Argyrophilic nucleolar organizer regions as a promising biomarker for the detection of brain hypoxia levels caused by different doses of carbon monoxide poisoning.

OBJECTIVES: The purpose of the study is to investigate whether there is any relationship between mean argyrophilic nucleolar organizing regions (AgNOR) number and total AgNOR area/total nuclear area (TAA/TNA) ratio and the levels of brain hypoxia after exposure to different acute doses of carbon monoxide (CO) gas. METHODS: Each experimental group was exposed to CO gas (concentrations of 1,000, 3,000 and 5,000 ppm). Then, the rats were anesthetized, and blood samples were taken from the right jugular vein for carboxyhemoglobin levels detection. The rats were sacrificed on seventh day. AgNOR staining was applied to brain tissues. TAA/TNA and mean AgNOR number were detected for each nucleus. RESULTS: Significant differences were detected among all groups for TAA/TNA ratio, mean AgNOR number and carboxyhemoglobin level. According to a double comparison of groups, the differences between control and 1,000 ppm, control and 3,000 ppm, control and 5,000 ppm, and between 1,000 and 5,000 ppm were significant for TAA/TNA ratio. When mean AgNOR number was considered, significant differences were detected between control and 1,000 ppm, control and 3,000 ppm, control and 5,000 ppm, and between 1,000 and 3,000 ppm. CONCLUSION: AgNOR proteins may be used for early detection of the duration, intensity, and damage of brain injury caused by CO poisoning. Thus, effective treatment strategies can be developed for the prevention of hypoxic conditions.

OBJETIVOS: El objetivo del estudio es investigar si existe alguna relación entre el número medio de regiones organizadoras nucleolares argirófilas (AgNOR) y la proporción de área total de AgNOR/área nuclear total (TAA/TNA) y los niveles de ­hipoxia cerebral en la exposición a diferentes dosis agudas de gas monóxido de carbono (CO). MÉTODOS: Cada grupo experimental fue expuesto a gas CO (concentraciones de 1,000, 3,000 y 5,000 ppm). Luego las ratas fueron anestesiadas, se tomaron muestras de sangre de la vena yugular derecha para la detección de los niveles de carboxihemoglobina. Las ratas se sacrificaron el séptimo día. Se aplicó tinción con AgNOR en los tejidos cerebrales. Se detectaron el TAA/TNA y el número medio de AgNOR para cada núcleo. RESULTADOS: Se detectaron diferencias significativas entre todos los grupos para la relación TAA/TNA, el número medio de AgNOR y el nivel de carboxihemoglobina. Según la doble comparación de grupos, las diferencias entre control y 1,000 ppm, control y 3,000 ppm, control y 5,000 ppm y 1,000 y 5,000 ppm fueron significativas para la relación TAA/TNA. Cuando se consideró el número de AgNOR medio, se detectaron diferencias significativas entre control y 1,000ppm, control y 3,000ppm, control y 5,000 ppm y 1,000 y 3,000 ppm. CONCLUSIÓN: Las proteínas AgNOR pueden usarse para la detección temprana de la duración, intensidad y daño de la lesión cerebral causada por la intoxicación por CO. Por lo tanto, se pueden desarrollar estrategias de tratamiento efectivas para la prevención de condiciones hipóxicas.

Does determination of drug level in intoxicated patients offer an advantage in diagnosis, treatment, and reducing complications?

OBJECTIVE: To investigate the effect of determining the drug type and level on emergency management in patients presenting with intoxication, and to identify the factors behind associated mortality. METHODS: The retrospective, observational, cross-sectional and single centre study was conducted at a large tertiary care teaching hospital in Istanbul, Turkey, between September and November 2016 using the hospital's toxicology registry. Data was extracted for patients who had presented to the emergency department from January 1, 2011, to February 28, 2013, and were found to have toxic doses of single active ingredients in the plasma. The patients were evaluated in terms of age, gender, demographic characteristics, time from ingestion to presentation, reason for drug ingestion, type of drug ingested, time elapsed before the emergency service was called, treatment given, drug level, hospitalisation and mortality. Data was analysed using SPSS 11.5. RESULTS: Of the 224 patients, 145(64.8%) were women. The overall mean age was 30.8±15.4 years. Drug ingestion was more common in women aged 18-30 years (p<0.0001). Besides, 215(96%) patients had ingested drugs with the intent to commit suicide. The minimum education level of 163(72.8%) patients was high school. The most frequently ingested drug was paracetamol 90(40.2%). Overall mortality was 4(1.8%) and all of them were brought to the emergency department after a delay of more than five hours (p<0.0001). CONCLUSIONS: Drug type and quantity were found to be of great importance in taking timely decisions while attending to patients with intoxication in an emergency setting. Delay in presentation was associated with mortality..

