Comparison of high-flow oxygen treatment and standard oxygen treatment in patients with hypertensive pulmonary edema.

OBJECTIVE: The aim compares the blood gases, vital signs, mechanical ventilation requirement, and length of hospitalization in patients with hypertensive pulmonary edema treated with standard oxygen therapy (SOT) and high-flow oxygen therapy (HFOT). METHODS: This prospective observational study was conducted in patients with tachypneic, hypoxemic, hypertensive pulmonary edema. The patients' 0th, 1st, and 2nd hour blood gas results; 0th, 1st, and 2nd hour vital signs; requirement of endotracheal intubation, length of hospitalization, and the prognosis were recorded on the study form. RESULTS: A total of 112 patients were included in this study, of whom 50 underwent SOT and 62 received HFOT. The initial blood gas analysis revealed significantly lower levels of pH, PaO2, and SpO2 and significantly higher levels of PaCO2 in the HFOT group. Patients in the HFOT group had significantly higher respiratory rate and pulse rate and significantly lower SpO2 values. The recovery of vital signs was significantly better in the HFOT group (p<0.05). Similarly, follow-up results of arterial blood gas analysis were better in the HFOT group (p<0.05). Both length of stay in the emergency department (p<0.05) and length of intensive care unit hospitalization s significantly shorter in the HFOT group (p<0.05). CONCLUSION: HFOT can be much more effective in patients with hypertensive pulmonary edema than SOT as it shortens the length of stay both in the emergency service and in the intensive care unit. HFOT also provides better results in terms of blood gas analysis, heart rate, and respiratory rate in the follow-up period.

Decreased left atrial global longitudinal strain predicts the risk of atrial fibrillation recurrence after cryoablation in paroxysmal atrial fibrillation.

PURPOSE: We aimed to investigate the association of atrial fibrillation (AF) recurrence with left atrial (LA) strain in nonvalvular paroxysmal AF patients after cryoablation. METHODS: We included 190 patients who underwent successful cryoablation due to paroxysmal AF. In addition to classical echocardiographic data, LA apical 2-chamber (A2C) strain, LA apical 4-chamber (A4C) strain, and LA global longitudinal strain (LA-GLS) values were calculated by speckle tracking echocardiography. Forty-eight-hour Holter monitoring was performed to all patients no later than 6 months after ablation. RESULTS: AF recurrence was detected in 42 patients (22.1%). End-systolic diameter, LA end-systolic diameter, LA-volume, LA-volume index, interatrial septum thickness, coronary sinus diameter, epicardial fat thickness (EFT), and septal E/E` ratio were significantly higher, LV-EF, IVRT, septal S and A` wave, lateral S wave, LA-A2C strain, LA-A4C strain, and LA-GLS were significantly lower in patients with AF recurrence. LA-GLS, LA-volume index, and EFT were found to be independent parameters for predicting AF recurrence. CONCLUSIONS: LA-GLS and LAVI should be included in routine evaluations to determine long-term AF recurrence preoperatively.

The relationship between blood glucose and nocturnal supraventricular tachycardia attacks in non-diabetic patients.

PURPOSE: Decrease in the blood glucose level may trigger the tachycardia or bradycardia because it has an arrhythmogenic effect on the heart. Our purpose in this study was to investigate whether the blood glucose level has an effect on patients who attended to the hospital with nocturnal supraventricular tachycardia (SVT). METHODS: We included 151 patients in our study who have SVT history. Plasma glucose levels which were taken during night hours, electrolytes, and 12 lead electrocardiography were evaluated. RESULTS: There were 105 patients without nocturnal SVT attack and 46 patients with nocturnal SVT attack. Patients with nocturnal SVT attack, blood glucose level, potassium, calcium, and hemoglobin levels were significantly lower, hs-CRP was significantly higher, basal cycle length (BCL) was significantly short, and QT interval was significantly longer. It was found that blood glucose (O.R. = 0.904, 95% GA 0.828-0.986, p = 0.023) and potassium levels (O.R. = 0.128, 95% GA 0.029-0.561, p = 0.006) and basal cycle length (BCL) (O.R. 0.988, 95% GA, 0.980-0.996, p = 0.005) values were in independently correlated with nocturnal SVT attacks. CONCLUSION: The decrease in blood glucose level of the patients who are being followed with SVT diagnosis might trigger the nocturnal SVT attacks.

