The ST-segment elevation (STE) myocardial infarction (MI)/non-STEMI (NSTEMI) paradigm has been the central dogma of emergency cardiology for the last 30 years. Although it was a major breakthrough when it was first introduced, it is now one of the most important obstacles to the further progression of modern MI care. In this article, we trace why a disease with an established underlying pathology (acute coronary occlusion [ACO]) was unintentionally labeled with a surrogate electrocardiographic sign (STEMI/NSTEMI) instead of pathologic substrate itself (ACO-MI/non-ACO-MI or occlusion MI [OMI]/non-OMI [NOMI] for short), how this fundamental mistake caused important clinical consequences, and why we should change this paradigm with a better one, namely OMI/NOMI paradigm.

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Monkeypox (MPXV) is an emerging zoonotic disease carrying a global health threat. Using a multi-disciplinary approach, we review the current MPXV virus infection outbreak including virology, prevention, clinical presentation, and disaster management. MPXV is caused by a double-stranded deoxyribonucleic acid virus. Despite its clinical similarities with smallpox, it is less severe with low mortality. Human-to-human transmission occurs through prolonged direct or close contact, or through blood, body fluids, or mucosal lesions. Risk groups include frontline health workers who care for MPXV patients, household members of an infected patient, and men who have sex with men. Skin lesions are usually, but not always, at the same stage. They may affect the face followed by the distal extremities with fewer lesions on the trunk (centrifugal distribution). Lesions may involve the mouth, genitalia, conjunctiva, and rectum. The majority of cases are mild. Nevertheless, the disease may have long-term effects on the skin, the neurological system, and the eye. Vaccination against MPXV is available but meanwhile should be limited to those who are at high risk. Those vaccinated against smallpox (usually older than 40 years) might be immune against MPXV. Infectious diseases are without borders. If proper action is not taken, there is considerable risk that MPXV will be entrenched worldwide. Our world has a delicate balance between animals, environment, and humans reflecting the need for a “one globe, one health approach” to address this risk. Following the principles of disaster management and using the lessons we have learned from the COVID-19 pandemic will reduce the impact of the MPXV outbreak.

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IgA nephropathy is a renal-limited form of systemic vasculitis, and pulmonary manifestations are uncommon. An initial presentation with severe diffuse alveolar hemorrhage (DAH) or pulmonary-renal syndrome is rare and only confined to a few case reports. Herein, we present a young male admitted with acute-onset dyspnea, hemoptysis, and rapidly progressive renal failure. With an initial diagnosis of an immune-mediated pulmonary-renal syndrome, he was treated with high-dose corticosteroids and therapeutic plasmapheresis along with intensive organ support (including hemodialysis, red cell transfusion, and high-flow oxygen). After a detailed laboratory evaluation and kidney biopsy, IgA nephropathy was diagnosed. The patient continued to worsen with persistent DAH and died. IgA nephropathy-associated severe DAH or pulmonary-renal syndrome is rare but increasingly recognized. The condition is difficult to diagnose early and has no proven disease-targeted therapy.

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Vasmol, a commonly used hair dye, is becoming apparent as one of the major causes of suicidal poisoning in India. The toxic components in the dye include paraphenylenediamine, sodium ethylenediaminetetraacetic acid, resorcinol, and propylene glycol. Acute poisoning by consumption of dye leads to characteristic angioedema of the cervicofacial region along with multiorgan dysfunction. Early intervention with tracheostomy can be lifesaving in such cases and helps in preventing the morbidity and mortality associated with it.

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OBJECTIVES: Various ultrasound (US)-guided probe positioning and needle procedures have been described in the literature for cannulation of the internal jugular vein (IJV). In the present study, we compared the conventional short-axis out-of-plane (SAX-OOP) method with a novel anteroposterior short-axis in-plane (APSAX-IP) technique for IJV cannulation under US guidance. The APSAX-IP method of IJV cannulation has not been compared to other IJV cannulation techniques. METHODS: A total of 104 patients above 18-year-old were randomly allocated to one of two groups - APSAX-IP or SAX-OOP and evaluated for US-guided IJV cannulation in either the operating room or critical care unit. The primary outcome of this research was the access time for IJV cannulation using both approaches. The secondary outcomes were the number of attempts of needle insertion, success rate, and complications of IJV cannulation. RESULTS: The access time for IJV cannulation was 13.0 (12.0–15.0) sec in the APSAX-IP group and 13.0 (12.0–14.0) sec in the SAX-OOP group; P = 0.947. The number of successful 1^st attempts was 90.91%, and the 2^nd attempts were 9.09% in the APSAX-IP group and 85.19% and 14.81% in the SAX-OOP group, respectively. Both techniques did not have any complications. CONCLUSIONS: We conclude that the US-guided APSAX-IP IJV cannulation method has comparable access time to the SAX-OOP technique.

