Cancer, platelet distribution width, and total protein levels as predictors of rebleeding in upper gastrointestinal bleeding.

Background: Rebleeding is associated with poor outcomes in upper gastrointestinal bleeding (UGIB). Identifying predictors of rebleeding can assist in risk assessment. The aim of the study is to investigate the factors affecting rebleeding in patients with UGIB admitted to the emergency department. Methods: This retrospective, observational, cross-sectional study was conducted on patients with UGIB presented to the emergency department. Patients who did not arrest in the first 24 h, who were not diagnosed with GI malignancy, and who were clinically diagnosed with UGIB were included in the study. Patient demographic characteristics, hemodynamic parameters, patient parameters, and bleeding that may affect rebleeding were evaluated. The primary endpoint was rebleeding within 7 days. Results: The study included 371 patients. A total of 55 patients (14.8%) had rebleeding within 7 days, and 62 patients (16.7%) presented without bleeding manifestations. Rebleeding rates were higher in those who presented with bloody or coffee-ground vomitus, had a diagnosis of cancer, had blood in their nasogastric tube, and had peptic ulcers due to endoscopy. Mean cell hemoglobin concentration, lymphocyte, albumin, and total protein values of patients with rebleeding were low; red blood cell distribution width, neutrophil count, platelet distribution width (PDW), and neutrophil lymphocyte ratio were high. In-hospital mortality and 30-day mortality values of patients with rebleeding were significantly increased. In the multivariate analysis, cancer, PDW, and total protein levels were statistically significant. Conclusion: The presence of cancer, low total protein level, and high PDW are effective parameters in predicting 7-day rebleeding in patients with UGIB admitted to the emergency department.

The role of the serum lactate level at the first admission to the emergency department in predicting mortality.

INTRODUCTION: Lactate is an easily measurable laboratory parameter that is considered a potentially useful prognostic marker for determining risk in emergency department patients. The aim of this study was to investigate the role of serum lactate in the patients who were admitted to the emergency department at the time of admission. METHODS: Patients who were admitted to the emergency department for various reasons between June 2017 and January 2018 were included in the study. Demographic data, laboratory findings, mortality and hospitalization rates of the patients were analyzed. The primary endpoint was determined as the role of serum lactate in predicting mortality, and the secondary endpoint in predicting hospitalization. RESULTS: Of the 1382 patients, 47.4% (n = 655) were female and 52.6% (n = 727) were male. The mean age of the patients was 60.99 ± 20.04 (18-100) years. In 59.6% (n = 824) of the patients, the most common hypertension (36%) was an additional disease. Mortality was found in 43 (3.1%) patients. It was observed that 20.5% (n = 284) of the patients were hospitalized. The ages of patients with hospitalization and mortality were found to be statistically significant higher than those without hospitalization and without mortality (p = 0.001; p < 0.01). There was no statistically significant difference between the serum lactate measurements of the patients according to hospitalization (p > 0.05). The serum lactate levels of the patients with mortality were found to be statistically significant higher than those without mortality (p = 0.001; p < 0.01). The cut off point for serum lactate level in predicting mortality was found to be ≥3.6 mmol/L. The mortality rate was found to be statistically significant higher in patients with serum lactate level 3,6 mmol/L and above (p = 0,001; p < 0,01). CONCLUSION: In conclusion, we believe in the light of the findings of our study that the serum lactate level is effective and reliable in the prediction of mortality in patients who present to emergency department for any reason. However, prospective studies with broader patient groups are required in this subject.

Evaluation of index of cardiac-electrophysiological balance as arrhythmia predictor in bonsai users.

BACKGROUND: Synthetic cannabinoids are part of a group of drugs called new psychoactive substances. The increase in substance use among young adults is becoming a major problem in the world. In this study we aimed to investigate the effects of synthetic cannabinoid drugs such as bonsai to electrocardiographic (ECG) parameters, in patients who were admitted to emergency service with self-reported usage of bonsai. METHODS: Seventy-two patients (68 males; mean age 33.8±11.8) with self-reported use of bonsai and 27 (22 males; mean age 37.1±8.7) age and sex-matched healthy control group enrolled the study. ECG parameters and rhythm holter were measurements calculated in both groups. RESULTS: Groups were age and sex matched. Glucose, potassium, white blood cell count, heart rate end smoking status was significantly different in patients compared to control group. P wave max time, P wave min. time, P wave dispersion, QT max. time QT dispersion, QT corrected time and index of cardiac-electrophysiological balance measurements (iCEB) were significantly different in groups of patients. A multivariate logistic regression analysis was used to determine independent predictors of ≥30 Ventricular premature beat (VPB)/h using parameters found to be associated with ≥30 VPB/h in a univariate analysis (potassium, QTmax time, QTc, QRS time, iCEB).In a multivariate analysis, independent predictors of ≥30 VPB/h were potassium (Odds ratio [OR]: 0.107, 95% CI: 0.024-0.481;P=0.004) and iCEB (OR: 4.474, 95% CI: 1.752-11.429;P=0.002). In generalize linear model ß-coefficient value of interaction terms between K*iCEB has no important effect on ventricular premature beats. CONCLUSIONS: If the results are confirmed in further studies, iCEB seems to be a simple, easily measurable and non-invasive marker to predict cannabinoid-induced ventricular arrhythmias.

