Figen Coşkun

Mean Platelet Volume and Red Cell Distribution Width as a Diagnostic Marker in Acute Appendicitis

Background: Acute appendicitis (AA) is one of the most common causes of emergent surgeries. Many methods are used for its diagnosis. Objectives: This study was conducted to investigate the diagnostic value of MPV and RDW in acute appendicitis. Patients and Methods: This study was a retrospective multi-center cross sectional planned study. The study included 260 patients operated for AA and 158 patients as the control group. Groups were compared in terms of MPV, RDW, white blood cell count (WBC), neutrophil predominance (NP) and platelet count (PC). Results: MPV was significantly lower in AA group, compared to the control group (P < 0.001). The best cut-off level for MVP in AA was ≤ 7.3 fL and the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy ratio were 45%, 89.2%, 87.3%, 49.6% and 61.7%, respectively. There was no significant difference between the two groups in terms of RDW and platelet values. Conclusions: MPV is a routinely measured parameter in complete blood count (CBC) and requires no additional cost. It significantly decreased in AA, having a greater sensitivity and NPV when combined with WBC and NP.

Holter monitoring for 24 hours in patients with thromboembolic stroke and sinus rhythm diagnosed in the emergency department

It is well known that patients with ischemic stroke show ST-T abnormalities and various rhythm abnormalities on an electrocardiogram (ECG). The most commonly encountered rhythm abnormality is atrial fibrillation. It was recently shown that paroxysmal atrial fibrillation (PAF) is an important causative factor in patients with stroke. Detection of PAF is important in identifying the cause, prognosis, and treatment in patients with thromboembolic stroke. Investigators in the present study followed patients with thromboembolic stroke who had been admitted to the emergency department in sinus rhythm; 24-h Holter monitoring was used, and patients were assessed at referral and every 6 h for 24 h with ECG, which was used to detect rhythm disturbances, especially PAF. In 26 patients with stroke who came to the emergency department, acute thromboembolic stroke was diagnosed on the basis of magnetic resonance imaging; no rhythm abnormalities were noted on Holter monitoring. Eighteen patients were male and 8 were female (mean age: 66±13 y). Arrhythmia was identified on ECG in 3 patients (11%) and on 24-h Holter monitoring in 24 patients (92%). PAF was diagnosed in 3 patients (11%) on ECG and in 11 patients (42%) on Holter monitoring. In 2 patients, nonsustained ventricular tachycardia was detected only on Holter monitoring, which was found to be significantly superior to ECG for the detection of arrhythmias (P < .001). Investigators found no significant relationship between PAF and variables such as hypertension, diabetes, coronary artery disease, history of myocardial infarction, ST-T changes, and elevations in cardiac markers. However, a significant relationship (P < .01) was seen between nonsustained ventricular tachycardia and a history of myocardial infarction. No relationship was discerned between arrhythmia and stroke localization. Study results suggested that (1) PAF is a commonly diagnosed rhythm abnormality, and (2) Holter monitoring is superior to routine ECG for the detection of arrhythmias such as PAF in patients anticipated to have thromboembolic stroke with sinus rhythm.

Acil serviste yeni steteskopumuz: El ultrasonu

BACKGROUND The concept of Focused Assessment with Ultrasound for Trauma (FAST), which was introduced by Rozycki et al. in 1996, has started a new era in the management of trauma patients. Today, Advanced Trauma Life Support (ATLS) suggests bedside ultrasonography (USG) evaluation of trauma patients. We aimed to investigate the usability and the reliability of handheld ultrasound (Vscan) in determining free fluid during the initial evaluation of trauma patients. METHODS This was a multi-center, prospective study involving multiple trauma patients who presented to three hospital emergency departments (EDs). FAST was completed using Vscan by an emergency physician and an abdominal USG was performed by a radiologist on all patients. Results of Vscan, abdominal USG and other radiological studies, if performed, were compared. RESULTS A total of 216 patients were included in the study. Of those, 203 had negative Vscan results, while 13 had positive results. When USG performed by a radiologist was considered as the gold standard, Vscan sensitivity for FAST was 88.9%, specificity was 97.6%, negative predictive value was 99.5%, and positive predictive value was 61.5% in our study. CONCLUSION Vscan, as the smallest portable imaging device, seems to have a promising future as an indispensable gadget, equal to stethoscopes, in evaluating trauma and other critical patients.

