Orhan Oyar

An unusual cause of death: spontaneous urinary bladder perforation

Spontaneous urinary bladder perforation is a rare and life-threatening condition similar to traumatic and iatrogenic perforation. The connection with the underlying bladder damage due to previous radiotherapy, inflammation, malignancy, obstruction, or other causes can be found in almost all cases. The symptoms are often nonspecific, and misdiagnosis is common. Here, we present a case of spontaneous urinary bladder perforation due to bladder necrosis in a diabetic woman. She presented to the emergency department with abdominal pain. Exploratory laparotomy was performed by surgeons and revealed necrosis of the anterior and lateral walls of the urinary bladder. Microscopic examination revealed necrotic changes throughout the bladder wall. Ghost-like cellular outlines were compatible with coagulative necrosis. Clusters of bacteria were also present in some necrobiotic tissues. Malignant cells were not present. It appears probable that the infection was due to local interference with the blood supply (arterial, capillary, or venous) combined with the systemic metabolic upset that led to the bladder condition. In our case, we observed partial necrosis of the bladder rather than distortion of the entire blood supply to the bladder as consequences of the microvascular effects of diabetes. Urinary bladder perforation must be considered in the differential diagnosis of patients presenting with free fluid in the abdomen/peritonitis, decreased urine output, and hematuria, and in whom increased levels of urea/creatinine are detected in serum and/ or peritoneal fluid aspirate.

Posterior semicircular canal dehiscence in asymptomatic ears

Abstract Conclusions: This study revealed that, in the adult population, the final diagnosis of this entity can only be made by combining imaging with clinical tests. Objective: We developed the largest temporal bone multislice computed tomography (CT) scan study so far by including 410 cases to investigate the prevalence of posterior semicircular canal dehiscence in patients with symptoms unrelated to the inner ear. Methods: A prospective study was performed in 410 consecutive adult individuals who underwent temporal bone multislice CT scan examinations. Results: The prevalence of posterior semicircular canal dehiscence was determined to be 1.2%. No superior or lateral semicircular canal defect was detected in these five patients. All cases with posterior semicircular canal defect were male. In two cases the canal was located unilaterally, while in three cases the defects were present bilaterally. Otological examination and audiovestibular tests revealed no abnormal findings in any of the individuals.

The missed extremity fractures in emergency department

BACKGROUND The purpose of the study was to analyze the accuracy of interpretation of extremity traumas by emergency physicians (EP) to determine the most difficult areas for interpretation in comparison to official radiology reports of direct X-ray. METHODS Radiologist reports and EP reports of direct X-rays from isolated extremity trauma patients were retrospectively compared from 01.05.2011 to 31.05.2011. A total of 181 fractures in 608 cases were confirmed. RESULTS The locations of the misinterpreted fractures were ankle and foot (51.4%), wrist and hand (32.4%), elbow and forearm (5.4%), shoulder and upper arm (5.4%), hip and thigh (2.7%), and knee and leg (2.7%). The diagnostic accuracy of the EPs and radiologists were not significantly different (kappa=0.856, p=0.001). CONCLUSION Knowledge about the types of fractures that are most commonly missed facilitates a specifically directed educational effort.

Lung ultrasound by emergency nursing as an aid for rapid triage of dyspneic patients: a pilot study

Dyspnea is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity (Zimmermann et al., 1994). Patients suffering from dyspnea or shortness of breath commonly seek care in the emergency department (ED) (West, 1985). Anticipating the dangerous diagnoses that cause this complaint and preventing the associated morbidity and mortality from such conditions has been the primary focus of emergency medicine. Differential diagnosis of dyspnea is an important issue for emergency physicians (EPs) to guide the appropriate treatment of patients. Treatment decisions and evaluation of the dyspneic patients must be conducted at the same time. The indiscriminate use of bronchodilatator treatment in patients who do not have a history of chronic obstructive pulmonary disease (COPD) is associated with a greater need for ‘aggressive interventions’, including mechanical ventilation and the need for intravenous vasodilators (Singer et al., 2008). Bedside lung ultrasonography (BLUS) has become an increasingly valuable diagnostic tool in various pulmonary and cardiac diseases, especially in emergency conditions (Copetti et al., 2008; Kirkpatrick et al., 2004; Lichtenstein and Meziere, 2008; Unluer and Kara, 2013; Unluer et al., 2012, 2013a, 2013b). There is a growing body of cluded in the diagnostic workup of such patients. Use of ultrasonography (USG) in pre-hospital care and in EDs could potentially provide critical information about dyspneic patients and could thereby optimize the early treatment of patients with dyspnea. The portability, accuracy, and non-invasiveness of the USG give it potential as an effective imaging modality to provide diagnostic information in an emergency setting. In addition, the traditional physical examination often has significant limitations in the diagnosis of cardiopulmonary pathology (Johnson and Carpenter, 1986; Liang and Schnittger, 2003; Mangione and Nieman, 1997). Our objective was to evaluate the accuracy of emergency nurse (EN)-performed BLUS for diagnosing dyspnea as having a cardiac or a non-cardiac cause in patients admitted to the ED.

CT and MRI findings of developmental abnormalities and ectopia varieties of the thyroid gland.

Ectopic thyroid tissue may be observed anywhere from the tongue base to the lower neck. It is rarely seen in the mediastinum and abdominal cavity. Computed tomography and magnetic resonance imaging are very sensitive for detection and localization of ectopic thyroid tissue. This pictorial essay presents the radiological characteristics of developmental abnormalities and ectopia varieties of the thyroid gland.