A systematic review of safety and adverse effects in the practice of therapeutic hypothermia.

OBJECTIVE: To carry out a systematic review to estimate the rate and magnitude of adverse effects following therapeutic hypothermia (TH) procedure in patients resuscitated from out-of-hospital cardiac arrest (OHCA) and highlight the specific complications seen after the procedure. METHODS: A systematic review of currently published studies was performed following standard guidelines. Online database searches were performed for controlled trials for the last twenty years. Papers were examined for methodological soundness before being included. Data were independently extracted by two blinded reviewers. Studies were also assessed for bias using the Cochrane criteria. The adverse effects attributed to TH in the literature were appraised critically. RESULTS: The initial data search yielded 78 potentially relevant studies; of these, 59 were excluded for some reason. The main reason for exclusion (n = 43, 55.8%) was that irrelevance to adverse effects of TH. Finally, 19 underwent full-text review. Studies were of high-to-moderate (n = 12, 63%) to low-to-very low (n = 7, 37%) quality. Five studies (27.7%) were found to have high risk of bias, while 8 (42.1%) had low risk of bias. INTERPRETATION: Although adverse effects related to the practice of TH have been studied extensively, there is substantial heterogeneity between study populations and methodologies. There is a considerable incidence of side effects attributed to the procedure, e.g., from life-threatening ventricular arrhythmias to self-limited consequences. Most studies analyzed in this systematic review indicated that the procedure of TH has not caused severe adverse effects leading to significant alterations in the outcomes following resuscitation from OHCA. PROSPERO, registration number is: CRD42018075026.

A systematic review of the pain scales in adults: Which to use?

OBJECTIVE: The study analysed the Visual Analogue Scale (VAS), the Verbal Rating Scale (VRS) and the Numerical Rating Scale (NRS) to determine: 1. Were the compliance and usability different among scales? 2. Were any of the scales superior over the other(s) for clinical use? METHODS: A systematic review of currently published studies was performed following standard guidelines. Online database searches were performed for clinical trials published before November 2017, on the comparison of the pain scores in adults and preferences of the specific patient groups. A literature search via electronic databases was carried out for the last fifteen years on English Language papers. The search terms initially included pain rating scales, pain measurement, pain intensity, VAS, VRS, and NRS. Papers were examined for methodological soundness before being included. Data were independently extracted by two blinded reviewers. Studies were also assessed for bias using the Cochrane criteria. RESULTS: The initial data search yielded 872 potentially relevant studies; of these, 853 were excluded for some reason. The main reason for exclusion (33.7%) was that irrelevance to comparison of pain scales and scores, followed by pediatric studies (32.1%). Finally, 19 underwent full-text review, and were analysed for the study purposes. Studies were of moderate (n=12, 63%) to low (n=7, 37%) quality. CONCLUSIONS: All three scales are valid, reliable and appropriate for use in clinical practice, although the VAS is more difficulties than the others. For general purposes the NRS has good sensitivity and generates data that can be analysed for audit purposes.

What do we know about ALARA? Is our knowledge sufficient about radiation safety?

BACKGROUND: The aim of this study was to determine the knowledge of neurosurgeons and emergency physicians about ALARA (as low as reasonably achievable) and to gain awareness to them about this topic. METHODS: A multiple-choice survey comprising 17 questions was performed to 30 neurosurgeons and 70 emergency room doctors. RESULTS: Emergency medicine doctors, neurosurgeons, emergency medicine residents, neurosurgery residents and general practitioners participated in the survey. Sixty-six percent of participants stated that they examined more than 50 patient with headache, dizziness and head trauma in emergency service per diem and more than half of the participants stated that brain CT was performed in the event of patient's request, even if there was not an indication. 75% of the participants stated that they requested CT scan without neurological examination when the number of patients increased in the emergency room. Eighty-three percent of the participants did not think there was a safe dose limit in CT, 92% did not know the radiation dose received during brain CT, 96% did not know the meaning of the ALARA. Fifty-seven percent of the participants stated that if they informed about the criteria of ALARA, they will take into acount these criteria while requesting CT scan. CONCLUSIONS: In our country, doctors working in emergency services request brain CT needlessly because of taking into account the patient's wish and fear of malpractice. The knowledge of the neurosurgeons and emergency service doctors about ALARA is insufficient. It is necessary to educate our physicians about ALARA protocol, for taking these criteria into their consideration when requesting CT examination. For protecting the patients from the effects of ionizing radiation and reducing the economic loss of hospitals, it is necessary to increase awareness of the ALARA protocol and to increase the number of hospitals which protocol is applied.