A new criterion to differentiate atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia: Combined AVR criterion.

AIM: A combined aVR criterion is described as the presence of a pseudo r' wave in aVR during tachycardia in patients without r' wave in aVR in sinus rhythm and/or a ≥50% increase in r' wave amplitude compared to sinus rhythm in patients with r' wave in the basal aVR lead. We aimed to investigate the use of combined aVR criterion in differential diagnosis of atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT). METHODS: In this prospective study, 480 patients with inducible narrow QRS supraventricular tachycardia (SVT) were included. Twelve-lead electrocardiogram (ECG) was conducted during tachycardia and sinus rhythm. The patients were divided into two groups according to the arrhythmia mechanism that determined via EPS, AVNRT, and AVRT. Criteria of narrow QRS complex tachycardia were compared between the two groups. RESULTS: AVNRT was present in 370 (77%) patients and AVRT in 110 (23%) patients. Combined aVR criterion was found to be more frequent in patients with AVNRT (84.1% and 9.1%, p < 0.001). In logistic regression analysis, combined aVR criterion and classical ECG criterion were found to be the most important predictors of AVNRT (p < 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of the combined aVR criterion for AVNRT were 84.1%, 90.9%, 96.9%, and 62.9%, respectively. CONCLUSION: In the differential diagnosis of patients with SVT, the combined aVR criterion identifies the presence of AVNRT with an independent and acceptable diagnostic value. In addition to classical ECG criteria for AVNRT, it is necessary to evaluate the combined aVR criterion in daily practice.

Comparison of midazolam and propofol for sedation in pediatric diagnostic imaging studies.

OBJECTIVE: This study aims to compare the efficacy of propofol and midazolam in terms of adverse effect potentials and to determine the appropriate strategy for pediatric procedural sedation. METHODS: A total of 200 pediatric patients (aged < 14 years) undergoing diagnostic procedures were recruited for this nonrandomized prospective controlled cohort study. The patients were assigned to 2 treatment arms: either propofol (Group 1: IV bolus dose of 2 mg/kg during a 2-minute period, IV maintenance dose of 100 mcg/kg/min) or midazolam (Group 2: IV bolus dose of 0.15 mg/kg during a period of 2 to 3 minutes) to achieve sedation. Demographic data, body weight, and clinical status of the patients were evaluated and recorded. The vital signs and sedation levels (ie, Ramsay sedation scale scores) were evaluated and recorded, as well as the complications detected and medications administered in 10-minute intervals throughout the sedation procedure. Findings between the study arms were compared. RESULTS: Arterial blood pressures decreased significantly in both groups (P = 0.001). The patients in Group 1 experienced a greater difference in diastolic blood pressure (P = 0.001) than those in Group 2. Sedation scores in Group 1 were more favorable (P = 0.014) and reached the appropriate sedation level in a shorter time than those in Group 2 (P = 0.010). Likewise, recovery time of patients was shorter in Group 1 than in Group 2 (P = 0.010). Hypoxia was found to be more common in the propofol group, but the difference was not significant (P = 0.333). CONCLUSION: Propofol seems to be more effective, achieve the appropriate sedation level more quickly, and provide a faster onset of sedation than midazolam in pediatric procedural sedation and analgesia. Propofol is preferred for imaging studies (computed tomography and magnetic resonance imaging) to reduce the occurrence of undesired motion artefacts. Although both drugs are safe to use for sedation before pediatric imaging procedures, propofol is preferred with appropriate preparation.

Anorectal Injuries due to Foreign Bodies: Case Reports and Review of the Management Options.