Bedside ultrasonography by emergency physicians for anterior talofibular ligament injury

Objective: Our objective was to study the accuracy of emergency physician (EP) performed bedside ultrasonography (BUS) in patients with suspected anterior talofibular ligament (ATFL) injury. Materials and Methods: After a 6-h training program, from January to December 2011, an EP used BUS to prospectively evaluate patients presenting to the emergency department (ED) with suspected ATFL injury. Then, patients underwent ankle X-ray and Magnetic Resonance (MR) imaging. Outcome was determined by official radiology reports of the MR imaging. BUS and MR imaging results were compared using Chi-square testing. Results: Of the 65 enrolled patients, 30 patients were BUS positive. Of these, MR imaging results agreed with the BUS findings in 30 patients. In 35 cases, BUS was negative, and 33 of these were corroborated by MR imaging. The sensitivity, specificity, positive predictive value, negative predictive value, and negative likelihood ratio for BUS were 93.8%, 100%, 100%, 94.3%, and 0.06%, respectively. The diagnostic accuracy of BUS was not statistically different from MR imaging (K = 0.938, P = 0.001). Conclusion: BUS for the diagnosis of ATFL injury is another application of BUS in the ED. EPs can diagnose ATFL injury using BUS with a high degree of accuracy.

Respiratory epithelial adenomatoid hamartoma: a rare nasopharyngeal mass lesion.

Respiratory epithelial adenomatoid hamartoma (REAH) is a rare and nonneoplastic lesion of upper respiratory tract characterized by an abnormal mixture of tissues which are peculiar to the involved anatomic region. The most common site reported is nasal cavity and its nasopharyngeal origin is extremely rare. The lesion can be confused with a variety of benign and malignant entities. In this article, we report a 22-year-old female case of REAH of posterior nasopharyngeal wall. The clinical and radiological features of the lesion are discussed in the light of literature data.

An unusual Hodgkin's lymphoma case presenting with upper extremity multiple masses.

Almost always, Hodgkins lymphoma presents with lymph node involvement. Primary extranodal lymphoma is rare and mostly has a type of non-Hodgkins lymphoma. We present an unusual presentation of a Hodgkins lymphoma in a 33-year-old man. There were numerous soft tissue masses localized in the subcutaneous tissue of the left arm along the neurovascular bundle and the ipsilateral axillary region. We found only one Hodgkins lymphoma case that presented as an upper extremity mass reported in the literature. In cases where a great number of successively lined up soft tissue masses are detected on the extremity, lymphoma takes place among the differential diagnoses.

Value of Apparent Diffusion Coefficient Values in Differentiating Malignant and Benign Breast Lesions.

BACKGROUND Magnetic resonance imaging (MRI) has become a diagnostic and problem solving method for the breast examinations in addition to conventional breast examination methods. Diffusion-weighted imaging (DWI) adds valuable information to conventional MRI. AIMS Our aim was to show the impact of apparent diffusion coefficient (ADC) values acquired with DWI to differentiate benign and malignant breast lesions. STUDY DESIGN Diagnostic accuracy study. METHODS Forty-six women with 58 breast masses (35 malignant, 23 benign) were examined on a 1.5 T clinical MRI scanner. The morphologic characteristics of the lesions on conventional MRI sequences and contrast uptake pattern were assessed. ADC values of both lesions and normal breast parenchyma were measured. The ADC values obtained were statistically compared with the histopathologic results using Paired Samples t-Test. RESULTS Multiple lesions were detected in 12 (26%) of the patients, while only one lesion was detected in 34 (74%). Overall, 35 lesions out of 58 were histopathologically proven to be malignant. In the dynamic contrast-enhanced series, 5 of the malignant lesions were type 1, while 8 benign lesions revealed either type 2 or 3 time signal intensity curves (85% sensitivity, 56% spesifity). Mean ADC values were significantly different in malignant vs. benign lesions. (1.04±0.29×10(-3) cm(2)/sec vs. 1.61±0.50×10(-3) cm(2)/sec for the malignant and benign lesions, respectively, p=0.03). A cut-off value of 1.30×10(-3) mm(2)/sec for ADC detected with receiver operating characteristic analysis yielded 89.1% sensitivity and 100% specificity for the differentiation between benign and malignant lesions. CONCLUSION ADC values improve the diagnostic accuracy of solid breast lesions when evaluated with the conventional MRI sequences. Therefore, DWI should be incorporated to routine breast MRI protocol.

Stethoscope versus point-of-care ultrasound in the differential diagnosis of dyspnea: a randomized trial.

We aimed to determine the accuracies of point-of-care ultrasound (PoCUS) and stethoscopes as part of the physical examinations of patients with dyspnea. Three emergency medicine specialists in each of two groups of ultrasound and stethoscope performers underwent didactic and hands-on training on PoCUS and stethoscope usage. All the patients enrolled were randomized to one of two predetermined PoCUS or stethoscope groups. The diagnostic performance of ultrasonography was higher than that of the stethoscope in the diagnoses of heart failure (90 vs. 86%, 1.00 vs. 0.89, and 5.00 vs. 4.92, respectively) and pneumonia (90 vs. 86.7%, 0.75 vs. 0.73, and 16.50 vs. 13.82, respectively). No significant differences were observed in the utility parameters of these modalities in these diagnoses. Although some authors argue that it is time to abandon the ‘archaic tools’ of past centuries, we believe that it is too early to discontinue the use of the stethoscope.