Characteristics of the traumatic forensic cases admitted to emergency department and errors in the forensic report writing

Objective: To identify errors in forensic reports and to describe the characteristics of traumatic medico-legal cases presenting to the emergency department [ED] at a tertiary care hospital

Methods: This study is a retrospective cross-sectional study. The study includes cases resulting in a forensic report among all traumatic patients presenting to the ED of Adiyaman University Training and Research Hospital, Adiyaman, Turkey during a 1-year period. We recorded the demographic characteristics of all the cases, time of presentation to the ED, traumatic characteristics of medico-legal cases, forms of suicide attempt, suspected poisonous substance exposure, the result of follow-up and the type of forensic report

Results: A total of 4300 traumatic medico-legal cases were included in the study and 72% of these cases were male. Traumatic medico-legal cases occurred at the greatest frequency in July [10.1%] and 28.9% of all cases occurred in summer. The most frequent causes of traumatic medico-legal cases in the ED were traffic accidents [43.4%], violent crime [30.5%], and suicide attempt [7.2%]. The most common method of attempted suicide was drug intake [86.4%]. 12.3% of traumatic medico-legal cases were hospitalized and 24.2% of those hospitalized were admitted to the orthopedics service. The most common error in forensic reports was the incomplete recording of the patient's "cooperation" status [82.7%]. Additionally, external traumatic lesions were not defined in 62.4% of forensic reports

Conclusion: The majority of traumatic medico-legal cases were male age 18-44 years, the most common source of trauma was traffic accidents and in the summer months. When writing a forensic report, emergency physicians made mistakes in noting physical examination findings and identifying external traumatic lesions. Physicians should make sure that the traumatic medico-legal patients they treat have adequate documentation for reference during legal proceedings. The legal duties and responsibilities of physicians should be emphasized with in-service training

value of frontal planar QRS-T angle in patients without angiographically apparent atherosclerosis

Objective: The present study was undertaken to investigate the prognostic value of the frontal planar QRS-T angle in patients without angiographically apparent coronary atherosclerosis

Subjects and Methods: Three hundred and seven patients with normal coronary arteries on coronary angiography were included. The absolute difference between the frontal QRS- and T-wave axes was defined as the frontal planar QRS-T angle, and patients were divided into 3 subgroups based on the frontal planar QRS-T angle [<45, 45-90, and >90]. Demographic, clinical, laboratory, and angiographic data were compared between groups. Based on the regression analysis results, patients were recategorized into 4 groups according to their luminal calibers of left main coronary artery [LMCA] and history of hypertension [HT] [nonhypertensive LMCA 4.13 mm, hypertensive LMCA 4.13 mm]

Results: The median value of the frontal planar QRS-T angle of all participants was 38°. Subjects with the widest frontal planar QRS-T angle were older [p = 0.027], were hypertensive [p = 0.001], and had higher corrected QT values [p = 0.001]. Patients with the widest frontal planar QRS-T angle had larger LMCA and left anterior descending coronary artery diameters compared to subjects with a normal and borderline frontal QRS-T angle [p = 0.004 and p = 0.028, respectively]. Corrected QT, HT, and LMCA diameter were found as independent predictors of the frontal planar QRS-T angle. Subjects with HT and a larger luminal caliber of LMCA had the widest frontal planar QRS-T angle

Conclusion: Patients with a history of HT and a larger luminal caliber of LMCA had the widest frontal planar QRS-T angle. Since HT-induced electrophysiological changes are still not well established and we observed that changes in the luminal caliber of coronary arteries are associated with an abnormal frontal QRS-T angle, the frontal QRS-T angle could serve as a marker of ventricular repolarization heterogeneity in hypertensive patients in addition to keeping track of arrhythmic events, even before overt disease

Relationship between Pulmonary Artery Stiffness and Functional Capacity in Patients with Heart Failure with Reduced Ejection Fraction

BACKGROUND AND OBJECTIVES: Functional capacity varies significantly among patients with heart failure with reduced ejection fraction (HFrEF), and it remains unclear why functional capacity is severely compromised in some patients with HFrEF while it is preserved in others. In this study, we aimed to evaluate the role of pulmonary artery stiffness (PAS) in the functional status of patients with HFrEF. METHODS: A total of 46 heart failure (HF) patients without overt pulmonary hypertension or right HF and 52 controls were enrolled in the study. PAS was assessed on parasternal short-axis view using pulsed-wave Doppler recording of pulmonary flow one centimeter distal to the pulmonic valve annulus at a speed of 100 mm/sec. PAS was calculated according to the following formula: the ratio of maximum flow velocity shift of pulmonary flow to pulmonary acceleration time. RESULTS: PAS was significantly increased in the HFrEF group compared to the control group (10.53±2.40 vs. 7.41±1.32, p < 0.001). In sub-group analysis of patients with HFrEF, PAS was significantly associated with the functional class of the patients. HFrEF patients with poor New York Heart Association (NYHA) functional capacity had higher PAS compared those with good functional capacity. In multivariate regression analysis, NYHA class was independently correlated with PAS. CONCLUSION: PAS is associated with functional status and should be taken into consideration as an underlying pathophysiological mechanism of dyspnea in patients with HFrEF.

