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   Table of Contents - Current issue
October-December 2023
Volume 23 | Issue 4
Page Nos. 195-257

Online since Wednesday, October 11, 2023

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Receiver operating characteristic curve analysis in diagnostic accuracy studies: A guide to interpreting the area under the curve value p. 195
Şeref Kerem Corbacioglu, Gökhan Aksel
This review article provides a concise guide to interpreting receiver operating characteristic (ROC) curves and area under the curve (AUC) values in diagnostic accuracy studies. ROC analysis is a powerful tool for assessing the diagnostic performance of index tests, which are tests that are used to diagnose a disease or condition. The AUC value is a summary metric of the ROC curve that reflects the test's ability to distinguish between diseased and nondiseased individuals. AUC values range from 0.5 to 1.0, with a value of 0.5 indicating that the test is no better than chance at distinguishing between diseased and nondiseased individuals. A value of 1.0 indicates perfect discrimination. AUC values above 0.80 are generally consideredclinically useful, while values below 0.80 are considered of limited clinical utility. When interpreting AUC values, it is important to consider the 95% confidence interval. The confidence interval reflects the uncertainty around the AUC value. A narrow confidence interval indicates that the AUC value is likely accurate, while a wide confidence interval indicates that the AUC value is less reliable. ROC analysis can also be used to identify the optimal cutoff value for an index test. The optimal cutoff value is the value that maximizes the test's sensitivity and specificity. The Youden index can be used to identify the optimal cutoff value. This review article provides a concise guide to interpreting ROC curves and AUC values in diagnostic accuracy studies. By understanding these metrics, clinicians can make informed decisions about the use of index tests in clinical practice.
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Prehospital management of earthquake crush injuries: A collective review p. 199
Fikri M Abu-Zidan, Kamal Idris, Arif Alper Cevik
Earthquakes are natural disasters which can destroy the rural and urban infrastructure causing a high toll of injuries and death without advanced notice. We aim to review the prehospital medical management of earthquake crush injuries in the field. PubMed was searched using general terms including rhabdomyolysis, crush injury, and earthquake in English language without time restriction. Selected articles were critically evaluated by three experts in disaster medicine, emergency medicine, and critical care. The medical response to earthquakes includes: (1) search and rescue; (2) triage and initial stabilization; (3) definitive care; and (4) evacuation. Long-term, continuous pressure on muscles causes crush injury. Ischemia–reperfusion injury following the relieving of muscle compression may cause metabolic changes and rhabdomyolysis depending on the time of extrication. Sodium and water enter the cell causing cell swelling and hypovolemia, while potassium and myoglobin are released into the circulation. This may cause sudden cardiac arrest, acute extremity compartment syndrome, and acute kidney injury. Recognizing these conditions and treating them timely and properly in the field will save many patients. Majority of emergency physicians who have worked in the field of the recent Kahramanmaraş 2023, Turkey, earthquakes, have acknowledged their lack of knowledge and experience in managing earthquake crush injuries. We hope that this collective review will cover the essential knowledge needed for properly managing seriously crushed injured patients in the earthquake field.
