Challenges in COVID-19 diagnosis.

OBJECTIVE: In this narrative review, our aim was to clarify the roles of diagnostic methods used in COVID-19 disease. BACKGROUND: Coronavirus disease 2019 (COVID-19) caused by coronavirusis emerged as the major healthcare challenge globally. The mainstay approach to limit this virus spread is an early and accurate diagnosis of the viral infection and appropriate quarantine of patients with coronavirus infection. RESULTS: Real time polymerase chain reaction (PCR) offers a quick detection of the disease in either symptomatic or asymptomatic patients. In literature, there are numerous studies that underline the importance of CT as the first-step diagnostic tool in COVID-19 diagnosis. Even in asymptomatic patients, COVID-19 pneumonia may manifest with chest CT imaging abnormalities. CONCLUSION: There is a need for an algorithm, which involves a combination of PCR and CT in diagnosis of COVID-19 (Ref. 85).

The relationship between neutrophil/lymphocyte, monocyte/ /lymphocyte, platelet/lymphocyte ratios and clinical outcomes after ninety days in patients who were diagnosed as having acute ischemic stroke in the emergency room and underwent a mechanical thro.

AIM: To determine whether there was a relationship between the neutrophil/lymphocyte (NLR), monocyte//lymphocyte (MLR), and the platelet/lymphocyte ratios (PLR) measured in blood samples taken at admission and clinical outcomes (CO) on the 90th day in patients, who were diagnosed as acute ischemic stroke (AIS) in the emergency department (ED) and underwent a mechanical thrombectomy (MT). METHOD: Patients aged ≥ 18 years, who were diagnosed as AIS in the ED and underwent MT were included in the study. Patients, who received diagnostic codes of "Cerebrovascular Diseases" (CVD) according to the ICD-10 diagnostic codes were identified. One hundred fifty patients were enrolled in the study. Modified Rankin Scale (mRS) score was used to determine neurologic status on the 90th day. The patients were divided into the two groups: good and poor CO (mRS 0-2 and mRS 3-6, respectively). The groups were compared in terms of age, sex, and NIHSS, ASPECT, and mRS scores. RESULTS: The rates of successful recanalization and good CO were 81.3 % and 38.7 %, respectively. The mortality rate was 22 %. The recanalization rates in the good and poor CO groups were 100 % and 69.6 %,respectively. Recanalization was achieved in 73.6 % of those with hyperlipidaemia and 88.5 % of those without hyperlipidaemia, which was statistically significant (p = 0.034). We observed a statistically significant relationship between the clinical outcome and NLR, MLR, PLR (p < 0.05). As the result of multivariate analysis, we found only NLR as an independent risk factor for poor CO (p = 0.043). There was also a statistically significant difference between mortality and NLR, PLR (p = 0.001). CONCLUSION: We found that NLR, MLR, PLR values were associated with CO after 90 days; high rates were associated with poor CO and low rates were associated with good CO (Tab. 7, Ref. 38). Text in PDF www.elis.sk Keywords: acute ischemic stroke; neutrophil/lymphocyte ratio, monocyte/lymphocyte ratio; platelet/ /lymphocyte ratio; thrombectomy.

Comparison of pentraxin-3 and ischemia-modified albumin with troponin in early diagnosis of acute coronary syndrome.

INTRODUCTION: In this study, our aim was to evaluate clinical utilities of Pentraxin 3 (PTX3) and Ischemia-modified Albumin (IMA) in diagnosis of acute coronary syndrome (ACS) and compare these two biomarkers with a conventional diagnostic marker, cardiac troponin I (cTnI). MATERIALS AND METHODS: Sixty adult patients with ACS diagnosis were involved into this prospective study. Additionally, 20 healthy subjects were determined as control group (Group IV). Patients were divided into 3 groups as follows: Patients with Acute Myocardial Infarction (STEMI Group, n=20, Group I), patients without ST elevation but with elevated cTnI levels (NSTEMI Group, n=20, Group II), and patients with unstable angina pectoris (USAP Group, n=20, Group III). Blood measurements were obtained for each marker at admission and in the 4th hour. RESULTS: Troponin level was significantly different between groups I and II at both admission and in the 4th hour. Additionally, PTX 3 level was significantly different at admission and 4th hour between groups II and III. CONCLUSION: This study revealed that cTnI is the most sensitive test in ACS diagnosis at the admission to Emergency Department. Our results also revealed that PTX 3 may be a useful diagnostic tool for ACS at admission, however, IMA alone cannot be used for diagnosis of ACS. Similarly, in the 4th hour, cTnI was found to be the most useful marker in ACS diagnosis, however, PTX 3 and IMA were found to be inadequate for diagnosis of ACS (Tab. 3, Ref. 19).

