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Background: The present study aimed to determine the validity of hs-cTnT in predicting the mortality among patients presented to the emergency department (ED) likely to be acute coronary syndrome (ACS)., Method: Patients in whom hs-cTnT was tested in the ED for a possible ACS composed the study cohort. Hs-cTnT levels of the study patients were obtained from the hospital computerized database. The outcome and mortality of the study patients was detected using the digitalized national mortality registry. All-cause mortality and cardiac mortality at the end of one month was the primary outcome., Results: 11795 patients were eligible for mortality detection and included into the final analysis. 1246 of 11795 patients were established to be dead during the study period and 358 of them supposed to be cardiac in origin. The Area Under the Curve (AUC) value of initial hs-cTnT for predicting one-month cardiac mortality was 0.869 (95% CI: 0.863 - 0.875) and 0.861 (95% CI: 0.855 - 0.867) for one-month all-cause mortality. The upper reference limit, 14 ng/L, has a sensitivity and specificity of 87% (95% CI: 77% to 94%) and 69% (95% CI: 68% to 70%), respectively, for predicting one-month cardiac mortality., Conclusions: The reference value of initial hs-cTnT does not have the ability to predict the cardiac mortality in a sufficient manner. However, reductions or increases in absolute or relative hs-cTnT levels are in concordance with mortality rates.

Background: Chronic obstructive pulmonary disease (COPD) is associated with high mortality and morbidity., Objective: The aim of the present study was to determine the role of nitric oxide (NO) and other possible factors in predicting the revisit of patients with COPD exacerbation to the emergency department (ED)., Methods: This is a prospective cohort study on patients with exacerbated COPD in the ED setting. Bedside nasal NO values were measured with a hand-held analyzer device. Revisit to the ED has been defined as any unscheduled visit to an ED or to primary physician's office within 2 weeks of the initial ED visit for worsening COPD symptoms. A follow-up survey via telephone was conducted on all patients at the end of 2 weeks., Results: The data from 64 patients who visited the ED once was compared to 28 revisits. Total of 92 patients were analyzed and variables were compared. The rate of revisits to the ED was 30%. Nasal NO measurement could not predict the revisits of patients with COPD exacerbation to the ED. The mean respiratory rate, exacerbations in previous year, home nebulizer therapy, prescribed antibiotic at discharge, home oxygen therapy, and abnormal chest x-ray studies were associated with increased rate of revisits to ED in univariate analysis. After multivariate analysis, only the mean respiratory rate at presentation and the prescribed antibiotic at discharge were significant determinants., Conclusions: There was no statistically significant difference measured in NO level at presentation or before discharge between the groups. The mean respiratory rate at presentation and the prescribed antibiotic at discharge may predict the return of a COPD-exacerbated patient within 14 days to ED., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Study Objective: Although electroencephalography (EEG) is a useful diagnostic tool for patients with a suspected seizure, its value in informing the acute care of patients in the emergency department (ED) remains unclear. The aim of this study is to determine the effects of EEG results on subsequent patient management in or from the ED., Materials and Methods: This prospective observational study was carried out in the ED of a tertiary-care university hospital. All patients presenting to the ED with seizure or seizure-mimicking symptoms were included in the study. EEG was advised for all patients after an initial evaluation. Before EEG, the ED physician and neurologist were asked clinical questions about the patient. The consistency between the clinical decision of emergency physicians before the EEG report and the final management of patients determined by the consultant neurologist was analyzed. The interobserver reliability of the physicians was determined., Results: Overall, 110 patients were enrolled in the study. The sensitivity and specificity of ED physicians' diagnosis of the presence of seizure were both 88% (95% confidence interval, 79-93 and 62-97%). The interobserver reliabilities and κ values of ED physicians and neurologists were found to be 'moderate'. Patients with abnormal EEG results were prescribed new medication (P=0.003) and changes in therapy (P=0.59) were more than for patients with normal results., Conclusion: As seizure is a clinical event, EEG is not essential for diagnosing the presence of a seizure clinically in the ED. However, the results of EEG provide useful information especially for treatment choices. As the timing of the study affects the diagnostic efficacy of the test, EEG recordings should be performed within 24 h either in ED or in the epilepsy clinic.