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E-HEART score: A novel scoring system for undifferentiated chest pain in the emergency department p. 211
V Yuvaraj, Sachin Sujir Nayak, S Vimal Krishnan
OBJECTIVE: Cardiovascular disease is the leading cause of death worldwide. As there is an increase in the global burden of ischemic heart disease, there are multiple scoring systems established in the emergency department (ED) to risk stratify and manage acute coronary syndrome (ACS) in patients with chest pain. The objective of this study was to integrate point-of-care echo into the existing history, electrocardiogram, age, risk factors, and troponin (HEART) score and evaluate a novel scoring system, the echo HEART (E-HEART) score in risk stratification of patients presenting with undifferentiated chest pain to the ED. The E-HEART Score was also compared with existing traditional scoring systems for risk-stratifying acute chest pain. METHODS: A diagnostic accuracy study involving 250 patients with chest pain at the ED of a single tertiary care teaching hospital in India was conducted. The emergency physicians assessed the E-HEART score after integrating their point-of-care echo/focused echo findings into the conventional HEART score on presentation. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE) within 4 weeks of initial presentation. The accuracy of the E-HEART score was compared with other conventional risk stratification scoring systems such as the thrombolysis in myocardial infarction (TIMI), history, electrocardiogram, age, and risk factors, Troponin Only Manchester ACS (T-MACS), and HEART scores. RESULTS: A total of 250 patients with a median age of 53 years (42.25–63.00) were part of the study. Low E-HEART scores (values 0–3) were calculated in 121 patients with no occurrence of MACE in this category. Eighty-one patients with moderate E-HEART scores (4–6) were found to have 30.9% MACE. In 48 patients with high E-HEART scores (values 7–11), MACE occurred in 97.9%. The area under receiver operating characteristics (AUROC) of E-HEART score is 0.992 (95% confidence interval: 0.98–0.99), which is significantly higher than AUROC values for HEART (0.978), TIMI (0.889), T-MACS (0.959), and HEAR (0.861), respectively (P < 0.0001). At a cutoff of E-HEART score >6, it accurately predicted ACS with a sensitivity of 92% and a specificity of 99% with a diagnostic accuracy of 97%. CONCLUSION: The E-HEART score gives the clinician a quick and accurate forecast of outcomes in undifferentiated chest pain presenting to the ED. Low E-HEART scores (0–3) have an extremely low probability for short-term MACE and may aid in faster disposition from the ED. The elevated risk of MACE in patients with high E-HEART scores (7–11) may facilitate more aggressive workup measures and avoid disposition errors. E-HEART is an easily adaptable scoring system with improved accuracy compared to conventional scoring systems.
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Scholarly impact of the dissertation requirement for postgraduate medical education and factors affecting transformation into publication: A bibliometric analysis of 2434 dissertations in the field of emergency medicine p. 219
İbrahim Ozturan, İbrahim Sarbay
OBJECTIVES: In Turkey, conducting research for a dissertation is necessary to obtain a specialist degree, but publication of this research is not mandatory. Previous studies have shown a low rate of publication for dissertation-derived research. The aim of this study was to determine publication rates, factors affecting the transformation of the dissertations into high-quality publications, and bibliometric analysis of published articles in the field of emergency medicine (EM). METHODS: This was a retrospective bibliometric study of EM dissertations submitted between 1998 and 2021 to the National Thesis Center. Research characteristics, publication status, journal characteristics, indexing, citation analysis, and institution characteristics were recorded. Journals indexed in the web of science (WOS) were defined as high-quality journals. A logistic regression was performed to identify factors affecting publication in high-quality journals. RESULTS: A total of 2434 dissertations were included. Of these, 864 (35.5%) were published and 474 (54%) were published in WOS-indexed journals. The most common area of research was trauma (n = 150, 17%), and the most common journal was the American Journal of EM (n = 74, 8%). Prospective data collection (odds ratio [OR] = 2.5, 95% confidence interval [CI] = 1.8–2.5), experimental design (OR = 2, 95%, CI = 1.3–3), university-type residency program (OR = 1.4, 95% CI = 1.02–2.1), and duration between year of graduation and publication (OR = 0.9, 95% CI = 0.84–0.95) were associated with publishing in WOS-indexed journals. CONCLUSION: EM is a relatively successful specialty for publishing dissertation-derived studies. Prospective and experimental research design, graduation from a university-type residency program, and shorter duration between the graduation and publication may increase the chance of publishing in high-quality journals.
