Bulent Erdur

A study of depression and anxiety among doctors working in emergency units in Denizli, Turkey

Background: Major work has been carried out on the psychological well-being of emergency room doctors in the US, Canada and in other developed countries, but little has been published regarding the same in the countries in economic transition. Objective: To determine the level of, and the factors related to, depression and anxiety among doctors working in emergency units in Denizli, Turkey. Methods: This cross-sectional study was conducted in May 2004, using a sample of 192 doctors employed in emergency units in Pamukkale University Hospital, the City Hospital, the Social Security Hospital, private hospitals, citywide primary healthcare centres and 112 emergency services in Denizli, Turkey. Data were obtained using a self-administered questionnaire, including questions on sociodemographic characteristics and two instruments determining the level of depressive symptoms and anxiety. Logistic regression was the method chosen for multivariate statistical analysis. Results: The mean (standard deviation (SD)) depression score was 10.6 (6.5) and the frequency (%) of depression was 29 (15.1). Not having any hobby and having high anxiety scores were salient factors among doctors experiencing depressive symptomatology in bivariate comparisons. Logistic regression analysis showed that not having any hobby (p = 0.07) and having increased anxiety scores (p<0.001) were positive contributors to depression scores. The mean (SD) anxiety score was 8.7 (8.2) and the frequency (%) of anxiety was 28 (14.6). Being a woman, having a low monthly income and having high depression scores contributed considerably to the anxiety of doctors in bivariate comparisons. Low monthly income (<1000 v 1000–2000 YTL) (p = 0.03), the number of years spent in emergency units (p = 0.03) and having high depression scores (p<0.001) were the factors that contributed significantly to the anxiety of doctors in the multivariate regression analysis. Conclusion: The considerable amount of depression and anxiety found among doctors in this study should trigger further work. Studies using more powerful designs would help to illuminate the factors leading to depression and anxiety, which result in attrition among doctors from emergency units.

Violence toward health care workers in emergency departments in Denizli, Turkey

This study sought to determine the frequency and types of violence that occurred during the previous year against health care workers in emergency departments in Denizli, Turkey, and to discern the views of workers on the prevention of such aggressive behavior. This study was conducted from March 1 to April 15, 2003, and included a group of 79 health care workers from the emergency departments of 3 hospitals in Denizli, namely, the Hospital of Pamukkale University Medical Faculty, the City Hospital of Denizli, and the Hospital of the Social Insurance Foundation. Data were collected from a self-administered questionnaire. In all, 88.6% of participants had been subjected to or had witnessed verbal violence, and 49.4% of them had been subjected to or had witnessed physical violence during the previous year. The most frequent reason (31.4%) for violence was abuse of alcohol and drugs by perpetrators. The second most frequent reason (24.7%) was the long waiting times typical of emergency departments. The most common type of violence was loud shouting; swearing, threatening, and hitting were the next most frequent violent behaviors. In all, 36.1 % of subjects who had experienced violence reported that they developed psychological problems after the incident. Most participants commented on the insufficiency of currently available security systems within emergency departments and on the need for further training about violence. All health care personnel within emergency departments should be aware of the risk of violence and should be prepared for unpredictable conditions and events; in addition, security systems should be updated so that violence within emergency departments can be prevented.

Feasibility of low-dose unenhanced multi-detector CT in patients with suspected acute appendicitis: comparison with sonography

OBJECTIVES To compare unenhanced low-dose computed tomography (LDCT) and ultrasound (US) in patients with suspected acute appendicitis. METHODS A total of 104 patients underwent US and LDCT examinations within an hour. RESULTS Thirty-nine of the 104 patients had surgically confirmed acute appendicitis. Sensitivity, specificity, and accuracy for US vs. LDCT were 82.5% vs. 92.5%, 83% vs. 89%, and 82.7% vs. 90.4%, respectively. The area under the curve (Az) was 0.85 for US and 0.92 for LDCT. The diagnostic performance of LDCT was better than US (P<.001). CONCLUSIONS Unenhanced LDCT is a feasible technique in the diagnosis of acute appendicitis.

Severe metformin intoxication treated with prolonged haemodialyses and plasma exchange.

Background Biguanides pose a significant risk of morbidity, mortality and permanent sequelae secondary to prolonged periods of hypoglycaemia. Objectives To investigate the treatment of massive metformin overdose associated with lactic acidosis. Case report We present the case of a 30-year-old woman, who attempted to commit suicide by ingesting an 85-g massive metformin overdose associated with severe lactic acidosis, which we treated by performing prolonged haemodialysis with bicarbonate and plasma exchange. Conclusion For the maximum elimination of metformin, extended haemodialysis is required and the treatment of the accompanying metabolic acidosis with bicarbonate is important for the effectiveness of the treatment. Patients benefit much more from the treatment of combined haemodialysis with plasma exchange.

