Yildiray Cete

Intravenous paracetamol or morphine for the treatment of renal colic: a randomized, placebo-controlled trial.

STUDY OBJECTIVE This randomized, placebo-controlled trial evaluates the analgesic efficacy and safety of intravenous single-dose paracetamol and morphine for the treatment of renal colic. METHODS We conducted a randomized, double-blind, placebo-controlled clinical trial comparing single intravenous doses of paracetamol (1 g), morphine (0.1 mg/kg), and placebo (normal saline solution) for patients presenting to the emergency department (ED) with suspected renal colic. Subjects with inadequate pain relief at 30 minutes received rescue fentanyl (0.75 microg/kg). We compared changes in pain intensity 30 minutes after treatment among the 3 arms, as well as the need for rescue medication and the presence of adverse effects. RESULTS Six hundred forty-five consecutive patients were screened for study and 165 were entered. Eight subjects were subsequently excluded from analysis because of protocol violations and 11 were excluded because of uncertain diagnoses, leaving 146 subjects available for analysis. The mean reduction in visual analogue scale pain intensity scores at 30 minutes was 43 mm for paracetamol (95% confidence interval [CI] 35 to 51 mm), 40 mm for morphine (95% CI 29 to 52 mm), and 27 mm for placebo (95% CI 19 to 34 mm). Statistically significant mean differences in pain intensity reductions compared with those for placebo were observed for paracetamol (16; 95% CI 5 to 27; P=.005) and morphine (14; 95% CI 0.4 to 27; P=.05); however, no difference was found between paracetamol and morphine (2; 95% CI -13 to 16; P=.74). Rescue analgesics at 30 minutes were required by 21 subjects (45%) receiving paracetamol, 24 subjects (49%) receiving morphine, and 34 subjects (67%) receiving placebo (P=.08). At least 1 adverse effect was experienced by 11 (24%) receiving paracetamol, 16 (33%) receiving morphine, and 8 (16%) in the placebo group (P=.14). There were no serious adverse events. CONCLUSION Intravenous paracetamol is an efficacious and safe treatment for ED patients with renal colic.

A randomized prospective placebo‐controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department

The objective of this randomized, placebo-controlled, double-blind study was to determine the effectiveness of intravenous magnesium sulphate and intravenous metoclopramide in the treatment of acute migraine attacks in the Emergency Department when compared with placebo. Adult patients who presented to the Emergency Department with a headache that met International Headache Society (IHS) criteria for acute migraine were infused with either 10 mg of intravenous metoclopramide, 2 g of intravenous magnesium sulphate or normal saline over 10 min. At 0, 15, and 30 min, patients were asked to rate their pain on a standard visual analogue scale. At 30 min, patients were asked in a standard manner about the need for rescue medication. Adverse affects were also recorded. Patients were followed up by telephone within 24 h for any recurrence after discharge. The primary endpoint of the study was the difference in pain relief between the groups at 30 min. Of the 120 patients who met IHS criteria, seven were excluded from the study due to insufficient data. The number of patients, gender, age and initial visual analogue scale (VAS) scores were comparable between groups. Each group experienced more than a 25-mm improvement in VAS score at 30 min. However, there was no significant difference detected in the mean changes in VAS scores for pain. The rescue medication requirement was higher in the placebo group. The recurrence rate in 24 h was similar between the groups. Although patients receiving placebo required rescue medication more than the others, metoclopramide and magnesium have an analgesic effect similar to placebo in migraine attacks.

Anxiety and Depressive Disorders in Patients Presenting with Chest Pain to the Emergency Department: A Comparison Between Cardiac and Non-Cardiac Origin

OBJECTIVE The aim of this study was to determine the prevalence of anxiety and depressive disorders in patients presenting with chest pain to the Emergency Department (ED) and determine if there is a relationship between these and cardiac vs. non-cardiac chest pain. METHODS This prospective cross-sectional study was performed in an urban tertiary care hospital between March and October 2005. Consecutive patients presenting with chest pain were enrolled in the study. The prevalence of anxiety and depressive disorders in patients with chest pain were determined by using the Hospital Anxiety and Depression Scale. RESULTS A total of 324 patients presented to the ED with chest pain during the study period. The mean age of the patients studied was 50.5 +/- 14 years; 67% were men and 33% were women. Of the 324 study patients, 194 (59.9%) patients were diagnosed with non-cardiac chest pain, 16 (4.9%) with stable angina, 84 (25.9%) with unstable angina, and 30 (9.3%) with acute myocardial infarction. No statistically significant differences were determined between patients with cardiac and non-cardiac chest pain both for anxiety (40% vs. 38.1%, respectively; p = 0.737) and depressive disorders (52.3% vs. 52.1%, respectively; p = 0.965). CONCLUSION Anxiety and depressive disorders are common among patients presenting with chest pain to the ED. However, the prevalence of anxiety and depressive disorders is similar between patients with chest pain of cardiac and non-cardiac origin. Chest pain should not be attributed to an anxiety or depressive disorder before organic etiologies are excluded.

Portal vein thrombosis related to Cassia angustifolia

Introduction. Cassia angustifolia (Senna), used as a laxative, is a plant from the Fabaceae family. It includes hydroxyanthracene glycosides, also known as Senna Sennoside. These glycosides stimulate the peristalsis of the colon and alter colonic absorption and secretion resulting in fluid accumulation and expulsion. In the literature, there are repots illustrating the hepatotoxic effects of Cassia angustifolia but there is no report of portal vein thrombosis caused by Cassia Angustifolia. Case Report. A 42-year-old woman was admitted to the emergency department with a five-day history of worsening epigastric pain, anorexia, episodic vomiting, and intermittent fever. She reported that she had boiled dried senna leaves she had bought from herbalists and drank approximately 200 mL daily for two years. Color Doppler screening found an echogen thrombus obliterating portal vein bifurcation and the right branch. The lumen was obstructed at this level and there was no blood flow through it. Treatment with thrombolytics was unsuccessful. Discussion. Severe hepatotoxicity senna use is unusual. The cause of senna-related hepatotoxicity is unclear but could be explained by the exposure of the liver to unusual amounts of toxic metabolites of anthraquinone glycosides. Conclusion. Chronic use of Cassia angustifolia may rarely be associated with portal vein thrombosis.