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Diagnostic accuracy of drooling, reluctance, oropharynx, others, and leukocytosis score as a predictor of mortality and complications following acute corrosive ingestion p. 225
Fawaz Poonthottathil, Soorya Suresh, Jamshed Nayer, Praveen Aggarwal
OBJECTIVES: Esophagogastroduodenoscopy is considered the gold standard in assessing the severity of injury to the gastrointestinal tract following corrosive ingestion. Zargar's endoscopic grading of injury helps in prognostication as well as guiding management. Since the major burden of cases lies in resource-limited settings, the availability of endoscopic evaluation is a limiting factor. Hence, it is prudent to develop bedside tools that can be used as screening tools to identify patients at high risk of mortality and complications so that timely referrals and judicious utilization of resources can be made. Literature in this regard is limited and published studies have shown that clinical features fail to predict the severity of injury. We aimed our study to find the role of Drooling, Reluctance, Oropharynx, Others, and Leukocytosis (DROOL) score as a predictor of mortality and complications following acute corrosive ingestion. METHODS: This was a diagnostic accuracy study conducted in the emergency department (ED) of a tertiary care hospital in North India. We screened all cases of acute corrosive ingestion presented to our ED. We collected the data on demographic profile, clinical features, investigations, endoscopy findings, treatment, and DROOL score. We followed patients for up to 12 weeks for outcomes including mortality and complications. RESULTS: We studied 79 patients of acute corrosive ingestion. The median age was 26 years with a female predominance. Nausea, vomiting, and pain abdomen were the common symptoms. The median DROOL score was 4. The majority of our patients had normal to Zargar grade 1 injury to the stomach and esophagus. Out of 79 patients, 27 patients developed some complications. The overall mortality up to 12 weeks was 10%. The receiver operating characteristics (ROC) analysis was performed, and the area under the ROC (AUROC) curve of Zargar classification in predicting overall complications was 0.909 (96% confidence interval [CI]: 0.842–0.975) and it was 0.775 (95% CI: 0.553–1.000) in predicting mortality. The AUROC of DROOL score in predicting overall complications was 0.932 (95% CI: 0.877–0.987) and the AUROC of DROOL score in predicting mortality was 0.864 (95% CI: 0.758–0.970). The ROC analysis showed that a DROOL score ≤4 has a sensitivity of 96.2% and a specificity of 77.8% in predicting overall complications. Similarly, DROOL score ≤5 has a sensitivity of 81.7% and a specificity of 62.5% in predicting the development of mortality. Delong test showed that there was no statistically significant difference in Zargar versus DROOL score in terms of prediction of mortality and overall complications (P > 0.05). CONCLUSION: DROOL score is comparable to Zargar score in identifying patients at high risk of mortality and complications. Hence, DROOL score can be used for risk stratification of patients presenting with corrosive ingestion.
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Accidents and injuries related to paragliding on mount Babadağ, Turkey: A cross-sectional study p. 232
Ömer Faruk Karakoyun, Yalcin Golcuk
OBJECTIVES: In light of the growing popularity of paragliding, this cross-sectional study aimed to investigate the epidemiology of paragliding accidents, providing insights into the types and severity of injuries sustained as well as the body regions most commonly affected. METHODS: This cross-sectional retrospective study utilized data on adverse paragliding events on Mount Babadağ in Turkey, collected by the Muğla Sports Tourism Board (STB) between January 2020 and December 2021, with data sources including out-of-hospital STB forms and in-hospital electronic health records. RESULTS: Out of 241,420 paragliding flights, a total of 44 accidents were identified, with only three resulting in fatalities. Most of the accidents occurred during take off and landing, but the deadliest phase was during flight. The majority of accidents were of low severity, with a median National Advisory Committee for Aeronautics score of 1 (interquartile range [IQR] 1–3) and a median injury severity score of 1 (IQR 1–7.75). The lower limb was the most commonly injured body part, accounting for 55.8% of injuries, followed by the upper limb at 30.8%. CONCLUSIONS: Despite being considered an extreme sport, paragliding carries a relatively low risk of accidents and serious injuries, owing to advancements in training, equipment inspection, and protective gear.
