Oktay Eray

Point of Care Blood Ketone Testing of Diabetic Patients in the Emergency Department

The aim of our study was to determine the utility of point‐of‐care blood ketone testing in diabetic patients presenting to the emergency department. In this prospective, observational clinical study, patients with known or newly diagnosed diabetes mellitus presenting to our tertiary care university emergency department with any nontrauma related medical complaint and a high fingerstick glucose (≥ 200 mg/dL) were eligible for inclusion. Capillary blood β‐hydroxybutyrate (β‐HBA), venous blood β‐HBA level, venous blood glucose level, arterial blood gas analysis, and urine ketone dipstickstick were measured in each patient as primary outcome measures. Of the 479 diabetic patients presenting during the study period, a total of 139 diabetic patients with high capillary blood glucose level (≥ 200 mg/dL) and a positive capillary blood β‐HBA (≥ 0.1 mmol/L) were included in the study. Hyperketonemia (≥ 0.42 mmol/L) was found in 48 of these patients by Sigma Diagnostics reference testing (diabetic ketosis in 35%). The calculated blood pH was less than 7.3 in 18 of these 48 patients (ketoacidosis in 31%). Capillary and venous blood β‐hydroxybutyrate levels were not statistically different from each other (P = 0.824). There was a positive correlation between capillary and venous blood β‐HBA levels (r = 0.488, P < 0.001). The sensitivity and specificity of urine ketone dipstick testing and capillary blood ketone testing in determining diabetic ketoacidosis were 66% and 78%, and 72% and 82%; and in determining hyperketonemia (both in diabetic ketosis and diabetic ketoacidosis) were 82% and 54%, and 91% and 56%, respectively. A rapid, bedside capillary blood ketone test for β‐HBA can accurately measure blood concentrations of β‐HBA in diabetic patients in an emergency department setting. This device can be used as a reliable diagnostic test to detect emergency metabolic problems in diabetic patients, such as diabetic ketosis or ketoacidosis.

Prospective validation of a current algorithm including bedside US performed by emergency physicians for patients with acute flank pain suspected for renal colic

Objective: The purpose of this study was to validate an algorithm recommended by current literature for the patients with acute flank pain and evaluate the validity of bedside ultrasonography (US) performed by emergency physicians (EP) as a part of this algorithm. Materials and methods: This prospective validation study was carried out over a 5 month period in a tertiary care hospital adult emergency department (ED) with annual attendance of 55 000. Adult patients presenting to the ED with unilateral acute flank pain during the study period were enrolled into the study consecutively. Oral consent was obtained after the protocol was briefly explained to the patient and before the administration of analgesia. A protocol form was recorded for each patient enrolled into the study, and patients were followed up under the guidance of a previously designated algorithm in the ED. Data were analysed with SPSS software. The χ2 test was used to compare the dichotomised data of patients, diagnosed with and without stones, and to select the significant parameters to be used in the logistic regression. Results: Of the 227 patients enrolled, 176 were proven to have urinary tract stones. There were 122 patients discharged from ED without further investigation except urinalysis and bedside US. Of these 122 directly discharged patients, 99 had a urinary stone, and the others did not have a life threatening disorder. Four of the 227 patients were admitted to the hospital. The remaining 51 patients did not have stones detected, and their pain subsided. Having a previous history of stones, radiation of pain to the groin, accompanying nausea, and detection of pelvicalyceal dilatation using bedside US performed by the EPs were found to be the most significant parameters in determining urinary stones in logistic regression analysis. Sensitivity and specificity of these parameters were: previous history of stones 59% and 66%, radiating pain to the groin 68% and 49%, nausea 71% and 51%, and detection of pelvicalyceal dilatation by bedside US 81% and 37%. Conclusion: Bedside US performed by EPs could be used safely in the evaluation of patients with acute flank pain as a part of a clinical algorithm. Previous history of urinary stones, radiation of pain to the groin, accompanying nausea. and detection of pelvicalyceal dilatation are major parameters and symptoms of urinary stone disease, and could be used in the algorithms.

