A case of headache, double vision and ptosis in emergency department: Tolosa-Hunt syndrome.

Headache and double vision symptoms can be seen especially neurological and optical problems. We present Tolosa-Hunt syndrome in a 34-year-old female patient who presented to the emergency department (ED) with the complaints of unilateral severe headache, double vision and ptosis, presented asymmetric contrast enhancement in the right superior cavernous sinus on MR. This pain was reduced with steroid therapy. Pulse steroid therapy of 1 mg/kg/day was planned based on the patient's clinical manifestation, MRI findings and presumed diagnosis of THS. It was observed at patient's follow-up that there were occasional headache, ptosis and double vision were disappeared and MRI findings were regressed. In the differential diagnosis of patients presenting to the ED with the complaints of headache and double vision, rare pathologies such as THS should be considered in addition of common pathologies such as neurological and ocular diseases.

[Predictive calue of leucocyte count, neutrophil percent and C-reactive protein concentration "cut-off value" on the diagnosis of appendicitis]. / Lökosit sayisi, yüzde nötrofil orani ve C-reaktif protein konsantrasyonlarinin "kesim degeri" düzeylerinde apandisit tanisindaki degerleri.

BACKGROUND: The present study aimed to investigate the predictive importance of cut-off levels of preoperative WBC, neutrophil and CRP concentrations in operated appendicitis patients. METHODS: Patients operated for acute appendicitis between January 2008 and November 2010 were retrospectively screened. Patients were divided into three groups according to postoperative histopathology. Group I: normal appendix, Group II: Uncomplicated appendicitis, Group III: complicated appendicitis. ROC curves are intended for positive distinguishing pathological laboratory measurements. Cut-off values were determined and distinguishing performances were assessed. RESULTS: 175 of the 320 patients were males (54.7%) and 145 were females (45.3%). Average age was 35.95±14.75. While cut-off value for WBC was 12.080 and it was found significant in distinguishing total appandisitis (group II+group III) from normal appendixes and distinguishing group II from group I (p<0.001), it was determined that it was not significant in distinguishing group II from group III (p=0.768). While cut-off value for neutrophil was 73% and it was significant in distinguishing group II+group III from group I and group II from group I (p<0.001), it was detected that it was not significant in distinguishing group II from group III (p=0.681). While cut-off value for CRP was 45.98, it was not found significant in distinguishing group II+group III from group I and group II from group I; however it was significant in distinguishing group II from group III (p<0.001). When all measurements were evaluated together, it was detected that the increase in only the neutrophil percentage rised the non-complicated acute appendisitis (OR: 1.082; p<0.001), and the increase in both neutrophiles and CRP resulted in a rise in the risk of complication (OR: neutrophil=1.066; p=0.009- CRP=1.005; p=0.013). DISCUSSION: The cut-off value of labaratuary tests may help determine the diagnosis and treatment. Especially, cut-off value of CRP may be helpful to determine the method of incision during the operation as conventional appendectomy or laparoscopic appendectomy.

Validity of modified early warning, Glasgow Blatchford, and pre-endoscopic Rockall scores in predicting prognosis of patients presenting to emergency department with upper gastrointestinal bleeding.

BACKGROUND: GBS, MEWS, and PER scoring systems are not commonly used for patients presenting to emergency department with GIS bleeding. This study aimed to determine the value of MEWS, GBS, and PER scores in predicting bleeding at follow-up, endoscopic therapy and blood transfusion need, mortality, and rebleeding within a 1-month period. METHODS: A total of 202 consecutive patients with upper GIS bleeding between July 2013 and November 2014 were prospectively enrolled in the study. The relationship between MEWS, GBS, and PER scores and hospital outcome, bleeding at follow-up, endoscopic therapy, transfusion need, rebleeding, and death were examined. RESULTS: The study included a total of 202 subjects, with 84 (41.6 %) females and 118 (58.4 %) males. There was a significant correlation between GBS, MEWS, and PER scores and hospital outcomes (p <0.004, p <0.001, p <0.001, respectively). A GBS score greater than 11 succesfully predicted bleeding at follow-up (p = 0.0237). GBS score's sensitivity for predicting endoscopic therapy was greater than those of other scoring systems. The discriminatory power of each scoring system was significant for predicting transfusion (p <0.0001, p = 0.0470, and p = 0.0014, respectively). A GBS score greater than 13, a MEWS score greater than 2, and a PER score greater than 3 predicted death. A PER score greater than 3 predicted rebleeding (p <0.0001). CONCLUSION: The scoring systems in question can be easily calculated in patients presenting to ED with upper GIS bleeding and may be beneficial for risk stratification, determination of transfusion need, prediction of rebleeding, and decisions of hospitalization or discharge.

