Objective This study aimed to assess the prevalence of anemia in Hungary between 2019 and 2022 as detailed data in this regard was not available. Methods This retrospective, observational, cross-sectional study enrolled 85628 patients with a median age of 63 (44-76 interquartile range) years admitted to the Emergency Department of the University of Pécs, Hungary, between January, 2019, and December, 2022. Results The overall prevalence of anemia was 22.68%. The prevalence of anemia did not change significantly during the study period (2019: 22.30%; 2020: 22.88%; 2021: 22.55%; 2022: 23.00%). However, the prevalence of severe anemia (Hgb<8g/dL) was higher compared to 2019, in each year (2019:2.00%; 2020:2.52%; 2021:2.60%; 2022:2.47%, p<0.001). The increase was observed in each analyzed year among the elderly male patients and in 2021 and 2022 among the elderly female patients. The rising number of patients with COVID-19 diagnosis presenting severe anemia may have contributed to this change. Among all anemic patients, the overall prevalence of microcytic and macrocytic anemia accounted for one-third, while hypochromic and hyperchromic anemia for half of the cases. Hypochromic anemia prevalence decreased and normochromic anemia prevalence increased significantly in each year. The prevalence of microcytic anemia decreased in the year 2020 compared to 2019, the changes being observed among the female patients only. Conclusions Over the study period, anemia affected approximately one-quarter of the patients each year, while the proportion of severe anemia increased, especially in the elderly.

2021-ben az anémia a világ népességének 24,3%-át érintette. Irodalmi adatok szerint az anémia súlyosbíthatja a fertőzések lefolyását, és felvetődik, hogy az anémiás állapot fokozhatja a fertőzésekre való fogékonyságot. A COVID–19-pandémia lehetővé tette ezen hipotézis vizsgálatát. Retrospektív vizsgálatunk célja az anémia és a COVID–19-betegség előfordulásának vizsgálata sürgősségi ellátást igénylő járóbetegek között. 2020 és 2022 között a Pécsi Tudományegyetem – Klinikai Központ, Sürgősségi Orvostani Tanszék, Sürgősségi Osztályára felvett járóbetegek demográfiai és vérkép adatait elemeztük. A tanulmányba 62 924 esetet vontunk be. 4367 esetben volt elérhető a korábbi vérkép eredmény is. Az eseteket korcsoportonként, nemenként és diagnóziscsoportonként elemeztük. A betegek átlag életkora 60,28 ± 20,04 (SD) év volt. 10 552 esetben volt klinikailag igazolható a COVID–19-betegség. 14 129 esetben találtunk anémiát. A klinikailag diagnosztizált COVID–19-betegek között az anémia előfordulása 6,33%-kal magasabb volt. Az anémiás betegek között a COVID–19-megbetegedés előfordulása magasabb volt, mint a nem anémiás betegek csoportjában összességében, minden korcsoportban és minden évben. A felvételkor anémiás betegek között a COVID–19-betegség nagyobb eséllyel fordult elő (odds ratio – OR: 1,409). Jelentősen magasabb esélyt jelentett a COVID–19-betegség szempontjából a korábban igazolható és felvételkor is fennálló anémiás állapot (OR: 2,420), különösen az 50–65 év közötti betegek csoportjában (OR: 4,816). Az anémiás állapot oki kezelése jelentősen javíthatja a betegek életminőségét, csökkentheti fertőzésekre való fogékonyságot és a fertőző betegségekben szenvedők rosszabb klinikai kimenetelének kockázatát. Az anémia kezelése a betegellátás során a jelenleginél nagyobb figyelmet érdemel.