Anorectal injuries due to autoerotic activity with rectal foreign bodies were identified in four male patients. The objects were bottle in one patient, glasses in two patients, and showerhead in one patient. Foreign bodies were extracted within lithotomy position after anal dilatation, under general anesthesia in 3 patients. One patient presented with peritoneal irritation and had a diagnosis of rectal perforation. He underwent transanal rectal repair with proximal fecal diversion. In this paper we described 4 patients who had anorectal injuries due to autoerotic activity with foreign bodies and reviewed the management options in literature.

An unusual case of mesalazine intoxication: oral and rectal overloading of the rectal suppository form.

Drugs containing 5-acetylsalicylic acid (5-ASA) have been commonly used for inflammatory bowel diseases for more than half a century, but no case about overdose of suppository form of mesalazine which was taken both orally and rectally has been reported in the related literature up to now. In the present case, a 20-year-old male patient who took 14.5 g of mesalazine rectally and orally for suicide purpose is discussed. He was an ulcerative colitis patient and depressed about his illness and routine life traffic. Although it was hard for him to take the suppository form orally because of its bad taste and structure, he took it with the help of water. In the patient's colonoscopy, diffuse hyperemia and edema extending from the anal channel to the proximal rectal mucosa and a 1.5 cm diameter ulcer expanding from anal channel through the rectum were identified. No pathology was found in the upper gastrointestinal endoscopy. Routine laboratory examination was performed and no abnormality was identified in the patient's total blood account, biochemical parameters and full-urine examination. In the control rectoscopy applied to the patient 15 days later, recovery of the ulcer was observed and he was discharged to be followed in the psychiatry clinic.

Increased nutritional risk in major trauma: correlation with complications and prolonged length of stay.

BACKGROUND: Acute Physiology and Chronic Health Evaluation II (APACHE II) and the Trauma Injury Severity Score (TRISS) are physiological and anatomical severity scores to predict trauma outcome. Nutritional Risk Screening (NRS-2002) is used for the screening of nutritional risk, which can affect outcome adversely. The objective of this study was to determine the reliability of these scales to predict disease severity, complications and mortality, and to compare the reliability of the NRS-2002 in predicting outcome with different scoring systems in trauma-intensive care unit (ICU) patients. METHODS: The study enrolled 100 consecutive patients who were admitted to the ICU in a training hospital due to trauma in the six-month study period (1 July 2008 and 1 January 2009). Discrimination characteristics of the scoring systems were evaluated using receiver operating characteristic (ROC) curves. RESULTS: Overall mortality was 14%, and the complication rate was 22%. Nutritional risk at admission was found to be increased in 58% of the patients. The NRS-2002 score was increased in patients with complication. ISS, TRISS and APACHE II at admission had a reliable power of discrimination (AUC>0.8) for mortality and complication prediction. The NRS-2002 score had moderate discrimination power for complication prediction (AUC=0.708) but showed high correlation with increased length of stay (LOS). CONCLUSION: A significant percent of trauma patients are at nutritional risk. The NRS-2002 score can be useful in predicting complication and prolonged LOS in trauma patients.

Bradycardia and hypotension in mianserin intoxication.

Cardiotoxicity is an important adverse effect of tricyclic antidepressants. But cardiac side effects after intoxication with the tetracyclic mianserin are rare. In this paper, we describe a case in which bradycardia and hypotension occured due to mianserin overdose. A 37-year-old woman was admitted to the medical intensive care unit for self-poisoning with 30 tablets of 10 mg mianserin 2 hours before her admission. The patient denied taking any other drugs. Four hours after her admission, bradycardia and hypotension occurred and she began to suffer from giddiness. Atropine and theophylline were given. On the second and third day, her heart rate and blood pressure were normal. Based on this case, we estimate the probability of bradycardia and hypotension in mianserin intoxication and the significance of closely monitoring the patient.

The relationship between mortality and inflammation in patients with gastrointestinal bleeding.