Comparison of the Full Outline of Unresponsiveness Score Coma Scale and the Glasgow Coma Scale in an emergency setting population.

Background The Glasgow Coma Scale (GCS) is the most widely used tool for the evaluation of the level of consciousness. The Full Outline of Unresponsiveness (FOUR) Score is a new coma Scale that was developed considering the limitations of the GCS, and has been found to be useful in an intensive care setting. We aimed to compare FOUR Score and GCS in the emergency setting. Methods All patients older than 17 years who presented with an altered level of consciousness, after any trauma to the head or with neurological complaints were included in this study. Three-month mortality, in-hospital mortality, and poor outcome using a Modified Rankin Scale (MRS) of 3–6 points were used as the primary outcome measures. Results A total of 185 patients were included in the study. Area under the curve (AUC) values in predicting 3-month mortality for GCS was 0.726 [P=0.0001 and 95% confidence interval (CI): 0.656–0.789] and 0.776 (P=0.0001 and 95% CI: 0.709–834) for FOUR Score. AUC in predicting hospital mortality for GCS was 0.735 (P=0.0001 and 95% CI: 0.655–0.797) and 0.788 (P=0.0001 and 95% CI: 0.722–0.844) for FOUR Score. AUC in predicting poor outcome (Modified Rankin Scale: 3–6) was 0.720 (P=0.001 and 95% CI: 0.650–784) for GCS and 0.751 (P=0.0001 and 95% CI: 0.682–0.812) for FOUR Score. Conclusion The new coma Scale, FOUR Score, is not superior to the GCS. However, the combination of the eye and motor components of FOUR Score is a valuable tool that can be used instead of either the FOUR Score or GCS.

ETco2: a predictive tool for excluding metabolic disturbances in nonintubated patients

OBJECTIVES The purpose of this study is to examine the relation between end-tidal carbon dioxide (ETCO₂) measurement and bicarbonate (HCO₃) level reflecting the patients metabolic status. METHOD This prospective cross-sectional study has been carried out during a 3-month period in a tertiary care university hospitals emergency department (ED). During the study period, every spontaneously ventilating ED patient requiring arterial blood gas analysis for any medical indication, regardless of presenting symptoms, had a simultaneous ETCO₂ measurement using a Medlab Cap 10 side stream capnograph. The demographics and clinical outcomes of the patients were recorded. RESULTS Of 399 eligible patients, 240 with possible metabolic disturbance were enrolled into the study. There was a statistically significant correlation between the value of ETCO₂ and HCO₃ levels (r = 0.506). The mean ET(CO)₂ level was statistically significantly lower in patients who died (26.5 ± 7.2, 95% confidence interval [CI], 24.2-28.6, vs 30 ± 7.5, 95% CI, 29-31; P = .007) and who had low bicarbonate levels (25.7 ± 6.7, 95% CI, 24.3-27.1, vs 31.6 ± 7.1, 95% CI, 30.4-32.8; P = .000). The value of ET(CO)₂ measurement to detect low bicarbonate level was found to be significant. The area under the receiver operating characteristic curve was 0.734, the (+) likelihood ratio for ETCO₂ less than or equal to 25 was 2.7, and the (-) likelihood ratio for ETCO₂ greater than or equal to 36 was 0.05. CONCLUSION ETCO₂ values correlate moderately with HCO₃ levels and thus might predict mortality and metabolic acidosis. Therefore, side stream capnograph can be used as a noninvasive diagnostic tool for ruling out suspected severe metabolic disturbance in the ED.

Intravenous single-dose tramadol versus meperidine for pain relief in renal colic.

