Does contrast media volume affect long-term survival in patients with chronic kidney disease?

INTRODUCTION: The aim of this study was to investigate the relationships between survival and related features in patients with chronic kidney disease undergoing cardiac catheterization and coronary angiography. MATERIAL AND METHODS: Three hundred and seven consecutive patients with an estimated glomerular filtration rate (e-GFR) less than 60 ml/min/1.73 m2 undergoing coronary angiography were enrolled in the study. The study population was pursued with a median follow-up duration of 41.5 months. RESULTS: In the Cox proportional hazards regression model, age (HR = 1.047, 95% CI: 1.011-1.084, p = 0.01), contrast media volume (HR = 1.004, 95% CI: 1.001-1.007, p = 0.008), angiotensin II receptor blocker (ARB) use (HR = 0.485, 95% CI: 0.261-0.901, p = 0.02), and e-GFR (HR = 0.978, 95% CI: 0.940-1.016, p = 0.04) were found to be independent predictors of long-term all-cause mortality. The survival analysis showed that the long-term all-cause mortality rate was higher in patients using contrast media volume greater than 140 ml compared to patients given less than or equal to 140 ml during the coronary angiography (3.6% vs. 11.6% log-rank, p = 0.001). CONCLUSIONS: In patients with chronic kidney disease undergoing cardiac catheterization, age, contrast media volume, e-GFR and low ARB use were found to be independent predictors of long-term all-cause mortality. Contrast media volume used > 140 ml was independently associated with long-term all-cause mortality compared to less than or equal to 140 ml during cardiac catheterization.

Is this a simple drug eruption to be discharged?

'Erythema Multiforme associated with Phenytoin And Cranial radiation Therapy' (EMPACT) is a very rare clinic situation and classified in EM-like drug reactions. It can be easily misdiagnosed as acute urticaria or drug eruption in ED. Initial symptoms may resemble a simple skin problem, but diagnosing and early hospitalization of the patients can be lifesaving. Here, we present a man with renal cell cancer and brain metastases who admitted to ED due to fever and generalized rash. His skin lesions beginning from his head and spreading through the torso appeared four days after the end of radiotherapy (11 days after the initial dose of both radiation and oral phenytoin). Inspection showed erythematous lesions on the scalp, neck, torso and arms. These lesions had desquomative character on the scalp. Erythematous maculopapular lesions with the tendency of fusion were also visible on the chest, abdomen, back, on the flexor areas of the arm, forearm and femoral region. Laboratory studies showed normal complete blood counts, high creatinine kinase, creatinine kinase-MB, gamma-glutamyl transpeptidase, aspartate aminotransferase, lactate dehydrogenase, albumin and total protein. After discontinuation of phenytoin and giving H1, H2 receptor blockers and steroid intravenously, he was discharged two weeks later with full recovery.

Can we predict agitation in patients with suicide attempts in the emergency department?

BACKGROUND: The agitation in patients presenting to the emergency department (ED) after suicide attempts is common and an important problem. OBJECTIVE: To establish whether we can predict agitated patients among suicide attempt patients in ED. METHODS: This is a cross-sectional observational study of adult suicide attempt events in ED. Information was collected prospectively on a specially designed data-collection form. Patients aged 16 years old and above who presented to the ED for care due to suicide attempts were included in the study. Suicide attempts were grouped as aggressive and non-aggressive attempts. RESULTS: A total of 533 patients were included. Forty-three of these patients had agitation in ED (8%). Non-aggressive suicide attempts were referred to psychiatry services more than aggressive ones (73.6%, n=345 vs 32.8%, n=21, P<0.0001). Agitation in ED and being male increased aggressive suicide attempt risk 3.5 (95% CI:1.6-7.6) and 3.2 times (95% CI:1.8-5.5), respectively. Agitation was statistically more frequent among these patients: those on antidepressant overdose, with previous suicide attempt; with aggressive suicide attempt; and those with confusion; and unconsciousness (P<0.05). CONCLUSION: Patients who attempted suicide and whose risk of harm to others included those with: antidepressant overdose, aggressive suicide attempt and the unconscious. Response teams should be prepared for these subgroups.