Complete Blood Count Parameters for Prediction of non-ST Segment Elevation Myocardial Infarction.

OBJECTIVE: To evaluate whether the complete blood count parameters can be used to predict patients who will have positive troponin levels during emergency department observation, and to establish whether any single parameter or combination of parameters has sufficiently good diagnostic test criteria results to be recommended for use in daily clinical practice. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Department of Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey, from October 2015 to October 2016. METHODOLOGY: Study group had patients with positive troponin levels during observation in the emergency department. The control group had normal troponin levels. Their complete blood count parameters were compared individually and in combination. RESULTS: Total white blood cell count, neutrophil count, red cell distribution width, neutrophil-to-lymphocyte ratio, and some combinations of these parameters were found to be predictive of troponin elevation. The best one was combination of white blood cell count, red cell distribution width and neutrophil-to-lymphocyte ratio. CONCLUSION: Some of the complete blood count parameters may provide some clues when predicting troponin elevation in patients with chest pain. However, none of these parameters or no combination of them have sufficiently good diagnostic test criteria results to safely predict non-ST segment elevation myocardial infarction.

Short Term Unscheduled Revisits to Paediatric Emergency Department - A Six Year Data.

INTRODUCTION: Reviewing the reasons for return visits within 24 hours is a very important method of determining possible problems of emergency health care. Several causes stay behind unscheduled emergency return visits. Therefore, identifying these factors is crucial to set strategies in order to decrease the number of unnecessary visits. AIM: To define the characteristics of the patients returning to the Paediatric Emergency Department (PED) within 24 hours via determining rate, number and demographic data of patients. MATERIALS AND METHODS: The present study design involves retrospective data collection of patients who returned to PED within 24 hours after being discharged. Data was included over six year period and was collected from July 1, 2010 to June 30, 2016. The data was analysed with SPSS17.0 statistical package for windows. RESULTS: A total of 1994 patients returned to PED within 24 hours from July 1, 2010 to June 30, 2016. The most common group of revisiting patients were toddlers (aged 0-2-year old), n=1168 (58.5%), and the least number represented young adolescents (aged 15-18-year old), n=82 (4.1%). Number of patients returning to PED in 24 hours has significantly increased within years from approximately 90 patients to 720 (p<0.05). This increase in number was observed in all and each age group (from 0-18 years of age) without any exception. Seasonal distribution of the patients showed no significant difference (p>0.05) for each age, but again, presented definite negative correlation with age (the older is the patient group, the less is the number of revisits). The most common time for revisits was 17-24 hours after first discharge from PED, n=1277 (64.04%). CONCLUSION: The number of return visits is increasing over the years. The younger the patient is, more likely is the risk of unscheduled revisit to PED. Most of the patients returned to PED in 17 to 24 hours after discharge.

An unexpected presentation of sick sinus syndrome: Isolated ventricular asystole.

Sick sinus syndrome is a disorder of sinus node function characterized by various dysrhythmias such as sinus bradycardia or pause, paroxysmal regular or irregular atrial tachycardia, tachycardiabradycardia attacks or atrial fibrillation with slow ventricular response. Ventricular asystole with preserved atrial electrical activity is a rarely seen presenting rhythm in the ED and an extremely rare cause of syncope. A 67-year-old male having a syncope attack was admitted to the emergency department. His Glasgow coma scale score was 15 on admission. He became unconscious during his observation in the emergency department, and cardiopulmonary resuscitation was initiated because he was seen to be apneic; his arterial pulse was impalpable, and ventricular asystole with preserved atrial electrical activity was seen on the monitor. He regained consciousness and normal sinus rhythm was seen on the monitor after 2min of cardiopulmonary resuscitation. Then, an alternating rhythm with short periods of bradycardia and tachycardia suggesting sick sinus syndrome was developed. A dual-chamber pacemaker was placed, and he was discharged after 2days of in patient follow-up. His symptoms have not recurred after placement of the pacemaker device. When sudden changes in vital parameters and/or consciousness develop during observation of a patient with sick sinus syndrome, although it is not a common circumstance, accompanying high degree atrioventricular block and simultaneous ventricular asystole should be considered, and cardiopulmonary resuscitation should be initiated immediately because cardiopulmonary arrest is inevitable when ventricular asystole develops even if the atrial electrical activity is maintained.