Background and Aim: Seizure-related visits are common in the emergency department (ED) but the clinical situations for ordering emergency electroencephalography (EEG) are unclear. The aim of this study is to identify which clinical conditions meet with the pathological EEG and whether patient management is changed by abnormal results., Methods: A retrospective chart review study of all patients visiting the ED with a seizure or symptoms mimicking a seizure was performed. Patients who recorded an EEG within 16 h after the initial event were enrolled. Demographic data and EEG results of patients with provoked and unprovoked seizures were recorded and related factors were analysed., Results: A total of 449 patients (219 men) of mean ± SD age of 45.48 ± 21.83 years were evaluated. The seizure was thought to be provoked in 98 patients (21.8%) and unprovoked in 352 (78.2%) patients (31.2% remote symptomatic and 47.4% idiopathic). The EEG results of 281 patients (62.6%) revealed an abnormality, and the abnormal EEG ratio was high in patients with presumed seizure (p<0.001). One hundred and thirty-eight patients (30.7%) were hospitalised and the remainder (n=311, 69.3%) were discharged from the ED. An abnormal EEG was found in 98 (71%) of the hospitalised patients and in 183 (59.5%) of those discharged (p=0.019)., Conclusion: EEG provides useful diagnostic information and should be considered in all patients presenting to the ED with a seizure. Since the timing of the study affects the diagnostic efficacy of the test, EEG recordings might be done within 24 h either in the ED or epilepsy clinic.

Background: The Glasgow Coma Scale (GCS) is the most widely used tool for the evaluation of the level of consciousness. The Full Outline of Unresponsiveness (FOUR) Score is a new coma Scale that was developed considering the limitations of the GCS, and has been found to be useful in an intensive care setting. We aimed to compare FOUR Score and GCS in the emergency setting., Methods: All patients older than 17 years who presented with an altered level of consciousness, after any trauma to the head or with neurological complaints were included in this study. Three-month mortality, in-hospital mortality, and poor outcome using a Modified Rankin Scale (MRS) of 3-6 points were used as the primary outcome measures., Results: A total of 185 patients were included in the study. Area under the curve (AUC) values in predicting 3-month mortality for GCS was 0.726 [P=0.0001 and 95% confidence interval (CI): 0.656-0.789] and 0.776 (P=0.0001 and 95% CI: 0.709-834) for FOUR Score. AUC in predicting hospital mortality for GCS was 0.735 (P=0.0001 and 95% CI: 0.655-0.797) and 0.788 (P=0.0001 and 95% CI: 0.722-0.844) for FOUR Score. AUC in predicting poor outcome (Modified Rankin Scale: 3-6) was 0.720 (P=0.001 and 95% CI: 0.650-784) for GCS and 0.751 (P=0.0001 and 95% CI: 0.682-0.812) for FOUR Score., Conclusion: The new coma Scale, FOUR Score, is not superior to the GCS. However, the combination of the eye and motor components of FOUR Score is a valuable tool that can be used instead of either the FOUR Score or GCS.

The aim of this study was to reveal the effects of anxiety and depression on pain perception in the emergency setting. This randomized prospective study was performed in an urban tertiary care hospital emergency department (ED). Consecutive patients presenting to the ED with pain who had an intramuscular injection of diclofenac sodium were enrolled in the study. The prevalence of anxiety and depressive disorders in study subjects was determined by using the Hospital Anxiety and Depression Scale. A total of 302 patients were included. Study subjects had a mean age of 41.3 +/- 13.7 years and 35.4% (n = 107) were male. Pain perception in women was significantly higher than in men (median 8.5 vs. 5, respectively; p = .033). Pain perception in elderly patients, >/=65 years old, was found to be lower than in patients <65 years old (median 1 vs. 6.5, respectively; p = .02). Anxiety was found to be related to higher pain perception after adjusting for confounding variables (13.8 vs. 7.6, respectively; adjusted p = .022). Gender, age, and anxiety, but not depression, are possible factors related to pain perception in the emergency setting. Further studies are needed to reveal the factors affecting pain perception and the complex relationship between psychiatric status and pain.