A Review of Melatonin, Its Receptors and Drugs.

After a Turkish scientist took Nobel Prize due to his contributions to understand clock genes, melatonin, closely related to these genes, may begin to shine. Melatonin, a hormone secreted from the pineal gland at night, plays roles in regulating sleep-wake cycle, pubertal development and seasonal adaptation. Melatonin has antinociceptive, antidepressant, anxiolytic, antineophobic, locomotor activity-regulating, neuroprotective, anti-inflammatory, pain-modulating, blood pressure-reducing, retinal, vascular, anti-tumor and antioxidant effects. It is related with memory, ovarian physiology, and osteoblast differentiation. Pathologies associated with an increase or decrease in melatonin levels are summarized in the review. Melatonin affects by four mechanisms: 1) Binding to melatonin receptors in plasma membrane, 2) Binding to intracellular proteins such as calmoduline, 3) Binding to Orphan nuclear receptors, and 4) Antioxidant effect. Receptors associated with melatonin are as follows: 1) Melatonin receptor type 1a: MT1 (on cell membrane), 2) Melatonin receptor type 1b: MT2 (on cell membrane), 3) Melatonin receptor type 1c (found in fish, amphibians and birds), 4) Quinone reductase 2 enzyme (MT3 receptor, a detoxification enzyme), 5) RZR/RORα: Retinoid-related Orphan nuclear hormone receptor (with this receptor, melatonin binds to the transcription factors in nucleus), and 6) GPR50: X-linked Melatonin-related Orphan receptor (it is effective in binding of melatonin to MT1). Melatonin agonists such as ramelteon, agomelatine, circadin, TIK-301 and tasimelteon are introduced and side effects will be discussed. In conclusion, melatonin and related drugs is a new and promising era for medicine. Melatonin receptors and melatonin drugs will take attention with greater interest day by day in the future.

Treatment in carbon monoxide poisoning patients with headache: a prospective, multicenter, double-blind, controlled clinical trial.

BACKGROUND: There is a lack of specificity of the analgesic agents used to treat headache and underlying acute carbon monoxide poisoning. OBJECTIVE: To compare effectiveness of "oxygen alone" vs "metoclopramide plus oxygen" vs "metamizole plus oxygen" therapy in treating carbon monoxide-induced headache. DESIGN: A prospective, multicenter, double-blind, controlled trial. SETTING: Three emergency departments in Turkey. POPULATION: Adult carbon monoxide poisoning patients with headache. METHODS: A total of 117 carbon monoxide-intoxicated patients with headache were randomized into 3 groups and assessed at baseline, 30 minutes, 90 minutes, and 4 hours. MAIN OUTCOME MEASURE: The primary outcome was patient-reported improvement rates for headache. Secondary end points included nausea, need for rescue medication during treatment, and reduction in carboxyhemoglobin levels. RESULTS: During observation, there was no statistical difference between drug type and visual analog scale score change at 30 minutes, 90 minutes, or 4 hours, for either headache or nausea. No rescue medication was needed during the study period. The reduction in carboxyhemoglobin levels did not differ among the 3 groups. CONCLUSION: The use of "oxygen alone" is as efficacious as "oxygen plus metoclopramide" or "oxygen plus metamizole sodium" in the treatment of carbon monoxide-induced headache.

Characteristics of Patients Who Admitted to the Emergency Department Because of Burns Due to Dens Liquids Such as Hot Milk/Oil.

OBJECTIVE: Burn is the tissue damage on body caused due to various reasons. Although all burns caused by hot liquids are investigated as scalding burns, dense liquid burns (DLB) caused by such as milk and oil are different from other burns. The aim of this study was to report the properties of DLB. MATERIALS AND METHODS: Patients admitted to the Emergency Service of Atatürk University Hospital, with DLB from June 2003 to December 2008, were examined retrospectively. RESULTS: During the study, 28 DLB patients were admitted to the emergency service. The most common admission were found in autumn 28.6% (n=8), and in May and June, 17.9% (n=5). The frequency of burns on the right upper extremity was seen in 50% (n=14) of the patients. The burn degree of all patients was determined as 2(nd) degree. Seventy-five percent (n=21) of the patients were discharged, 14.3% (n=4) were hospitalized. None of the patients died. CONCLUSION: Dense liquid burns is a burn type that is commonly seen in women, absolutely causing 2(nd) degree burns, frequently reported in upper extremity and head/neck regions, and in contrast to other studies, in our region it is completely seen in patients living in city centre.

