients referred to emergency services, health professionals should be suspicious when examining patients 65 years or older because of the difficulties of diagnosing EPA. Second, in patients with no history of suspicious trauma or suspicious radiological imaging results, EPA is also common. Third, because of the undetected EPA mechanism, patients should be examined forensically in suspicious cases and deaths.

Methemoglobinemia treated with hyperbaric oxygen therapy: A case report.

Methemoglobinemia is a rare but clinically important condition that should be considered among differential diagnosis' in cyanosis. The conventional treatments of methemoglobinemia are high flow oxygen and methylene blue therapies. We present a 52-year-old male patient who admitted to emergency room with severe cyanosis and dyspnea after he was exposed to paint thinner and zinc phosphate solution. The patient was diagnosed with methemoglobinemia with a MetHb level of 49.1mm/Hg in his arterial blood gas test. Patient's symptoms and increased MetHb levels were resistant to high flow oxygen and methylene blue therapies so hyperbaric oxygen therapy (HBO) as an alternative treatment was initiated and the patient was cured promptly. In this case presentation, we aim to discuss the alternative treatment modalities in methemoglobinemia patients with persistent hypoxia and cyanosis, who are unresponsive to standard methylene blue treatment.

Serum and Tissue HIF-2 Alpha Expression in CIN, N-Acetyl Cysteine, and Sildenafil-Treated Rat Models: An Experimental Study.

Background and Objectives: Contrast-induced nephropathy (CIN), is acute renal damage due to contrast agents. This study is conducted to evaluate serum and renal heterodimeric nuclear transcription factor (HIF)-2 alpha levels and its tissue expression in contrast-induced nephropathy, and in N-acetyl cysteine (NAC)-and Sildenafil-treated rat models. Materials/Methods: This randomized, controlled, interventional animal study was conducted on Wistar rats. Rats (n = 36) were randomly assigned to four groups: control (n = 9), CIN group (n = 9), CIN + NAC group (n = 9), and sildenafil (n = 9). The rat model was used to form iohexol-originated CIN. During the modeling, prophylactic treatment was performed at the 24th and 48th h. After 48 h of modeling, blood, urine, and tissue samples were obtained for biochemical analyses. HIF-2-α levels were measured in renal tissue, serum, and urine samples. Renal sections were also performed for histopathologic and immunohistochemical evaluations of renal injury and HIF-2-α expression. Results: In the CIN model, HIF-2α levels and other biochemical parameters were significantly increased (p < 0.01). Both sildenafil and NAC efficiently decreased renal damage due to contrast agents, as shown in histopathologic examinations (p < 0.05). Similarly, after treatment with sildenafil and NAC, HIF-2α levels were significantly decreased (p < 0.05). Conclusions: The current study shows that serum and tissue HIF-2α levels decrease in CIN. Besides, the levels and tissue expression of HIF-2α decrease with both NAC and sildenafil treatments. With further studies, HIF-2α can be investigated as a biomarker of CIN and can be used in the follow-up of patients with CIN.

The Chameleon-Like Properties of Psychoactive Drugs: Examinations with HR LC-MS/MS Technology of Patients Presenting at the Emergency Department Following the Use of Synthetic Cannabinoids: A Case Series and Literature Review.

The chameleon can disguise itself in nature by taking on different colors and forms. As synthetic cannabinoids (SC) have clinically similar effects to those of several psychoactive agents, they are one of the most difficult intoxications to diagnose. The reasons for this are due to clinical variations throughout the world and the differences in symptoms having not been determined due to their similarity to the intoxication of several other drugs. The aim of this study was to obtain prospective data of patients presenting at the Emergency Department (ED) with suspected SC intoxication, and as a result of prospective examination of samples, to determine a new generation of SC use, SC types, clinical findings, and treatments. Method: A total of a 15 patients with suspected SC intoxication who presented at the ED of the Health Sciences University Kayseri Training and Research Hospital between January 2017 and January 2018 were examined. Samples taken prospectively from patients who were followed-up for a diagnosis of SC intoxication were examined with the HR LC-MS/MS method; SC were determined, and the test results of other psychoactive agents that were used concurrently were examined. Conclusions: Three significant findings emerged as a result of this study. Firstly, due to the different clinical forms of presentation at ED associated with SC use and the range of intoxications that cannot be diagnosed, advanced laboratory tests are required, in addition to routine tests for the determination of SC. Secondly, those diagnosed as having taken SC were also determined to have used it concurrently with substances that have a high potential for addiction, such as amphetamines and quetiapine. Thirdly, in regard to examples of cases presented in the literature, anti-psychotics, fluid hydration, and anxiolytics can be used as treatment options for those diagnosed with SC use.