MPV and other inflammatory markers in diagnosing acute appendicitis.

OBJECTIVE: To investigate whether mean platelet volume can be used as an inflammatory marker for the diagnosis of acute appendicitis, and to determine the role, if any, of white blood cell count, C-reactive protein and neutrophil count in this regard. METHODS: The retrospective study was conducted at Mersin University (MEU) Health Research and Application Center, Emergency Department, Mersin, Turkey, and included medical record of patients having gone appendectomy between April 2012 to July 2013. Based on pathology examination, the cases were grouped as uncomplicated, complicated, and non-appendicitis cases. Preoperative white blood cell, neutrophil, C-reactive protein and mean platelet volume were noted. SPSS 16 was used for statistical analysis. RESULTS: Records of 275 patients were studied. Overall, 90(32.7%) patients were uncomplicated, 120(43.7%) complicated, and 65(23.6%) were non-appendicitis cases. The first two groups had a significantly higher white blood cell (p=0.001) and neutrophil (p<0.001) counts than the third one. Mean platelet volume levels were not statistically different (p=0.478).The neutrophil count had a sensitivity of 76.19%, specificity of 56.92%, positive predictive value of 85.11%, and negative predictive value of 42.53%; white blod cell count had sensitivity 68.10%, specificity 61.54%, positive predictive value 85.12%, and negative predictive value 37.38%; mean platelet volume level had sensitivity 74.76%, specificity 35.38%, positive predictive value 78.89%, and negative predictive value 30.26%; and C-reactive protein level had sensitivity 84.29%, specificity 30.77%, positive predictive value 79.73%, and negative predictive value 37.74%. CONCLUSIONS: Elevated white blood cell and neutrophil counts may be used as diagnostic tests in cases of acute appendicitis, while C-reactive protein and mean platelet volume levels were not useful as diagnostic markers.

[Misdiagnosis of pulmonary embolism and causes]. / Pulmoner embolide yanlis tani ve sebepleri.

INTRODUCTION: Pulmonary thromboembolism (PTE) is not only one of the prevelant diseases with a high mortality risk but also has a high ratio of delayed diagnosis and misdiagnosis. In this study, it was aimed to determine the demographical characteristics, risk factors, clinical and laboratory findings of the patients that were diagnosed as PTE at their first hospital visit and of the PE patients who were misdiagnosed at their first admission. We aimed to investigate the factors which can leads to misdiagnosis of PE, and to determine the ways to avoid misdiagnosis. MATERIALS AND METHODS: One hundred PTE patients who were admitted to University Hospital between the dates January 2007-December 2011 were included in the study. Clinical and laboratory findings of these patients were evaluated. Among these patients, 26 were misdiagnosed at their first admission but diagnosed accurately (as PTE) in our hospital and 74 were diagnosed accurately. Two groups were compared with respect to various data of the patients clinical and demographical characteristics. RESULTS: Between the two groups, there was no difference in terms of physical examination and laboratory findings. The patients with the symptoms onset was over a week ago had a higher misdiagnosis rate (p= 0.002). The patients with no risk of PTE had a higher misdiagnosis rate (p= 0.017). Misdiagnosis rate of the patients with cardiac diseases was lower (p= 0.033) According to Geneva risk score, we observed that the misdiagnosis risk was reduced in the patients with higher clinical probability (p= 0.011). CONCLUSION: In conclusion, misdiagnosis rate was found to be statistically significant in the patients with low score according to the Geneva risk classification, and whose pre-diagnosis period lasted for more than a week and with no risk factors of PTE or cardiac diseases. We are in the opinion that considering these parameters will help to reduce in misdiagnosis of pulmonary embolism cases.

Lingual angioedema after alteplase treatment in a patient with acute ischemic stroke.

BACKGROUND: In recent years, thrombolytic therapy has become the main treatment of ischemic stroke. But the increasing use of alteplase in ischemic stroke has made some complications more evident. Angioedema is a rare but potentially life-threatening complication of alteplase treatment. Only a few studies have examined the incidence of angioedema after treatment with alteplase for stroke. METHODS: A 75-year-old man complaining of right hemiparesis was admitted to our emergency department. He was diagnosed as having acute ischemic stroke, and alteplase infusion was given two hours after the onset of stroke symptoms. Immediately after the completion of infusion he was noted to have a large swollen tongue. RESULTS: His neurological symptoms resolved gradually within 4 hours, whereas his upper extremity strength improved to 4/5 and lower extremity 5/5. Lingual edema resolved within 16 hours without any complication. He died from presumed nosocomial infection 5 days later. CONCLUSIONS: Lingual angioedema may appear as a possible complication in patients who were treated with alteplase. The management of these patients should be very careful.

