Onur Polat

The accuracy of ultrasound evaluation in foot and ankle trauma

OBJECTIVES Foot and ankle injuries that result in sprains or fractures are commonly encountered at the emergency department. The purpose of the present study is to find out the accuracy of ultrasound (US) scanning in injuries in the aforementioned areas. METHODS Ottawa Ankle Rules-positive patients older than 16 years who presented to the emergency department with foot or ankle injuries were eligible. For all patients, US evaluation of the whole foot and ankle was performed by an emergency physician before radiographic imaging. All radiographic images were evaluated by an orthopedic specialist and compared with the interpretations of the US. RESULTS One hundred thirty-one patients were included in the study. Radiographic evaluation enabled the determination of fractures in 20 patients, and all of these were identified with US imaging. Moreover, US evaluation radiographically detected a silent ankle fracture in 1 patient. The sensitivity of US scanning in detecting fractures was 100% (95% confidence interval [CI], 83.8-100), the specificity was 99.1% (95% CI, 95-99.8), the positive predictive value was 95.2% (95% CI, 89.6-98), and the negative predictive value was 100% (95% CI, 96.4-100), respectively. The most common fractures were detected at the lateral malleolus and at the basis of the fifth metatarsal. CONCLUSIONS Ultrasound imaging permits the evaluation of foot and ankle fractures. Because it is a highly sensitive technique, US can be performed in the emergency department with confidence.

Establishment of interdisciplinary child protection teams in Turkey 2002–2006: Identifying the strongest link can make a difference!

OBJECTIVES The University of Iowa Child Protection Program collaborated with Turkish professionals to develop a training program on child abuse and neglect during 2002-2006 with the goals of increasing professional awareness and number of multidisciplinary teams (MDT), regional collaborations, and assessed cases. This paper summarizes the 5-year outcome. METHODS A team of instructors evaluated needs and held training activities in Turkey annually, and provided consultation when needed. Descriptive analysis was done via Excel and SPSS software. RESULTS Eighteen training activities were held with 3,570 attendees. Over the study period, the number of MDTs increased from 4 to 14. The MDTs got involved in organizing training activities in their institutions and communities. The number of medical curriculum lectures taught by MDTs to medical students/residents, conferences organized by the MDTs, and lectures to non-medical professional audiences increased significantly (R(2)=91.4%, 83.8%, and 69.2%, respectively). The number of abuse cases assessed by the MDTs increased by five times compared to pre-training period. CONCLUSIONS A culturally competent training program had a positive impact on professional attitudes and behaviors toward recognition and management of child abuse and neglect in Turkey. The need to partner with policy makers to revise current law in favor of a greater human services orientation became clear. PRACTICE IMPLICATIONS Pioneers in developing countries may benefit from collaborating with culturally competent instructors from countries with more developed child protection systems to develop training programs so that professional development can improve recognition and management of child abuse and neglect.

Septic Pulmonary Embolism Associated with Renal Abscess: A Case Report

BACKGROUND Septic pulmonary embolism (SPE) is a rare condition that is difficult to diagnose. OBJECTIVES To describe the clinical course and diagnosis of a patient with SPE. CASE REPORT We report on a case of SPE diagnosed in the emergency department and review the current literature. CONCLUSION The diagnosis of SPE can be made using computed tomography scan. Early diagnosis and appropriate antibiotic therapy are important factors for the control of the infection.

Bone Tumors of the Clavicle: Risk of Malignancy in the Elderly and Safe Needle Biopsy

The clavicle is a rare site for bone tumors and little is known from the limited literature about the prognostic factors and management techniques, including biopsy. The method of biopsy is controversial in the clavicle because of the risk of injury to the neighboring neurovascular structures. Twenty patients with clavicular lesions were retrospectively reviewed with clinical, radiological, and histopathological reports. A needle biopsy was planned in the presence of an osteolytic lesion providing nonforceful entry of the needle, detailed knowledge obtained about the local anatomy, and known availability of an oblique angle for the needle entry away from vascular structures. A needle or tru-cut biopsy was performed for preoperative histopathological diagnosis in 6 selected patients with no complications. Considering the histological diagnosis and prevalence of clavicular bone tumors, benign and malignant lesions had a similar prevalence rate; however, malignant tumors occurred in an older (>50 years) population (P=005). Statistical analysis revealed that the best cutoff point for age for discriminating malignant lesions was 50 years with high sensitivity. The main concern for these patients is primary lesion site treatment and symptom palliation. Every clavicular lesion in patients older than 50 years should be considered as malignant unless proven otherwise. This article demonstrates that needle biopsy can be performed safely in selected lesions with particular attention to cross-sectional local anatomy during needle insertion.