Predictors of Crimean-Congo hemorrhagic fever in the Emergency Department.

OBJECTIVE: Crimean-Congo hemorrhagic fever (CCHF) is an acute illness affecting multiple organ systems characterized by thrombocytopenia, and/or leukopenia, elevated levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH) and creatine kinase (CK) and it has a case-fatality of 8% to 80%. In this article, we aimed to determine the clinical and laboratory findings that predicts the disease on admission. PATIENTS AND METHODS: We retrospectively analyzed the medical data of the patients admitted to our emergency department (ED) due to tick bite. These patients were divided into two groups according to their transcriptase-polymerase chain reaction (RT-PCR) test results. Findings of PCR (+) (Group 1) and PCR (-) (Group 2) patients were compared. RESULTS: Epistaxis was found to be statistically significant clinical finding in Group 1. Also, while aspartate transaminase (AST) levels and potassium (K) level were significantly higher, platelet count and white blood count (WBC) were significantly lower in Group 1 when compared to Group 2. CONCLUSIONS: Predictors of CCHF in the ED are epistaxis, leukopenia, thrombocytopenia and elevated K and AST levels. In our study, the fatality rate of CCHF was found to be 21.6%.

Copeptin: a diagnostic factor for critical patients.

Copeptin is important in determining the prognosis of the disease, assigning mortality, setting treatment modalities and increasing the patients' chances for survival in life threatening conditions. Any stress factor activating the hypothalamic-pituitary-adrenal (HPA) axis causes an increase in arginine vasopressin (AVP) plasma concentrations also known as antidiuretic hormone (ADH). Copeptin is derived from preprovasopressin along with neurophysin II and AVP. Copeptin is released in an equimolar ratio to AVP. Various studies have shown copeptin to be an independent indicator in determining the prognosis of the disease and assigning mortality. The purpose of this review article was to analyze the advantages of copeptin in patients with life threatening illnesses by reviewing medical data bases.

Outcomes of cardiopulmonary resuscitation in trauma patients in the Emergency Department.

OBJECTIVE: We aimed to determine our performance and factors effecting outcomes in cardiopulmonary resuscitation (CPR) for the patients with trauma in the Emergency Department (ED). PATIENTS AND METHODS:   In a period of 5 years, file data of 136 consequtive adult trauma patients who have required CPR in our ED were collected, retrospectively. Patients were divided into subgroups according to years, mechanism of trauma, hour of the trauma, location of cardiac arrest, the period of the CPR, the rhythm during the onset of arrest, atropine use and ED specialist accompaniment. Patients were also divided into two subgroups as those who died in the ED and those who survived. RESULTS: The leading cause of trauma was motor vehicle accidents. The period between arrest and CPR was 0-5 minutes in 92 patients. Of these 92 patients 12 have survived and as the time prolonges, number of survivors tended to decrease. The most common rhythm determined shortly before cardiac arrest was asystole. When all patients with trauma requiring CPR were considered, overall rate of survival was found to be 9.5%. When an ED specialist accompanied, survival rate increased. According to the rates of survival, atropine was found to be useless. CONCLUSIONS: Our results revealed that, when performed in the leadership of an ED specialist, more successful outcomes may be obtained in CPR in trauma patients. We also determined that use of atropine does not contribute to survival rate. As CPR prolonges, the success rate falls.

The role of serum cholinesterase activity and S100B protein in the evaluation of organophosphate poisoning.