Bevezetés: Az akut ellátás egyik leggyakoribb kihívása a térben és időben limitált kommunikáció a betegekkel, hozzátartozókkal és egymás közt a kollégákkal. Ugyanakkor számos bizonyíték szól amellett, hogy az ellátás minősége, a betegelégedettség, a dolgozói elégedettség egyszerű kommunikációs eszközökkel (tréningekkel) javítható, mérhető, kutatható. Célkitűzés: A Pécsi Tudományegyetem Klinikai Központja Sürgősségi Orvostani Tanszékének Sürgősségi Betegellátó Osztályán dolgozókkal önkéntes részvétellel végzett vizsgálatokkal is ezt a célt tűztük ki. Módszer: Képzett pszichológus-színésszel és orvosi kommunikációban jártas szenior szakorvos közreműködésével vizsgáltuk az orvosi alkalmazott improvizáció kommunikációra gyakorolt lehetséges hatását oly módon, hogy a résztvevők – improvizációs gyakorlatok, feladatok teljesítése után – különböző kommunikációs kihívást szimuláló szituációkban tudták tesztelni magukat. A foglalkozásokat bemelegítő improvizációs elemekkel kezdtük, majd előre meghatározott feladatokkal folytattuk, végül a tréningeket megbeszéltük. Kérdőíves vizsgálattal (Személyközi Bizalom Kérdőív – ICQ) ellenőriztük az improvizáció potenciálisan kedvező hatását a sürgősségi kommunikációra. Eredmények: Vizsgálataink igazolták, hogy az alkalmazott orvosi improvizációs elemek, a kommunikációs készségek játékos keretek közötti fejlesztése nemcsak asszertívebbé és empatikusabbá teszi a résztvevőket, hanem – felkészítés után – gördülékenyebb és hatékonyabb információcserét eredményez. Megbeszélés: A tréningeken részt vevőktől érkezett pozitív visszajelzések ugyancsak ezt támasztják alá. Célunk egy olyan, az akut ellátókra fókuszáló improvizációs tréning kidolgozása, mely kezdeti tapasztalataink alapján optimalizálhatja a betegekkel, hozzátartozókkal történő és a szakemberek egymás közötti kommunikációját. Következtetés: Az improvizációs technikák alkalmazása az akut betegellátás általunk vizsgált szegmensében új utakat nyithat meg a kommunikáció javításában. Orv Hetil. 2023; 164(19): 739–746.

There are several overlapping clinical practice guidelines in acute pancreatitis (AP), however, none of them contains suggestions on patient discharge. The Hungarian Pancreatic Study Group (HPSG) has recently developed a laboratory data and symptom-based discharge protocol which needs to be validated. (1) A survey was conducted involving all members of the International Association of Pancreatology (IAP) to understand the characteristics of international discharge protocols. (2) We investigated the safety and effectiveness of the HPSG-discharge protocol. According to our international survey, 87.5% (49/56) of the centres had no discharge protocol. Patients discharged based on protocols have a significantly shorter median length of hospitalization (LOH) (7 (5;10) days vs. 8 (5;12) days) p < 0.001), and a lower rate of readmission due to recurrent AP episodes (p = 0.005). There was no difference in median discharge CRP level among the international cohorts (p = 0.586). HPSG-protocol resulted in the shortest LOH (6 (5;9) days) and highest median CRP (35.40 (13.78; 68.40) mg/l). Safety was confirmed by the low rate of readmittance (n = 35; 5%). Discharge protocol is necessary in AP. The discharge protocol used in this study is the first clinically proven protocol. Developing and testifying further protocols are needed to better standardize patients’ care.

INTRODUCTION One of the most common challenges in acute care is the time- and space-limited communication with patients, relatives and colleagues. There is ample evidence, however, that the quality of care, patient and staff satisfaction can be improved, measured and researched using simple communication tools (e.g., training). OBJECTIVE This improvement was what we focused on when carrying out voluntary participation surveys with the staff of the Department of Emergency Medicine of the Clinical Centre of the University of Pécs. METHOD With the help of a trained psychologist-actor and a senior specialist in medical communication, we investigated the potential impact of applied improvisation on medical communication by testing the participants in various situations simulating communication challenges after having completed an improv-based communication training full of exercises, games and tasks. After warm-up games taken from improv, the participants completed pre-defined tasks and finished every session with discussion and self-reflective feedback. Questionnaire (Interpersonal Confidence Questionnaire - ICQ) was used to check the potentially positive impact of improvisation on emergency communication. RESULTS Our studies confirmed that the applied elements of medical improvisation, developing communication skills through play not only make participants more assertive and empathic, but also - after preparation - lead to a smoother and more effective exchange of information. Positive feedback from participants in the training sessions also confirms this. DISCUSSION Our aim is to develop an improvisation-based communication training focused specifically on acute care providers, which, based on our initial experience, could optimize communication with patients, relatives and also between professionals. CONCLUSION Application of improvisational techniques in this segment of acute care studied by us might open new perspectives to improve communication. Orv Hetil. 2023; 164(19): 739-746.

