Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Renal Colic in the ED: A Randomized, Double-Blind, Placebo-Controlled Trial.

STUDY OBJECTIVE: To determine the analgesic efficacy of TENS treatment in patients with renal colic in the emergency department (ED). METHODS: This double-blind, randomized controlled trial was conducted in a tertiary care ED. Patients with a definitive diagnosis of renal colic were assigned (1:1) as randomized to receive the real TENS with frequency 100 Hz, pulse width 200 microseconds, voltage 2 mA, or placebo with sham TENS. Pain intensity was measured using visual analog scales (VAS) at baseline, after 15 and 30th minutes. RESULTS: A total of 100 patients were included in the final analysis: 50 patients treated with real TENS and 50 patients treated with sham TENS. VAS scores in both groups were similar at baseline. The mean reduction in VAS score at 15 min was 33.3 ± 17.6 (95% Confidence interval (CI): 28.3 to 38.3) for the real TENS group and 14.9 ± 11.6 (95% CI 11.6 to 18.2) for the sham TENS group (mean difference: 18.4 (95% CI: 12.5 to 24.4, P < 0.0001). The mean reduction in VAS score at 30 min was 63.7 ± 21.1 (95% CI: 57.7 to 69.7) for the real TENS group and 14.9 ± 16.2 (95% CI: 19.5 to 10.3) for the sham TENS group (mean difference: 48.8, 95% CI: 41.4 to 56.3, P < 0.0001). Four patients (8%) in the real TENS group and 24 patients (48%) in the sham TENS group required the rescue medication after 30th minutes. CONCLUSIONS: TENS is effective for acute pain treatment in renal colic patients in the ED. TENS therapy could be a treatment option for renal colic.

Predictive and prognostic role of mean platelet volume in patients with first-ever acute ischemic stroke.

OBJECTIVE: To investigate any possible effects of mean platelet volume (MPV) on short-term stroke prognosis and functional outcome in patients with first-ever acute ischemic stroke (FEAIS). METHODS: This retrospective cross-sectional study included 798 FEAIS patients admitted to the emergency department of a tertiary care hospital in Adiyaman, Turkey between January 2013 and June 2015. The data were evaluated according to whether alive or dead, MPV levels, modified Rankin scale (MRS) scores, National Institutes of Health Stroke Scale (NIHSS) scores. The patients were divided into 3 groups based on MPV level as 4.4-7.4 fL, 7.5-10.4 fL, higher than 10.4 fL. RESULTS: A total of 250 patients with FEAIS were included in the study. In both those who survived and those who died, the area under the curve related to hospitalization days, time interval of venipuncture (TIV), and MPV measurements was not statistically significant (p>0.05). The 3 MPV groups showed no significant differences in terms of MRS score, median NIHSS score, hospitalization, and TIV. In subgroups based on MRS scores, there were no statistically significant differences according to median latency (p=0.087), median hospitalization (p=0.394), TIV (p=0.201), and MPV levels (p=0.847). Furthermore, there were no differences in MPV levels between the MRS based groups (p=0.527). CONCLUSION: The results showed that MPV was not a significantly associated and reliable marker for the prediction of prognosis or functional outcome of FEAIS attack.

An Analysis of WhatsApp Usage for Communication Between Consulting and Emergency Physicians.

The aim of this study was to evaluate WhatsApp messenger usage for communication between consulting and emergency physicians. A retrospective, observational study was conducted in the emergency department (ED) of a tertiary care university hospital between January 2014 and June 2014. A total of 614 consultations requested by using the WhatsApp application were evaluated, and 519 eligible consultations were included in the study. The WhatsApp messages that were transferred to consultant physicians consisted of 510 (98.3%) photographic images, 517 (99.6%) text messages, 59 (11.3%) videos, and 10 (1.9%) voice messages. Consultation was most frequently requested from the orthopedics clinic (n = 160, 30.8%). The majority of requested consultations were terminated only by evaluation via WhatsApp messages. (n = 311, 59.9%). Most of the consulting physicians were outside of the hospital or were mobile at the time of the consultation (n = 292, 56.3%). The outside consultation request rate was significantly higher for night shifts than for day shifts (p = .004), and the majority of outside consultation request were concluded by only WhatsApp application (p < .001). WhatsApp is useful a communication tool between physicians, especially for ED consultants who are outside the hospital, because of the ability to transfer large amounts of clinical and radiological data during a short period of time.

The role of thyroid and parathyroid metabolism disorders in the etiology of sudden onset dizziness.