Comparison of Intravenous Morphine Versus Paracetamol in Sciatica: A Randomized Placebo Controlled Trial.

OBJECTIVE: The objective was to compare intravenous morphine and intravenous acetaminophen (paracetamol) for pain treatment in patients presenting to the emergency department with sciatica. METHODS: Patients, between the ages of 21 and 65 years, suffering from pain in the sciatic nerve distribution and a positive straight leg-raise test composed the study population. Study patients were assigned to one of three intravenous interventions: morphine (0.1 mg/kg), acetaminophen (1 g), or placebo. Physicians, nurses, and patients were blinded to the study drug. Changes in pain intensity were measured at 15 and 30 minutes using a visual analog scale. Rescue drug (fentanyl) use and adverse effects were also recorded. RESULTS: Three-hundred patients were randomized. The median change in pain intensity between treatment arms at 30 minutes were as follows: morphine versus acetaminophen 25 mm (95% confidence interval [CI] = 20 to 29 mm), morphine versus placebo 41 mm (95% CI = 37 to 45 mm), and acetaminophen versus placebo 16 mm (95% CI = 12 to 20 mm). Eighty percent of the patients in the placebo group (95% CI = 63.0% to 99%), 18% of the patients in the acetaminophen group (95% CI = 10.7% to 28.5%), and 6% of those in the morphine group (95% CI = 2.0% to 13.2%) required a rescue drug. Adverse effects were similar between the morphine and acetaminophen groups. CONCLUSION: Morphine and acetaminophen are both effective for treating sciatica at 30 minutes. However, morphine is superior to acetaminophen.

Lenalidomide Induced Late-Onset Acute Respiratory Distress Syndrome.

A 77-year-old man with multiple myeloma (MM) presented with shortness of breath to the emergency department. He also had history of chronic obstructive pulmonary disease, chronic pulmonary embolism and nephrectomy due to malignancy 10 years ago. He had been treated for 9 months with lenalidomide because of MM. He diagnosed with adult respiratory distress syndrome due to lenalidomide. We aimed to demonstrate late onset and destructive effects of lenalidomide on the lungs.

The utility of cardiac magnetic resonance imaging in Kounis syndrome.

INTRODUCTION: Current diagnostic measurements used to assess myocardial involvement in Kounis syndrome, such as electrocardiography (ECG), cardiac enzymes, and troponin levels, are relatively insensitive to small but potentially significant functional change. According to our review of the literature, there has been no study using magnetic resonance imaging (MRI) on Kounis syndrome except for one case report. AIM: To identify the findings of dynamic contrast-enhanced magnetic resonance imaging (CE-MRI) in patients with Kounis syndrome (KS) type 1. MATERIAL AND METHODS: We studied 26 patients (35 ±11.5 years, 53.8% male) with known or suspected KS type 1. The patients underwent precontrast, first-pass, and delayed enhancement cardiac MRI (DE-MRI). Contrast enhancement patterns, edema, hypokinesia, and localization for myocardial lesions were evaluated in all KS type 1 patients. RESULTS: Contrast-enhanced magnetic resonance imaging demonstrated an early-phase subendocardial contrast defect, and T2-weighted images showed high-signal intensity consistent with edema in lesion areas. None of the lesion areas was found upon contrast enhancement on DE-MRI. The area of early-phase subendocardial contrast defect was reported as follows: the interventricular septum in 14 (53.8%) patients, the left ventricular lateral wall in 8 (30.7%), and the left ventricular apex in 4 (15.4%). CONCLUSIONS: Dynamic cardiac MR imaging is a reliable tool for assessing cardiac involvement in Kounis syndrome. Delayed contrast-enhanced images show normal washout in the subendocardial lesion area in patients with Kounis syndrome type 1.