Improving communication skills in emergency medicine is an understudied and underutilized research field, however physicians in emergency medicine must be prepared for the unexpected. Medical improvisation is a novel method in improving skills of interpersonal communication, flexibility and adaptibility to change. With the aid of improvisation techniques pitfalls in medical communication can be rectified by increasing empathy, active listening, and adjusting oneself to accommodate to the communication needs and values of the others while managing to deliver clear messages both at interprofessional and interpersonal levels at high-stress, high stake environments. A group of postgraduate trainees ( n=17) in emergency medicine were recruited at the a tertiary university hospital emergency department( Department of Emergency Medicine, Clinical Centre, University of Pécs) for a pilot study to take part in a two session training. During the training applied improvisation Methods: were implemented to prime the participants to sensitive and effective communication. Changes in communication skills were measured pre- and post training. We hypothesized that communication skills would improve following the improv training. Statistical analysis was carried out by one sample T-test and linear regression. A significant improvement was detected between interpersonal communication skills regarding the questionnaires completed before and after training. Apart from a statistical difference, individual responses and feedback on the usefulness of such training were encouraging. Introduction of elements of medical improvisation proves to be an effective method to improve communication in acute care providers. We would like to extend our research to other groups of stakeholders in acute medicine with appropriately tailored trainings, along with the introduction of a new approach in acute care providers under huge pressure due to the pandemic.

The aim of our study was to investigate short- and medium-term survival in patients with sudden cardiac death (SCD) after resuscitation. We continued a retrospective study at the University of Pécs from April 2018 to December 2019. 192 patients with SCD were selected. Exclusion criteria were incomplete documentation and unstable rhythm, after which we continued the study with 181 patients. Our data were obtained from documents recorded by the Emergency Department. The study population was divided into two groups, with proven shockable (I) and non-shockable (II) initial rhythm, and their data were compared at hospital discharge, at 1 month, and at 3 months. The main endpoint was the mortality between the two groups. Our results already showed that hospital survival was significantly higher in the shockable rhythm group than in the non-shockable group (62% vs. 38%, P=0.002). We also obtained similar results for 1-month survival (54% vs. 16%, P=0.004). When risk factors were examined, there was a significant difference in the survival of diabetic (P=0.001) and hypertensive patients (P=0.001). Patients with shockable rhythm have significantly better survival rates.

Background: The adrenocortical system and copeptin as prognostic markers were intensively investigated in critical illness. The potential predictive power of apelin-13 as a biomarker is largely unknown. We aimed to investigate the prognostic role of apelin-13 in relation to free cortisol, aldosterone, CRH, and copeptin in critically ill patients. Methods: In this prospective observational study, 124 critically ill patients (64 men, 60 women, median age: 70 (59–78) years) were consecutively enrolled at the time of admission. All routinely available clinical and laboratory parameters were evaluated and correlated to hormonal changes. Results: Serum apelin-13 was 1161 (617–2967) pg/mL in non-survivors vs. 2477 (800–3531) pg/mL in survivors (p = 0.054). The concentrations of apelin-13 and CRH had strong positive correlations (r = 0.685, p < 0.001) and were significantly higher in surviving non-septic patients (Apelin-13 (pg/mL): 2286 (790–3330) vs. 818 (574–2732) p < 0.05; CRH (pg/mL) 201 (84–317) vs. 89 (74–233) p < 0.05). Apelin-13 and free cortisol were independent determinants of survival in the multivariate Cox regression analysis, while copeptin, CRH, or aldosterone were not. Conclusions: Beyond free cortisol, serum apelin-13 may also help refine prognostic predictions in the early phase of critical illness, especially in non-septic patients.

It is hard to imagine a modern hospital ward without a mobile ultrasound, bedside (point-of-care) sonography (POCUS) is a technique of the 21st century, which in emergency medicine settings (for example during primary survey) might replace the stethoscope at times. In emergency medicine - which is the hospital discipline closest to primary care - bedside ultrasound is part of the routine care by now, and its use is based on evidences of thorough research. Given that the emergency outpatient population is getting closer to primary care patients both in presentation and demography, we believe that the current POCUS evidences are probably applicable to primary care as well. Based on the clinical experience gained in emergency medicine, we assume that bedside ultrasound may also be helpful in general practice reliably diagnosing certain, potentially life-threatening pathologies, reducing the length of time until definitive treatment, increasing the success rate of certain interventions, improving patients' experience, and potentially alleviating staff burnout. The present article summarizes experiences with bedside sonography in the Anglo-Saxon world and tries to find its place in the Hungarian primary care. The widespread use of bedside ultrasound, however, in the Hungarian general practice is still lagging due to numerous barriers, the most pressing of those are training, legal responsibility and financing. Regardless, we believe, that even in this early, unregulated phase, it is worth considering to introduce bedside ultrasound into daily primary care. Competent use, however, requires continuous practice; based on the average adult patient turnover in an urban Hungarian "adult only" surgery, it might take six months to gain the necessary skills to provide high level, safe patient care. Orv Hetil. 2022; 163(52): 2067-2071.

