Computer-based simulation training in emergency medicine designed in the light of malpractice cases.

BACKGROUND: Using computer-based simulation systems in medical education is becoming more and more common. Although the benefits of practicing with these systems in medical education have been demonstrated, advantages of using computer-based simulation in emergency medicine education are less validated. The aim of the present study was to assess the success rates of final year medical students in doing emergency medical treatment and evaluating the effectiveness of computer-based simulation training in improving final year medical students' knowledge. METHODS: Twenty four Students trained with computer-based simulation and completed at least 4 hours of simulation-based education between the dates Feb 1, 2010 - May 1, 2010. Also a control group (traditionally trained, n =24) was chosen. After the end of training, students completed an examination about 5 randomized medical simulation cases. RESULTS: In 5 cases, an average of 3.9 correct medical approaches carried out by computer-based simulation trained students, an average of 2.8 correct medical approaches carried out by traditionally trained group (t = 3.90, p < 0.005). We found that the success of students trained with simulation training in cases which required complicated medical approach, was statistically higher than the ones who didn't take simulation training (p ≤ 0.05). CONCLUSIONS: Computer-based simulation training would be significantly effective in learning of medical treatment algorithms. We thought that these programs can improve the success rate of students especially in doing adequate medical approach to complex emergency cases.

[Strongyloides stercoralis in a patient with ankylosing spondylitis: case report]. / Ankilozan Spondilitli Bir Hastada Strongyloides stercoralis: Olgu Sunumu.

Strongyloidiasis is a nematode-borne disease caused by several Strongyloides species. This case was presented in order to indicate Strongyloidosis in immunocompromised patients with several clinical findings. A fifty-five year old male patient on corticosteroid medication for a long time because of ankylosing spondylitis was on infliximab medication for 5 years. He presented with swelling of his right foot for ten days, right shoulder stiffness and low back pain. The presence of anaemia was remarkable. S. stercoralis was reported in histological examination of endoscopic duodenal biopsy specimen. Peripheral blood smear showed 68.4% neutrophils, 17% lymphocytes, 7.5% monocytes, and 6.7% (normal range 2%-6.2) eosinophils. The level of IgE was raised: 285IU/mL (normal range 5-120IU/mL). A large number of S. stercoralis larvae were detected upon stool examination with saline and iodine mounts and the formaldehyde ether concentration method. After treatment with two cure albendazole 400 mg/day for 7 days, S. stercoralis larvae were not detected in stool examination. It is interesting that response to treatment was not observed on the first cure and the recovery was seen on the second cure. We suggest that hyperinfections should be taken into consideration in the diagnosis and treatment of immunocompromised patients with several complaints so that life-threatening effects of the nematode may be prevented.

Strongyloides stercoralis hyperinfection in a patient with rheumatoid arthritis and bronchial asthma: a case report.

OBJECTIVE: Strongyloides stercoralis is a soil-transmitted intestinal nematode that has been estimated to infect at least 60 million people, especially in tropical and subtropical regions. Strongyloides infection has been described in immunosupressed patients with lymphoma, rheumatoid arthritis, diabetes mellitus etc. Our case who has rheumatoid arthritis (RA) and bronchial asthma was treated with low dose steroids and methotrexate. METHODS: A 68 year old woman has bronchial asthma for 55 years and also diagnosed RA 7 years ago. She received immunusupressive agents including methotrexate and steroids. On admission at hospital, she was on deflazacort 5 mg/day and methotrexate 15 mg/week. On her physical examination, she was afebrile, had rhonchi and mild epigastric tenderness. She had joint deformities at metacarpophalengeal joints and phalanges but no active arthritis finding. RESULTS: Oesophagogastroduodenoscopy was performed and it showed hemorrhagic focus at bulbus. Gastric biopsy obtained and showed evidence of S.Stercoralis infection. Stool and sputum parasitological examinations were also all positive for S.stercoralis larvae. Chest radiography result had no pathologic finding. Albendazole 400 mg/day was started for 23 days. After the ivermectin was retrieved, patient was treated with oral ivermectin 200 µg once a day for 3 days. On her outpatient control at 15th day, stool and sputum samples were all negative for parasites. CONCLUSION: S.stercoralis may cause mortal diseases in patients. Immunosupression frequently causes disseminated infections. Many infected patients are completely asymptomatic. Although it is important to detect latent S. stercoralis infections before administering chemotherapy or before the onset of immunosuppression in patients at risk, a specific and sensitive diagnostic test is lacking. In immunosupressed patients, to detect S.stercoralis might help to have the patient survived and constitute the exact therapy.

