Arda Demirkan

The accuracy of ultrasound evaluation in foot and ankle trauma

OBJECTIVES Foot and ankle injuries that result in sprains or fractures are commonly encountered at the emergency department. The purpose of the present study is to find out the accuracy of ultrasound (US) scanning in injuries in the aforementioned areas. METHODS Ottawa Ankle Rules-positive patients older than 16 years who presented to the emergency department with foot or ankle injuries were eligible. For all patients, US evaluation of the whole foot and ankle was performed by an emergency physician before radiographic imaging. All radiographic images were evaluated by an orthopedic specialist and compared with the interpretations of the US. RESULTS One hundred thirty-one patients were included in the study. Radiographic evaluation enabled the determination of fractures in 20 patients, and all of these were identified with US imaging. Moreover, US evaluation radiographically detected a silent ankle fracture in 1 patient. The sensitivity of US scanning in detecting fractures was 100% (95% confidence interval [CI], 83.8-100), the specificity was 99.1% (95% CI, 95-99.8), the positive predictive value was 95.2% (95% CI, 89.6-98), and the negative predictive value was 100% (95% CI, 96.4-100), respectively. The most common fractures were detected at the lateral malleolus and at the basis of the fifth metatarsal. CONCLUSIONS Ultrasound imaging permits the evaluation of foot and ankle fractures. Because it is a highly sensitive technique, US can be performed in the emergency department with confidence.

Primary Hydatid Cyst of the Axillary Region: Report of a Case

Abstract A 53-year-old woman presented to our hospital with a painful mass in her axilla. Magnetic resonance imaging revealed a lobular cystic mass localized in the right pectoralis major muscle, with no significant invasion of the peripheral soft tissue or bone structures and no pulmonary or hepatic involvement. An echinococcal hemagglutination test was positive. Excision of the cystic mass as definitive therapy and histopathologic examination of the resected specimen confirmed that it was a hydatid cyst. For treating hydatidosis in uncommon sites, the cyst must be totally removed whenever possible. The combination of albendazole and praziquantel seems to be the most effective medical treatment, but not an alternative to surgery. This case report serves to demonstrate that hydatid disease should be borne in mind as the possible cause of a palpable lesion in the breast, axillary region, or chest wall, especially in endemic locations.

Intussusception in adult and pediatric patients: Two different entities

PurposeIntussusception is one of the most common abdominal emergencies in pediatrics, but adult intussusception is an uncommon entity and most surgeons have only limited experience in treating this disease. The purpose of this study was to highlight the differences between pediatric and adult intussusception.MethodsThe records of 40 patients during 14 years were reviewed retrospectively. The symptoms, diagnosis, sites of intussusception, associated pathologies, and treatment methods of each patient were analyzed.ResultsA total of 31 pediatric and 9 adult patients were included in the study. In the pediatric group, bloody stool and vomiting were the most common symptoms whereas adult patients commonly presented with abdominal pain. The physical examination was diagnostic in a remarkable proportion of the pediatric patients but the diagnosis was suggested based on imaging techniques in the adults, and preoperative diagnosis was more successful in the pediatric group. Intussusception was more often associated with an underlying pathology in adults and no adult patient underwent nonoperative reduction, whereas pediatric patients were managed either with hydrostatic reduction or surgery.ConclusionsAlthough intussusceptions occur at all ages, there are major differences in the clinical presentation, diagnostic approach, and management between pediatric and adult populations. Intussusception is remarkably different in these two age groups and it must be approached from a different clinical perspective.

Septic Pulmonary Embolism Associated with Renal Abscess: A Case Report

BACKGROUND Septic pulmonary embolism (SPE) is a rare condition that is difficult to diagnose. OBJECTIVES To describe the clinical course and diagnosis of a patient with SPE. CASE REPORT We report on a case of SPE diagnosed in the emergency department and review the current literature. CONCLUSION The diagnosis of SPE can be made using computed tomography scan. Early diagnosis and appropriate antibiotic therapy are important factors for the control of the infection.

Suprarenal Symplastic Leiomyoma of the Inferior Vena Cava

We report on a case of a leiomyoma in the inferior vena cava that appeared in the image to be located in the adrenal gland. En bloc excision of the tumor with the right adrenal gland and the involved segment of the vena cava was carried out. Histopathological work-up of the tumor revealed smooth muscle fibers and marked nuclear pleomorphism consistent with symplastic leiomyoma. This case report presents a distinct histological variant of the rarely seen primary smooth muscle tumor of the inferior vena cava.

A simple and inexpensive device for collecting urine samples from rats

Many studies require collection of metabolic wastes from laboratory animals, and oftentimes it is important that feces and urine be collected separately. The authors describe an easily assembled and inexpensive device that can be used to collect urine samples from rats without any invasive operations. The device affords reasonable separation of feces and urine.