COVID-19 infection may lead to serious complications, e.g., need for mechanical ventilation or death in some cases. A retrospective analysis of patients referred to our COVID Emergency Department, indiscriminately, was performed. A routine lab analysis measured amino acids in plasma and urine of patients. Data of surviving and deceased patients and those requiring or not requiring mechanical ventilation were compared, and logistic regression analyses have been performed. Deceased patients were older, had higher blood glucose, potassium, AST, LDH, troponin, d-dimer, hsCRP, procalcitonin, interleukin-6 levels (p < 0.05 for all). They had lower plasma serine, glycine, threonine, tryptophan levels (p < 0.01), higher tyrosine and phenylalanine levels (p < 0.05), and higher fractional excretion of arginine, methionine, and proline (p < 0.05) than survivors. In a regression model, age, severity score of COVID-pneumonia, plasma levels of threonine and phenylalanine were predictors of in-hospital mortality. There was a difference in ventilated vs. non-ventilated patients in CT-scores, glucose, and renal function (p < 0.001). Using logistic regression, CT-score, troponin, plasma level, and fractional excretion of glycine were predictors of ventilation. Plasma levels and renal excretion of certain amino acids are associated with the outcome of COVID-19 infection beside other parameters such as the CT-score or age.

Implementation of the Guidelines - How do we put the new ERC Guidelines into practice? On 16 and 17 June, we are organising our first-ever hybrid congress. You will be able to join us live at the beautiful conference venue in Antwerp, Belgium and present your Poster. We are happy to welcome you to Resuscitation 2022!

Mobil ultrahangvizsgálati lehetőség nélkül nehezen képzelhető el ma már modern kórházi osztály, az ágy melletti szonográfia („point-of-care ultrasonography”, POCUS) a 21. század technikája, amely például a sürgősségi ellátásban (például az úgynevezett „primary survey” során) esetenként akár kiválthatja a fonendoszkópot is. A sürgősségi orvoslásban – mely az alapellátáshoz legközelebb álló kórházi diszciplína – az ágy melletti ultrahangvizsgálat a napi rutinellátás része, használata magas szintű tapasztalaton alapul. Tekintettel arra, hogy a sürgősségi ambuláns populáció egyre közelebb kerül az alapellátás beteganyagához, elképzelhető, hogy a jelenlegi POCUS-evidenciák nagy valószínűséggel jól alkalmazhatók/vonatkoztathatók a felnőtt háziorvosi ellátásra is. A sürgősségi tapasztalatok alapján feltételezhető ugyanis, hogy az ágy melletti ultrahangvizsgálat a háziorvosi gyakorlatban is segíthet egyes, potenciálisan életet veszélyeztető kórképek diagnózisának felállításában, csökkentheti a definitív ellátásig eltelt időt, növelheti egyes beavatkozások sikerét, javíthatja a betegek ellátási élményét, valamint nem elhanyagolható módon hozzájárulhat az ellátószemélyzet kiégésének mérsékléséhez. A jelen áttekintés összefoglalja a külföldi alapellátásbeli tapasztalatokat, és igyekszik hazai perspektívába helyezni azokat. Orv Hetil. 2022; 163(52): 2067–2071.