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The impact of the first wave of the COVID-19 pandemic on hospital admissions and treatment management of ectopic pregnancy p. 238
Hande Gurbuz, Gulfem Basol, Mehmet Mustafa Altintas, Betul Kuru
OBJECTIVES: We aimed to evaluate the clinical features and treatment strategies applied to the patients with ectopic pregnancy admitted to our tertiary care center before and during the pandemic. METHODS: Women aged 18–45 years, who were admitted to the hospital with a diagnosis of ectopic pregnancy in the pre- and postpandemic periods, were included in this case–control study. RESULTS: A total of 173 patients, 116 patients before the pandemic and 57 patients during the pandemic, were included in the study. The rate of admissions from the emergency department was higher during the pandemic than before the pandemic (P = 0.003). The rupture was detected significantly higher during the outbreak (13/116 [11.2%]) than before the pandemic (16/57 [28.1%]) (P = 0.009). While conservative treatment was applied more frequently in the prepandemic period, it was observed that patients were treated surgically more frequently during the pandemic period (P = 0.003). While laparoscopic surgery was preferred before the pandemic, laparotomy was applied to all patients during the pandemic (P < 0.001). CONCLUSIONS: In the first wave of the outbreak, there were delays in the diagnosis of ectopic pregnancies, and these patients presented with ruptures more frequently than before the pandemic. Furthermore, surgical treatment methods were used more than conservative therapies during the outbreak.
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Invited commentary on “The impact of the first wave of the COVID-19 pandemic on hospital admissions and treatment management of ectopic pregnancy” p. 244
Fikri M Abu-Zidan
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Severe pulmonary-renal syndrome in honeybee sting envenomation – A case report p. 246
Alan Shaji, Malik Parvez, Naresh Kumar Chirumamilla, Nalin Sharma, Ashok Kumar Pannu
Honeybee stings with features of envenomation (either local or allergic and rarely systemic toxicity) are often seen in agriculture workers. An initial presentation with severe diffuse alveolar hemorrhage or pulmonary-renal syndrome is rare and only confined to a few case reports. Herein, we describe a case of a 45-year-old male who presented with multiple bee stings and subsequently developed acute kidney injury and pulmonary hemorrhage. He was managed with hemodialysis, invasive mechanical ventilation, red-cell transfusion, and pulse methylprednisolone. However, he developed cardiac arrhythmias with ventricular tachycardia and died.
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Mediastinal extension of amoebic liver abscess: A case report on the rare thoracic complication of Entamoeba histolytica p. 250
Gautam Jesrani, Jaspreet Kaur, Samiksha Gupta, Yuvraj Singh Cheema, Prashant Ahlawat
Amoebic liver abscess is one frequently encountered intra-abdominal infection, caused by Entamoeba histolytica and has various abdominal and thoracic life-threatening complications. Herein, describe a case of a 30-year-old female, who suffered from multiple amoebic liver abscesses and presented with massive right-sided pleural effusion. She was managed with recommended antibiotics and pigtail catheter for liver abscess and an intercostal drainage tube for massive pleural effusion. However, postintercostal drainage, her chest X-ray demonstrated a right mediastinal shadow, which was confirmed as an intrathoracic extension of the hepatic liver abscess on computed tomography. An ultrasound-guided pigtail catheter was manipulated and placed at the site of thoracic communication. This led to clinical and radiological improvement, but unfortunately, she developed ventilator-acquired pneumonia and died due to her illness. The case represents an uncommon complication of amoebic liver abscess, which is rarely described and adds more knowledge on the thoracic complexities of this infectious disease.
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Ultrasound-guided low-volume anterior suprascapular nerve block for reduction of anterior shoulder dislocation in the emergency department: A case series p. 254
Chitta Ranjan Mohanty, Anju Gupta, Rakesh Vadakkethil Radhakrishnan, Neha Singh, Saroj Kumar Patra
Anterior shoulder dislocation (ASD) is the most common type of dislocation presented to the emergency department (ED) with severe pain and limitation of range of movement. Procedural sedation and analgesia are commonly used for ASD, but regional techniques are gaining popularity. Interscalene brachial plexus block is effective but has several limitations. Suprascapular nerve block (SSNB) has been explored for this indication. The SSNB is commonly performed using the posterior approach in a sitting position and can be technically difficult in dislocated patients. Recently, anterior subomohyoid approach performed in the lower neck has been described but has not yet been reported in the ED. We, hereby, report our experience of using low-volume ultrasound-guided anterior SSNB for procedural analgesia in 10 patients with ASD.
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