Archives of Academic Emergency Medicine最新文献

Introduction: Hyperammonemia and hepatotoxicity are well-known complications of valproic acid (VPA) poisoning. The objective of this study is to evaluate the potential role of carnitine in mitigating the adverse effects of acute VPA toxicity in mice.

Methods: 54 male mice (25-30 g) were randomly assigned to one of three categories, including acute, sub-acute, and chronic poisoning. Each category contained 3 groups, each consisting of 6 mice (Group 1: control, Group 2: VPA treated, and Group 3: VPA + carnitine treated). The animals were sacrificed 24 hours after the initial injection, and their blood, liver, and brain samples were compared between groups of each category regarding liver function biomarkers, oxidative stress markers, ammonia level, and liver histopathologic changes using one-way ANOVA followed by Tukey's multiple comparison test.

Results: The administration of VPA increased the serum level of aspartate aminotransferase (AST) (p=0.003) and alanine aminotransferase (ALT) (p=0.001), as well as serum, and brain level of ammonia (p=0.0001 for both) in the intervention group. Elevated levels of lipid peroxidation and oxidative stress (p=0.0001 for both) in the liver tissue, decreased liver glutathione (p=0.0001) and ferric ion-reducing antioxidant power (FRAP) (p=0.0001), and histopathologic changes in the form of moderate to severe inflammation were observed. Administration of VPA + carnitine reduced AST (p=0.05) and ALT (p=0.01), increased the FRAP, reduced free oxygen radicals and liver lipid peroxidation (p=0.0001 for all), and decreased tissue damage in the form of moderate inflammation. The administration of carnitine was ineffective in reducing brain or plasma ammonia levels in acute VPA-treated animals (p = 0.0115).

Conclusions: Although the administration of carnitine has been suggested as a protective remedy in cases of VPA toxicity, according to the present study, it did not have an antidotal effect and did not prevent encephalopathy or liver injury in acute VPA toxicity.

Introduction: The specific impact on calcium dynamics after non-massive blood transfusions remains relatively unexplored. This study aimed to compare pre- and post-transfusion calcium levels in patients receiving blood and blood product in the emergency department.

Methods: This is a single-center, prospective, cross-sectional study conducted at the Emergency Department of Gazi University Health Research and Application Center Hospital in Ankara, Turkey, from January 1, 2020, to August 31, 2020. The study included adult patients who underwent blood and blood product transfusions, and serum calcium levels were measured and compared from samples taken before and after transfusion.

Results: A total of 292 participants were enrolled in the study, with 242 participants included in the final analysis. The mean total calcium level was 8.41 ± 0.76 mg/dL before transfusion and 8.34 ± 0.71 mg/dL after transfusion (p=0.012). When examining the corrected calcium values after receiving blood products based on the type of blood products, participants who received apheresis platelets had a post-transfusion corrected calcium value of 8.26 ±0.41 mg/dL, with a pre-transfusion value of 9.09 ±0.49 mg/dL (p<0.01). The post-transfusion ionized calcium value for participants receiving apheresis was 1.04 ±0.08 mg/dL, compared to 1.15 ±0.09 mg/dL for those who did not receive apheresis (p=0.049). There was a significant relationship between receiving fresh frozen plasma and post-transfusion ionized calcium values (p=0.024).

Conclusion: This study demonstrated that transfusion-associated hypocalcemia can occur even at mild levels in patients receiving blood and blood product transfusions in the emergency department. However, it is suggested that the clinical effects of hypocalcemia, even when occurring based on the type and quantity of blood products, are minimal and negligible.

Introduction: Previous studies have reported numerous clinico-pathologic risk factors associated with increased risk of leaked repair following omental patch for perforated peptic ulcer disease (PPUD). This study aimed to analyze the risk factors associated with leaked repair of omental patch and document the management and outcome of established cases of leaked repair in a resource-poor setting.