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OBJECTIVES: Ultrasound (US) airway indexes were frequently compared with other scoring systems such as Mallampati score and Cormack − Lehane classification system, but to the best of our knowledge never with LEMON. Here, in this study, we evaluated the accuracy of some recommended airway US parameters in terms of screening difficult airway using the LEMON criteria as a reference. METHODS: This was a cross-sectional diagnostic accuracy study in which people with at least 18 years old coming to the emergency departments for any reason who had consent for participation, were enrolled with the simple random sampling method. Hyo-mental distance (HMD), skin to epiglottis distance (EP), and peri-epiglottic space to epiglottis to vocal cord ratio (PEP/E. VC) were the US indexes that were calculated in all participants. Using a preprepared checklist, measured US parameters were recorded. For each participant, the LEMON score variables were also assessed and recorded, and the cutoff point for considering as a difficult airway case, based on LEMON score, was 2. Demographic characteristics of the participants were also registered. RESULTS: A total of 299 cases with a mean age of 41.1 years (95% confidence interval [CI]: 39.3–42.9), were participated. Based on LEMON score ≥2, 20 participants (6.7%) were categorized in difficult airway group. Comparison of the PEP/E. VC (P = 0.007) and EP distance (P = 0.049) of the participants based on LEMON score showed a statistically significant difference; but comparison of the means of HMD in the two groups was not statistically significant (P = 0.144). The median of EP of the participants was 7.70 mm (interquartile range [IQR]: 6.70–9.40). The best cutoff point of EP distance for evaluating a difficult airway was 12.27 mm and more with the sensitivity of 35% and the specificity of 86.96% (accuracy = 0.614; 95% CI: 0.492–0.736). The median of PEP/E. VC was 1.01(IQR: 0.79–1.23). The best cutoff point of PEP/E. VC for evaluating a difficult airway was 0.88 and less with the sensitivity of 70% and the specificity of 67.38% (accuracy = 0.701; 95% CI: 0.583–0.818). CONCLUSION: As per our results, PEP/E. VC and EP distance measured with sonography can be used in distinguishing the difficult airway, using the LEMON criteria as the reference. However, further studies are needed to use PEP/E. VC and EP distance as a part of reliable indexes.

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OBJECTIVES: This study was conducted to investigate the association between visible cardiac activity in point-of-care ultrasound (POCUS) and outcomes of cardiac arrest such as the return of spontaneous circulation (ROSC), survival to inpatient admission (SIA), and survival to hospital discharge (STHD). METHODS: This was a single-center, prospective cohort study conducted in the emergency department (ED). Adult (age >18 years) patients in cardiac arrest were included in the study. Exclusion criteria of the study were – traumatic arrest, out-of-hospital cardiac arrest resuscitated before ED admission, and patients presenting with initial shockable rhythm. Patients whose ultrasound images could not be obtained and whose resuscitation stopped following POCUS were also excluded from the study. POCUS examination was done after 2 min of initiation of cardiopulmonary resuscitation (CPR) and visible cardiac activity was defined as any visible movement of the myocardium, excluding movement of blood within cardiac chambers, or isolated valve movement. The duration of POCUS examinations was limited to 10 s. The association of initial cardiac activity in POCUS with the outcomes of cardiac arrest was investigated. RESULTS: Out of 140 patients screened, 84 patients were included in the study. Rates of ROSC, SIA, and STHD were found in 23 (27.4%), 9 (10.7%), and 2 (2.4%) patients, respectively. Only 15 out of 84 (17.9%) patients had cardiac activity on the initial POCUS examination. Cardiac activity was seen in 52.2% of patients with ROSC, which was significantly higher (P < 0.001) as compared with the no-ROSC group (4.9%). Unlike the above association, there was no difference in the incidence of initial cardiac activity in patient groups who got admitted (SIA) and discharged (STHD) versus those who died. In the multivariate regression analysis, the duration of CPR and initial cardiac activity significantly predicted the rate of ROSC, with an adjusted odds ratio of 0.93 (95% confidence interval [CI]: 0.86–0.99, P = 0.04) and 24.8 (95% CI: 3.17–89.41, P = 0.002), respectively. None of the variables predicted SIA and STHD. The positive likelihood ratio of cardiac activity for predicting ROSC, SIA, and STHD were 10.6, 2.1, and 2.9, respectively. CONCLUSION: Integration of POCUS in cardiac arrest resuscitation was shown to be helpful in terms of prognostic significance of the presence of initial cardiac activity in terms of ROSC.