The objective of this study was to investigate the association between mortality and inflammation in patients who were admitted to the emergency room with gastrointestinal bleeding. Patients (n = 96) managed at two medical centres were included in the study. Initial levels of serum C-reactive protein (CRP), haemoglobin and albumin, and leucocyte and thrombocyte counts for 28 patients who died were compared with those for the 68 patients who survived and were successfully discharged. The data were analysed using the chi(2)-test. Serum levels of CRP and leucocyte counts were significantly higher, and albumin and haemoglobin were significantly lower in patients who died compared with patients who survived. The increased levels of serum CRP and leucocyte counts, and decreased levels of albumin and haemoglobin were found to be independent risk factors for mortality. It is concluded that increased serum CRP levels and leucocyte counts combined with decreased albumin and haemoglobin levels on admission to the emergency room may be used as predictive factors of mortality in patients with gastrointestinal bleeding.

The effects of low-dose erythropoiesis-stimulating agents on peritoneal fibrosis induced by chemical peritonitis and on peritoneal tissue MMP-2 and TIMP-2 Levels in rats.

AIM: The objective of the present study was to investigate the effect of low-dose erytropoesis-stimulating agents (ESA) on the development of peritoneal fibrosis in chlorhexidine gluconate-induced peritoneal sclerosing rats and to assess the peritoneal tissue levels of MMP-2 and TIMP-2, which may be regarded as factors in the development of peritoneal fibrosis. SUBJECTS AND METHODS: Twenty-four Wistar albino rats were divided into three groups. The control group received 0.9% saline (3 ml/d) intraperitoneally, the CH group received 3 ml daily injections of 0.1% chlorhexidine gluconate (CH) intraperitoneally, and the CH+ESA group received 3 ml daily injections of 0.1% CH intraperitoneally and epoetin beta (3 x 20 IU/kg/week) subcutaneously. On the twenth-first day, rats were sacrificed, and parietal peritoneum samples were obtained from the left anterior abdominal wall. Pathological samples were examined using Hematoxyline & Eosin (HE) stains. The thickness, vascular proliferation, and inflammation were determined by light microscopy. MMP-2 and TIMP-2 were studied immunohistochemically by monoclonal antibody staining. RESULTS: Inflammation, vascular proliferation, and fibrotic area percentages were not statistically significant between groups. Histopathologically control, CH, CH+ESA groups peritoneal thickness were 8.02 +/- 2.89, 146.74 +/- 26.1, and 48.12 +/- 16.8 micrometers, respectively. The decrease in thickness of parietal peritoneum in CH+ESA group was statistically significant when compared to CH. Immunohistochemically, interferon was shown to decrease MMP-2 expression on parietal peritoneum than group CH, but has no effect on TIMP-2. DISCUSSION: Low-dose ESA histopatologically reduces peritoneal fibrosis induced by chlorhexidine gluconate. However, from dosage and duration points of view, we need extended clinical and experimental studies.

Dangers faced by emergency staff: experience in urban centers in southern Turkey.

BACKGROUND: The aim of this study was to investigate the incidence and characteristics of aggression, threat and physical violence directed towards the staff in emergency departments. METHODS: A questionnaire was completed by the emergency staff. The individualized data collected included the pattern and incidence of violence, sex, age, profession, and years of experience of the emergency staff, and the behavioral characteristics of the assailants, together with outcome of incidents. Data regarding incidences occurring between May 1-31, 2006 were abstracted. RESULTS: A total of 109 staff were evaluated. There was a statistically significant relationship between aggression and profession (p=0.000), but no relation was determined with sex, age or years of experience (p values 0.464, 0.692, and 0.298, respectively). The relationship of incidences of threat with sex, age, profession, and experience was insignificant (p values 0.311, 0.278, 0.326, 0.994, respectively). On the other hand, significant relationships were identified between physical assault and sex, age, profession, and experience (p values 0.042, 0.000, 0.000, 0.011). CONCLUSION: Violence directed towards the emergency staff is common. Aggression occurs towards the emergency physician distinctively. Otherwise, there is no significant relationship between aggression or threat and personal characteristics. However, male sex, > or =31 years of age, being an emergency physician, and having worked for longer than five years in the emergency department are the risk factors for physical violence.