The diagnostic and prognostic value of first hour glycogen phosphorylase isoenzyme BB level in acute coronary syndrome.

BACKGROUND Evaluating patients with symptoms suggestive of acute coronary syndrome (ACS) is a time consuming, expensive and problematic process in the emergency department. This study aimed to evaluate the diagnostic and prognostic value of glycogen phosphorylase isoenzyme-BB (GP-BB) in ACS. METHODS A total of 72 patients (mean age 61.8 ± 11.6 years) with ACS were enrolled. The ELISA method for determining GP-BB level was performed and considered positive at 〉 10 ng/mL. Duration of angina, type of ACS, demographic features, myoglobin, creatinine kinase and troponin T (cTnT) were also assessed. The cTnT levels eight hours after pain onset was considered the gold standard test for the diagnosis of myocardial infarction. RESULTS The most sensitive biomarker at first hour of admission was GP-BB (95.8%). However, the specificity of GP-BB was low (43.7%). Receiver operating characteristics curve analysis of the GP-BB level for predicting myocardial infarction revealed the area under the curve value as 0.82 (SE 0.04; 95% CI 0.78-0.85). Positive treadmill exercise test (60% vs 17%, p = 0.047), coronary artery disease (CAD; 59% vs 19%, p = 0.007), percutaneous coronary intervention (44% vs 27%, p = 0.031) and 30-day mortality and/or readmission (33% vs 5%, p = 0.028) were found to be higher in unstable angina (UA) patients having GP-BB (+). CONCLUSIONS GP-BB is considerably cardiosensitive at the first hour of admission in patients with ACS, but the specificity of GP-BB is lower and it is elevated in nearly half of the patients with UA. However, in this group, GP-BB predicts significant CAD and the combined end-point of mortality and re-hospitalization.

Comparison of success and pain levels of supination-flexion and hyperpronation maneuvers in childhood nursemaid's elbow cases.

OBJECTIVE The aim of this study was to compare the hyperpronation (HP) and the supination-flexion (SF) reduction techniques for reducing nursemaids elbow in terms of efficacy and pain. METHODS This prospective, pseudorandomized, controlled, nonblinded study was conducted in an urban tertiary care emergency department between October 1, 2009, and October 1, 2010. A total of 150 patients (51 males [34%] and 99 females [66%] between the ages of 0 to 6 years) were included in the study. When the first reduction attempt failed, second attempt was performed using the same technique. After failure of the second attempt, reduction technique was changed to an alternate technique. Level of pain was evaluated using the Modified Childrens Hospital of Eastern Ontario Pain Scale in 113 patients older than 1 year who had a successful reduction process on the first attempt. RESULTS Successful reduction was accomplished in 121 (80.7%) of the patients during the first attempt, in 56 (68.3%) of the patients using the SF technique and in 65 (95.6%) of the patients using the HP technique (P < .001). At the end of total attempts, we found that the SF (59/84) technique was less successful than the HP (91/93) technique (P < .001). The pain levels of the both techniques were not statistically different. CONCLUSION The HP technique was found to be more successful compared with the SF technique in achieving reduction. We were unable to find any significant difference in pain levels observed between the 2 techniques.

Hemodialysis as an alternative treatment of mexiletine intoxication

Mexiletine is a class IB antiarrhythmic agent. Although it is primarily used in treating ventricular arrhythmias, recent indications for use of mexiletine include chronic and neuropathic pains. At high doses, mexiletine causes drowsiness, confusion, nausea, hypotension, sinus bradycardia, paresthesia, seizures, bundle branch block, atrioventricular heart block, ventricular arrhythmias, asystole, cardiovascular collapse, and coma. A 23-year-old male patient presented to the emergency department with intentional ingestion of high-dose mexiletine. Despite decontamination and supportive treatment, his vitals deteriorated during the observation period; and he developed stupor and dysarthria. Patient then underwent hemodialysis. His vital signs and overall condition improved rapidly following hemodialysis treatment. In this case report, we aimed to emphasize hemodialysis as a useful alternative therapy for severe mexiletine intoxications.

