Ozcan Keskin

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.

Accidental Oral Poisoning Caused by Rdx (Cyclonite): A Report of 5 Cases

The explosive RDX (hexogen, cyclonite) is usually used for the production of C-4 explosive. The rare occurrence of accidental and intentional RDX intoxications has been reported during manufacturing process or in wartime. In this article, the authors report 5 cases of accidental oral RDX poisoning. On admission, observed signs and symptoms included repetitive generalized tonic-clonic convulsions, postictal coma, lethargy, confusion, hyperreflexia, postictal amnesia, nausea, vomiting, abdominal tenderness, sinusal tachycardia, dysrhythmia with frequent ventricular premature beats, generalized muscle spasms, and myoclonus. Leukocytosis, mild anemia, methemoglobinemia, elevated levels of blood glucose, serum aspartate transaminase, alanine transaminase, lactic dehydrogenase, creatine phosphokinase, amilase, hypokalemia, metabolic acidosis, proteinuria, glucosuria, and myoglobinuria were also noted. Plasma RDX concentrations were 268 to 969 ng/mL at 3 hours of ingestion. For management, supportive and symptomatic measures were taken. Whole-bowel irrigation might have been an effective therapeutic procedure due to probable slow gastrointestinal absorption of RDX. Three patients who developed severe metabolic acidosis underwent urgent hemodialysis. All patients were discharged 7 to 21 days after admission without any sequelae. Plasma RDX levels were strongly correlated with the clinical and laboratory manifestations. The available toxicological data on this rare accidental poisoning are reviewed in light of the literature.

Comparison of the effects of hypertonic saline and crystalloid infusions on haemodynamic parameters during haemorrhagic shock in dogs

Haemorrhagic shock, a leading cause of mortality, frequently accompanies cardiac interventions. The administration of small volumes of hypertonic saline solutions and crystalloid solutions may reduce the severity and duration of shock, and result in a decrease in adverse outcomes. Under general anaesthesia, hypotension was induced in 12 healthy dogs. After 30 min, dogs received either hypertonic saline solution or lactated Ringers solution for fluid resuscitation. In both groups, decreases in haemodynamic variables were observed during the shock period. Following resuscitation, increases in haemodynamic variables were observed. This increase lasted longer in dogs receiving hypertonic saline. In both groups, haematocrit and oxygen content values decreased after resuscitation and lactate levels increased. During resuscitation, lactate levels decreased. Sodium and osmolarity increased with resuscitation, then subsequently decreased. In conclusion, in a model of haemorrhagic shock, the administration of hypertonic saline solutions provides haemodynamic stability and tissue oxygenation more rapidly.

White blood cell count and C-reactive protein predict short-term prognosis in acute myocardial infarction

An elevated white blood cell (WBC) count and C-reactive protein (CRP) concentration are associated with acute myocardial infarction (AMI) and long-term mortality in patients with coronary artery disease. Their relationship with short-term prognosis following AMI is less clear, however. We investigated the relationship between WBC count and CRP concentration, obtained at the time of admission, and the development of subsequent ischaemic coronary events (SICE) within 30 days of AMI in 177 patients. After adjustment for confounding factors, CRP concentration was found to be a strong independent predictor for SICE within 30 days in patients with AMI. WBC count was not found to be an independent predictor, but there was a strong correlation between high WBC counts and the onset of SICE within 30 days in patients with AMI. We conclude that CRP concentration and WBC count could be used to predict the short-term prognosis of patients with AMI.

Effects of Fluvastatin Treatment on Insulin Sensitivity in Patients with Hyperlipidaemia