Retrospective analysis of poisoning cases admitted to the emergency medicine.

BACKGROUND: We aimed herein to assess demographic, etiological, and clinical characteristics of patients presenting to our hospital's emergency department with acute poisoning. METHOD: This study included a total of 509 (0.27%) patients diagnosed with poisoning at our emergency department within a 3-year period. This was a retrospective study.  RESULTS: Seventy-one point three (n = 363) percent of the patients were female. The majority of the victims were in the 18-25 years age group (P < 0.001). The poisoning incident was for suicidal purposes in 83.7% of patients. Among the patients presenting with prescription drug poisoning, 92.9% were poisoned in a suicide attempt while 73.2% of patients presenting with poisoning with non-medical substances were poisoned accidentally. Suicidal poisonings were more common in young age group and females (P < 0.001). The most common poisoning agent was antidepressants (17.6%) followed by analgesics (12.8%), and other psychotropic drugs (6.1%). Antidepressant drugs were the most common prescription drugs taken for suicidal purposes (P < 0.001). Poisonings occurred with a single agent in 72.5% of cases and with two or more agents in 27.5% of cases.  Analysis of duration of hospital stay revealed that 52.6% (n = 60) of patients stayed in hospital for 2 days. The mortality rate was 0.4%. CONCLUSION: The majority of poisonings were with prescription drugs, for suicidal purposes, in young age group, and in females. In our study, the three most common agents causing poisoning were antidepressants, analgesics, and other psychotropic substances.

A Rare Cause of Sudden Ptosis: Posterior Communicating Artery Aneurysm.

A forty-seven-year-old female patient was admitted to our clinic with sudden ptosis and diplopia without pain. She had no trauma or systemic disease history. Ptosis and mydriasis were observed in her left eye. Eye movement was restricted all directions without lateral. Isolated oculomotor nerve paralysis was diagnosed based on clinical findings, and posterior communicating artery aneurysm was observed in magnetic resonance angiography.

Retrospective analysis of whole-body multislice computed tomography findings taken in trauma patients.

OBJECTIVES: Using whole-body multislice computed tomography (MSCT) excessively or with irrelevant indications can be seen in many centers. The aim of this study was to analyze retrospectively the MSCT findings in trauma patients admitted to the emergency department. METHODS: Records of the patients who have applied to the emergency department due to blunt trauma in a 12 month period and whose whole body MSCT images have been taken, were evaluated using the "Nucleus Medical Information System". RESULTS: The most frequent type of trauma was traffic accidents in 61.4%, falling down from the height in 22.4%, and motorcycle accidents in 11.4% of patients. Of the patients, 25.2% were discharged from the emergency, while 73.8% were hospitalized. At least one CT findings associated with trauma was present in 61.4% of our patients. Pathological findings in MSCT were most frequently detected in the head and face (35.3%) and thoracic (28.6%) regions, respectively. The most common finding in the head and face region was fractures. The most common pathological findings in the thoracic region were pulmonary contusion and rib fractures. A significant relationship was detected between trauma type and spinal MSCT result (p < 0.001). In a large percentage of the patients, MSCT findings were normal in the abdominal region and genitourinary system. Vertebral fractures were most frequently detected in the thoracolumbar region. CONCLUSIONS: In our study, our rate of negative CT was found to be 38.6%, which is a higher ratio compared to other studies conducte on this topic.

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.

Red flag in the emergency department: fracture and primary failure of a prosthetic valve.

This case report concerns a patient with fracture and primary dysfunction of a prosthetic valve. A 40-year-old man presented to the Emergency Department with a chief complaint of breakthrough pleuritic back pain and shortness of breath. Past surgical history was significant only for an aortic valve replacement and mitral valve replacement performed 16 years prior. The transthoracic echocardiography raised suspicion of prosthesis malposition. The patient was taken to the operating room by cardiothoracic surgeons for valve replacement. Operative findings revealed that a prosthetic valve leaflet in the mitral position had broken off. Primary prosthetic valve failure should not be overlooked in the differential diagnosis of patients with valve replacement and a rapidly deteriorating clinical course. Emergency echocardiography is a guide to convenient diagnosis and management. Early surgical consultation and early reparative surgery might prevent unnecessary morbidity and mortality.