Burnout: need help?

BACKGROUND: Burnout syndrome is a psychological situation induced with working, especially in high-risk parts of the hospitals that affects the physical and mental conditions of the staff. The aim is to identify the characteristics of the staff related to Burnout Syndrome in the Emergency Department (ED). METHODS: The study includes the Maslach Burnout Inventory and other new individual research questions. The responders were the volunteers and comprised physicians, nurses, nurses' aides from EDs of all urban state hospitals of Adana (43.3%). Burnout scores were analyzed with regard to individual characteristics; supplementary work, marital status, the number of children, occupation, salary, career satisfaction, satisfaction in private life. Mann-Whitney U test and Kruskall-Wallis test were performed using SPSS 15.00. RESULTS: There were no relation between Burnout scores and supplementary work, marital status, number of children, occupation, salary, private life satisfaction, except for career satisfaction. CONCLUSION: Presence and severity of Burnout syndrome were linked to career satisfaction without personal features and salaries. All branches of healthcare occupations in ED seem to have been affected by Burnout Syndrome similarly.

The efficacy of low-dose antivenom therapy on morbidity and mortality in snakebite cases.

UNLABELLED: Similar to the cases seen around the world, snakebite causes mortality and morbidity in Turkey. The venom of different types of snake in the region of Cukurova causes serious systemic and local tissue damage. METHODS: We performed this prospective study on 45 patients who complained of snakebite. We grouped the patients according to their clinical presentations to facilitate treatment and follow-up period procedures. RESULTS: Whereas the patients with grade 1 envenomation did not receive any antivenom, grades 2 and 3 patients received 2.70 +/- 0.77 and 4.88 +/- 1.65 vials of antivenom, respectively. One of our patients had to undergo finger amputation but there were no deaths. Allergic reactions developed after antivenom therapy in 8 patients (17.8%). CONCLUSIONS: When we considered the cost and complications of the antivenom treatment, it was seen that low-dose antivenom treatment effectively treated the patients with venomous snakebite injuries in our region.

Use of prazosin in the treatment of scorpion envenomation.

Although scorpion bite is usually lethal in children under 6, sometimes it might cause death for those over 6. Acute lethal systemic seizures (cardiovascular and central nervous systems) have been frequently reported from the countryside of developing countries. Numerous researchers have suggested quite different approaches to the treatment of scorpion bites. In this report, we describe a case brought to the emergency service after the patient had been bitten by a scorpion and had significant sympathetic nervous system symptoms. The patient was treated with prazosin successfully.

Ultrastructural changes in rat liver treated with pralidoxime following acute organophosphate poisoning.

We investigated the ultrastructural effects of methamidophos and the positive effects of 2-pralidoxime (2-PAM) on the liver. Male Wistar-albino rats were assigned to 4 groups and all were treated per os: Group 1 (n=10) received 30 mg/kg methamidophos; Group 2 (n=7) (serving as controls for Group 1) received physiologic NaCl; Group 3 (n=10) received 30 mg/kg methamidophos and was treated with 2-PAM and atropine when cholinergic symptoms were noted; and Group 4 (n=7) (serving as controls for Group 3) was treated with physiologic NaCl. Plasma cholinesterase was measured using radioimmunoassay. Liver tissues were prepared for electron microscopic studies. Methamidophos treatment of Group 1 led to serious changes in hepatocytes and organelles. These changes were not detected in Group 3. In Group 1, the chromatin content of some hepatocyte nuclei and cytoplasmic density increased; these cells also became vacuolar in appearance as a result of lysis in the mitochondrial matrices. In some cells, the lipid content constituted the majority of the cytoplasm. Furthermore, these cells were surrounded by glycogen accumulation. In some areas of the perisinusoidal zone, collagen fibers had increased to form bands. None of these changes were noted in Group 3. These findings suggest that acute organophosphate poisoning causes serious histopathological effects in rat liver, but that these changes are reversible with appropriate treatment strategies.