Intra-articular injection of dexketoprofen in rat knee joint: histopathologic assessment of cartilage & synovium.

BACKGROUND & OBJECTIVES: Effective pain control following outpatient surgical procedures is an important aspect of patient discharge. This study was carried out with an aim to investigate the histopathological effects of intra-articular dexketoprofen trometamol injection in knee joint on synovium and cartilage in an experimental rat model. METHODS: In each of 40 rats, the right knee was designated as the study group and the left knee as the control group (NS group). Under aseptic conditions, 35 rats received an injection of 0.25 ml (6.25 mg) dexketoprofen trometamol into the right knee joint and an injection of 0.25 ml 0.9 per cent normal saline solution into the left knee joint. On the 1st, 2nd, 7th, 14th, and 21st days after intra-articular injection, rats in specified groups were sacrificed by intraperitoneal injection of 120 mg/kg sodium thiopental. Knee joints were separated and sectioned for histopathological examination. Inflammatory changes in the joints were recorded according to a grade scale. RESULTS: No significant difference in terms of pathological changes both in synovium and cartilage was observed between the NS group and the study group on days 1, 2, 7, 14 and 21 after intra-articular injection of dexketoprofen or saline in the knee joint. INTERPRETATION & CONCLUSIONS: The findings showed no evidence of significant histopathological damage to the cartilage and synovia for a period up to 21 days following intra-articular administration of dexketoprofen trometamol in the knee joints of rats.

A New Model in Reducing Emergency Department Crowding: The Electronic Blockage System.

OBJECTIVES: Emergency department (ED) crowding is a growing problem across the world. Hospitals need to identify the situation using emergency department crowding scoring systems and to produce appropriate solutions. METHODS: A new program (Electronic Blockage System, EBS) was written supplementary to the Hospital Information System. It was planned that the number of empty beds in the hospital should primarily be used for patients awaiting admission to a hospital bed at the ED. In the presence of patients awaiting admission at the ED, non-urgent admissions to other departments were blocked. ED overcrowded was measured in the period before initiation of EBS, the early post-EBS period and the late post-EBS period, of one-week's duration each, using NEDOCS scoring. RESULTS: NEDOCS values were significantly lower in the early post-EBS period compared to the other periods (p≤0.0001). Although outpatient numbers applying to the ED and existing patient numbers at time of measurement remained unchanged in all three periods, the number of patients awaiting admission in the early post-EBS period was significantly lower than in the pre-EBS and late post-EBS periods (p=0.0001, p=0.001). CONCLUSIONS: EBS is a form of triage system aimed at preventing crowding and ensuring the priority admission of emergency patients over that of polyclinic patients. In hospitals with an insufficient number of total beds it can be used to reduce ED crowding and accelerate admissions to hospital from the ED.

Subarachnoid Pleural Fistula Due to Gunshot Wound.

Subarachnoid pleural fistula (SPF) is an extremely rare complication that occurs after dural space and vertebral columns injuries. SPF is divided into two diagnoses based on the absence or presence of pneumocephalus and pneumorrachis. While pneumocephalus is defined as the presence of air the cranial cavity, if there is air in the spinal canal, this is defined as pneumorrhachis. In general, the association of SPF with pneumocephalus and pneumorrachis is rare but can occur after blunt trauma. In our patient, pneumorrhachis and pneumocephalus with SBF developed after the patient suffered a gunshot wound. This paper reports an SPF case accompanied by pneumorrachis and pneumocephalus, which occurred after thoracic spine injury due to a gunshot wound.

Dyslipidemia and sternum fracture.