Introduction The pooled worldwide prevalence of low-back pain-related presentations in primary care varies between 6.8% and 28.4% in the high-income countries rendering it a major healthcare/economy problem. To best manage this complex bio-psycho-social condition a 360-degree approach is needed, as the psycho-social components are often more important than the scant pathophysiology. Pattern analysis of cannabis users suggested that attempts to alleviate musculo-skeletal pain is often seen as a major drive to use cannabinoids. Areas covered Unlike NSAIDs/opioids, cannabidiol might directly affect more than one modality of pain signaling/perception. The 2019 guideline of the National Institute for Clinical Excellence recommended further studies with cannabidiol in pain medicine because of its excellent safety profile and presumed therapeutic potential. Therefore, we have researched relevant databases for pharmaco-physiological papers published between 2000 and 2021 to collate evidence in a narrative fashion to determine the clinical rationale for this cannabinoid in low-back pain. Expert opinion Observational research reported good results with CBD in pain and fear reduction, which are both key factors in low-back pain. Given the paucity of high-quality evidence, further research is needed to determine the efficacy/non-inferiority of CBD in primary/emergency care setting, using multimodal assessment of various patient-reported outcomes.

The incidence and medical costs of acute pancreatitis (AP) are on the rise, and severe cases still have a 30% mortality rate. We aimed to evaluate hypoalbuminemia as a risk factor and the prognostic value of human serum albumin in AP. Data from 2461 patients were extracted from the international, prospective, multicentre AP registry operated by the Hungarian Pancreatic Study Group. Data from patients with albumin measurement in the first 48 h (n = 1149) and anytime during hospitalization (n = 1272) were analysed. Multivariate binary logistic regression and Receiver Operator Characteristic curve analysis were used. The prevalence of hypoalbuminemia (< 35 g/L) was 19% on admission and 35.7% during hospitalization. Hypoalbuminemia dose-dependently increased the risk of severity, mortality, local complications and organ failure and is associated with longer hospital stay. The predictive value of hypoalbuminemia on admission was poor for severity and mortality. Severe hypoalbuminemia (< 25 g/L) represented an independent risk factor for severity (OR 48.761; CI 25.276–98.908) and mortality (OR 16.83; CI 8.32–35.13). Albumin loss during AP was strongly associated with severity (p < 0.001) and mortality (p = 0.002). Hypoalbuminemia represents an independent risk factor for severity and mortality in AP, and it shows a dose-dependent relationship with local complications, organ failure and length of stay.

Összefoglaló. Bevezetés: A szédülés gyakori panasz, amellyel a betegek felkeresik a sürgősségi osztályt. Emellett fontos tünet, hiszen kihívást jelent mind a diagnosztika, mind a terápia szempontjából, és nagy hatással lehet a betegek életminőségére. Célkitűzés: Kutatásunk célja annak vizsgálata, hogy mennyire befolyásolta a szédülés a betegek életminőségét a sürgősségi osztály elhagyását követően. Módszer: A vizsgálat időtartama alatt 879, szédülést panaszoló beteg jelent meg a Semmelweis Egyetem sürgősségi osztályán. Részükre kérdőív került kiküldésre, amely tartalmazta a 'Dizziness Handicap Inventory' (DHI-) kérdőívet is. Megkeresésünkre 308 beteg (110 férfi, 198 nő; átlagéletkor: 61,8 ± 12,31 SD) válaszolt, az általuk visszaküldött kérdőíveket részletesen elemeztük. Eredmények: A leggyakoribb diagnózisok közé a benignus paroxysmalis positionalis vertigo, a centrális egyensúlyrendszeri eltérések és a szédülékenység tartoztak. Az elemzés alapján különbség volt látható a fizikális, a funkcionális és az emocionális pontszámok között. Kiemelendő, hogy a legmagasabb értékeket a fizikális csoportban regisztráltuk. A részletes otoneurológiai kivizsgáláson átesett betegek DHI-értékeit összevetettük azokéival, akik nem jártak ilyen vizsgálaton, a két csoport értékei között azonban nem volt szignifikáns különbség (p = 0,97). Emellett a DHI-érték emelkedése volt látható a végleges diagnózisig eltelt idő függvényében. Következtetés: A végleges diagnózisig eltelt idő, illetve a megfelelő kivizsgálás hiánya jelentős hatással van a szédülő betegek életminőségére. Lényeges a kivizsgálás, a mielőbbi diagnózis és a részletes egyensúlyrendszeri vizsgálat szerepe, ugyanakkor az utóbbi indokolt esetben kell, hogy történjen. Orv Hetil. 2021; 162(30): 1216-1221.SUMMARY:INTRODUCTION:Dizziness and vertigo are among the most common complaints in the emergency department. This may require interdisciplinary cooperation due to their complex presentation in the department and the effects on the patients' quality of life.OBJECTIVE:Our study aimed to assess the effect of an acute vertigo episode on the quality of life after patients' discharge from the emergency department.METHOD:879 patients examined at the Semmelweis University emergency department with vertigo and dizziness were included in the study. A questionnaire, including the Dizziness Handicap Inventory (DHI), was addressed to this population. We received 308 answered questionnaires back (110 males, 198 females; mean age 61.8 years ± 12.31 SD), which were further analyzed.RESULTS:The most frequent diagnoses were benign paroxysmal positional vertigo, central lesions and dizziness. According to the analysis of the DHI questionnaire, a difference between physical, functional and emotional scores was shown, whereas the highest scores were registered in the physical group. The DHI questionnaire scores of patients undergoing a neurotological examination and those who did not were further compared, whereas no significant statistical difference was indicated (p = 0.97). In addition, an increase in DHI scores was seen depending on the time elapse for the definitive diagnosis.CONCLUSION:The absence of adequate examination and a late diagnosis of the dizziness cause have a significant impact on the quality of life of patients. Therefore, substantial investigation, early diagnosis, and detailed vestibular examination are essential, but the latter should take place in justified cases. Orv Hetil. 2021; 162(30): 1216-1221.