Methods: This is a multicenter cross-sectional study of leaked repair after omental patch of PPUD between January 2016 to December 2022. Following primary repair of PPUD with omental pedicle reinforcement, associated factors of leaked repair were evaluated using univariate and multivariate analyses.

Results: Overall, 360 cases were evaluated (62.8% male). Leaked repair rate was 11.7% (42 cases). Those without immunosuppression were 3 times less likely to have leaked repair (aOR= 0.34; 95% CI: 0.16 - 0.72; p = 0.003) while those with sepsis were 4 times more likely to have leaked repair (aOR=4.16; 95% CI: 1.06 - 12.36; p = 0.018). Patients with delayed presentation (>48 hours) were 2.5 times more likely to have leaked repair than those who presented in 0 - 24 hours (aOR=2.51; 95% CI: 3.62 - 10.57; p = 0.044). Those with Perforation diameter 2.1-3.0 cm were 8 times (aOR=7.98; 95% CI: 2.63-24.21; p<0.0001), and those with perforation diameter > 3.0cm were 33 times (aOR=33.04; 95% CI: 10.98-100.25; p<0.0001) more likely to have leaked repair than those with perforation diameter of 0-1.0 cm. Similarly, in those with no perioperative shock, leaked repair was 4 times less likely to develop than those with perioperative shock (aOR= 0.42; 95% CI: 0.41-0.92; p = 0.041). There was significant statistical difference in morbidity (p = 0.003) and mortality (p < 0.0001) rates for cases of leaked repairs and successful repairs.

Conclusion: Leaked repair following omentopexy for peptic ulcer perforation was significantly associated with large perforation diameter, delayed presentation, sepsis, immunosuppressive therapy, and perioperative shock.

Introduction: MONTH Difficult Laryngoscopy Score was developed for effectively identifying difficult intubations in the emergency department (ED). This study aimed to evaluate the accuracy of MONTH Score in predicting difficult intubations in ED.

Methods: We prospectively collected data on all patients undergoing intubation in the ED of Ramathibodi Hospital, Bangkok, Thailand. The screening performance characteristics of the MONTH score in identifying the difficult intubation in ED were analyzed. All data were analyzed using STATA software version 18.0.

Results: 324 intubated patients with the median age of 73 (63-82) years were studied (63.58% male). The proportion of difficult intubations was 19.44%. The sensitivity and specificity of MONTH in predicting difficult intubations were 74.6% (95% CI: 61.6%-85.0%) and 92.8% (95% CI: 89.0%-95.6%), respectively. These measures in subgroup of patients with Intubation Difficulty Scale (IDS) score ≥ 6 were 44.1% (95%CI: 31.2-57.6) and 98.5% (95% CI: 96.2%- 99.6%), respectively. The area under the receiver operation characteristic (ROC) curve of MONTH in predicting difficult intubations was 0.895 (95% CI: 0.856- 0.926).

Conclusions: It seems that the MONTH Difficult Laryngoscopy Score could be considered as a tool with high specificity and positive predictive values in identifying cases with difficult intubations in ED.

Introduction: In light of the potential of enhanced functional and neurological recovery in traumatic brain injury (TBI) with the administration of rapamycin, this systematic review and meta-analysis aimed to investigate the efficacy of rapamycin treatment in animal models of TBI.

Methods: An extensive search was conducted in the electronic databases of Medline, Embase, Scopus, and Web of Science by July 1^st, 2023. Two independent researchers performed the screening process by reviewing the titles and abstracts and the full texts of the relevant articles, including those meeting the inclusion criteria. Apoptosis rate, inflammation, locomotion, and neurological status were assessed as outcomes. A standardized mean difference (SMD) with a 95% confidence interval (95%CI) was calculated for each experiment, and a pooled effect size was reported. Statistical analyses were performed using STATA 17.0 software.