Patients admitted to the emergency room with upper gastrointestinal bleeding: Factors influencing recurrence or death

The aim of this study was to determine the clinical, laboratory, and endoscopic findings that might be related to poor prognoses, such as rebleeding or death, in patients admitted to the emergency room with upper gastrointestinal (UGI) bleeding. A prospective evaluation was conducted in 99 patients with UGI bleeding who were admitted to the emergency room of Hacettepe University Medical School between May and December 2001. Twenty-four patients were considered to have a poor prognosis. In multivariate analyses, presence of diabetes mellitus or of visible vessel at endoscopy, treatment with proton pump inhibitors, and decrease in mean blood pressure were found to be independent predictors for poor prognoses in this population. Several factors, such as comorbidities, type of treatment, or clinical and endoscopic findings, were found to be related to rebleeding or death in patients admitted to the emergency room with UGI bleeding necessitating intensive care.

The relationship between B-type natriuretic peptide levels and echocardiographic parameters in patients with heart failure admitted to the emergency department.

OBJECTIVE Brain natriuretic peptide (BNP) is a peptide, which has recently been used in the differential diagnosis and follow-up of patients with heart failure. Our aim in the present prospective and diagnostic designed study is to investigate the role of BNP in determining the etiology of dyspnea and to evaluate its relation with newer echocardiographic parameters. METHODS Thirty-four patients presenting to the emergency department with dyspnea and fulfilling the Framingham criteria for heart failure were included in the study. Blood samples were obtained in the first hour of presentation for measurement of BNP levels from all patients. Detailed transthoracic two-dimensional, Doppler and tissue Doppler echocardiographic studies were then performed within 24 hours of presentation. Statistical analyses were performed using Students t-test for independent samples, Mann Whitney U test and Pearson or Spearman correlation tests. RESULTS Plasma BNP levels were found to be significantly correlated with left ventricular end-systolic and end-diastolic diameter, left atrial diameter and the degree of mitral insufficiency (r=0.46, p=0.007; r=0.39, p=0.02; r=0.32, p=0.065; r=0.50, p=0.014, respectively). A significant inverse correlation was observed between plasma BNP levels and left ventricular ejection fraction (r=-0.5, p=0.003). When the patients were grouped according to their BNP levels, the mean ejection fraction of the group with BNP levels below median (578 pg/l) was 60.65+/-13.84%, whereas the mean ejection fraction of the group with BNP levels of 578 pg/l or above (BNP 2) was 49.41+/-15.26% (p=0.027). Out of parameters reflecting left ventricular diastolic functions, only transmitral Epeak/Apeak ratio was found to be significantly associated with BNP levels (r=0.4, p=0.05). Tissue Doppler study revealed significant correlations between BNP levels and right ventricular basal and midsystolic velocities (r=-0.507, p=0.008; r=-0.562, p=0.005, respectively) while none of the left ventricular tissue velocities displayed significant correlation with BNP values. CONCLUSION Plasma BNP levels are found to be significantly associated with conventional echocardiographic parameters reflecting left ventricular systolic and diastolic functions and tissue Doppler velocities reflecting right ventricular functions. Our findings are in agreement with the notion that plasma BNP levels are beneficial in the differential diagnosis of patients admitted to emergency service with acute dyspnea.

Iatrogenic water intoxication after pelvic ultrasonography imaging.

Ultrasound (US) is a simple, easily accessible, and noninvasive method. Thus, it is commonly used. The bladder should be sufficiently filled to acquire pelvic images by US. This report describes water poisoning in 3 patients with no hepatic, cardiac, or renal disease. Both patients had a history of excessive fluid intake.

The role of blood S100B and lactate levels in minor head traumas in children and adults and correlation with brain computerized tomography

BACKGROUND In this study, we aimed to set levels of blood S100B and lactate and to determine any correlation with brain computerized tomography in minor head traumas in children and adults. METHODS This clinical trial is a prospective study including 100 head trauma patients who applied to Ankara Training and Research Hospital emergency service. RESULTS In this study, cut-off ranges of 0.0-0.15 ug/ml and 0.9-1.7 mmol/L for blood S100B and lactate levels, respectively, were used. S100B level was higher than the cut-off range in 42% of patients and lactate level was higher in 56% of patients. No significant differences were determined between age groups. When the relation between S100B and lactate levels with brain CT was evaluated, no statistically significant relation was determined. CONCLUSION According to our results, in minor head traumas, the determination of elevated serum S100B and lactate levels cannot take the place of clinical examination and the use of cranial CT. Although the patients in our study group had minor head trauma, we do not consider S100B and lactate to be reliable markers for estimating progression.