Bedia Gulen

Anxiety and Depressive Disorders in Patients Presenting with Chest Pain to the Emergency Department: A Comparison Between Cardiac and Non-Cardiac Origin

OBJECTIVE The aim of this study was to determine the prevalence of anxiety and depressive disorders in patients presenting with chest pain to the Emergency Department (ED) and determine if there is a relationship between these and cardiac vs. non-cardiac chest pain. METHODS This prospective cross-sectional study was performed in an urban tertiary care hospital between March and October 2005. Consecutive patients presenting with chest pain were enrolled in the study. The prevalence of anxiety and depressive disorders in patients with chest pain were determined by using the Hospital Anxiety and Depression Scale. RESULTS A total of 324 patients presented to the ED with chest pain during the study period. The mean age of the patients studied was 50.5 +/- 14 years; 67% were men and 33% were women. Of the 324 study patients, 194 (59.9%) patients were diagnosed with non-cardiac chest pain, 16 (4.9%) with stable angina, 84 (25.9%) with unstable angina, and 30 (9.3%) with acute myocardial infarction. No statistically significant differences were determined between patients with cardiac and non-cardiac chest pain both for anxiety (40% vs. 38.1%, respectively; p = 0.737) and depressive disorders (52.3% vs. 52.1%, respectively; p = 0.965). CONCLUSION Anxiety and depressive disorders are common among patients presenting with chest pain to the ED. However, the prevalence of anxiety and depressive disorders is similar between patients with chest pain of cardiac and non-cardiac origin. Chest pain should not be attributed to an anxiety or depressive disorder before organic etiologies are excluded.

Effect of harmless acute pancreatitis score, red cell distribution width and neutrophil/lymphocyte ratio on the mortality of patients with nontraumatic acute pancreatitis at the emergency department.

BACKGROUND Harmless acute pancreatitis score (HAPS), neutrophile/lymphocyte ratio and red blood cell distribution width (RDW) are used to determine the early prognosis of patients diagnosed with nontraumatic acute pancreatitis in the emergency department (ED). METHODS Patients diagnosed with acute pancreatitis (K 85.9) in the ED according to the ICD10 coding during one year were included in the study. Patients with chronic pancreatitis and those who had missing data in their files were excluded from the study. Patients who did not have computed tomography (CT) in the ED were not included in the study. RESULTS Ultimately, 322 patients were included in the study. The median age of the patients was 53.1 (IQR=36-64). Of the patients, 68.1% (n=226) had etiological causes of the biliary tract. The mortality rate of these patients within the first 48 hours was 4.3% (n=14). In the logistic regression analysis performed by using Balthazar classification, HAPS score, RDW, neutrophile/lymphocyte ratio, age, diabetes mellitus and systolic blood pressure, the only independent variable in determining mortality was assigned as Balthazar classification (OR: 15; 95% CI: 3.5 to 64.4). CONCLUSIONS HAPS, neutrophile/lymphocyte ratio and RDW were not effective in determining the mortality of nontraumatic acute pancreatitis cases within the first 48 hours. The only independent variable for determining the mortality was Balthazar classification.

Pain treatment in patients with acute pancreatitis: A randomized controlled trial

BACKGROUND/AIMS In this study, the analgesic effectiveness of tramadol, a synthetic opioid, was compared with paracetamol and dexketoprofen in adult patients with acute pancreatitis in the emergency department. MATERIALS AND METHODS Study drugs were similar in color and appearance, enabling the patients to be blind to the intervention. Study patients were intravenously administered 1 g paracetamol, 50 mg dexketoprofen trometamol, or 1 mg/kg tramadol with 100 mL normal saline with a 4-5 min infusion. Pain measurements of the patients were conducted at baseline and 30 min after the treatment intervention. Changes in pain scores were calculated by subtracting the median scores at baseline and 30 min as pairs. RESULTS In this study, 90 patients were enrolled and included in the final analysis. The study subjects had a mean age of 53.5±13.3 years and 58.9% (n=53) of them were male. Gallstones and biliary etiology for pancreatitis was documented in 73.3% (n=66) of patients. Mean VAS scores at baseline and 30 min were similar in the three groups. Similarly, the change of scores from the baseline to the 30th minute did not differ among the groups. Comparison of pain improvements failed to reveal any differences among groups. CONCLUSION Intravenous paracetamol, dexketoprofen, and tramadol are not superior to each other in the management of pain caused by nontraumatic acute pancreatitis.

The efficacy of absorbable polysaccharide haemostats in wound healing.