Kounis Syndrome Induced by Oral Intake of Diclofenac Potassium.

An acute coronary syndrome (ACS) occurring during the course of an allergic reaction is called Kounis syndrome (KS). The second case of KS induced by diclofenac potassium (DP) is presented in this report. A 67-year-old man was brought to our emergency department with the possible diagnosis of anaphylactic shock by the ambulance staff. It emerged that widespread erythema and pruritus developed after taking DP. Then, he lost consciousness. Diffuse urticarial lesions were detected on physical examination at the emergency department. He complained of chest pain during his observation, and progressive ST segment elevation was seen in the inferior leads on serial electrocardiograms. His coronary angiography showed 100% occlusion of the right coronary artery.  Then, KS was diagnosed. The patient was discharged on the second day, and he was doing well on the control visit 2 weeks later. All allergic reactions may trigger an ACS so physicians should be aware of KS and always keep that unique clinical entity in mind to recognize it promptly and direct the therapy at suppressing the allergic reaction and improving the coronary circulation simultaneously when encountering a patient with symptoms suggesting an allergic reaction and a concomitant ACS.

An Unusual Cause of Asystole: Insertion of a Central Venous Catheter.

Central venous catheters are a commonly used medical device which may sometimes cause complications. We present first case who had an asystolic cardiac arrest during insertion of a central venous catheter, needed cardiopulmonary resuscitation (CPR), and was resuscitated successfully. A46-year lady presented to the emergency department due to mushroom poisoning. Acentral venous catheter was inserted through the internal jugular vein. However, the patient suddenly lost consciousness and asystole was seen on the monitor immediately after the insertion of the catheter. Cardiopulmonary resuscitation was started, and the catheter was withdrawn nearly 5 cm. Spontaneous circulation returned 2 minutes later. The patient was hospitalised, hemodialysis was performed, and she was discharged the next day. Emergency physicians should be prepared for dysrhythmias and asystole during insertion of a central venous catheter. If cardiac arrest develops, the catheter should be withdrawn a few centimeters while CPR continues.

The relationship between ischemic stroke and weather conditions in Duzce, Turkey.

BACKGROUND: Weather conditions are thought to increase the risk of stroke occurrence. But their mechanism has not yet been clarified. We investigated possible relationships between ischemic stroke and weather conditions including atmospheric pressure, temperature, relative humidity, and wind speed. METHODS: One hundred and twenty-eight patients with ischemic stroke who had been admitted to our hospital between January 1 and December 31, 2010 were enrolled in this study. We investigated the relationship between daily cases and weather conditions the same day or 1, 2, and 3 days before stroke. RESULTS: A negative correlation was found between maximum wind speed and daily cases 3 days before stroke. As the relationship between daily cases and changes of weather conditions in consecutive days was evaluated, a negative correlation was found between daily cases and change of atmospheric pressure in the last 24 hours. CONCLUSIONS: The maximum wind speed 3 days before stroke and change of atmospheric pressure in the last 24 hours were found to increase the cases of ischemic stroke. We recommend that individuals at risk of ischemic stroke should pay more attention to preventive measures, especially on days with low maximum wind speed, on subsequent 3 days, and on days with low atmospheric pressure in the last 24 hours.

Lumbar Morel-Lavallee lesion after trauma: a report of 2 cases.

Morel-Lavallee syndrome is a posttraumatic soft tissue injury in which the subcutaneous tissue is broken off from the underlying fascia, creating a cavity filled with hematoma and liquefied fat. It commonly occurs over the greater trochanter and, rarely, may also occur in the lumbal region.Morel-Lavallee syndrome can be often diagnosed late because of ommitted diagnosis in emergency services. The emergency physician and radiologist must keep this syndrome in mind because early diagnosis can enable conservative management, whereas delayed diagnosis may lead to surgical exploration. In this article,we present the clinical and radiologic features of 2 cases of lumbar Morel-Lavallee syndrome detected after trauma.

Acute intoxication cases admitted to the emergency department of a university hospital.