Hypotension, bradycardia and syncope caused by honey poisoning.

Honey intoxication, a kind of food poisoning, can be seen in the Black Sea region of Turkey and in various other parts of the world as well. In this study, 66 patients were hospitalized with a variety of symptoms including nausea, vomiting, salivation, dizziness, weakness, hypotension, bradycardia and syncope several hours after the ingestion of small amounts of honey. All patients had hypotension, and majority had bradycardia. These features resolved completely in 24 h with i.v. fluids and atropine, and none died. In conclusion, honey poisoning should be taken into consideration in the differential diagnosis of acute myocardial infarction and in the patients with vomiting, hypotension and bradycardia.

In acute organophosphate poisoning, the efficacy of hemoperfusion on clinical status and mortality.

The aims of this study were to report experience in patients with organophosphate poisoning (OPP) and to discuss the potential role for hemoperfusion (HP) in the management of severe OPP. At the emergency service of a university hospital, 52 patients with acute OPP were included in this retrospective study. The patients were divided into 2 groups (Group 1, severe poisoning, n = 25; and Group 2, mild poisoning, n = 27). All patients with mild OPP survived. Seven patients (28%) of the 25 with severe OPP died. This study supports previous data documenting that HP is unnecessary in the management of mild OPP. Although there was not a control group (severe poisoning without HP treatment) in this study, experience suggests that HP can be useful in severe cases. Reports from centers having experience with severe OPP can help clarify this controversial issue. Randomized controlled (prospective) studies investigating the possible beneficial effects of HP on patient survival in patients with severe OPP with control group are needed.

An increase of BNP levels in massive pulmonary embolism and the reduction in response to the acute treatment.

Type B Natriuretic Peptide (BNP) is a neurohormone that is secreted from the cardiac ventricles in response to dilatation or an increase of pressure. Right ventricle dysfunction is seen in pulmonary embolism patients, but it may be hard to diagnose. Echocardiography is the most sensitive means of diagnosis for acute right ventricle dysfunction. However, echocardiography is also limited in some ways. BNP levels may increase with right ventricle dysfunction when the patients is in bed and decrease with treatment. We presented a case study in which diagnosed with mitral valve regurgitation, pulmonary embolism and pregnant for 1.5 months. Initial BNP levels of 633 pg/ml decreased to 233, 65.2, 58.4 levels respectively which was parallel to improvements in the clinical state and right ventricle function detected in echocardiography. We used a rapid bedside test for determination of BNP.

Climatic and diurnal variation in suicide attempts in the ED.

The aim of this study was to determine whether there is a relationship between climatic factors and suicidal behavior. A total of 1,119 suicide attempts were collected from hospital records between 1996 and 2001. A clear seasonal variation was seen in suicide attempts in the 15-24, 25-34, and over 65 age groups in men and in the 15-24, 25-34, and 35-44 age groups in women with peaks in the spring and summer. Suicide attempts were more frequent between the hours of 6:00-9:00 pm in males and 3:00-6:00 pm in females. People attempting suicide who have depression, anxiety, or a psychotic disorder usually attempt suicide in the summer. Whereas the monthly averages of humidity, ambient temperature, duration and intensity of sunlight were positively correlated with the number of monthly suicide attempts, cloudiness and atmospheric pressure were negatively correlated. In conclusion, we must keep in mind that suicides and suicide attempts are not only the effect of climatic changes and that the most important component is the individual's ability to deal with conflicts.

[The incidence of pathologic findings of the cranial computed tomography in patients with minor head trauma and its correlation with age and clinical features]. / Hafif kafa travmali olgularin kraniyal tomografisindeki patolojik bulgu sikiliginin yas gruplari ve klinik ile korelasyonu.

BACKGROUND: Our objective was to determine the incidence of diagnosing lesions by cranial computed tomography (CT) and to evaluate prospectively whether this incidence correlated with clinical features and age in patients with minor head trauma (MHT). METHODS: This prospective study included 78 patients with MHT. All of the cases underwent CT following their clinical assessment. RESULTS: In the 34.61% of cases, there was a pathologic finding in the CT however the incidence of intracranial injury was 15.38%. There were no significant differences between children (n:22) and adults (n:56), the patients with and without a history of the loss of consciousness/amnesia and the patients with and without clinical symptoms (p>0.05). CONCLUSION: Our results support the studies which have reported that there is no non-focal clinical factor as a predictor for pathologic CT findings.