Tenderness over the sternum is a clue for possible sternal fracture. Sternal fractures usually occur at the body or manubrium. Lateral chest radiography could detect a sternum fracture, but the diagnosis is usually made by chest tomography. Traumatic sternum fracture considered as a marker of seriously life-threatening, high-energy injury. In hyperlipidemia, oxidized lipids accumulate in vascular tissues and trigger atherosclerosis. Such lipids also deposit in bone tissues where they may promote osteoporosis. In the literature, there is no previously reported traumatic sternal fracture due to hyperlipidemia-induced osteoporosis. Here, we report a case of a combined mixed type familial hyperlipidemia-induced osteoporosis in which the patient having seat belt on had an unexpected sternum fracture in a low-energy motor vehicle accident.

The effect of Beta-aminopropionitrile and prednisolone on the prevention of fibrosis in alkali esophageal burns: an experimental study.

Objective. The aim of this study was to investigate the efficacy of beta-aminopropionitrile (BAPN) and prednisolone on the prevention of esophageal damage and stricture formation after caustic esophageal burn. Method. Twenty-eight rats were divided into four equal groups. In groups 1, 2, and 3, caustic esophageal burns were generated by applying NaOH to the 1.5 cm segment of the abdominal esophagus. Group 4 was for the sham. Normal saline to group 1, BAPN to group 2, and prednisolone to group 3 were administered intraperitoneally as a single daily dose. Results. Treatment with BAPN decreased the stenosis index (SI) and histopathologic damage score (HDS) seen in caustic esophageal burn rats. The SI in group 4 was significantly lower compared with groups 1, 2, and 3. Group 2 had the minimum SI value in corrosive burn groups. The differences related to SI between groups 1, 2, and 3 were not statistically significant. The HDS was significantly lower in group 4 compared with groups 1, 2, and 3. The HDS in group 2 was significantly lower compared with groups 1 and 3. Conclusion. This study demonstrated that BAPN was able to decrease the development of stenosis and tissue damage better than prednisolone.

Clinical efficacy of dexamethasone for acute exudative pharyngitis.

The objective of this study was to investigate whether treatment with single-dose dexamethasone can provide relief of symptoms in acute exudative pharyngitis. A prospective, randomized, double-blinded, placebo-controlled clinical trial was undertaken over a 3-month period in a university-based Emergency Department. The study included all consecutive patients between 18 and 65 years of age presenting with acute exudative pharyngitis, sore throat, odynophagia, or a combination, and with more than two Centor criteria. Each patient was empirically treated with azithromycin and paracetamol for 3 days. The effects of placebo and a fixed single dose (8 mg) of intramuscular injection of dexamethasone were compared. The patients were asked to report the exact time to onset of pain relief and time to complete relief of pain. After completion of the treatment, telephone follow-up regarding the relief of pain was conducted. A total of 103 patients were enrolled. Thirty patients with a history of recent antibiotic use, pregnancy, those who were elderly (>65 years of age) and patients who failed to give informed consent were excluded. Forty-two patients were assigned to the placebo group and 31 were assigned to the intramuscular dexamethasone group (8-mg single dose). Time to perceived onset of pain relief was 8.06+/-4.86 h in steroid-treated patients, as opposed to 19.90+/-9.39 h in the control group (p=0.000). The interval required to become pain-free was 28.97+/-12.00 h in the dexamethasone group, vs. 53.74+/-16.23 h in the placebo group (p=0.000). No significant difference was observed in vital signs between the regimens. No side effects and no new complaints attributable to the dexamethasone and azithromycin were observed. Sore throat and odynophagia in patients with acute exudative pharyngitis may respond better to treatment with an 8-mg single dose of intramuscular dexamethasone accompanied by an antibiotic regimen than to antibiotics alone.

Cardiovascular toxicity due to metoprolol poisoning in a patient with coronary artery disease.

AIM: To demonstrate that beta-blocker poisoning results in cardiovascular and central nervous system findings. METHODS: A 56-year-old woman was brought to the emergency department, having been admitted to hospital with 1500 mg of metoprolol ingestion 2 h previously. She had undergone percutaneous transluminal coronary angioplasty and stenting because of acute myocardial infarction (AMI). Her ECG revealed ST segment elevation in inferior leads and junctional dysrhythmia. Her clinical symptoms relieved after pacing and hospitalization and she was discharged. RESULTS: Our patient demonstrated findings of AMI with hypotension and bradycardia that appeared to result from metoprolol poisoning. Although one patient has been reported to have AMI associated with metoprolol poisoning, our patient is unique with her ECG changes and elevated cardiac markers: this is the first time that AMI characterized by elevated cardiac markers associated with metoprolol toxicity has been reported. CONCLUSIONS: Emergency physicians should bear in mind that AMI can accompany the presentation of metoprolol overdose in those with coronary artery disease. In other words, metoprolol poisoning can trigger myocardial ischaemia and dysrhythmia in those with coronary artery disease.