BACKGROUND: The aim of this study was to evaluate thyroid and parathyroid functions as a cause of sudden onset dizziness (SOD) in patients who were admitted to the Emergency Department (ED). MATERIAL AND METHODS: This study was conducted prospectively in 100 patients with sudden onset dizziness (SOD) admitted to the ED. Neurologic, ear-nose-throat, detailed neck examinations, serum calcium levels, thyroid function tests (TFT), and parathormone and thyroid ultrasounds were performed on all patients in our study. RESULTS: Thirty-seven (37%) females and 63 (63%) males were included in this study. Four patients (4%) had elevated serum TSH levels, 6 (6%) had decreased serum fT3 levels, 10 (10%) had decreased serum fT4 levels, 2 (2%) had elevated serum fT4 levels, and 2 (2%) had elevated serum parathormone levels. In 4 (4%) patients, the serum calcium levels were lower than normal, and 2 (50%) of these patients had symptomatic hypocalcemia. Thyroid ultrasound examinations showed multinodular goiter in 28 (28%) patients, 2 (2%) patients had thyroiditis, 12 (12%) had an isolated unilateral nodule, and 58 (58%) had normal thyroid tissues. CONCLUSIONS: We suggest that detailed neck examination, TFT, and thyroid ultrasound examination should be considered in the diagnostic algorithms of SOD to provide rapid diagnosis and proper treatment for a patient in the ED.

Bilateral thalamic infarct as a diagnosed conversion disorder.

Bilateral thalamic infarcts are an uncommon type of cerebral infarct. Bilateral paramedian thalamic infarctions may lead to a severe impairment of consciousness. The sudden onset of a lethargy or comatose state, in the absence of motor deficits, easily evokes the idea of a subarachnoid hemorrhage. Other patients present with behavior changes, disorientation in space and time, memory loss, or thought disorders. We believe that bilateral thalamic infarction is often missed in emergency department (ED) in relatively young patients, especially when magnetic resonance imaging is not performed. In these cases, the patient can be discharged with various psychiatric diagnoses. We suggest that bilateral thalamic infarct should be considered in patients in the ED with new diagnoses of conversion disorder.

Escalator-related injuries in one of the deepest subway stations in Europe.

BACKGROUND: Escalator-related injuries (ERI) have emerged as a new injury type due to the frequent use of escalators in Metro stations. OBJECTIVES: Investigate ERI in the stations on the Marmaray metro line. DESIGN: Retrospective, observational study. SETTING: Patients admitted to the emergency department of a training and research hospital. PATIENTS AND METHODS: All patients with ERI were included in the study. We analyzed demographic characteristics, injury type and anatomical location of injury, Glasgow coma score, and body mass index (BMI). Patients were grouped by BMI: underweight (BMI less than 18.5 kg/m2), normal weight (BMI=18.5-24.9 kg/m2), overweight (BMI=25-29.9 kg/ m2) and obese (BMI greater than or equal 30kg/m2). MAIN OUTCOME MEASURES: Injury characteristics and BMI values of patients with ERI. SAMPLE SIZE: 82 patients. RESULTS: The mean age was 45.1 (15.5) years (range:14-77 years). Forty-two were women (52.5%). The mean BMI was 26.7 (2.2) kg/m2 (range: 22.1-33.3 kg/m2)]. Most of the patients who were injured due to escalators were older than 50 years (n=39, 47.6%) and 77.5% (n=62) of all patients were overweight. There was a significant relationship between increased BMI and serious ERI (P=.010, OR: 1.85, 95% C.I: 1.132.65). The most frequent mechanism of injuries was a fall (97.6%). The majority of injuries were the head (42%) and extremity injuries (33%). The major type of ERI was soft tissue injuries (41.3%), followed by lacerations (20.7%), closed head injuries (18.5%), fractures (15.2%) and serious injuries (4.4%). Serious injuries were more prevalent in patients aged older than 50 years (P less than .05), and in overweight and obese individuals (P less than .001) CONCLUSION: Novel protective measures against ERI should be developed for crowded subway stations. LIMITATIONS: The small sample size and retrospective nature. CONFLICT OF INTEREST: None.

Characteristics of the Traumatic Forensic Cases Admitted To Emergency Department and Errors in the Forensic Report Writing.