[Management of brain edema in acute head injury]. / Akut kafa travmasinda antiödem tedavi.

BACKGROUND: We aim was to review the basic concepts and to analyze the current management of cerebral edema following acute head trauma (AHT). METHOD: Cerebral edema should be recognized and treated early and aggressively to avoid disastrous results such as cerebral herniation. After clinical evaluation and early cardiorespiratory stabilization, the patients should be treated with the elevation of head, oxygen, mannitol, hyperventilation, and sedation-myorelaxation and may avoid from hypotension-hypoxia. If these treatments be unsuccessful, barbiturates may be used. There are also other possibilities such as hypothermia, ventriculostomy, hypertonic saline and neuroprotector agents. CONCLUSIONS: All patients with AHT should be evaluated early and cerebral edema should be treated with correct therapy. Therefore, the mortality and morbidity rates may reduce.

Diagnostic value of procalcitonin levels as an early indicator of sepsis.

Researchers and clinicians have been investigating and implementing various methods of early diagnosis for sepsis before documentation of infection. The aim of this study was to outline the efficiency of procalcitonin (PCT), C-reactive protein (CRP), and white blood cell count (WBC) in determining the early diagnosis of sepsis in the emergency department. Between January 1999 and September 2000, 34 patients with signs of systemic inflammatory response syndrome (SIRS) were enrolled in the study. The patients were divided into 2 groups according to non-suspected sepsis and suspected sepsis clinically. Admission PCT was significantly higher in suspected sepsis group (median 68.7 microg/L; lower [L] = 15.24 microg/L, upper [U] = 120.54 microg/L) compared with the unsuspected sepsis group (.23 microg/L; L =.10 microg/L, U =.44 microg/L). PCT values were compared with WBC and CRP levels. Predictive accuracy for sepsis expressed as area under the receiver operating characteristic (ROC) curve was.88 for PCT,.44 for WBC, and.34 for CRP. PCT can probably be used as a predictive marker in bacterial infections in emergency departments.

Serum acetylcholinesterase and prognosis of acute organophosphate poisoning.

OBJECTIVE: The aim of this study is to investigate the prognostic value of serum acetylcholinesterase levels and their relationship with neurological syndromes (Type 1 syndrome, intermediate syndrome, and delayed polyneuropathy) in acute organophosphate poisoning. MATERIALS AND METHODS: Thirty-two consecutive patients with acute organophosphate poisoning admitted to the Ondokuz Mayis University Emergency Department from June 1999 to January 2001 were evaluated. Patients were assessed according to admission time, symptoms, and results of clinical exams and their serum acetylcholinesterase levels were determined on days 1, 2, 3, 7, and the last day. RESULTS: There was no significant difference between the first-day serum acetylcholinesterase of the patients with severe poisoning (n = 22, 68.75%) and of the patients with mild poisoning (n = 10, 31.25%; NS). There was no discernible difference between the serum acetylcholinesterase obtained on days 1 and 3 after poisoning from the patients with intermediate syndrome (n = 5, 15.6%; means: 0.90 +/- 0.65 vs. 0.88 +/- 0.53, 19.35 vs. 18.92%; NS, sensitivity = 80%; specificity = 87.5%). There was a significant difference between the serum acetylcholinesterase obtained on days 1 and 3 from the patients with nonintermediate syndrome (n = 24, 75%; means: 1.05 +/- 0.24 vs. 1.68 +/- 0.29, 22.58 vs. 36.12%; p < 0.001). There was no discernible significant difference in serum acetylcholinesterase between the patients with organophosphorus-induced delayed polyneuropathy (n = 7, 21.8%) and nonorganophosphorus-induced delayed polyneuropathy. In the patients who died (n = 5, 15.6%), serum acetylcholinesterase showed no discernible increase day 1-the last day (means: 0.50 +/- 0.25 vs. 0.46 +/- 0.26, 10.75 vs. 9.89%; NS). There was a significant difference between the serum acetylcholinesterase levels obtained on days 1 and the last day from the patients who survived (n = 27, 84.3%; means: 1.14 +/- 0.25 vs. 2.32 +/- 0.26, 24.51 vs. 49.89%; p < 0.001). CONCLUSION: In the acute phase of organophosphate poisoning, low serum acetylcholinesterase (> 50% of minimum normal value) supports the diagnosis of organophosphate poisoning but it does not show a significant relationship to the severity of poisoning (NS). The serum acetylcholinesterase activity may be a useful parameter in following the acute prognosis of organophosphate poisoning.