Results: Twelve articles were deemed eligible for inclusion in this meta-analysis. Pooled data analysis indicated notable reductions in the number of apoptotic cells (SMD _{for Tunnel-positive cells} = -1.60; 95%CI: -2.21, -0.99, p<0.001), p-mTOR (SMD=-1.41; 95%CI: -2.03, -0.80, p<0.001), and p-S6 (SMD=-2.27; 95%CI: -3.03, -1.50, p<0.001) in TBI post-treatment. Our analysis also indicated substantial IL-1β reductions after rapamycin administration (SMD= -1.91; 95%CI: -2.61, -1.21, p<0.001). Moreover, pooled data analysis found significant neurological severity score (NSS) improvements at 24 hours (SMD= -1.16; 95%CI: -1.69, -0.62, p<0.001; I²=0.00%), 72 hours (SMD= -1.44; 95%CI: -2.00, -0.88, p<0.001; I²=0.00%), and 168 hours post-TBI (SMD= -1.56; 95%CI: -2.44, -0.68, p<0.001; I²=63.37%). No such improvement was observed in the grip test.

Conclusion: Low to moderate-level evidence demonstrated a significant decrease in apoptotic and inflammatory markers and improved neurological status in rodents with TBI. However, no such improvements were observed in locomotion recovery.

Introduction: Noninvasive positive pressure ventilation (NIPPV) is recognized as an efficient treatment for patients with acute respiratory failure (ARF) in emergency department (ED). This study aimed to develop a scoring system for predicting successful weaning from NIPPV in patients with ARF.

Methods: In this retrospective cohort study patients with ARF who received NIPPV in the ED of Ramathibodi Hospital, Thailand, between January 2020 and March 2022 were evaluated. Factors associated with weaning from NIPPV were recorded and compared between cases with and without successful weaning from NIPPV. Multivariable logistic regression analysis was used to develop a predictive model for weaning from NIPPV in ED.

Results: A total of 494 eligible patients were treated with NIPPV of whom 203(41.1%) were successfully weaned during the study period. Based on the multivariate analysis the successful NIPPV weaning (SNOW) score was designed with six factors before discontinuation: respiratory rate, heart rate ≤ 100 bpm, systolic blood pressure ≥ 100 mmHg, arterial pH≥ 7.35, arterial PaCO2, and arterial lactate. The scores were classified into three groups: low, moderate, and high. A score of >14.5 points suggested a high probability of successful weaning from NIPPV with a positive likelihood ratio of 3.58 (95%CI: 2.56-4.99; p < 0.001). The area under the receiver operating characteristic (ROC) curve of the model in predicting successful weaning was 0.79 (95% confidence interval (CI): 0.75-0.83).

Conclusion: It seems that the SNOW score could be considered as a helpful tool for predicting successful weaning from NIPPV in ED patients with ARF. A high predictive score, particularly one that exceeds 14.5, strongly suggests a high likelihood of successful weaning from NIPPV.

The optimal therapy for deep wounds is based on the early debridement of necrotic tissue followed by wound coverage to avoid a systemic inflammatory response and optimize scar-free healing. The outcomes are affected by available resources and underlying patient factors, which cause challenges in wound care and suboptimal outcomes. Here we report a patient with deep dermal injury wounds, who was treated with platelet-rich fibrin (PRF) gel, plasma rich in growth factor (PRGF) gel, and acellular fish skin. Patient's outcomes regarding healing and scar quality were collected objectively and subjectively for one year after the injury. Wounds treated with acellular fish skin demonstrated accelerated wound healing, a significantly higher water-storage capacity, and better pain relief. Furthermore, improved functional and cosmetic outcomes, such as elasticity, skin thickness, and pigmentation, were demonstrated. It seems that, the PRGF gel and PRF in combination with acellular fish skin grafts resulted in the faster healing of wounds and better functional and aesthetic outcomes than split-thickness skin grafts treatment.

Introduction: Ignoring outliers in data may lead to misleading results. Length of stay (LOS) is often considered a count variable with a high frequency of outliers. This study exemplifies the potential of robust methodologies in enhancing the accuracy and reliability of analyses conducted on skewed and outlier-prone count data of LOS.