BACKGROUND: This study aimed to describe the clinical and socio-demographic aspects of acute poisoning in 2010 in Duzce City, Northwest Anatolian Region of Turkey. METHODS: Acute poisoning was due to the intentional ingestion of drugs in young and adult people (≥16), who were treated at the Emergency Service of Duzce University Medical Hospital, Turkey from January 1, 2010 to December 31, 2010. In this retrospective and descriptive study, 95 patients were diagnosed with intoxications and 30 of them intentionally ingested drugs to commit suicide. Records of the patients diagnosed with intoxication were obtained from the Clinical Archive of the hospital. Their diagnoses were established according to the International Statistical Classification of Diseases and Related Health Problems. Codes X60-X84 of this classification were used to classify self-infringed drug injuries and drug poisoning. RESULTS: In this series, 35 (36.8%) patients were male and 60 patients (63.2%) female. The male/female ratio was 1.0/1.7. The mean age of the patients was 33.1±14.2 years; 17 (17.9%) patients were below 20 years old and 9 (9.5%) were older than 50 years. Of these patients, 29 (30.5%) were single, 7 (7.4%) divorced or separated, and 59 (62.1%) married. Their mean time for admission to the emergency service after the incident was 208±180 (15-660) minutes. The mean time for admission to the emergency service for patients with food intoxication after the incident was 142±160 minutes, for those with drug intoxication 173±161 minutes, for those with carbon monoxide (CO) intoxication 315±209 minutes, and for those with undefined intoxication 289±166 minutes (P=0.005). Most of the intoxication cases occurred in winter (41.1%, 39 of 95 patients). Admissions to the emergency service were most common in December and April (21 and 16 of 95 patients, respectively). Sixty-five (68.4%) cases were involved in non-deliberate poisoning, whereas 30 (31.6%) were involved in deliberate poisoning. Twenty-six of the 95 patients with acute poisonings had mortality risk at admission, however only one died from CO intoxication in the emergency service (1.1%). Suicide attempts were more common in females than in males (21 of 30 patients, 70%, P<0.05). CONCLUSION: In Duzce City of Turkey, most intoxication cases occurred in winter, especially in December. They had non-deliberate poisoning, but deliberate poisoning in suicide attempts was more common in females than in males.

Does an energy drink cause a transient ischemic attack?

Energy drinks have become a popular beverage especially among young individuals. The growing literature sheds light on acute health problems associated with these products, although they have not yet been in existence long enough to build a solid, evidence-based appreciation of potential long-term effects. Perhaps the greatest concern about energy drinks is the amount of caffeine they contain, which generally far exceeds that in other beverages. A transient ischemic attack (TIA) has been traditionally defined as an episode of neurologic dysfunction caused by focal cerebral ischemia with complete recovery within 24 hours. We report a patient who had a TIA after intake of an energy drink without alcohol. To the best of our knowledge, the following case is the first report of TIA after intake of an energy drink.

Colloid cyst mimicking intracranial hemorrhage after head trauma.

Trauma patients consist vast majority of the patients who admit to emergency department, and most of them have a head trauma. A 58-year-old patient was taken to emergency department with head trauma, and a hyperdense lesion neighboring to third ventricle was detected. A diagnosis of colloid cyst was made in the patient who was being followed up for hemorrhage. In patients with head trauma, colloid cyst may easly be confused with intracranial hemorrhage due to hyperdensity. The aim of this report is to emphasize the importance of clinical thinking in the differential diagnosis of hyperdense lesion on computed tomography imaging of a patient with head injury.

Amatoxin and phallotoxin concentration in Amanita phalloides spores and tissues.

Most of the fatal cases of mushroom poisoning are caused by Amanita phalloides. The amount of toxin in mushroom varies according to climate and environmental conditions. The aim of this study is to measure α-, ß-, and γ-amanitin with phalloidin and phallacidin toxin concentrations. Six pieces of A. phalloides mushrooms were gathered from a wooded area of Düzce, Turkey, on November 23, 2011. The mushrooms were broken into pieces as spores, mycelium, pileus, gills, stipe, and volva. α-, ß-, and γ-Amanitin with phalloidin and phallacidin were analyzed using reversed-phase high-performance liquid chromatography. As a mobile phase, 50 mM ammonium acetate + acetonitrile (90 + 10, v/v) was used with a flow rate of 1 mL/min. C18 reverse phase column (150 × 4.6 mm; 5 µm particle) was used. The least amount of γ-amanitin toxins was found at the mycelium. The other toxins found to be in the least amount turned out to be the ones at the spores. The maximum amounts of amatoxins and phallotoxin were found at gills and pileus, respectively. In this study, the amount of toxin in the spores of A. phalloides was published for the first time, and this study is pioneering to deal with the amount of toxin in mushrooms grown in Turkey.