An unusual cause of atrial fibrillation: exposure to insecticides.

BACKGROUND: Although there are many well-known cardiac results of insecticide poisoning, atrial fibrillation (AF) has not been reported as the result of insecticide intoxication. CASE: Twenty-six-year-old male, complaining of nausea and vomiting, presented to the emergency department with a history of methomyl dust exposure. All physical examination findings were normal except irregular heart rate on cardiac auscultation. The electrocardiogram of the patient showed AF with normal ventricular response. Patient's acetylcholinesterase (ACE) level was 3,319 IU/L in presentation and pralidoxim use was seen unnecessary for the treatment. The patient's rhythm spontaneously returned to sinus rhythm 24 hr after the presentation and no cardiopulmonary pathology was found during the follow-up. The patient was discharged without symptoms. CONCLUSION: AF is a rare complication of insecticide intoxication. In this case, treatment of symptoms was adequate until a normal sinus rhythm returned.

Do we really need plain and soft-tissue radiographies to detect radiolucent foreign bodies in the ED?

OBJECTIVE: The objective of this study was to compare 3 imaging techniques-plain radiography, soft-tissue radiography, and ultrasonography-in detecting nonradiopaque foreign bodies in soft tissue. METHODS: In this randomized, blinded, and descriptive in vitro study, 40 chicken thighs with 2 types of nonradiopaque foreign bodies (wood and rubber) and 40 chicken thighs as part of a control group were evaluated to detect soft-tissue foreign bodies with plain radiography, soft-tissue radiography, and high-frequency ultrasonography. RESULTS: The overall sensitivity, specificity, as well as positive predictive and negative predictive values of plain radiography for both nonradiopaque foreign bodies were 5%, 90%, 33%, and 48%, respectively; those of soft-tissue radiography for both nonradiopaque foreign bodies were 5%, 90%, 33%, and 48%, respectively; and those of ultrasonography for both nonradiopaque foreign bodies were 90%, 80%, 81%, and 89%, respectively. CONCLUSIONS: In this experimental model, the results show that high-frequency ultrasonography is superior to plain and soft-tissue radiographies and that the latter 2 techniques are similarly poor at detecting nonradiopaque foreign bodies.

Acute subdural hemorrhage while traveling by bus: a risk factor in the elderly?

A 71-year-old man was delivered to our emergency department by an intercity bus. About 4 hours into a journey, he had complained of a headache to his wife. After one more hour, she noted a change in his level of alertness and notified the bus driver. A computed tomography scan of the head showed a subdural hemorrhage.

Evaluation of prehospital emergency care in the field and during the ambulance drive to the hospital.

This study was conducted to evaluate the appropriateness of ambulance procedures and interventions in the management of patients dispatched to 2 emergency departments (EDs) of urban hospitals in Izmir. Use of trauma boards and cervical collars, airway patency, breathing, and circulation problems were recorded in both EDs. Eighty-one patients with a mean age of 47.54 +/- 2.36 years (range, 4-89) brought into the ED via ambulances were enrolled in the study. Airway maneuvers were performed in patients with airway and breathing problems. There was no significant relationship between administration of IV fluids and the presence of circulatory impairment (P=.053). A trauma board was used in 9 of 30 trauma cases (30%) and a cervical collar in 6 of 30 (20%). It was concluded that basic procedures used in the management of patients brought into the ED via ambulances were inadequate.

A model of standardized training in basic life support skills of emergency medicine residents.

This intervention study was designed to determine the current level of basic life support knowledge and skills of residents in a university-based emergency medicine residency program, and to investigate the potential benefit derived by these residents from a standardized theoretical and practical training session. All residents underwent tests before and after the training session. The residents were asked to perform basic life support on a recording cardiopulmonary resuscitation mannequin. Assessments were made using a 10-item checklist, with the highest score being 17. Each step performed by the resident was scored by an emergency physician for accuracy and effectiveness. Twenty-eight residents participated in the study. According to the modified Berden scale, the pretest and posttest scores were 11.2 +/- 2.9 and 15.6 +/- 1.0, respectively, and the mean difference was 4.36 +/- 2.9 (t test, P<.001). Only 11 residents (39.3%) were rated as "good" or "very good" in the pretest, whereas the corresponding figure in the posttest was 27 (96.4%) (P<.001). Skills, such as checking the airway patency (P<.001), checking breathing (P<.001), appropriate compression rate (P<.003), and delivering 2 effective breaths (P<.001), improved significantly. Depth of chest compression (P<.023) was improved significantly only in residents with fewer than 2 years of experience. The training process should comprise standardized courses to facilitate acquisition of the desired skills.