Murat Kalemoğlu

A Clinic Investigation into Prehospital and Emergency Department Delays in Acute Stroke Care

Objective: The aim of our study was to investigate the factors which cause prehospital and emergency department (ED) delays in acute stroke care. Subjects and Methods: We prospectively studied 229 acute stroke patients (median age: 71 ± 19 years, 90 female and 139 male) who presented to the ED of the Gulhane Military Teaching Hospital, Istanbul, Turkey. Prehospital delay was defined as time from symptom onset to arrival at the ED. Emergency delay was defined as time from initial examination in the ED to arrival at the Neurology Intensive Care Unit. Results: The median interval of prehospital and emergency delays were 92.66 and 53 min, respectively. The major cause of the prehospital delay was the time from symptom onset to first call for medical help (68.21 min, 73.93%, β coefficients: 0.99; p < 0.001), and the major cause of the ED delay was waiting for the neurological consultation (21.28 min, 39.6%), β coefficients: 0.03; p < 0.001). Conclusion: The results indicate that prehospital and ED delays are due to late decision to seek medical care and delayed neurological consultation. Hence, educational campaigns are needed to increase public awareness of stroke signs and the necessity of calling emergency services immediately when persons are suffering a possible stroke. Equally, ED physicians need to be trained in the recognition of symptoms and signs of acute stroke and the necessity for rapid neurological evaluation.

Comparison of Laparoscopic and Open Surgery for Total Rectal Prolapse

PurposeTotal rectal prolapse is a devastating disorder causing constipation and anal incontinence. We compared open and laparoscopic surgical approaches in a limited series.MethodsThe subjects of this study were 23 patients who underwent laparoscopic procedures (LP group) and 17 patients who underwent open procedures (OP group) for rectal prolapse. We assessed the preoperative colonic transit time, postoperative pain scoring, pre- and postoperative anal functions, and changes in constipation and related symptoms.ResultsThe median operation time was 140.8 min for the LP group and 113.1 min for the OP group (P = 0.037). The median postoperative hospital stay was 4.8 days after the LPs and 9.6 days after the OPs (P = 0.001). Less analgesia was needed in the early postoperative period after the LPs (P = 0.007). While more than 70% improvement in continence was seen in the patients who underwent OPs, it was about 85% in those who underwent LPs. Improvement in constipation and related symptoms were similar in both groups. More than 30% of patients still suffered from hard stools and other symptoms of constipation. The colonic transit times were reduced in about 50% of patients who had suffered constipation in both groups. There was no incidence of recurrence in the median follow-up period.ConclusionAlthough transabdominal rectopexy has been performed conventionally for rectal prolapse for many years, laparoscopic rectopexy and laparoscopic resection rectopexy are associated with lower morbidity and less postoperative pain. We eliminated the total prolapse and cured incontinence in almost all patients, with a short hospital stay.

Missed injuries in military patients with major trauma : Original study

OBJECTIVE The incidence and subsequent outcomes of missed injuries and the primary factors contributing to each missed injury were analyzed. METHODS Records of 709 trauma patients were reviewed between December 2003 and December 2004. Demographic data were compared and analyzed for two patient groups: those with multiple injuries diagnosed in 24 hours and those with multiple injuries diagnosed in >24 hours. RESULTS Fifty-two missed injuries were determined in 34 (4.8%) patients. There were significant differences between the patients with and without delayed diagnoses, including the mean injury severity scores (23 vs. 16.9), morbidity, and mortality (p < 0.05 for all). Among 69 contributing factors identified, 28 (40.6%) were unavoidable and 41 (59.4%) were potentially avoidable. CONCLUSIONS Missed injuries could usually be encountered in the most seriously injured patients, particularly in those with altered levels of consciousness. Missed injuries were mostly avoidable and most were the result of inadequate clinical examination.