Wound healing represents an ancient problem for humans, and various materials and methods have been tried for wound dressing. A dressing should protect against infection and shorten healing; moreover, it should not cause tissue damage and should be nonallergenic, cost effective and easy to apply. These are characteristics that may be found in herbal extracts. An absorbable polysaccharide haemostat (APH) is a plant-based haemostatic agent. We aimed to evaluate the effect of APH on wound healing. A total of 24 Wistar rats were divided into three groups, each consisting of eight rats. We generated triangular tissue defects on the dorsal regions of the rats. The wound size of each rat was drawn on acetate paper on the 3rd, 7th and 14th days and dressed with APH, saline and wheat meal. Wound healing rates were calculated using planimetric software. Scar tissue excision was performed on the 14th day and histopathological examination was carried out. The mean wound contraction rate was statistically higher in the APH group than in the wheat meal and saline groups on the 14th day (P < 0.05). There was no significant difference in polymorphonuclear leukocytes intensity between the saline and APH groups when stained with haematoxylin and eosin (P > 0.05). However, the intensities of fibroblasts (P < 0.01), vascular proliferation (P = 0.01) and inflammatory score (P = 0.02) were significantly different in the saline and APH groups. APH has favourable effect on wound healing. In addition to its blood-stopping effect, APH may be useful for tissue defects, which arise after trauma or surgical procedures.

The efficacy of a hemostatic agent in anticoagulant drug-induced rat bleeding model.

BACKGROUND Bleeding is a major problem in warfarin pretreated patients who need emergency surgical procedures. APH is a hemostatic agent with ultra-hydrophilic and particulate properties. This study aimed to evaluate the in vivo hemostatic effect of APH in rats pretreated with warfarin. METHODS Forty-eight Wistar rats were divided into two main groups: one group was pretreated with warfarin and the other group was not. These two groups were further divided into three subgroups according to the administration of APH, wheat meal, or saline, for a total of six subgroups. Standard full thickness tissue defects were performed on the backs of the rats. Saline, wheat meal, or APH were administered to the bleeding defect site in both main groups. Hemostasis time and amount of bleeding were calculated. RESULTS The bleeding time in rats administered APH was significantly shorter than those administered wheat meal and saline. Consequently, the amount of bleeding was significantly less in the APH groups than in the control groups. CONCLUSION APH has an effective hemostatic property in rats pretreated or non-pretreated with anticoagulants. Hemostatic agents can be useful for incidences of external bleedings, which are increasing because of anticoagulation.

Oxidative status and lymphocyte DNA damage in patients with acute pancreatitis and its relationship with severity of acute pancreatitis

BACKGROUND/AIMS Acute pancreatitis (AP) is a life-threatening disease with a rising incidence. The aim of this study was to investigate the association between oxidative status, lymphocyte deoxyribonucleic acid (DNA) damage, and acute pancreatitis. MATERIALS AND METHODS A total of 45 patients with AP and 35 healthy controls were included in the study. We assessed pancreatic enzymes, oxidative stress, and lymphocyte DNA damage. The severity of AP disease was determined by the Harmless Acute Pancreatitis Score (HAPS) and Balthazar scoring systems. RESULTS In AP patients, lymphocyte DNA damage was significantly higher than in controls [49.84±25.48 arbitrary units (AU) vs. 28.80±13.98 AU, p<0.001]. The plasma total oxidative status (TOS) and oxidative stress index (OSI) were higher in patients than in healthy controls (10.36±5.54 vs. 8.47±2.66, p<0.05; 0.64±0.35 vs. 0.45±0.13 AU, p<0.001, respectively). The plasma total antioxidant status level in patients was lower than in healthy controls (1.66±0.19 vs. 1.86±0.18, p<0.001). Lymphocyte DNA damage was correlated with TOS, OSI, and HAPS and Balthazar scores. CONCLUSION This study shows that patients with AP have higher lymphocyte DNA damage and more deteriorated oxidative status than healthy controls.

Interhemispheric Acute Subdural Hematoma: A Distinct Entity of Subdural Hematoma

We wish to notify the readers on a rare case of interhemispheric acute subdural hematoma (ASH) who presented to our emergency department (ED) with a falx syndrome of contralateral hemiparesis in lower extremity and severe headache. A 25-year-old previously healthy man was involved in a traffic accident and presented to our ED with complaints of repeated vomiting and severe headache. On arrival to the ED, he had an initial Glasgow coma scale (GCS) of 14 (opening her eyes with verbal stimuli, obeys commands, orientated) and normal vital signs (blood pressure: 130/85 mm Hg; heart rate: 86 bpm). No other injuries were noted. Neurological examination revealed mild weakness of the right lower extremity (strength score: 4/5). His routine blood tests, including complete blood counts, prothrombin time, and thromboplastin time were unremarkable. The plain films of the skull were normal. Non-enhanced cranial (CT) scan performed 4 h after the accident revealed a small left-sided acute interhemispheric subdural hematoma, which was posteriorly located (Fig. 1a). Magnetic resonance imaging (MRI) of the brain during the first 24 h after admission confirmed minimal ASH in the posterior interhemispheric fissure with subacute subdural hematoma in the left parietooccipital cortex and occipital regions (Fig. 1b). Considering the clinical condition of the patient, surgery was not planned by the neurosurgical department but the patient was kept under observation in the ED. He was discharged home 48 h after the trauma with a normal neurological examination and mild intermittent headaches. Interhemispheric ASH is a relatively uncommon type of ASH because of their unusual location [1]. They usually occur in patients with bleeding disorders and are associated with trauma in the majority of cases [2]. Computed tomography (CT) and MRI are important neuroradiological techniques for the accurate diagnosis of interhemispheric ASH [1, 2]. Although interhemispheric ASH is a rare form of subdural hematoma, early diagnosis and treatment is of great importance because of its emergent condition [2, 3]. CT and MRI are important diagnostic tools, as it was in this case. MRI may have the advantage rather than CT due to the absence of beam-hardening and multiplanar imaging. The best management modality for interhemispheric ASH depends upon the neurologic status on admission and clinical course [2]. If the patient is neurologically stable, conservative treatment is generally preferred. Surgical treatment is reserved in patients with disturbances of consciousness and for patients with progressive neurological deterioration [3].