Background: Tourists are exposed to traditional health problems of the host country, such as trauma and the exacerbation of previously existing illnesses during their travels., Objective: The purpose of this study is to determine the clinical characteristics of tourist patients and any predictors of hospital admission., Material and Method: This retrospective observational study was carried out in the tertiary care hospital emergency department (ED) of a Mediterranean destination city, Antalya, Turkey. Hospital data from all tourist patients presenting or transferred to the ED between August 2003 and September 2004 were evaluated. Tourist patients were defined as all non-Turkish citizens., Results: A total of 961 tourist patients was studied, of whom 295 (31%) were admitted and 666 (69%) were discharged. Fifteen patients died in the hospital, 49 critically ill patients were transferred back to their home country, and 153 patients underwent a surgical intervention. The most common discharge diagnoses were trauma (405, 42%), nonspecific symptoms (106, 11%), and circulatory disorders (108, 11%). Admitted tourist patients were significantly older than those discharged; however, there were no differences in sex among the groups. Applying a logistic regression model, age, tachycardia, mode of arrival, and triage category were all found to be significant predictors of admission, but only the initial Glasgow Coma Scale was found to be a significant predictor of mortality. In total, 347 patients were from European Union (EU) countries, and 614 were from non-EU countries. A significant difference was found between the EU and non-EU patient groups according to age, mortality, admission rate, exposure to trauma, ED length of stay, hospital length of stay. Tourist patients from EU countries were older, had higher mortality, lesser trauma exposure, longer ED, and hospital length of stay., Conclusion: EDs can be expected to manage tourist patients presenting for traumatic injuries and circulatory disorders. Clinical differences relating to patients' nationality might help in the development of targeted patient education and injury-prevention programs. Emergency physicians and the tourism industry should recognize the challenges of caring for this growing and aged patient population.

Patients presenting to the emergency department with chest pain are evaluated by emergency physicians in hospitals without cardiology cover 24 h a day. The purpose of this study is to determine the consistency of electrocardiography (ECG) interpretation and chest pain likelihood classification between emergency physicians and cardiologists. This randomised prospective cross-sectional study was performed in a tertiary care university hospital emergency department. The study form included ECG interpretation and chest pain likelihood classification according to American College of Cardiology (ACC)/American Heart Association (AHA) guideline which were recorded by emergency physicians and cardiologists separately in a blinded fashion. All chest pain patients who consulted with a cardiologist were enrolled into the study during the study period. The consistency between the two groups and the kappa value were calculated. Recorded study forms of 133 patients with cardiology consultations were evaluated. The consistency in the interpretation of ECG between the emergency physicians and cardiologists was found to be 94.6% (kappa = 0.85) for ST segment elevation, 78.6% (kappa = 0.57) for ischaemic ECG findings and 79.3% (kappa = 0.36) for dynamic ECG changes. The consistency for the likelihood classification between two groups for predicting the pain as angina or non-cardiac was 90.8% (kappa = 0.30), for classifying as acute coronary syndrome or stable angina pectoris (SAP) was 95.6% (kappa = 0.26) and for classifying patients as low likelihood or intermediate-high likelihood was 86.3% (kappa = 0.61). A strong consistency was shown between the emergency physicians' and cardiologists' ECG interpretation especially in determining the ST segment elevation. And also, there is a strong concordance in the likelihood classification of chest pain patients.

Objective: The aim of this study was to determine the factors most affecting emergency physicians' decisions in the management of chest pain patients., Methods: This prospective randomized cross-sectional study was carried out between March 2004 and September 2004 in an urban university hospital emergency department. Residents collected data on patients' demographic features, chest pain characteristics, electrocardiography, cardiac enzymes and outcome of patients., Results: Five hundred and sixty-two patients were enrolled in the study; 389 (69.2%) patients were classified as having cardiac chest pain. Of the 389 patients suggested to have cardiac chest pain, 369 (94.4%) were classified as probable acute coronary syndrome; 286 (50.9%) patients were seen by cardiologists and 187 (33.3%) were admitted to the cardiology ward. The logistic regression analysis revealed that angina equivalents (P<0.001), age (P=0.002), history of coronary artery disease (P=0.003), electrocardiography (P=0.001), substernal chest pain (P=0.001), typical chest pain (P=0.000) and radiation of chest pain (P=0.039) were independent factors affecting emergency physicians' decisions., Conclusion: The factors affecting emergency physicians' decisions are correlated with guidelines.