Objectives Conditions that have similar initial presentations as sepsis may make early recognition of sepsis in an emergency room (ER) difficult. We investigated whether selected physiologic and metabolic parameters can be reliably used in the emergency department to differentiate sepsis from other disease states that mimic it, such as dehydration and stroke. Methods Loess regression on retrospective follow-up chart data of patients with sepsis-like symptoms ( N = 664) aged 18+ in a large ER in Hungary was used to visualize/identify cutoff points for sepsis risk. A multivariate logistic regression model based on standard triage data was constructed with its corresponding receiver operating characteristic (ROC) curve and compared with another model constructed based on current sepsis guidelines. Results Age, bicarbonate, HR, lactate, pH, and body temperature had U, V, W, or reverse U-shaped associations with identifiable inflexion points, but the cutoff values we identified were slightly different from guideline cutoff values. In contrast to the guidelines, no inflexion points could be observed for the association of sepsis with SBP, DPB, MAP, and RR and therefore were treated as continuous variables. Compared to the guidelines-based model, the triage data-driven final model contained additional variables (age, pH, bicarbonate) and did not include lactate. The data-driven model identified about 85% of sepsis cases correctly, while the guidelines-based model identified only about 70% of sepsis cases correctly. Conclusion Our findings contribute to the growing body of evidence for the necessity of finding improved tools to identify sepsis at early time points, such as in the ER.

In sepsis cytokine-mediated inflammation, clotting cascade activation and glycocalyx shedding impair both function and structure of the microcirculation, compromising adequate tissue oxygenation/perfusion. Such mismatch results in "dysoxia", an imbalance in mitochondrial respiration. Microvessel injuries can be grouped into four types: cytotoxic oedema, micro-vessel heterogeneity, sluggish/absent flow, and focal anaemia. Recognition of such diversity in microcirculatory pathology, alongside with the implementation of novel biomarkers might reveal previously unobserved heterogeneity in adults diagnosed with sepsis. Early identification of distinct subtypes may help not only to better stratify disease severity but may also provide explanation to the often seen insufficient/absent response to resuscitative treatment. Experimental evidence suggests that impaired microcirculatory flow may correlate with organ dysfunction and mortality. Therefore, reliable/reproducible diagnostic tools, that provide real-time information about the dynamic state of the microcirculation, might be practice changers in managing the critically ill. The sublingual mucosa and the nailfolds provide easy access to microcirculation via hand-held, point-of-care devices. Accessing these windows, clinicians may recognise, understand and potentially correct the underlying tissue oxygenation/perfusion mismatch. This new clinical information might facilitate an individualised approach vs protocolised care aiming to administer the right balance of intravenous fluids/vasopressors, time/dose auxiliary treatment modalities and, most importantly, might also guide determining the optimal duration of resuscitation to avoid/minimise harm and maximise benefits in sepsis management. However, before every-day clinical use of such point-of-care microcameras, validation studies are needed to establish not only feasibility but reliability and reproducibility as well.