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.

Predictors of success in the conversion of new-onset atrial fibrillation using oral propafenone.

We have investigated the relationship of clinical variables to successful cardioversion of atrial fibrillation (AF) to sinus rhythm using an oral loading dose of propafenone. Fifty consecutive patients with recent onset (< 72 hours) atrial fibrillation of various aetiologies were included in the study cohort. All patients were given the study medication while in the emergency department and then monitored for 8 hours. All patients converting to sinus rhythm (39 out of 50, 78%) were discharged and re-evaluated at 24 hours and 30 days. We investigated the effect of clinical factors such as age, sex, presence of hypertension (HT), chronic obstructive lung disease (COPD), diabetes mellitus (DM), mitral stenosis (MS), congestive heart failure (CHF), coronary artery disease (CAD) and the duration of atrial fibrillation on conversion to sinus rhythm. Of these factors, univariate and multivariate analysis showed that only the duration of atrial fibrillation was a significant predictor of conversion (p = 0.002). Our results suggest that most patients with new-onset AF can be converted successfully to sinus rhythm with a low incidence of adverse reactions using oral propafenone in the emergency department.

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.

Ketamine is still safe without concurrent midazolam and atropine for pediatric procedures in the emergency department

Abstract Aim. Although the safety of ketamine for pediatric procedural sedation and analgesia is well established, use of concurrent benzodiazepines and atropine to diminish the adverse events is still controversial. We wanted to determine whether the adjunctive midazolam reduces the recovery agitation and to compare the incidence of adverse events with those reported in the literature. In particular, we wanted to assess whether adjunctive atropine can diminish salivation in order not to cause compromise of the airways. Methods. This prospective study was conducted in the Emergency Department of Akdeniz University Hospital. A detailed conscious sedation protocol was developed, and emergency physicians and nurses were educated regarding its contents. All patients who underwent procedural sedation and analgesia were evaluated by using a standardized conscious sedation form. Patients presenting with any trauma who were aged 15 or younger and requiring sedation and analgesia were evaluated. Results. During a ...

Artificial neural network in predicting craniocervical junction injury: an alternative approach to trauma patients.

Objective The aim of this study is to determine the efficiency of artificial intelligence in detecting craniocervical junction injuries by using an artificial neural network (ANN) that may be applicable in future studies of different traumatic injuries. Materials and methods Major head trauma patients with Glasgow Coma Scale ≤8 of all age groups who presented to the Emergency Department were included in the study. All patients underwent brain computerized tomography (CT), craniocervical junction CT, and cervical plain radiography. A feedforward with back propagation ANN and a stepwise forward logistic regression were performed to test the performances of all models. Results A total of 127 patients fulfilling inclusion criteria were included in the study. The mean age of the study patients was 31±17.7, 77.2% (n=98) of them were male, 13.4% of the patients (n=17) had craniocervical junction pathologies. About 64.7% (n=11) of these pathologies were detected only by CT; 23.5% (n=4) of them by both craniocervical CT and cervical plain radiography; and 11.8% (n=2) of them only by cervical plain radiography. A logistic regression model had a sensitivity of 11.8% and specificity of 99.1%. Positive predictive value was 66.7% and negative predictive value was 87.9%. Area under the curve for logistic regression model was 0.794 (P=0.000). ANN had a sensitivity of 82.4% and specificity of 100%. Positive predictive value was 100% and negative predictive value was 97.3%. Area under the curve for ANN model was 0.912 (P=0.000). Conclusion ANN as an artificial intelligence application seems appropriate for detecting and excluding craniocervical junction injury but it should not replace craniocervical junction CT. However, these findings should lead us to test the applicability of ANN on hard-to-diagnose trauma patients or in constructing clinical decision rules.

Utility of 360-degree assessment of residents in a Turkish academic emergency medicine residency program

Objectives This study was designed to test a 360-degree assessment tool for four of the emergency medicine resident competencies as outlined by the Council of Residency Directors in Emergency Medicine on patient care, communication skills, professionalism and system based practice in an academic Emergency Department. Material and methods Using the competency framework of the American Accreditation Council for Graduate Medical Education, a 57 item-containing assessment tool was created. Based on the different exposure aspects of the involved evaluator groups, the items were integrated into seven different evaluation forms. All sixteen of 16 residents and members from each evaluator group voluntarily participated in the study. Internal consistency scores, multilayer and multilevel Kappa values were measured. Evaluator group scores and resident ranks in competency areas were compared. All evaluators were asked to comment on the applicability and usefulness of the assessment tool in emergency medicine. Results Seven groups completed a total of 1088 forms to evaluate 16 residents. The reliability coefficient for the faculty members was 0.99 while it was 0.60 for the ancillary staff. The interrater Kappa values for faculty members, nurses and peer assessment were relevant with a value of greater than 70%. Discussion and conclusion Our results showed that the 360-degree assessment did meet expectations by the evaluator group and residents, and that this method was readily accepted in the setting of a Akdeniz University Emergency Medicine residency training program. However, only evaluations by faculty, nurses, self and peers were reliable to have any value. Doing a 360° evaluation is time and effort consuming and thus may not be an ideal tool for larger programs.