Comparing Three Different Doses of Caudal Morphine for Analgesia after Salter Innominate Osteotomy.

Background: Single dose caudal block application is preferred among children since it is a safe and easy method. Caudal morphine has an important advantage with its long half-life. However, caudal morphine application has some side effects such as nausea-vomiting, urinary retention, pruritus, sedation and respiratory stiffness and many of those are dose-dependent. The aim of this study was to determine the minimum morphine doses that will provide adequate analgesia and by this way to diminish the life threatening side effects such as respiratory depression as well as comfort-threatening side effects such as nausea-vomiting. Methods: This double blind, randomized, prospective study, was performed in Gaziantep University among 60 pediatric patients aged between 1-9 years, who were planned to have Salter operation for congenital hip dislocation, with ASA classification of I-II. Premedication was not applied in any of the cases. Patients were sub-grouped randomly and for 15, 20 or 25 μg.kg-1 caudal morphine administration: G15, G20 and G25. Caudal injections were performed under general anesthesia just before the operations. Having total volumes of 0.75 ml.kg-1, caudal injections were performed with 15, 20 or 25 μg.kg-1 morphine together with 0.25% bupivacaine according to the groups. The first time of analgesic requirement was recorded. Results: The number of cases required analgesia in first 24 hours was determined as 4 (20%), 3 (15%) and 2 (10%) in Group 15, Group 20 and Group 25, respectively. There was not statistically significant difference between groups (P>0.05). In none of the patients, the pain level was as high as causing restlessness (score 2). With single dose Paracetamol, pain cured in all of these patients. Postoperative nausea and vomiting in first 24 hours was reported in 1 (5%), 2 (10%) and 8 (40%) cases in 15, 20 and 25 µg.kg-1 groups, respectively. Although the difference between Groups 15 and 20 was not statistically significant (p=0.548), the number of patients with nausea and vomiting in Group 25 was statistically significantly higher than that of Group 15 and Group 20 (p=0.009 and p=0.025, respectively). In first 24 hours in postoperative period, respiratory depression was not observed in any of the cases. Conclusions: We determined that decreasing the caudal morphine dose to 15 µg.kg-1 in Salter osteotomy does not decrease analgesia in 24 hours but minimizes nausea-vomiting incidence.

Increased serum uric acid levels are correlated with decreased left atrial appendage peak flow velocity in patients with atrial fibrillation

We aimed to examine the relationship between serum uric acid levels and left atrial appendage [LAA] peak flow velocity, an indicator of the mechanical functions of the LAA, and atrial fibrillation [AF]. Transesophageal echocardiography was performed before cardioversion in 153 patients with AF. The patients were categorized into 2 groups based on their LAA blood flow velocity. Group 1 included 87 patients with a low LAA flow velocity [<35 cm/s], and group 2 comprised 66 patients with a normal LAA flow velocity [>/=35 cm/s]. The chi[2]and Student's t tests were used to compare categorical and quantitative data between the groups. Linear regression analyses were performed to demonstrate the independent association between serum uric acid levels and LAA peak flow velocity. The LAA blood flow velocity was 24.62 +/- 5.90 cm/s in group 1 and 49.28 +/- 13.72 cm/s in group 2, respectively [p < 0.001]. The serum uric acid levels were 6.88 +/- 1.85 mg/dl in group 1 and 5.97 +/- 1.51 mg/dl in group 2, and the difference was statistically significant [p = 0.001]. There was a negative correlation between serum uric acid levels and LAA blood flow velocity [r = -0.216, p = 0.007]. Multivariate regression analysis showed that serum uric acid levels, age and gender differences were significant predictors of the LAA peak flow velocity. High serum uric acid levels were associated with a low contractile function of the LAA and could provide additional prognostic information on future thromboembolic events in patients with AF

Aorta-Right Atrial Tunnel: An Interesting Type of a Congenital Coronary Artery Anomaly

An 18-year-old girl with an aortico-right atrial tunnel originating from the left sinus of Valsalva, in which the left anterior descending and circumflex coronary arteries arose independently from the different parts of the tunnel, was reported. In the differential diagnosis of continuous murmur, this type of tunnel should be taken into consideration. Surgical approach should be offered.