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OBJECTIVES: Pulmonary embolus (PE) is a form of venous thromboembolism associated with increased morbidity and mortality if not diagnosed and treated early. Variations in clinical presentation make the diagnosis challenging. The gold standard for diagnosing PE is a computed tomography pulmonary angiogram (CTPA). Physicians show a low threshold for over-investigating PE. The evaluation of patients with suspected PE should be efficient, including but not limited to the use of risk stratification methods. This study aims to assess the adherence to the recommended diagnostic pathways of ordering CTPAs in patients with suspected PE. METHODS: This retrospective cohort study included patients above 18 years of age who received a CTPA for a suspected PE in the emergency department (ED) of a hospital between 2015 and 2019. Patient demographic data, chief complaint, variables of the Wells and pulmonary emboli rule-out criteria scores, pregnancy status, investigations, and the patient's final PE diagnosis were extracted from the hospital electronic medical records. Diagnostic pathways that took place were compared to the internationally recommended pathway. RESULTS: Four hundred and eighty-six patients were included in this study. The mean age was 51.01 (±19.5) years, and 377 (69.3%) patients were female. The recommended PE diagnostic pathway to order CTPA was incorrectly followed in 288 patients (59.3%). Seventy-five (15.4%) patients received an unnecessary CTPA. D-dimer test was ordered unnecessarily in 144 patients (29.6%). The overall prevalence of PE in our population was 9.47% (n: 46). Out of the 75 unnecessarily ordered CTPAs, 2 (2.7%) showed PE, while CTPAs ordered using the correct pathway showed 31 (10.9%) PEs. CONCLUSION: Our study revealed that approximately two-thirds of all CTPA requests did not adhere to the recommended PE clinical decision pathway. There was a significant improper and unnecessary utilization of CTPA imaging and D-dimer testing. Improvements seem imperative to enhance physicians' clinical approach to PE diagnosis.

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OBJECTIVES: This single-center, retrospective study investigates the predictive value of cardiovascular (CV) risk-calculation systems in patients admitted to the emergency department with carbon monoxide (CO) intoxication for the identification of potential myocardial injury. METHODS: The total CV risk of 558 patients presenting to the emergency department with CO intoxication were calculated on admission using different CV risk scoring systems, including SCORE Turkey, European Heart SCORE, and FRAMINGHAM to predict potential myocardial injury secondary to poisoning, and the risk levels were categorized based on the calculated scores. The presence of myocardial injury was identified based on the level of elevation of a cardiac biomarker (Serum cardiac troponin-I >99^th percentile upper reference limit). RESULTS: Myocardial injury due to CO intoxication was detected in 132 (23.7%) of the patients. A comparison of the risk scoring systems' ability to detect the presence of myocardial injury revealed that all had significant, similar, but low predictive values (the “area under the curve” values of SCORE Turkey, European Heart SCORE and FRAMINGHAM were 0.653, 0.632, and 0.629, respectively; P < 0.001). Among the three risk scoring systems, SCORE Turkey was the most successful test in diagnosing myocardial injury with 87% specificity, while FRAMINGHAM scoring was the most successful test in excluding the presence of myocardial injury with 72.1% sensitivity. CONCLUSION: Among the tested CV risk-calculation systems SCORE Turkey, was found to be the most effective in the prediction of myocardial injury secondary to CO poisoning, but all produced similar and significant results.

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We present a patient with multiple bee stings who developed lung and liver injuries and subsequently tested positive for coronavirus disease 2019 (COVID-19). A 65-year-old male patient presented to the emergency department after being stung by more than 100 honeybees. His physical examination revealed pustular lesions distributed across his chest, arms, back, legs, and head, marking the sting zones. While the patient had no history of liver disease, initial laboratory test results showed elevated liver enzyme levels. A chest computer tomography scan was ordered, revealing bilateral ground-glass opacities suggesting COVID-19. His condition worsened over the course of the following day, and when he was admitted to the intensive care unit (ICU), his SpO₂ decreased to 83% despite oxygen support with a mask. The second polymerase chain reaction test taken in the ICU was positive for COVID-19 infection. After stung with multiple bees, the patient developed acute liver injury and suffered from concomitant COVID-19-related respiratory insufficency, and he was treated accordingly. Starting on the 5^th day, the patient's liver markers began to improve, and on the 13^th day, he was discharged with normal vital signs and liver enzyme values. There seem to be varying outcomes across different studies with regard to the relationship between bee stings and COVID-19. Further research is needed to explore the possibility of this complementary treatment with bee venom in the prevention of severe acute respiratory syndrome coronavirus-2 infection.

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