Methods: The application of Zero-Inflated Poisson (ZIP) and robust Zero-Inflated Poisson (RZIP) models in solving challenges posed by outlier LOS data were evaluated. The ZIP model incorporates two components, tackling excess zeros with a zero-inflation component and modeling positive counts with a Poisson component. The RZIP model introduces the Robust Expectation-Solution (RES) algorithm to enhance parameter estimation and address the impact of outliers on the model's performance.

Results: Data from 254 intensive care unit patients were analyzed (62.2% male). Patients aged 65 or older accounted for 58.3% of the sample. Notably, 38.6% of patients exhibited zero LOS. The overall mean LOS was 5.89 (± 9.81) days, and 9.45% of cases displayed outliers. Our analysis using the RZIP model revealed significant predictors of LOS, including age, underlying comorbidities (p<0.001), and insurance status (p=0.013). Model comparison demonstrated the RZIP model's superiority over ZIP, as evidenced by lower Akaike information criteria (AIC) and Bayesians information criteria (BIC) values.

Conclusions: The application of the RZIP model allowed us to uncover meaningful insights into the factors influencing LOS, paving the way for more informed decision-making in hospital management.

Introduction: During the unprecedented COVID-19 lockdowns, road traffic was limited, and a change in the traumatic emergency admission pattern was anticipated. We conducted the current systematic review and meta-analysis to assess the impact of the COVID-19 pandemic on hospital admissions due to road traffic crashes.

Methods: This systematic review and meta-analysis was conducted based on the Joanna Briggs Institute (JBI) instructions. The following databases were searched: PubMed, ISI Web of Knowledge, Scopus, ProQuest, and the Cochrane Library. Two independent reviewers screened articles based on the inclusion criteria for the review and assessed the methodological quality of the included studies using an appropriate appraisal checklist, introduced by the JBI, based on the study type. The meta-analysis was performed using Comprehensive meta-analysis (CMA) software. Considering the heterogeneity among studies, a random effect model was adopted to estimate the pooled effect with 95% confidence interval (CI) for binary outcomes.

Results: A total of 13 studies were included in this systematic review, and all of them were considered for meta-analysis. According to the meta-analysis, differences in hospital admission rates during the COVID-19 pandemic and one year before this pandemic were statistically significant [RR: 0.685 CI 95% (0.578 -0.813) p<0.00001]. The heterogeneity assessment of the included studies in the meta-analysis showed high heterogeneity (I²=78%, p<0.00001).

Conclusion: The results of this systematic review showed that the COVID-19 pandemic dramatically reduced the number of hospital admissions related to road traffic crashes because of both quarantines and lifestyle changes. Health policymakers and top health managers might use the results of this systematic review in similar contexts in the future.

The simultaneous occurrence of intestinal ascariasis and appendicitis presents a challenge in diagnosing pediatric abdominal emergencies due to overlapping symptoms. We present the case of an 8-year-old boy who experienced acute abdominal pain, characterized by a severe cramp in the mid and lower right abdomen, with pain rated 7 out of 10, a mild fever, and continuous nausea. The initial evaluation suggested appendicitis, supported by an Alvarado score of 9. However, ultrasonography did not conclusively confirm appendicitis but revealed an Ascaris worm in the ileum. This finding highlights the importance of careful diagnostic processes that combine clinical assessment with imaging techniques, while being mindful of their limitations. Surgical exploration confirmed retrocecal appendicitis coexisting with an Ascaris lumbricoides infection. The treatment involved surgical removal of the affected appendix and pharmacological expulsion of the parasitic worm using albendazole, which proved effective. This report emphasizes the consideration of ascariasis in diagnosing appendicitis, particularly in areas where intestinal parasites are common. It also demonstrated the improved diagnostic accuracy achieved through clinical scoring and imaging, thus reducing the risk of missing dual pathologies in young patients with acute abdominal pain.