Neşe Çolak Oray

Novel biochemical marker for differential diagnosis of seizure: ischemia-modified albumin

INTRODUCTION Differential diagnosis of seizure is critical in patients presented to emergency department (ED) with altered mental status or loss of consciousness. Although electroencephalogram is important for the diagnosis of seizures, its use in EDs is limited. The level of ischemia-modified albumin (IMA) increases in conditions of ischemic distress such as acute coronary syndrome, pulmonary embolism, and mesenteric ischemia. No studies exist in literature regarding the increase of IMA levels parallel to increased seizure activity in adults. The aim of the study was to investigate the diagnostic value of IMA in adult patients presented to ED with seizures. METHODS Forty patients presented to ED with seizure, and 40 control patients of similar age and sex as the study group were enrolled in this study. Initial and fourth-hour levels of IMA and albumin were measured. Groups were compared in terms of sociodemographic data and details regarding their seizures as well as initial and fourth-hour levels of IMA. RESULTS Mean levels of IMA were 61.5 IU/mL and 18.5 IU/mL (P < .001) initially and 56.7 IU/mL and 15.4 IU/mL (P < .001) at the fourth hour; levels were higher in the study group compared with control group. Ischemia-modified albumin/albumin ratios in study and control groups were 1555.3 IU/g and 462.4 IU/g (P < .001) initially and 1431.4 IU/g and 383.6 IU/g (P < .001) at the fourth hour, respectively. CONCLUSION Blood IMA level and IMA/albumin ratio significantly increase in adult patients who experienced seizures. Ischemia-modified albumin may be considered as a useful biomarker in the differential diagnosis of seizure.

Retrospective evaluation of patients with elevated digoxin levels at an emergency department

Objectives We investigated the demographic characteristics, clinical and laboratory findings, treatment strategies and clinical outcomes of patients presenting at emergency department (ED) with digoxin levels at or above 1.2 ng/ml. Materials and methods The demographic and clinical characteristics of patients with serum digoxin levels at or above 1.2 ng/ml admitted to an ED between January 2010 and July 2011 were investigated in this cross-sectional descriptive study. Patients with ECG and clinical findings consistent with digoxin toxicity and no additional explanation of their symptoms were evaluated for digoxin toxicity. Results In this study 137 patients were included, and 68.6% of patients were women with mean age 76.1 ± 12.2. There was no significant difference between gender and digoxin intoxication. The mean age of intoxicated group was significantly higher than the non-intoxicated group (P = 0.03). The most common comorbidities were congestive heart failure (n = 91) and atrial fibrillation (n = 74). The most common symptoms were nausea, vomiting and abdominal pain. The levels of hospitalization and mortality in this group were significantly higher. Conclusion Digoxin intoxication must be suspected in patients present in the ED, particularly those with complaints that include nausea and vomiting, as well as new ECG changes; serum digoxin levels must be determined.

Massive pulmonary embolism and cardiac arrest; thrombolytic therapy in a patient with recent intracranial surgery and glioblastoma multiforme.

Treatment options for pulmonary embolism are increasing, but the scale of the treatments and their availability in the emergency department (ED) are limited. Thrombolytic therapy remains the most commonly used treatment in patients who present a massive pulmonary embolism in the ED. However, systemic thrombolysis is contraindicated in certain cases, such as a known intracranial tumor or a history of cranial surgery.In this case report, we report a 63-year-old man with a history of intracranial surgery due to glioblastoma multiforme 20 days prior to being admitted to the ED. Multidetector-row computed tomography angiography revealed embolisms in both main pulmonary arteries.There was a progression of cardiac arrest while preparing for catheterization; thus, cardiopulmonary resuscitation was initiated.After administering 10 minutes of cardiopulmonary resuscitation, a50-mg alteplase bolus was given. Within minutes, a pulse has returned. No complications associated with the thrombolytic therapy were observed.Our aim was to discuss the management of massive pulmonary embolism with a contraindication to systemic thrombolytic therapy.

Workplace violence against physicians in Turkey’s emergency departments: a cross-sectional survey

Objective We aimed to determine the prevalence of violence directed at emergency department (ED) physicians in Turkey and confirm the factors influencing such violence. Design Cross-sectional survey study. Setting Country of Turkey. Participants Physicians currently practising in EDs in Turkey. Main outcome measures The prevalence of violence directed at physicians and factors that may influence it, such as physicians’ personal characteristics, ED characteristics and physicians’ opinions regarding the causes of and suggested methods of preventing violence. Results A total of 713 physicians participated. Of these, 78.1% reported being subjected to violence in the past year and 65.9% reported more than one such incident. Being subjected to violence was related to age (p=0.008), working in an ED with a high patient admission rate (p=0.018), current position (p<0.001), working outside regular work hours (p<0.001), working in a state hospital (p<0.001) and level of experience (p<0.001). Gender, type of patient typically seen, region and patient waiting period did not influence subjection to violence. The present safety precautions against violence do not appear to influence the prevalence of violence. Conclusions Our results indicated that ED physicians’ experience of violence is related to personal characteristics such as age and level of expertise, and hospital and ED characteristics such as high patient admission rates. Presently, no measures taken to reduce this violence have been proven effective.