BACKGROUND AND OBJECTIVE Comparison of the effectiveness of tramadol with meperidine given intravenously to emergency patients with suspected renal colic. METHODS A double-blind, randomized clinical trial was performed in the Emergency Department of a tertiary-care university hospital. Consecutive patients with suspected renal colic (n = 47) were randomized to receive intravenously an initial dose of tramadol 50 mg (n = 23) or meperidine 50 mg (n = 24). After 30 min, additional doses of meperidine 50 mg were given intravenously as a rescue medication in an open fashion. Pain relief was assessed using a 10 cm visual analogue scale, the primary outcomes being pain relief at 15 and 30 min after the analgesics. Secondary outcomes were the frequency of rescue meperidine use and the development of side-effects. RESULTS Visual analogue scale pain scores after 15 and 30 min decreased in both tramadol and meperidine groups (P < 0.05). However, pain relief was better in the meperidine group at the 15 and 30 min evaluations (P < 0.05). Only 11 patients (48%), initially receiving meperidine, needed more meperidine compared with 16 patients (67%) initially receiving tramadol. Both drugs were well tolerated with no adverse effects occurring in either group. CONCLUSIONS Meperidine 50 mg was superior to tramadol 50 mg for acute pain relief in patients with suspected renal colic when given intravenously. Because many patients in both groups received supplemental meperidine and the response to tramadol alone cannot be predicted, clinicians may want to choose higher doses of meperidine alone or other alternative combinations.

Severe uvular edema and nasal mucosal necrosis due to Ecbalium elaterium (squirting cucumber): an allergic reaction or direct toxic effect?

Ecbalium elaterium or squirting cucumber is a plant growing in the Mediterranean region, belong to Cucurbitaceae family. Its juice has been used as an herbal medicine since ancient times because of its cathartic and anti-inflammatory effects. It has been reported to cause upper airway edema, especially after the administration of its undiluted form. It has generally been attributed to allergic reaction. In this case report we aimed to interrogate this anticipation by presenting a case of severe uvular edema and nasal mucosal necrosis after dripping undiluted Ecbalium elaterium juice that did not improved by anti-allergic therapies.

Pain Perception of Patients Predisposed to Anxiety and Depressive Disorders in Emergency Department

The aim of this study was to reveal the effects of anxiety and depression on pain perception in the emergency setting. This randomized prospective study was performed in an urban tertiary care hospital emergency department (ED). Consecutive patients presenting to the ED with pain who had an intramuscular injection of diclofenac sodium were enrolled in the study. The prevalence of anxiety and depressive disorders in study subjects was determined by using the Hospital Anxiety and Depression Scale. A total of 302 patients were included. Study subjects had a mean age of 41.3 +/- 13.7 years and 35.4% (n = 107) were male. Pain perception in women was significantly higher than in men (median 8.5 vs. 5, respectively; p = .033). Pain perception in elderly patients, >/=65 years old, was found to be lower than in patients <65 years old (median 1 vs. 6.5, respectively; p = .02). Anxiety was found to be related to higher pain perception after adjusting for confounding variables (13.8 vs. 7.6, respectively; adjusted p = .022). Gender, age, and anxiety, but not depression, are possible factors related to pain perception in the emergency setting. Further studies are needed to reveal the factors affecting pain perception and the complex relationship between psychiatric status and pain.

Artificial neural network, genetic algorithm, and logistic regression applications for predicting renal colic in emergency settings