A controlled trial of glutamine effects on bone healing

Glutamine is considered a nonessential amino acid, but it may be conditionally essential in patients with catabolic conditions. For centuries, researchers have looked for ways to promote and accelerate fracture healing. This controlled animal study examines the effects of glutamine on fracture healing. The left tibias of 10 standardized albino rats were broken at the distal third to produce a closed fracture. L-glutamine/L-alanyl solution (2.0 mL/kg) was administered through the tail veins of half the rats for the first 7 d, and physiologic serum alone was given to the control group. On the 21 st day, all rats were euthanized and their left legs removed; after histologic observation, the tibias were examined under light microscopy. In the glutamine-injected group, development of primary callus was quicker and more regular than in the control group. The control group produced insufficient fibrous callus, and the glutamine group attained formed cartilaginous callus. Glutamine was noted to have positive effects on healing of traumatically fractured bone through attainment of positive nitrogen balance. This effect was minimal in enhancing the quality of fracture healing under conditions of stress, but some effect was noted on the speed of healing. Further research is needed in this area

Independent Factors for Prediction of Poor Outcomes in Patients with Febrile Neutropenia

Background Febrile neutropenia (FN) is a life-threatening condition that requires urgent management in the emergency department (ED). Recent progress in the treatment of neutropenic fever has underscored the importance of risk stratification. In this study, we aimed to determine independent factors for prediction of poor outcomes in patients with FN. Material/Methods We retrospectively evaluated 200 chemotherapy-induced febrile neutropenic patients who visited the ED. Upon arrival at the ED, clinical data, including sex, age, vital signs, underlying systemic diseases, laboratory test results, estimated GFR, blood cultures, CRP, radiologic examinations, and Multinational Association of Supportive Care in Cancer (MASCC) score of all febrile neutropenic patients were obtained. Outcomes were categorized as “poor” if serious complications during hospitalization, including death, occurred. Results The platelet count <50 000 cells/mm3 (OR 3.90, 95% CI 1.62–9.43), pulmonary infiltration (OR 3.45, 95% CI 1.48–8.07), hypoproteinemia <6 g/dl (OR 3.30, 95% CI 1.27–8.56), respiratory rate >24/min (OR 8.75, 95% CI 2.18–35.13), and MASCC score <21 (OR 9.20, 95% CI 3.98–21.26) were determined as independent risk factors for the prediction of death. The platelet count <50 000 cells/mm3 (OR 3.93, 95% CI 1.42–10.92), serum CRP >50 mg/dl (OR 3.80, 95% CI 1.68–8.61), hypoproteinemia (OR 7.81, 95% CI 3.43–17.78), eGFR ≤90 ML/min/1.73 m2 (OR 3.06, 95% CI 1.13–8.26), and MASCC score <21 (OR 3.45, 95% CI 1.53–7.79) were determined as independent risk factors for the prediction of poor clinical outcomes of FN patients. Platelet count, protein level, respiratory rate, pulmonary infiltration, CRP, MASCC score, and eGFR were shown to have a significant association with outcome. Conclusions The results of our study may help emergency medicine physicians to prevent serious complications with proper use of simple independent risk factors besides MASCC score.

Slipped capital femoral epiphysis in osteopetrosis: an unusual case

Abstract. We report on a 9-year-old boy who has type II autosomal dominant osteopetrosis associated with a chronic grade II slipped capital femoral epiphysis. He was treated with a single cannulated screw. This rare association has been reported only once.

Neutrophil-to-Lymphocyte Ratio as a Marker in Patients with Non-arteritic Anterior Ischemic Optic Neuropathy.