The aim of this study was to investigate the role of serum cholinesterase (SChE) activity and S100B protein in the evaluation of patients with acute organophosphate (OP) poisoning. Patients with acute OP poisoning admitted to the emergency department were included in this cross-sectional study. Twenty healthy volunteers served as controls. The SChE activity and serum S100B were determined on admission. Patients were divided into two groups (low severity and high severity). Thirty-six patients diagnosed with acute OP poisoning were enrolled. Serum S100B concentrations were higher in patients than in the control group (p < 0.05). In the high-severity group, the SChE levels were lower and the S100Bs levels were higher than in the low-severity group. The SChE level was not different between survivors and nonsurvivors. S100B levels were higher in nonsurvivors than in survivors. According to receiver-operating characteristic curve analysis, the optimal cutoff value of serum S100B level to predict mortality was 236.5 pg/mL, with 71.4% sensitivity and 89.7% specificity. Our data suggest that initial SChE level is related to the clinical severity but not with mortality. S100B may be a useful marker in the assessment of clinical severity and prediction of mortality in acute OP poisoning.

B-type natriuretic peptide as an indicator of right ventricular dysfunction in acute pulmonary embolism.

OBJECTIVE: B-type natriuretic peptide (BNP) is a neurohormone secreted from cardiac ventricles in response to ventricular strain. The aim of present study was to evaluate the role of BNP in the diagnosis of the right ventricular (RV) dysfunction in acute pulmonary embolism (PE). METHODS: BNP levels were measured in patients with acute PE as diagnosed by high probability lung scan or positive spiral computed tomography. All patients underwent standard echocardiography and blood tests during the second hour of the diagnosis. RESULTS: Forty patients diagnosed as acute PE (mean age, 60.4 +/- 13.2 years; 62.5% women) were enrolled in this study. Patients with RV dysfunction had significantly higher BNP levels than patients without RV dysfunction (426 +/- 299.42 pg/ml vs. 39.09 +/- 25.22 pg/ml, p < 0.001). BNP-discriminated patients with or without RV dysfunction (area under the receiver operating characteristic curve, 0.943; 95% CI, 0.863-1.022). BNP > 90 pg/ml was associated with a risk ratio of 165 (95% CI, 13.7-1987.2) for the diagnosis of RV dysfunction. There was a significant correlation between RV end-diastolic diameter and BNP (r = 0.89, p < 0.001). Sixteen patients (40%) were diagnosed as having low-risk PE, 19 patients (47.5%) with submassive PE and five patients (12.5%) with massive PE. The mean BNP was 39.09 +/- 25.2, 378.4 +/- 288.4 and 609.2 +/- 279.2 pg/ml in each group respectively. CONCLUSION: Measurement of BNP levels may be a useful approach in diagnosis of RV dysfunction in patients with acute PE. The possibility of RV dysfunction in patients with plasma BNP levels > 90 pg/ml should be strongly considered.

A new minimally invasive experimental spinal cord injury model in rabbits.

The aim of this experimental study was to evaluate the effectivity of epidural microballoon inflation into the unroofed spinal column for the creation of a new experimental spinal cord injury model in rabbits. 10 New Zealand white rabbits were used for this study. Before operation and after anasthesia with 50 mg/kg ketamine and 8 mg/kg xylazine, spinal evoked potentials (SEP) were recorded in all rabbits. A midline skin incision was done on the lomber skin at the level of L1-L4. Paravertebral muscles were dissected bilaterally. A microhemilaminotomy was done in the right L3 lamina close to the midline by using Midas-rex micro-diamond drill instruments. The ligamentum flavum was opened and removed with microscissors. A microballoon was inserted into the spinal column between the bone and dura mater to the level of T12. The microballoon was inflated by using a pressure- and volume-controlled microballoon inflation device. Pre-injury and post-injury SEPs were recorded. The microballoon was deflated 15 minutes later and removed completely from the epidural space. 24 hours later the SEP study was repeated. Following microballoon inflation the SEP waves dropped to the basal level. All rabbits were paraplegic after the operation. In conclusion, this experimental study demonstrated that the microballoon inflation technique is a very successful method for the evaluation of spinal cord injury in rabbits. Unroofing of the spinal column is extremely important because decompression may be an effective treatment in spinal cord injury. Also the traumatic effect of aneurysm clips represents a different type of injury to the spinal cord. This new model may be used in experimental studies of spinal cord injury in rabbits.

Is there a relationship between the blood cholinesterase and QTc interval in the patients with acute organophosphate poisoning?