Intravenous administration of metoclopramide by 2 min bolus vs 15 min infusion: does it affect the improvement of headache while reducing the side effects?

Objective: To determine the therapeutic effect (alleviation of vascular type headache) and side effects of a slow intravenous metoclopramide infusion over 15 min compared with those effects of a bolus intravenous metoclopramide infusion over 2 min in the treatment of patients with recent onset vascular type headache. Material and methods: All adults treated with metoclopramide for vascular type headache were eligible for entry into this clinical randomised double blinded trial. This study compared the effects of two different rates of intravenous infusion of metoclopramide over a period of 13 months at a university hospital emergency department. During the trial, side effects and headache scores were recorded at baseline (0 min), and then at 5, 15, 30 and 60 min. Repeated measures analysis of variance was used to compare the medication’s efficacy and side effects. Results: A total of 120 patients presenting to the emergency department met the inclusion criteria. Of these, 62 patients (51.7%) were given 10 mg metoclopramide as a slow intravenous infusion over 15 min (SIG group) and 58 patients (48.3%) were given 10 mg metoclopramide intravenous bolus infusion over 2 min (BIG group). 17 of the 58 patients in the BIG group (29.3%) and 4 of the 62 patients (6.5%) in the SIG group had akathisia (p = 0.001). There were no significant differences between the BIG and SIG groups in terms of mean headache scores (p = 0.34) and no adverse reactions in the study period. Metoclopramide successfully relieved the headache symptom(s) of patients in both the BIG and SIG groups. Conclusion: Slowing the infusion rate of metoclopramide is an effective strategy for the improvement of headache and reducing the incidence of akathisia in patients with vascular type headache.

Assessment of Cardiac Ultrasonography in Predicting Outcome in Adult Cardiac Arrest

OBJECTIVE: A prospective follow-up study to evaluate the ability of cardiac ultrasonography performed by emergency physicians to predict resuscitation outcome in adult cardiac arrest patients. METHODS: Ultrasonographic examination of the subxiphoid cardiac area was made immediately on presentation to the emergency department with pulseless cardiac arrest. Sonographic cardiac activity was defined as any detected motion within the heart including the atria, ventricles or valves. Successful resuscitation was defined as any of: return of spontaneous circulation for ≥ 20 min; return of breathing; palpable pulse; measurable blood pressure. RESULTS: The study enrolled 149 patients over an 18-month period. The presence of sonographic cardiac activity at the beginning of resuscitation was significantly associated with a successful outcome (19/27 [70.4%] versus 55/122 [45.1%] patients without cardiac activity at the beginning of resuscitation). CONCLUSIONS: Ultrasonographic detection of cardiac activity may be useful in determining prognosis during cardiac arrest. Further studies are needed to elucidate the predictive value of ultrasonography in cardiac arrest patients.

Slow infusion metoclopramide does not affect the improvement rate of nausea while reducing akathisia and sedation incidence

Objective To compare the effects of metoclopramide infusion in emergency department (ED) patients complaining of nausea to determine the changes in its therapeutic effect and prevention of side effects such as akathisia and sedation. Methods A prospective, randomised, double blind trial, from 1 March 2007 to 1 May 2008 in the ED of Pamukkale University Faculty of Medicine. Patients with moderate to severe nausea were randomised and divided into two groups: group 1 received 10 mg metoclopramide as a slow intravenous infusion over 15 min plus placebo (SIG); group 2 received 10 mg metoclopramide as an intravenous bolus infusion over 2 min plus placebo (BIG). The whole procedure was observed, and nausea scores, akathisia and vital changes were recorded. Results 140 patients suffering from moderate to severe nausea in the ED were included in the study. There was no significant difference between the groups in terms of mean nausea scores during follow-up (p=0.97). A significant difference in akathisia incidence was observed between the groups (18 (26.1%) in the BIG and 5 (7%) in the SIG) (p=0.002). There was also a significant difference in sedation incidence between the groups (19 (27.5%) in the BIG and 10 (14.5%) in the SIG) (p=0.05). Conclusion Even though slowing the rate of infusion of metoclopramide does not affect the rate of improvement in nausea, it may be an effective strategy for reducing the incidence of akathisia and sedation in patients with nausea.

A comparison of the prophylactic uses of topical mupirocin and nitrofurazone in murine crush contaminated wounds.