Background: Metabolic risk factors, such as obesity, hypertension, and hyperlipidemia are independent risk factors for the development of various complications in acute pancreatitis (AP). Hypertriglyceridemia dose-dependently elicits pancreatotoxicity and worsens the outcomes of AP. The role of hyperglycemia, as a toxic metabolic factor in the clinical course of AP, has not been examined yet. Methods: We analyzed a prospective, international cohort of 2250 AP patients, examining associations between (1) glycosylated hemoglobin (HbA1c), (2) on-admission glucose, (3) peak in-hospital glucose and clinically important outcomes (mortality, severity, complications, length of hospitalization (LOH), maximal C-reactive protein (CRP)). We conducted a binary logistic regression accounting for age, gender, etiology, diabetes, and our examined variables. Receiver Operating Characteristic Curve (ROC) was applied to detect the diagnostic accuracy of the three variables. Results: Both on-admission and peak serum glucose are independently associated with AP severity and mortality, accounting for age, gender, known diabetes and AP etiology. They show a dose-dependent association with severity (p < 0.001 in both), mortality (p < 0.001), LOH (p < 0.001), maximal CRP (p < 0.001), systemic (p < 0.001) and local complications (p < 0.001). Patients with peak glucose >7 mmol/l had a 15 times higher odds for severe AP and a five times higher odds for mortality. We found a trend of increasing HbA1c with increasing LOH (p < 0.001), severity and local complications. Conclusions: On-admission and peak in-hospital glucose are independently and dose-dependently associated with increasing AP severity and mortality. In-hospital laboratory control of glucose and adequate treatment of hyperglycemia are crucial in the management of AP. (c) 2021 Published by Elsevier B.V. on behalf of IAP and EPC.

For about a quarter of a century, monitoring lactate levels and/or lactate clearance has been an unquestionable cornerstone in sepsis management. The elevated lactate level appeared to be an independent predictor of mortality, and the consequent metabolic acidosis was thought to explain a number of pathophysiological changes seen in septic shock. Recent physiological and clinical findings seem to challenge the adverse role of lactic acidosis in sepsis. Evidence suggests that lactate levels are not necessarily directly proportional to either tissue or cellular hypoxia, and conversely, despite high lactate levels, increased peripheral tissue oxygen pressure can be measured in adult patients with septic shock. According to the most recent understanding of in vitro and in vivo evidence, the elevated lactate level in sepsis might be a normal reaction due to adrenergic stress with potential beneficial/protective physiological effects, as well. On the one hand, burning lactic may help fuel the body during critical illness, but on the other hand, with a slight drop in pH, the body may counteract certain deleterious changes during the dysregulated host response; reduce the chances of reperfusion myocardial injury, and improve tissue oxygenation by shifting the haemoglobin dissociation curve to the right. Understanding the pathophysiological process in sepsis resulting in elevated lactate levels may aid management in an emergency, medicine, and intensive care settings. With more in-depth physiological knowledge, physicians may inevitably surpass normalisation heuristics and deliver personalized rather than protocolised sepsis resuscitation.

Background Chest pain is one of the commonest presenting complaints in urgent/emergency care, with a lifelong prevalence of up to 25% in the adult population. Pleuritic chest pain is a subset of high investigation burden because of a diverse range of possible causes varying from simple musculoskeletal conditions to pulmonary embolism. Case series Among otherwise fit and healthy adult patients presenting in our emergency department with sudden onset of unilateral pleuritic chest pain, within 1 month we identified a cohort of five patients with pin-point tenderness in one specific costo-sternal joint often with referred pain to the back. All cases had apparent and, previously undiagnosed mild/moderate scoliosis. Methods To confirm and validate the observed association between scoliosis and pleuritic chest pain, a retrospective audit was designed and performed using the hospital’s electronic medical record system to reassess all consecutive adult chest pain patients. Results The Odds Ratio for having chest pain with scoliosis was 30.8 [95%CI 1.71–553.37], twenty times higher than suggested by prevalence data. Discussion In scoliosis the pathologic lateral curvature of the spine adversely affects the functional anatomy of both the spine and ribcage. In our hypothesis the chest wall asymmetry enables minor slip/subluxation of a rib either in the costo-sternal and/or costovertebral junction exerting direct pressure on the intercostal nerve causing pleuritic pain. Conclusion Thorough physical examination of the anterior and posterior chest wall is key to identify underlying scoliosis in otherwise fit patients presenting with sudden onset of pleuritic pain. Incorporating assessment for scoliosis in the low-risk chest pain protocols/tools may help reducing the length of stay in the emergency department and, facilitate speedy but safe discharge with increased patient satisfaction.