The aim of our study was to determine the utility of point-of-care blood ketone testing in diabetic patients presenting to the emergency department. In this prospective, observational clinical study, patients with known or newly diagnosed diabetes mellitus presenting to our tertiary care university emergency department with any nontrauma related medical complaint and a high fingerstick glucose (> or =200 mg/dL) were eligible for inclusion. Capillary blood beta-hydroxybutyrate (beta-HBA), venous blood beta-HBA level, venous blood glucose level, arterial blood gas analysis, and urine ketone dipstickstick were measured in each patient as primary outcome measures. Of the 479 diabetic patients presenting during the study period, a total of 139 diabetic patients with high capillary blood glucose level (> or =200 mg/dL) and a positive capillary blood beta-HBA (> or =0.1 mmol/L) were included in the study. Hyperketonemia (> or =0.42 mmol/L) was found in 48 of these patients by Sigma Diagnostics reference testing (diabetic ketosis in 35%). The calculated blood pH was less than 7.3 in 18 of these 48 patients (ketoacidosis in 31%). Capillary and venous blood beta-hydroxybutyrate levels were not statistically different from each other (P = 0.824). There was a positive correlation between capillary and venous blood beta-HBA levels (r = 0.488, P < 0.001). The sensitivity and specificity of urine ketone dipstick testing and capillary blood ketone testing in determining diabetic ketoacidosis were 66% and 78%, and 72% and 82%; and in determining hyperketonemia (both in diabetic ketosis and diabetic ketoacidosis) were 82% and 54%, and 91% and 56%, respectively. A rapid, bedside capillary blood ketone test for beta-HBA can accurately measure blood concentrations of beta-HBA in diabetic patients in an emergency department setting. This device can be used as a reliable diagnostic test to detect emergency metabolic problems in diabetic patients, such as diabetic ketosis or ketoacidosis.

Aim: To determine the patterns and appropriateness of patients' use of a university hospital emergency department., Methods: During a 14-day period in November 1998, we collected demographic and socio-economic data, reasons for preferring emergency department care, and patient visit data from consecutive patients visiting our tertiary-care university hospital emergency department. The principle investigator reviewed the study information forms and classified visits according to the classification of Afilalo into three categories: category I--emergent emergency department visits; category II--needing evaluation within 6 hours, either in emergency department or elsewhere; or category III--needing evaluation after more than 6 hours. Three emergency medicine residency-trained physicians determined the appropriateness of emergency department evaluation. Patients in the categories II and III were retrospectively reclassified as appropriate or inappropriate, according to availability of care at the outpatient facility at the hour of initial emergency department presentation., Results: Complete data were collected from 1,155 (96.2%) of 1,201 patients visiting our emergency department during the study period. There were 69% (n=795) appropriate of visits. The mean stay at emergency department of inappropriate users lasted 66 min. The main reasons of inappropriate users to prefer emergency department care were its proximity, satisfaction with care, worsening symptoms, and unavailability of care in a regular clinic., Conclusion: Although inappropriate emergency department usage was high, these patients had relatively short emergency department stays. The impact on emergency department resource utilization and "over-crowding" by these patients may not be as great as commonly perceived.

This study aimed to establish the diagnostic value of paracentesis (peritoneal tap) in the assessment of patients with blunt abdominal trauma. Paracentesis, using a four-quadrant puncture technique, was performed in blunt abdominal trauma victims presenting to the emergency department of a tertiary-care university medical centre. Pregnant patients, those under 18 or those having an abdominal scar were excluded from the study. All patients then underwent one of the following procedures as indicated: emergency ultrasound, abdominal computed tomography scan, diagnostic peritoneal lavage or laparotomy. Paracentesis results were compared with the results of other tests and surgery in diagnosing haemoperitoneum. Haemoperitoneum was confirmed surgically in six of the seven patients with a positive paracentesis. Nine out of 65 patients with positive clinical findings but negative taps underwent surgical intervention, and abdominal bleeding was confirmed in eight. Three seriously injured patients died before diagnostic studies or laparotomy could be performed. In conclusion, a positive paracentesis result may be used to guide decision-making in the setting of blunt abdominal trauma if other diagnostic methods are unavailable. Its high false-negative rate limits its overall usefulness.