OBJECTIVES This work was conducted to study the prophylactic efficacy of 2 topical antibiotic ointments (mupirocin and nitrofurazone) against wound infection in experimental contaminated crush wounds. METHODS Male Wistar rats underwent two 2-cm incisions at the back side and randomized into 3 groups--placebo (n = 14), mupirocin (n = 14), and nitrofurazone (n = 14)--and infected with either Staphylococcus aureus or S. pyogenes. All wound edges were crushed for 5 seconds with hemostats to simulate crush injury before inoculation of the microorganisms. Half of the wounds were sutured and the other half left open. These wounds were treated 3 times daily for 6 days with topical mupirocin, nitrofurazone, or petrolatum (as placebo). At the end of 6 days, excisional biopsies were taken from wound edges and histopathologic assessments were made based on neutrophilic infiltration, edema formation, myofibroblastic proliferation, and granulation tissue formation. For the microbiologic assessments, quantitative tissue cultures were made. RESULTS In S. aureus-inoculated wounds, mupirocin showed higher antibacterial activity against bacterial colonization and reduced infection rates compared to placebo groups. The same effect was observed for the infection rates in S. pyogenes-inoculated wounds. In S. pyogenes-inoculated open wounds, nitrofurazone showed higher antibacterial activity against infection, but this effect was not observed in closed wounds. In S. pyogenes- and S. aureus-infected wounds, mupirocin treatment significantly lowered infection rates compared to nitrofurazone treatment. Histopathologic examination showed higher myofibroblastic proliferation and higher volume of granulation tissue in the nitrofurazone groups compared to the mupirocin groups. CONCLUSION Topical mupirocin application was effective against crush wound infections inoculated with S. pyogenes and S. aureus. Nitrofurazone provides better granulation tissue formation, but did not effectively prevent bacterial colonization and infection in crush contaminated wounds.

Evaluation of the outcome of out-of-hospital cardiac arrest resuscitation efforts in Denizli, Turkey.

The objective of this study was to evaluate the outcomes and associated factors for short-term success and long-term survival rates of resuscitated non-traumatic out-of-hospital cardiac arrest (OHCAs) in Denizli, Turkey. All non-traumatic OHCA patients from the Emergency Departments of the Pamukkale University and City Hospitals between the dates of January 1, 2004 and March 1, 2005 were included in this study. A successful outcome was defined as the return of spontaneous circulation or breathing, or evidence of a palpable pulse or a measurable blood pressure. Information on post-resuscitation long-term survival up to 9 months also was obtained by telephone. A total of 222 adults experiencing OHCAs were resuscitated. The number of successful outcomes was 85 (38.3%); 25 (11.2%) were discharged alive; and 21 (9.4%) were alive at the 9-month follow-up. The predicted mean arrest time was 11.7 min (95% confidence interval 10.27-13.2). Type of transportation to the Emergency Department (ambulance, 32.1% vs. private vehicle, 44.5%; p = 0.057), place of arrest (home, 32.6% vs. other, 44.0%; p = 0.08), first rhythm at the scene (asystole, 22.9% vs. ventricular fibrillation-pulseless ventricular tachycardia, 48.0%, vs. pulseless electrical activity, 12.5%; p = 0.056), and advanced cardiac life support starting time (the first 8 min, 46.8% vs. later than 8 min, 32.0%; p = 0.025) had an effect on outcome. Intensive public education for diagnosis and appropriate reporting of OHCA, the importance of bystander cardiopulmonary resuscitation, and the use of automated external defibrillators have an impact on the potential to increase the number of survivors.

A trial of midazolam vs diphenhydramine in prophylaxis of metoclopramide-induced akathisia

STUDY OBJECTIVE The study aimed to evaluate the effects of midazolam and diphenhydramine for the prevention of metoclopramide-induced akathisia. METHODS This randomized, double-blind, and controlled trial aimed to investigate coadministered midazolam vs diphenhydramine in the prophylaxis of metoclopramide-induced akathisia. Patients 18 to 65 years of age who presented to the emergency department with primary or secondary complaints of nausea and/or moderate to severe vascular-type headache were eligible for this study. Patients were randomized to one of the fallowing 3 groups: (1) metoclopramide 10 mg + midazolam 1.5 mg; (2) metoclopramide 10 mg + diphenhydramine 20 mg; (3) metoclopramide 10 mg + placebo. Metoclopramide was administered as a 2-minute bolus infusion. Midazolam, diphenhydramine, and normal saline solution were administered as a 15-minute slow infusion. The whole procedure was observed; and akathisia and sedation scores and vital changes were recorded. RESULTS There were significant differences among groups with respect to akathisia (P = .016) and sedation (P < .001). The midazolam group showed the lowest mean akathisia score but the highest mean sedation score. Akathisia scores of the diphenhydramine group were not different from placebo. There were significant differences among groups in terms of changes in mean vital findings such as respiration rates, pulse rates, and systolic blood pressures (P < .05). There were no significant difference among groups in terms of changes in mean diastolic blood pressures (P = .09). CONCLUSION Coadministered midazolam reduced the incidence of akathisia induced by metoclopramide compared to placebo but increased the rate of sedation. No difference was detected from diphenhydramine. Routine coadministered 20 mg diphenhydramine did not prevent metoclopramide-induced akathisia.