Organophosphates cause poisoning as a result of the excessive accumulation of acetylcholine at the cholinergic synapses due to inhibition of acetylcholinesterase (ChE). In the literature, it has been reported that there have been electrocardiographic abnormalities, including QT-interval prolongation in most patients with acute organophosphate poisoning (OPP), and a relation between blood ChE level and clinical severity in acute OPP. The aim of this study is to assess the relationship between blood ChE level and QTc interval in the patients with acute OPP. This retrospective study consists of 20 patients admitted to the emergency intensive care unit. A total of 93 QTc interval and blood ChE measures obtained on the same day from 20 cases were compared for their correlation. There were prolonged QTc intervals in 35.4% of the ECGs. There was a negative correlation between QTc interval and blood ChE measures. In following up the patients with acute OPP, QTc interval may be useful when blood ChE levels are low and may provide complementary information concerning the severity of poisoning. However, further prospective studies, supporting the present results, are needed.

Characteristics of endosulfan poisoning: a study of 23 cases.

INTRODUCTION: Organochloride insecticides are chlorinated cyclic hydrocarbons having molecular weights in the range of 300-550 Da. Case series of endosulfan poisoning are extremely rare in the literature. We report 23 cases of endosulfan poisoning. METHODS: This retrospective study enrolled patients with endosulfan poisoning presenting to our emergency department from January to December 2005. The data were collected from clinical records and laboratory files. RESULTS: On admission, initial symptoms were nausea and vomiting in 17 patients (73.9 percent), seizures in five patients (21.7 percent), and dizziness in one patient (4.3 percent). Symptoms began within one hour after ingestion in 12 patients (52.2 percent), in the second hour in nine patients (39.1 percent), and in the third hour in two patients (8.7 percent). Seizure types were generalised tonic-clonic in 16 patients (84.2 percent), and focal seizures in three patients (15.8 percent). 19 patients were observed for one day, two patients were observed for two days, and one patient was followed-up for ten days in the emergency department. One patient was transferred for liver transplantation on the fifth day to another centre. All patients were treated symptomatically by intravenous diazepam for controlling seizures. CONCLUSION: Endosulfan poisoning can be suspected in the presence of primary central nervous system manifestations including seizures, with or without clinical or laboratory evidence of other organ dysfunction such as liver failure.

Acute aortic dissection provoked by sneeze: a case report.

The response of the abdominal viscera and the contraction of the intercostal muscles during the respiratory phase of sneezing increases intrathoracic pressure, which may lead to several complications. However, there are no reports in the literature concerning aortic dissection after sneezing. We report a patient in whom the development of dissection was secondary to sneezing, although hypertension was present as a risk factor, and we discuss the relationship between sneezing and aortic dissection. To our knowledge, this is the first report of aortic dissection provoked by sneezing in the literature.

Electrocardiographic changes during migraine attacks.

OBJECTIVES: To clarify whether electrocardiographic (ECG) changes can be identified during a migraine attack and to determine whether there are ECG differences between periods with and without headache. BACKGROUND: The clinical signs and symptoms of migraine point to involvement of the autonomic nervous system, and especially to disrupted regulation of the circulatory system and autonomic balance. This disruption may be more marked during a migraine attack. During a migraine attack, autonomic imbalance within the heart and its vessels conceivably may result in ECG abnormalities. METHODS: In 30 patients with migraine, the ECG variables of heart rate, abnormalities of rhythm, PR interval, QRS duration, corrected QT interval, T inversion, and ST-segment changes were recorded during migraine attacks and pain-free periods. RESULTS: Of the 30 patients studied during a migraine attack, 9 (30%) had one or more abnormalities of rhythm (including sinus arrhythmia, atrial premature contraction, and ventricular premature contraction), 20% had PR intervals greater than 0.20 seconds, 40% had corrected QT intervals greater than 0.44 seconds, 66% had T inversion, and 40% had ST-segment abnormalities. No patient had arrhythmia, PR intervals greater than 0.20 seconds, or corrected QT intervals greater than 0.44 seconds during a pain-free period. No differences were noted for ST-segment changes, T inversion, and total ECG changes between periods with and without headache, but both PR and corrected QT intervals were significantly longer during migraine attacks than during pain-free periods. CONCLUSIONS: We conclude that ECG abnormalities often are present during a migraine attack, and for most of these, particularly PR and corrected QT interval lengthening, these abnormalities will be absent or less prominent during pain-free intervals.