Hemoptysis and Breath-Holding Diving

OBJECTIVE We aim to present one case with hemoptysis. Pulmonary barotrauma of descent (lung squeeze) has been described in breath-hold divers when the lung volume becomes smaller than the residual volume, with the effect of increased ambient pressure. METHODS We report one case of hemoptysis in a breath-hold diver who dove for exercise of military action. RESULTS The patients hemoglobin and hematocrit levels were 7.3 g/dL and 26%, respectively. The computed tomography of thorax obtained 5 hours after the diving event revealed images suggestive of hemoptysis. The diagnosis of hemoptysis was made based on the divers history and computed tomography findings. All of the divers performed voluntary diaphragmatic contractions at the beginning of their ascent, while their mouths and noses were closed. CONCLUSION We suggest that the negative intrathoracic pressure attributable to the forced attempt to breathe along with voluntary diaphragmatic contractions contributes to hemoptysis, since it may damage the pulmonary capillaries.

Non-urgent patients in an Emergency Medical Service

BACKGROUND Emergency Medical Services (ES) are medical-surgical facilities where extremely ill patients, victims of accidents, intoxications and other urgent clinical situations should be rapidly and efficiently attended. However, a worldwide experience is that a large proportion of patients who require attention in an ES do not qualify as emergencies and they obstruct the possibilities of other patients that should be attended immediately. AIM To evaluate the medical records in our ES and to assess whether patients understand what is a true emergency and which is the role of an ES. METHODS Patients attended in the ES of Haydarpasa Military Teaching Hospital in 2001-2002 were classified according to their diagnosis. A random sample of patients and relatives were surveyed about why they required medical attention in the ES. RESULTS 77,134 patients (39,327 female, 51%) were attended. The most common illness diagnosed was upper respiratory tract infection (18,423 patients, 23.9%). The true emergency condition rate in patients presenting to our ES was lower (44%) than the non-emergency condition rate. CONCLUSIONS Improvements in public education are needed to solve this problem. Also, Primary Care facilities should be improved in order to reduce the demand for medical attention in ES by non-urgent patients.

Dissection of the Thoracic Aorta in a Patient with Autosomal Dominant Polycystic Kidney Disease

Internal Medicine,Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey.Autosomal dominant polycystic kidney disease(ADPKD) is a systemic illness with a number of extra-renal manifestations. A 61-year-old male patient withknown ADPKD was admitted to the emergency roomof our hospital in May 2003 with severe chest painradiating to his neck and back, and a sense ofbreathlessness. There was no history of trauma.On admission, he was hypotensive (90/50 mmHg)and his heart rate was 110 beats/min. He had a mid-systolic murmur, which was most marked at the leftsternal edge. His peripheral pulses were weak. Bilater-al basal crepitations were found on pulmonaryexamination. Abdominal examination was normalexcept for large palpable polycystic kidneys. He hadno focal neurologic signs. Laboratory examinationshowed no significant abnormalities except for raisedserum urea (121 mg/dL) and creatinine (4.1 mg/dL).An electrocardiogram showed depression of ST seg-ments in the anterior leads. Emergency computerizedtomography scanning of the thorax and abdomen de-monstrated dissection and intramural thrombus withinthe descending thoracic aorta and bilateral polycystickidneys (Panels A and B).He was transferred immediately for aortic surgery.During the operation, a type II thoracic aortic dissectionwas observed. His recovery was complicated by theexpansion of the dissection and he died on the thirdpostoperative day.Numerous cardiovascular abnormalities have beenreported in ADPKD patients, including heart valvelesion, cerebral aneurysm, splenic artery aneurysm,aortic root dilatation, abdominal aortic aneurysm,thoracic aortic dissection, and cervical artery dissection[1–3]. The prevalence of intracranial aneurysm andrupture are five-fold higher in ADPKD patients than inthe general population [4]. However, the prevalence ofextracerebral aneurysms is not clear. One autopsy seriesdescribed aortic dissection as being seven times morecommon in patients with ADPKD than in the generalpopulation [2]. Spontaneous artery dissection wasreported as a major complication in five unrelatedADPKD patients. All underwent spontaneous dissect-ion and none had phenotype of elastic tissue disorderor thoracic aortic dissection. Torra et al, in their case-control study, found a similar distribution of aorticdiameters in 139 ADPKD patients and their 149unaffected relatives [5]. The case reported by Paynteret al appears to be very similar to our case [3]. Arterialdissection may belong to the spectrum of extrarenalmanifestations of ADPKD. The association of ADPKD