QT dispersion increases with low glomerular filtration rate in patients with coronary artery disease

We aimed to evaluate the relationship between estimated glomerular filtration rate [eGFR] and QT dispersion [QTd] in patients with coronary artery disease [CAD]. Sixty patients [mean age 62.72 +/- 12.48 years] included 46 male, [mean age 60.89 +/- 12.70 years] and 14 female [mean age 68.71 +/- 9.86 years] were enrolled in this study. Patients were divided into 2 groups according to their eGFR using the 6 variable MDRD equation. Group 1 consisted of patients with estimated eGFR < 60 ml/min/1.73m[2] and Group 2 consisted of patients with eGFR >/= 60 ml/min/1.73m[2]. Baseline patient characteristics were homogeneous in both groups except for age, gender and smoking. Also, the extent of CAD was similar in both groups [p > 0.05] QTd values were found higher in group 1 than those of group 2 [57.23 +/- 40.65 ms vs. 31.23 +/- 14.47 ms, p = 0.002]. After adjustment for age, gender and smoking using one-way ANCOVA test, statistically significant difference in QTd still existed between the groups [p=0.038]. QTd tends to be higher in patients with poor renal function independent of severity of angiographical CAD. QTd may be a potentially useful non-invasive test in the management of patients with poor renal function, especially those with CAD

Migration of fully deployed stent after intracoronary glyceryl trinitrate administration: an unusual percutaneous coronary intervention complication

Stent embolization is a rare complication of coronary stenting. If left untreated, it may lead to devastating consequences. Although there is much known about stent embolization, data about migration of stent after deployment is limited. We report an unusual case of a deployed stent migration into the distal part of right coronary artery after intracoronary glyceryl trinitrate administration during percutaneous coronary intervention

Transient cortical blindness can also be seen in the absence of contrast enhancement at computed tomography scan after coronary angiography

Transient cortical blindness after coronary angiography or angioplasty is a rare complication. Patients with aortocoronary bypass grafts such as internal mammary artery have a seperate risk factor probably because of the direct contrast injection to the vertebral artery during the catheterisation of the internal mammary artery ostium. In most cases, computed tomography scan revealed typical, symmetrical contrast enhancement in both occipital lobes Nevertheless, transient cortical blindness can be seen after coronary angiography without contrast enhancement at computed tomography scan

Thrombophilia in young patients with acute myocardial infarction

To investigate the association of thrombophilia and coronary artery disease [CAD] in patients with myocardial infarction [MI]. Under the age of 45 years, 129 patients with MI and 107 control subjects were included into the study. Traditional risk factors of CAD and protein C, S, antithrombin III deficiencies, factor V Leiden [FV Leiden], prothrombin G20210A and methylenetetrahydrofolate reductase [MTHFR] C677T mutations were investigated. There were statistically significant differences in terms of obesity, smoking, triglyceride, total cholesterol, high-density lipoprotein, high-density lipoprotein, and very-low-density lipoprotein cholesterol, family history, hypertension, diabetes, and left ventricular hypertrophy between patients and controls. None of the patients and controls had protein C, protein S, and antithrombin III deficiencies. Ten patients [7.8%] and 4 controls [3.7%] had heterozygote FV Leiden mutation. Homozygous prothrombine G20210A gene mutation was detected in one patient [1.1%]. Homozygous MTHFR C677T mutation was observed in 7.8% [patients] and in 6.5% [controls]. Heterozygous MTHFR C677T mutation was detected 36.4% in patients and 31.7% in controls. The difference was not statistically significant in terms of carriage of thrombophilic mutations. We found that traditional risk factors increased the risk of CAD. Prothrombin G20210A, FV Leiden and MTHFR C677T mutations, protein C, S and AT-III deficiencies did not increase the risk of CAD in our young population

Intracranial myeloid metaplasia in idiopathic myelofibrosis

Extramedullary hematopoiesis is a common finding in idiopathic myelofibrosis and is generally found in the liver, spleen and lymph nodes, but meningeal extramedullary hematopoiesis is very rare. Some diseases may be causes of intracranial masses and diagnosis is difficult. We present a case diagnosed as intracranial and meningeal extramedullary hematopoiesis with idiopathic myelofibrosis inducing serious headache