Can we distinguish stroke and stroke mimics via red cell distribution width in young patients?

INTRODUCTION: Discrimination of stroke and stroke mimics is problematic in young patients. The aim of the study was to determine whether arterial ischemic stroke and stroke mimics can be differentiated via the red cell distribution width (RDW) value in young patients. MATERIAL AND METHODS: In this retrospective cross-sectional study, a total of 236 patients hospitalized at the neurology ward were investigated. The patients were divided into 3 groups: the 1(st) group included young stroke patients, the 2(nd) group included patients with epilepsy, and the 3rd group included patients with multiple sclerosis (MS). Complete blood count and computed tomographic brain imaging tests were performed in all patients, and magnetic resonance imaging was done when necessary. RESULTS: A total of 236 patients were included in this study. Ninety-five (40%) patients were young stroke patients, 71 (30%) had epilepsy and 70 (30%) had MS. The mean RDW values of young patients with stroke were significantly higher than patients with epilepsy or MS (14.9 ±1.2, 13.3 ±1.2, 13.4 ±0.6, p < 0.0001, respectively). The diagnostic power of RDW in the differentiation of patients with stroke is good (area under the curve (AUC) = 0.89). When an RDW cut-off value of 14.05% is accepted for differentiating young patients with stroke from other disorders, the sensitivity, specificity, positive predictive and negative predictive values were 73.7%, 87.9%, 6.1 and 0.043, respectively. CONCLUSIONS: Red cell distribution width is a promising, rapid, easy and inexpensive parameter to distinguish young stroke from stroke mimics (such as epilepsy and MS) in young patients.

Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury.

This is the first case report of an adult who had spontaneous reduction of ileoileal intussusception occurred after punching to the abdomen. A 40-year-old man was brought to our emergency department by ground ambulance due to pounding and punching a few hours ago. Physical examination showed multiple dermabrasions on his face, abdomen, and lower extremities. All other examinations were unremarkable except that of mild abdominal pain. Laboratory results gave no clues. On abdominal x-ray, paucity of intestinal gas, pseudomass and surrounding gas appearances were visible. No nausea or vomiting occurred during observation. His abdominal pain resolved gradually. On the 24th hour after admission, control computed tomography showed that the findings of intussusception disappeared. He was discharged after 1 day of observation. Outpatient follow-up did not show any abnormality. We suggest that, in patients with mild to moderate trauma, even if the patient has mild abdominal pain, physicians should rule out invagination. Computed tomography is the suggested imaging modality. These patients should be kept in close follow-up. If symptoms resolve and intussusception findings disappear in computed tomography, no further treatment is required.

The role of vagal nerve root injury on respiration disturbances in subarachnoid hemorrhage.

AIM: We examined whether there is a relationship between vagal nerve root injury and the severity of respiration disorders associated with subarachnoid hemorrhage (SAH). MATERIAL AND METHODS: This study was conducted on 20 rabbits. Experimental SAH was induced by injecting homologous blood into the cisterna magna. During the experiment, electrocardiography and respiratory rhythms were measured daily. After the experiment, any axonal injury or changes to the arterial nervorums of the vagal nerves were examined. All respiratory irregularities and vagal nerve degenerations were statistically analyzed. RESULTS: Normal respiration rate, as measured in the control group, was 30 ± 6 bpm. In the SAH-induced group, respiration rates were initially 20 ± 4 bpm, increasing to 40 ± 9/min approximately ten hours later, with severe tachypneic and apneic variation. In histopathological examinations, axon density of vagal nerves was 28,500 ± 5,500 in both control and sham animals, whereas axon density was 22,250 ± 3,500 in survivors and 16,450 ± 2,750 in dead SAH animals. The severity of axonal degeneration of vagal nerves was greater in the six dead animals than in the survivors. CONCLUSION: If vagal nerves are lesioned, the muscles of respiration are paralyzed and respiratory reflexes are disrupted. That the ischemic and mechanical factors created by SAH cause vagal nerve root injury and respiration disorders may be inevitable and fatal.

