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Objectives: Overcrowding in the Emergency Department (ED) is a serious and growing problem during recent years and one of the main causes of it is dysfunctional consultation system. We aimed to determine the problems related to patients who were admitted to the ED and requested consultations from internal medicine (IM) physicians and to contribute to the gap in the literature regarding this isssue. Methods: In a period of one year, 3601 patients, who were admitted to the ED of a university hospital and were consulted by IM physicians were included in this prospective cross-sectional study. The epidemiological characteristics of patients, length of ED stay and consultation-related problems were investigated. Results: The most common problems related to consultations were delayed completion of the consultation procedures for 88 (2.4%) patients, and unnecessary consultation requests for 66 (1.8%) patients, and patient referrals with inappropriate indications from IM outpatient clinics to the ED for 53 (1.5%) patients. There were differences of opinion among IM physicians and emergency medicine specialists regarding the need for consultation for 36 (1%) patients. The most important difference was in the various infections seen in patients with histories of hematologic or solid organ malignancies (n = 9). Conclusions: According to these findings, good collaboration must be established among ED physicians and consultant physicians. Furthermore, physicians must avoid inappropriate referral patients from outpatient clinics to the ED. Additionally, unnecessary consultation requests from the ED must be avoided, and consultation requests must be addressed quickly.

Introduction: Amphotericin B (AmB-d) is one of the most effective therapeutic options against frequently life-threatening systemic fungal infections in patients with hematologic malignancies. However, significant adverse effects including nephrotoxicity associated with its use limit its more widespread use. The objectives of our study were to determine the incidence of AmB-d associated nephrotoxicity, to evaluate clinical and epidemiological characteristics of patients, and to support the notion that conventional amphotericin B remains a valid therapeutic option among hematologic patients with proper patient selection.Materials and methods: A total of 110 patients with hematologic malignancies were admitted to our Hematology Unit between January 2014 and November 2017 who required anti-fungal therapy during intensive systemic chemotherapy. The incidence of AmB-d associated nephrotoxicity, side effect profile, time to nephrotoxicity, and clinical and epidemiological characteristics associated with treatment success were assessed retrospectively.Results: Of the 110 patients receiving AmB-d, 70 (63.6%) were male and 40 (36.4%) were female. The mean age of participants was 44 years. The most common diagnosis was acute myeloid leukemia (n=53, 48.2%), and the most common chemotherapy protocol was 7 + 3 remission-induction (cytarabine 100 mg/m² days 1-7, Idarubicin 12 mg/m² days 1-3; n=24, 21.8%). In 56.4% of the patients, antifungal therapy was given empirically. In 40 patients (36.4%), nephrotoxicity was observed following antifungal treatment, and only four patients had stage 3 renal failure. The mean duration of time to nephrotoxicity from initiation of amphotericin B was four days (min: 2, max: 31). All patients were found to receive at least one additional potential nephrotoxic treatment during the antifungal treatment process. Conclusion: AmB-d is associated with a significant risk of nephrotoxicity. In most hematological patients, antifungal treatment is initiated empirically, and patients received prolonged courses of treatment. Therefore, it is plausible to initiate such treatment with AmB-d, when one considers the already high treatment costs in this patient group as well as the fact that AmB-d offers similar efficacy to antifungal agents at a lower cost. AmB-d may be recommended as a first-line agent in this patient group with the introduction of newer and more costly antifungal agents when needed, on the basis of the fact that these patients can be closely monitored in a hospital setting, reversible nature of nephrotoxicity upon discontinuation, and rare occurrence of severe renal failure requiring dialysis.

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