Oxidative Status and DNA Damage Following Analgesic Treatment in Patients with Acute Pancreatitis

BACKGROUND This study is designed to investigate the effect of three different analgesics, used to treat pain in AP, on oxidative stress, DNA damage in mononuclear leukocytes, and on oxidative status. METHODS This parallel design randomized controlled trial is composed of three treatment arms, intravenous paracetamol, intravenous dexketoprofen, and intravenous tramadol. RESULTS A total of 107 patients were diagnosed with acute pancreatitis within the study period in the ED. Seventyseven of them were included in the study; 26 patients for the paracetamol group, 24 patients for the dexketoprofen group, and 27 patients for the tramadol group. The mean age of study subjects was 52.73 ± 15.38 and 66% (n = 51) of them were men. At the beginning of the study (before treatment), mean levels of DNA damage, TOS, and OSI levels were significantly higher and TAS was significantly lower in the acute pancreatitis groups than in the control group. DNA damage and OSI in HAPS-positive patients were found to be significantly greater than HAPS-negative patients (p = 0.046). DNA damage and oxidative stress were compared between the three groups. There were no differences between the groups in terms of DNA damage (p = 0.42) and also for the oxidatif stress parameters (OSI,TAS,TOS had p-values of p = 0.26, p = 0.78, p = 0.35, respectively). CONCLUSIONS There is no difference between the effects of paracetamol, dexketoprofen, and tramadol, which are commonly used to manage acute pain in AP, on DNA damage in human T-lymphocytes and on serine parameters of oxidative status.

Serum S100B as a surrogate biomarker in the diagnoses of burnout and depression in emergency medicine residents

OBJECTIVES Burnout syndrome is recognized as a major global problem among emergency healthcare workers as it causes prevalent fatigue, job separations, and disappointment. The objective of this study was to investigate the relationship of the glial marker S100B in sera of emergency physicians with burnout syndrome and depression. METHODS This was a prospective observational study of emergency medicine residents in three distinct university-based departments of emergency medicine. S100B levels were measured before and after the shifts. In addition, the resident completed the Maslach Burnout Inventory (MBI) and the Beck Depression Inventory (BDI) prior to starting the shift. S100B levels were compared to the occurrence of burnout syndrome and depression as measured by the MBI and BDI. RESULTS Forty-eight of 53 emergency medicine residents actively working in the three university-based EDs participated in the study. The majority of the sample had BDI scores compatible with severe depression (n = 37, 77.1%). The median scores of MBI for emotional exhaustion, depersonalization, and personal accomplishment were 29 (interquartile range [IQR] = 25 to 33), 14 (IQR = 12 to 18), and 26.5 (IQR = 22 to 31), respectively. S100B levels were found to correlate best with scores of BDI and emotional exhaustion in burnout syndrome. The difference between median S100B levels recorded in the residents with severe depression and moderate depression was found statistically significant (median [IQR] = 150 [145 to 151] vs. 135 [128 to 140]; p = 0.0005). This is also true for S100B levels detected before and after night shifts (median [IQR] = 146 [136.5 to 153.2] and 149.5 [139-158], respectively; difference = 3, 95% confidence interval = 2 to 4 [p = 0.001]). CONCLUSIONS S100B levels correlate with depression scores and emotional exhaustion in burnout syndrome. The findings suggest that S100B can be used as a marker to screen emergency medicine residents and detect individuals with high risk for depression and burnout syndrome.

Role of H-FABP values in determining the etiologic factors of the cardiac injuries

Introduction Cardiac injury resulting from blunt thoracic trauma is a frequent clinical occurrence which is difficult to diagnose. Our purpose in this study was to research whether H-FABP, which is a new marker for the diagnosis of cardiac injury, can be used in this patient group. Methods 50 patients with blunt thoracic injury who were admitted to our emergency service within a period of 8 months and 50 cases as controls were included in our study. Results Of the 50 patients with blunt thoracic injury in our study, 88% were male while 12% were female. The average age of the patients was 43 ± 15.15. While 27 (54%) of the 50 patients with blunt thoracic injury had cardiac injury, 23 (46%) did not have cardiac injury. The results of the statistical analyses showed a significant association between thorax trauma and cTnI, CPK, CPKMB and H-FABP (p<0.05). While there was a significant association between cardiac injury resulting from thoracic trauma and cTnI, ECG and TTE (p<0.05), there was no significant association between CPK, CPKMB and H-FABP (p>0.05). Conclusion In thoracic traumas, cardiac injury diagnosis can be made as a result of the assessment with Troponin-I, ECG and ECHO. For cardiac injury diagnosis, wide scale prospective studies are needed for H-FABP use.