Blunt trauma patient with esophageal perforation.

Traumatic perforation of the esophagus due to blunt trauma is a rare thoracic emergency. The most common causes of esophageal perforation are iatrogenic, and the upper cervical esophageal region is the most often injured. Diagnosis is frequently determined late, and mortality is therefore high. This case report presents a young woman who was admitted to the emergency department (ED) with esophageal perforation after having fallen from a high elevation. Esophageal perforation was diagnosed via thoracoabdominal tomography with ingestion of oral contrast. The present report discusses alternative techniques for diagnosing esophageal perforation in a multitrauma patient.

A potential pitfall in the diagnosis of renal colic: renal infarction.

Renal infarction is a rarely seen clinical condition with a nonspecific presentation. It often presents as renal colic or an acute abdomen and is initially misdiagnosed. In patients who present to the emergency department (ED) with abdominal pain or flank pain resistant to treatment, renal infarction must be considered, especially if they have thromboembolic risk factors. Abdominal computerized tomography with intravenous contrast is the choice of imaging because of its high sensitivity. We report cases of 2 patients who presented to our ED with flank pain and hematuria. They were diagnosed with urethral colic from stones as an initial diagnosis. They were further evaluated for thromboembolic risk factors and persistent flank pain, and a final diagnosis of renal infarction was given. Renal infarction is a rare condition with a nonspecific presentation [1]. It is infrequently included in the differential diagnosis of abdominal and flank pain, and the diagnosis is often delayed [2,3]. Cases of renal infarction have been misdiagnosed as renal colic, nephrolithiasis, and acute abdomen. Patients with renal infarction most frequently present with abdominal pain, nausea, vomiting, and fever [1,4]. In half of the patients, the diagnosis is missed on initial presentation [1,3,5,6]. In many cases of renal infarction, the patient has a history of arrhythmia or valvular disease. We present 2 patients who came to the emergency department (ED) with renal colic and was given the diagnosis of renal infarction. With these cases, we discuss the clinical presentation, laboratory testing, and imaging techniques used to diagnose renal infarction. A 54-year-old woman presented to the ED with right flank pain radiating to the abdomen with onset 30 minutes This study has been accepted for poster presentation at The First Eurasian Congress on Emergency Medicine, November 5 to 9, 2008, in

Sedative-Hypnotic Medication Exposures and Poisonings in Izmir, Turkey*

The aim of this study was to analyse intoxications concerning sedative-hypnotic medication patients admitted to the Department of Emergency Medicine in Dokuz Eylul University Hospital (EMDEU) between 1993 and 2005. Demographics of the patients, characteristics of sedative-hypnotic exposures, performed treatment attempts and outcome of the poisoned patients were recorded on standard data forms that were later entered into a computerized database programme. Related to the sedative-hypnotic exposures, 686 poisoning cases were admitted to the EMDEU. Mean age was 10.8 +/- 6.5 years among the paediatric age group (<17 years old, 169, 24.6%) and 30.3 +/- 12.8 years among the adult group (>17 years old,509, 74.2%). The most common sedative-hypnotic agents were benzodiazepines (286, 35.8%), alprazolam accounted for41.6% of them (119). Most of the patients admitted to EMDEU were asymptomatic (61.7%). Observation alone was recommended in 53.9% of EMDEU cases. Although prescription of benzodiazepines is restricted, benzodiazepine was the most common cause of sedative-hypnotic medication exposures. As only a minority of patients (3%) had clinically serious signs and symptoms, most of the overdoses might be under toxic levels or the decontamination methods might be efficient. In this study, the clinical outcome of the patients is relatively better than previous results described in literature.