This study aimed to determine the effects of fluvastatin treatment on insulin sensitivity in patients with hyperlipidaemia. Non-obese, normoglycaemic, normotensive patients with hyperlipidaemia (n = 20) and a reference group of healthy subjects of similar age, sex, and body mass index (n = 20) were evaluated. Patients with other causes of peripheral insulin resistance were excluded. All participants underwent a diagnostic protocol, which included measurements of insulin sensitivity index and other metabolic parameters. Insulin sensitivity was assessed by Homeostasis Model Assessment (HOMA). Serum insulin levels were tested by radioimmunoassay. Patients were treated with fluvastatin 40 mg once daily for 3 months. Before fluvastatin treatment, fasting serum insulin levels were significantly raised in patients with hyperlipidaemia compared with subjects from the reference group (19.1 ± 13.4 versus 8.1 ± 3.4 μlU/ml). The fasting serum insulin levels and HOMA-estimated insulin sensitivity were correlated in the whole group. Correlation analysis showed a significant relationship between HOMA-estimated insulin resistance and plasma cholesterol and triglyceride concentrations. Patients with hyperlipidaemia had reduced insulin sensitivity that was reflected by high serum fasting insulin levels. Anti-hyperlipidaemic treatment with fluvastatin increases insulin sensitivity.

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.

Aortic elastic properties in young pregnant women

This study aimed to investigate the aortic elastic properties of young pregnant women by comparing them with those of age-matched healthy females. The study group consisted of 21 pregnant women at a mean age of 26 ± 1 years; 22 healthy women at a mean age of 25 ± 1 years constituted the control group. Doppler-color echocardiographic variables and serum estradiol (E2) levels were measured from both groups. The blood samples were obtained from the control group in the first week after menstrual bleeding. Diastolic and systolic blood pressure (DBP and SBP, respectively) were measured with a sphygmomanometer. Systolic and diastolic aortic diameters (AOS and AOD, respectively) were measured 3 cm proximal to the aortic valves. Aortic elastic properties were assessed according to the following formulas: 1, Aortic strain = (AOS − AOD)/AOD; 2, Aortic distensibility = 2 × (AOS − AOD)/(PP × AOD); 3, Aortic diameter change = AOS − AOD; 4, Aortic stiffness index = ln(SBP/DBP)/(AOS − AOD)/AOD. The results were expressed as mean ± standard deviation and compared by t-test between groups. P < 0.05 was considered as statistically significant. All women in the study group were in their first pregnancy and second trimester. The height and weight were 160 ± 5 vs 164 ± 6 cm and 60 ± 9 vs 54 ± 3 kg in the study vs control groups, respectively (P < 0.05). The AOD was 26 ± 3 vs 26 ± 4 mm and AOS 29 ± 3 vs 28 ± 4 mm. Pulse pressure was 43 ± 3 vs 45 ± 8 mmHg in the study vs control groups, respectively (P > 0.05). The serum E2 level was significantly higher in pregnant women (21 300 ± 2 300 pg/ml). Derived aortic elastic properties in pregnant women were also increased significantly (P < 0.0005). The indexes of aortic elastic properties are altered and aortic stiffness is decreased among young pregnant women. This may be due to the adaptation mechanisms including high estradiol levels detected in pregnancy.

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.

The Effects of Lipid-Lowering Therapy on Graft Patency in Coronary Bypass Surgery Patients

BACKGROUND Our aim was to investigate the effects of lipid-lowering treatment (LLT) on graft patency in coronary artery bypass grafting (CABG) patients. METHODS A total of 209 CABG patients (95 men, 45%) with a total cholesterol level above 200 mg/dL and a low-density lipoprotein level above 100 mg/dL were included. Patients were divided into 2 groups on the basis of administration of LLT after CABG: group 1 received LLT after the operation (those patients undergoing operations after 1998, n = 102, 49% male) and group 2 did not receive LLT after the operation (those patients undergoing operations between 1992 and 1998, n = 107, 42% male). Median duration of follow-up was 5.2 years. Follow-up angiography could be obtained in 108 (52%) patients (56 in group 1, 52 in group 2). RESULTS There was a 42% reduction in ischemic events and deaths in group 1, and 60% of these patients had a symptom-free or event-free period for 6 years. The 5-year graft patency for left internal mammary artery-to-left anterior descending artery grafts in group 1 was 95%, and the corresponding figure was 90% in group 2. Right coronary artery-to-saphenous vein graft patency was 66% for group 1 and 30% for group 2. Circumflex artery-to-saphenous vein patency rate was 59% for group 1 and 53% for group 2. A higher graft patency was found in group 1 as a whole. CONCLUSION Results of this retrospective study support the fact that LLT provides a higher graft patency for CABG 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