Independent Factors for Prediction of Poor Outcomes in Patients with Febrile Neutropenia

Background Febrile neutropenia (FN) is a life-threatening condition that requires urgent management in the emergency department (ED). Recent progress in the treatment of neutropenic fever has underscored the importance of risk stratification. In this study, we aimed to determine independent factors for prediction of poor outcomes in patients with FN. Material/Methods We retrospectively evaluated 200 chemotherapy-induced febrile neutropenic patients who visited the ED. Upon arrival at the ED, clinical data, including sex, age, vital signs, underlying systemic diseases, laboratory test results, estimated GFR, blood cultures, CRP, radiologic examinations, and Multinational Association of Supportive Care in Cancer (MASCC) score of all febrile neutropenic patients were obtained. Outcomes were categorized as “poor” if serious complications during hospitalization, including death, occurred. Results The platelet count <50 000 cells/mm3 (OR 3.90, 95% CI 1.62–9.43), pulmonary infiltration (OR 3.45, 95% CI 1.48–8.07), hypoproteinemia <6 g/dl (OR 3.30, 95% CI 1.27–8.56), respiratory rate >24/min (OR 8.75, 95% CI 2.18–35.13), and MASCC score <21 (OR 9.20, 95% CI 3.98–21.26) were determined as independent risk factors for the prediction of death. The platelet count <50 000 cells/mm3 (OR 3.93, 95% CI 1.42–10.92), serum CRP >50 mg/dl (OR 3.80, 95% CI 1.68–8.61), hypoproteinemia (OR 7.81, 95% CI 3.43–17.78), eGFR ≤90 ML/min/1.73 m2 (OR 3.06, 95% CI 1.13–8.26), and MASCC score <21 (OR 3.45, 95% CI 1.53–7.79) were determined as independent risk factors for the prediction of poor clinical outcomes of FN patients. Platelet count, protein level, respiratory rate, pulmonary infiltration, CRP, MASCC score, and eGFR were shown to have a significant association with outcome. Conclusions The results of our study may help emergency medicine physicians to prevent serious complications with proper use of simple independent risk factors besides MASCC score.

Intraosseous access learning curve; is it really practical?

Success rate and time need for vascular access are crucial in the emergency patient. However, in many cases, peripheral intravenous accessmight be difficult [1]. Intraosseous (IO) infusion is the quickest way to establish access for rapid administration ofmedications and liquids in emergency situations, where vascular access is difficult to achieve. In recent years, it has beenwidely used in pediatric population. Intraosseous infusion is now recommended in adult resuscitation by the American Heart Association [2] and the European Resuscitation Council [3]. Our study aims to examine IO route, a practical and easy vascular access, in terms of rapidity of learning and practice. A total of 50 interns,whohave studied in the emergencydepartment of the university hospital and who have never established IO route of administration, were taught the method of establishing an IO route of administration in the tibias obtained from adult cadavers, and thereafter, the procedure was demonstrated to them in practice once. Then, the interns were asked to perform this procedure on the tibias for 10 times. The procedure was performed using Vidacare (Shavano Park, TX) EZ-IO Power Driver gun and Vidacare EZ-IO15-gauge IO cannula. During the intern practices, the timewasmeasured using the chronometer. All data were statistically evaluated. Repeated-measures analysis of variance test was used to determine the difference among 10 measurements. When the P value obtained from repeated-measures analysis of variance test was statistically significant, Bonferroni adjustment was performed to assess themeasurements, which showed a difference. For dichotomous variables, McNemar test was used. SPSS for Windows 11.5 was used for statistical analyses (SPSS, Chicago, IL). A P value less than .05 was considered statistically significant. The period was gradually shortened from the first practice to the eighth practice and was found to be statistically different between the practices (P N .05). After the eighth practice, no statistically significant difference of period was found between the practices (P b .001). Given the total duration, although the first practice lasted averagely 84.64 seconds, the interns completed the eighth practice averagely in 39.48 seconds, which corresponded to a period shorter than the half of the first practices duration (Table). Given the error that the interns did during the period, in which they ensured the sterile conditions, at a percentage of 46% in the first practice, of 40% in the second practice, and 4% in the fourth practice and taking into consideration the likelihood of the development of serious conditions such as osteomyelitis as a complication, it would be more appropriate that inexperienced practitioners perform at least the first 3 or 4 practices under the supervision of experienced physicians. Chatchawan Piyaskulkaew, MD Saif Al-najafi, MD Department of Cardiology Wayne State University/St. John Hospital & Medical Center Detroit, MI, USA