BACKGROUND Non-arteritic anterior ischemic optic neuropathy (NAION) is the most common acute optic neuropathy in patients over the age of 50 and is the second most common cause of permanent optic nerve-related visual loss in adults after glaucoma. Although the precise cause of NAION remains elusive, the etiology of NAION is believed to be multifactorial. AIMS To evaluate the utility of neutrophil-to-lymphocyte ratio (NLR) as a simple and readily available prognostic factor for clinical disease activity in patients with NAION. STUDY DESIGN Case-control study. METHODS Forty-five patients with the diagnosis of NAION and 50 age- and sex-matched controls with/without any systemic or ocular diseases except cataract were retrospectively enrolled in the study. Demographic characteristics and laboratory findings including complete blood count of all patients and control subjects were obtained from the electronic medical record. The neutrophil and lymphocyte counts were recorded and the NLR was calculated. RESULTS White blood cell, neutrophil, NLR and platelet values of the NAION patients were significantly higher than those of the controls (p<0.001, p<0.001, p=0.004, p=0.037, respectively). Initial NLR values were negatively correlated with initial and the third month best corrected visual acuity levels in the study group. The optimum NLR cut-off point for NAION was 1.94. CONCLUSION NLR could be considered as a new inflammatory marker for assessment of the severity of inflammation in NAION patients with its quick, cheap, easily measurable property with routine complete blood count analysis.

Colocação segura de pinos percutâneos em fraturas subcapitais do quinto metacarpo: um estudo anatômico

OBJETIVOS: Durante o tratamento de fraturas fechadas do colo do metacarpo do dedo minimo (fraturas do boxeador) usando fixacao percutânea com fio K transversal e outros procedimentos, pode ocorrer lesao iatrogenica do ramo digital dorsal do dedo minimo (RDDDM) do ramo dorsal do nervo ulnar (RDNU). Neste estudo, visamos descrever a relacao do RDDDM do RDNU e os pontos de insercao na face lateral do quinto metacarpo durante fixacao percutânea com fio K transversal de fraturas subcapitais. METODOS: Foram realizadas dissecacoes e medicoes desse ramo depois de colocacao de pino transversal percutâneo na parte distal do quinto osso do metacarpo em dez maos de cadaveres fixadas em formalina. RESULTADOS: Os resultados desse estudo confirmam a grande proximidade da trajetoria do pino e desse ramo, e demonstram sua possivel lesao iatrogenica durante a fixacao do fio K no quinto metacarpo. CONCLUSOES: Para evitar a penetracao desse nervo e limitar as chances de lesao iatrogenica, e importante conhecer o trajeto desse nervo. Os autores descrevem os pontos de insercao anatomica e acreditam que com uso do conhecimento da anatomia das fraturas subcapitais do quinto metacarpo, elas podem ser tratadas sem risco de deficits sensoriais futuros.

The efficiency of bedside ultrasonography in patients with wrist injury and comparison with other radiological imaging methods: A prospective study☆☆☆

Study objective Our aim was to determine the efficiency of ultrasound (US) scanning in patients with wrist trauma admitted to the emergency department and to compare US diagnostic usage with other radiological imaging methods. Methods Patients who presented to the emergency department with wrist injury and who met the inclusion criteria and exclusion criteria were eligible. For all patients, US evaluation of the whole wrist was performed by an emergency physician before other radiological imaging methods (radiographies, computed tomography (CT) and magnetic resonance (MR) imaging). All of the patients included in the study underwent US, radiography, CT, and MR. Results During the study, 122 patients were admitted with a wrist injury. After filtering for the exclusion criteria, 80 patients were included in the study. The sensitivity of US scanning in detecting fractures was 95.31% (95% confidence interval [CI]: 87.1–98.39), the specificity was 93.75% (95% CI: 71.67–98.89), and the positive predictive value was 98.39% (95% CI: 91.72–99.85), and the negative predictive value was 83.33% (95% CI: 72.98–90.41). The sensitivity of US scanning in detecting tendon and ligamentous structural injury was 66.67% (95% CI: 41.71–84.82), the specificity was 100% (95% CI: 94.42–100), the positive predictive value was 100% (95% CI: 94.29–99.89), and the negative predictive was 92.86% (95% CI: 84.25–97.14). Conclusion US scanning is an effective method that can be applied in the emergency department to adult patients to diagnose distal forearm and carpal bones fractures. In soft tissue injuries, US and MR examinations produce similar results.