Utility of chest CT after a chest X-ray in patients presenting to the ED with non-traumatic thoracic emergencies

Background: Chest radiography is the initial choice for thoracic imaging. However, the wide availability of computed tomography (CT) has led to a substantial increase in its use in the emergency department (ED). We evaluated the utility of chest CT after a chest X‐ray in patients presenting to the ED with non‐traumatic thoracic emergencies, and determined if the diagnosis and management decision changed after CT. Methods: The study enrolled 500 consecutive patients with both chest X‐rays and CT who presented to the ED with non‐traumatic complaints. Chest X‐rays and CT images obtained within 12 h before any definitive treatment were randomly evaluated in consensus by two radiologists blinded to the clinical information. Results: The chest X‐ray and CT image findings were concordant in 49.2% of the 500 patients and this concordance was negatively correlated with patient age. Leading diagnosis and management decisions based on the chest radiograph changed after CT in 35.4% of the study group and this finding was also correlated with age. In 55% of 205 patients, pneumonic infiltrations were undiagnosed with radiography. Pulmonary edema was the most specific (93.3%) and sensitive (85.4%) radiography finding. Posteroanterior chest radiographs taken in the upright position had higher concordance with CT than anteroposterior (AP) radiographs taken in the supine position. Conclusions: Chest CT may be an appropriate imaging choice in patients presenting to the ED for non‐traumatic reasons, particularly for elderly patients and when the radiograph is taken with the AP technique in a supine position. HighlightsFindings of chest radiographs and CT images were concordant in 49.2% of 500 patients.Leading diagnosis and management decisions changed after CT in 35.4% of patients.In 55% of 205 patients, pneumonic infiltration was undiagnosed with radiography.Pulmonary edema was the most specific and sensitive finding of radiography.

Emergency physicians performed Point-of-Care-Ultrasonography for detecting distal forearm fracture

Objectives Several studies focusing diagnosis of forearm fracture using Point-of-Care-Ultrasonography (POCUS) had been carried out in children. There is a lack of evidence for the utility of sonographic (US) examination for detecting of distal forearm fracture in adults. We aim to determine the diagnostic sensitivity and specificity of POCUS examination for the fracture of the distal radius and ulna in adult patients presenting with blunt forearm trauma. Material and Methods Adult patients presenting with acute distal forearm trauma and suspicion of fracture were enrolled into study. POCUS had been performed by blinded emergency physicians, than anteroposterior and lateral x-rays was obtained. If inconsistency between x-rays and POCUS has been occurred, computed tomography were ordered. Assessment of orthopedic surgeon was accepted as a gold standard diagnosis. Results Ninety three POCUS were performed in 90 patients. Fifty nine radius and 19 ulna fracture had been diagnosed. POCUS detected all radius fracture, but missed 2 ulna fracture. There were 4 false positive results for both radius and ulna with POCUS. X-ray missed 4 radius, and 1 ulna fractures. Diagnostic sensitivity and specificity of POCUS for fracture of ulna were 89.5% (CI%95, 65.5–98.1) and 94.6 (CI%95, 86–98.2), for fracture of radius were 100% (CI%95, 92.4–100), and 88.2%. (CI%95, 71.6–96.1). Conclusion Emergency physician performed POCUS examination is very sensitive and specific the diagnosis of distal forearm fracture. Diagnostic sensitivity of POCUS for radius fracture is higher than x-ray.

The comparison of the efficiency of traditional lectures to video-supported lectures within the training of the Emergency Medicine residents.

Objectives Recent developments in computer and video technology, multimedia resources enter quickest way possible into medical education and have started to gain popularity. The aim of this study is to evaluate the impact of video-supported lectures on leaning, with comparison to traditional lectures. Methods According to lecture techniques, two separate groups; one is the traditional lectures group (TLG) and the other is video-supported lectures group (VSLG), are formed. While the TLG is offered a traditional lecture the VSLG is offered a video-supported lecture with imbedded videos which are related to the topics in the traditional lecture. Both study groups take pretest and posttest with MCQs (multiple choice questions) and OSCEs (objective structured clinical examination). Results The study includes 30 volunteer residents in Dokuz Eylul University School of Medicine Department of Emergency Medicine. No difference is observed between TGL and VSLG in pretest and posttest scores (p = 0.949, p = 0.580). And additionally, comparing the scores of both groups, we cannot observe any difference between the pretest OSCE scores of each group (p = 0.300), however posttest OSCE scores shows a dramatic odd in-between (p = 0.010). When pretest MCQs and posttest MCQs mean scores are compared, both tests (TLG, VSLG) has not any significant difference (p=0.949, p = 0.580). Nevertheless, after comparing OSCEs pretest and posttest mean scores, we can see significant difference in mean scores of both (TLG, VSLG), (p = 0.011, p = 0.001). Conclusions Taken into consideration, the findings of this study shows possibility of improving educational techniques to acquire clinical skills by using local resources and low-cost technology.