Familial Mediterranean fever gene mutations in north-eastern part of Anatolia with special respect to rare mutations.

We aimed to determine the frequency of mutations, carrier rates and the association of rare mutations with Familial Mediterranean Fever (FMF) symptoms. There is a need to evaluate as many different populations as possible in order to determine either specific rare mutations or a range of disease-associated mutations. The demographic data and FMF symptoms related to MEFV gene mutations were collected from 731 participants. Exon 2 and exon 10 of the MEFV gene were tested by DNA sequencing. The rare mutations were identified as: M694I (1.1%, n=12), E148V (0.6%, n=6), T267I (0.5%, n=5), L110P (0.2%, n=2), E167D (0.2%, n=2), K695R (0.1%, n=1) and an insertion G (Guanine) mutation (0.4%, n=4) at the 777th codon of exon 10. We used routine comprehensive detection systems such as Sanger sequence that can catch rare mutations, for definite diagnosis and treatment of FMF disease.

Demographic and clinical differences of aggressive and non-aggressive suicide attempts in the emergency department in the eastern region of Turkey.

BACKGROUND: Worldwide, suicide ranks among the three leading causes of death among those aged 15-44 years. An estimated 800000 people die by committing suicide annually. OBJECTIVES: To better understand the association between aggressive suicidal attempt and non-aggressive suicidal attempt in patients with suicide attempt in the emergency department. PATIENTS AND METHODS: A cross-sectional observational study was conducted on suicide attempters of eastern region of Turkey between May 2008 and January 2012. Information of all adult suicide attempts was collected prospectively on a form. Suicide attempts were grouped as aggressive and non-aggressive attempts on a specially designed data-collection form. The aggressive suicide attempts contained violent suicide methods such as firearm, hanging, jumping, car exhaust or drowning. RESULTS: A total of 533 patients were included. Sixty-four of these patients admitted to ED with aggressive suicide attempt (12%). Non-aggressive suicide attempts were consulted to psychiatry more compared to aggressive ones (%73.6, n = 345 vs. %32.8, n = 21, P < 0.0001). Agitation in ED and being male increased aggressive suicide attempt risk by 3.5 (%95 CI: 1.6-7.6) and 3.2 times (%95 CI: 1.8-5.5), agitated patients in ED group and male group respectively. Patients with aggressive suicide attempt were statistically more frequent among these patients; patients with agitation, those hospitalized in intensive care or surgical services and those whose length of stay in the emergency department was less than one day (P < 0.05 for all). Patients with non-aggressive suicide attempt were statistically more frequent in these patients; patients complained of nausea, vomiting, stomach pain, fatigue, those with confusion, those tending to sleep, those hospitalized in internal services or emergency ward and finally those whose length of stay in the emergency department was more than one day (P < 0.05 for all). CONCLUSIONS: Patients with aggressive suicide attempt who have high risk of dying should be recognized and requested psychiatric consultation even if not in the emergency department.

Dual-source computed tomography may define cardiac contusion in patients with blunt chest trauma in ED.

We report a 20-year-old woman with blunt chest trauma because of a motor vehicle injury who has traumatic asphyxia and hypotension. The diagnosis of blunt cardiac injury was put by using dual-energy computed tomography in the emergency department because other laboratory and imaging modalities were useless. After hospitalization in intensive care unit, she was treated with supportive and antiedema therapy. The patient was extubated on the fifth day and discharged on the ninth day without any sequel. Coexistence of traumatic asphyxia with blunt cardiac injury is rare. Several imaging techniques such as transthoracic and transesophageal echocardiography, contrast-enhanced multislice thorax computed tomography or initial electrocardiogram, and troponin I levels are used to detect the myocardial damage, but diagnostic capability is low. Dual-energy computed tomography is a promising new technology with the ability of defining blunt cardiac injuries and may have an indication in the emergency setting in patients with hemodynamic instability to rule in traumatic cardiac complications especially when electrocardiogram and transthoracic echocardiography are useless in the emergency department.