BackgroundLogistic regression is the most common statistical model for processing multivariate data in the medical literature. Artificial intelligence models like an artificial neural network (ANN) and genetic algorithm (GA) may also be useful to interpret medical data.AimsThe purpose of this study was to perform artificial intelligence models on a medical data sheet and compare to logistic regression.MethodsANN, GA, and logistic regression analysis were carried out on a data sheet of a previously published article regarding patients presenting to an emergency department with flank pain suspicious for renal colic.ResultsThe study population was composed of 227 patients: 176 patients had a diagnosis of urinary stone, while 51 ultimately had no calculus. The GA found two decision rules in predicting urinary stones. Rule 1 consisted of being male, pain not spreading to back, and no fever. In rule 2, pelvicaliceal dilatation on bedside ultrasonography replaced no fever. ANN, GA rule 1, GA rule 2, and logistic regression had a sensitivity of 94.9, 67.6, 56.8, and 95.5%, a specificity of 78.4, 76.47, 86.3, and 47.1%, a positive likelihood ratio of 4.4, 2.9, 4.1, and 1.8, and a negative likelihood ratio of 0.06, 0.42, 0.5, and 0.09, respectively. The area under the curve was found to be 0.867, 0.720, 0.715, and 0.713 for all applications, respectively.ConclusionData mining techniques such as ANN and GA can be used for predicting renal colic in emergency settings and to constitute clinical decision rules. They may be an alternative to conventional multivariate analysis applications used in biostatistics.

The utility of EEG in the emergency department.

Background and aim Seizure-related visits are common in the emergency department (ED) but the clinical situations for ordering emergency electroencephalography (EEG) are unclear. The aim of this study is to identify which clinical conditions meet with the pathological EEG and whether patient management is changed by abnormal results. Methods A retrospective chart review study of all patients visiting the ED with a seizure or symptoms mimicking a seizure was performed. Patients who recorded an EEG within 16 h after the initial event were enrolled. Demographic data and EEG results of patients with provoked and unprovoked seizures were recorded and related factors were analysed. Results A total of 449 patients (219 men) of mean±SD age of 45.48±21.83 years were evaluated. The seizure was thought to be provoked in 98 patients (21.8%) and unprovoked in 352 (78.2%) patients (31.2% remote symptomatic and 47.4% idiopathic). The EEG results of 281 patients (62.6%) revealed an abnormality, and the abnormal EEG ratio was high in patients with presumed seizure (p<0.001). One hundred and thirty-eight patients (30.7%) were hospitalised and the remainder (n=311, 69.3%) were discharged from the ED. An abnormal EEG was found in 98 (71%) of the hospitalised patients and in 183 (59.5%) of those discharged (p=0.019). Conclusion EEG provides useful diagnostic information and should be considered in all patients presenting to the ED with a seizure. Since the timing of the study affects the diagnostic efficacy of the test, EEG recordings might be done within 24 h either in the ED or epilepsy clinic.

Magnesium efficacy in magnesium deficient and nondeficient patients with rapid ventricular response atrial fibrillation.

&NA; We assessed the effect of magnesium sulphate (MgSO4) on lowering the rate in ventricular atrial fibrillation (AF), and evaluated the effect of this therapy in magnesium (Mg) deficient and nondeficient patients. This experimental clinical study was performed on 34 patients with rapid AF (ventricular rate [VR] > 120/minute) presenting to the emergency department of a tertiary care university hospital Patients with systolic blood pressure ≤ 100 mmHg, Hb level ≤ 11.8. saO2 of ≤ 96%, BUN ≥ 40 or creatine ≥ 1.8 were excluded (n = 15) Nineteen patients were given an initial 2 g MgSO4 bolus i.v and a 1 g/hour continuous infusion over 6 hours. To evaluate the presence of Mg deficiency, urine was collected from the onset of treatment and continued for the next 24 hours, and the excretion rate of administered Mg was calculated Ventricular rates were obtained at baseline, after MgSO4 bolus, and every 15 minutes for the first hour The decrease in the VR was statistically significant at 15, 30 and 60 minutes after Mg therapy (p = 0.0025. p < 0.001, p > 0.001). There was no difference in the response to Mg therapy between Mg deficient and nondeficient patients at 15, 30 or 60 minutes after therapy (p = 0.41, p = 0.28, p = 0.08). It is concluded that i.v MgSO4 has a statistically significant but clinically limited effect on VR and this effect did not differ between patients with and without Mg deficiency.