OBJECTIVE: To identify errors in forensic reports and to describe the characteristics of traumatic medico-legal cases presenting to the emergency department (ED) at a tertiary care hospital. METHODS: This study is a retrospective cross-sectional study. The study includes cases resulting in a forensic report among all traumatic patients presenting to the ED of Adiyaman University Training and Research Hospital, Adiyaman, Turkey during a 1-year period. We recorded the demographic characteristics of all the cases, time of presentation to the ED, traumatic characteristics of medico-legal cases, forms of suicide attempt, suspected poisonous substance exposure, the result of follow-up and the type of forensic report. RESULTS: A total of 4300 traumatic medico-legal cases were included in the study and 72% of these cases were male. Traumatic medico-legal cases occurred at the greatest frequency in July (10.1%) and 28.9% of all cases occurred in summer. The most frequent causes of traumatic medico-legal cases in the ED were traffic accidents (43.4%), violent crime (30.5%), and suicide attempt (7.2%). The most common method of attempted suicide was drug intake (86.4%). 12.3% of traumatic medico-legal cases were hospitalized and 24.2% of those hospitalized were admitted to the orthopedics service. The most common error in forensic reports was the incomplete recording of the patient's "cooperation" status (82.7%). Additionally, external traumatic lesions were not defined in 62.4% of forensic reports. CONCLUSION: The majority of traumatic medico-legal cases were male age 18-44 years, the most common source of trauma was traffic accidents and in the summer months. When writing a forensic report, emergency physicians made mistakes in noting physical examination findings and identifying external traumatic lesions. Physicians should make sure that the traumatic medico-legal patients they treat have adequate documentation for reference during legal proceedings. The legal duties and responsibilities of physicians should be emphasized with in-service training.

Comparison of secure messaging application (WhatsApp) and standard telephone usage for consultations on Length of Stay in the ED. A prospective randomized controlled study.

OBJECTIVE: Consultation, the process of an Emergency Physician seeking an opinion from other specialties, occurs frequently in the Emergency Department (ED). The aim of this study was to determine the effect of secure messaging application (WhatsApp) usage for medical consultations on Emergency Department Length of Stay (ED LOS) and consult time. METHODS: We conducted a prospective, randomized controlled trial in the ED using allocation concealment over three months. Consultations requested in the ED were allocated into two groups: consultations requested via the secure messaging application and consultations requested by telephone as verbal. RESULTS: A total of 439 consultations requested in the ED were assessed for eligibility and 345 were included in the final analysis: 173 consultations were conducted using secure messaging application and 172 consultations were conducted using standard telephone communications. The median ED LOS was 240 minutes (IQR:230-270, 95% CI:240 to 255.2) for patients in the secure messaging application group and 277 minutes (IQR:270-287.8, 95% CI:277 to 279) for patients in the telephone group. The median total ED LOS was significantly lower among consults conducted using Secure messaging application relative to consults conducted by telephone (median dif: -30, 95%CI:-37to-25, p<0.0001). The median consult time was 158 minutes (IQR:133 to 177.25, 95% CI:150 to 169) for patients in the Secure messaging application group and 170 minutes (IQR:165 to 188.5, 95% CI:170-171) for patients in the Telephone group (median dif: -12, 95%CI:-19 to-7,p<0.0001). Consultations completed without ED arrival was 61.8% in the secure messaging group and 33.1% in the Telephone group (dif: 28.7, 95% CI:48.3 to 66, p<0.001). CONCLUSIONS: Use of secure messaging application for consultations in the ED reduces the total ED LOS and consultation time. Consultation with secure messaging application eliminated more than half of in-person ED consultation visits.

Emergency department visits of Syrian refugees and the cost of their healthcare.

The aim of this study was to evaluate the demographic and clinical characteristics of Emergency Department (ED) visits made by Syrian refugees and to assess the cost of their healthcare. This retrospective study was conducted in adult Syrians who visited the ED of Adiyaman University Training and Research Hospital, Adiyaman Province, Turkey, between 01 January and 31 December 2015. We evaluated 10,529 Syrian refugees who visited the ED, of whom 9,842 were included in the study. The number of ED visits significantly increased in 2015 compared with 2010; the increase in the proportion of total ED visits was 8% (n = 11,275, dif: 8%, CI 95%: 7.9- 8.2, p < 0.001). Of this 8%, 6.5% were visits made by Syria refugees and the remaining 1.5% accounted for the visits made by other individuals. Upper respiratory tract infections (URTI) were the diseases most frequently presented (n = 4,656; 47.3%), and 68.5% of ED visits were inappropriate (n = 6,749). The median ED length of stay (LOS) of the Syrian refugees was significantly longer than that of the other individuals visiting the ED (p < 0.001). The total cost of the healthcare of the Syrian refugees who visited the ED was calculated as US$ 773,374.63. This study showed that Syrian refugees have increased the proportion of ED visits and the financial healthcare burden. The majority of ED visits made by Syrian refugees were inappropriate. In addition, their ED LOS was longer than that of other individuals making ED visits.

Management of Forgotten Ureteral Stents: Relationship Between Indwelling Time and Required Treatment Approaches.

BACKGROUND: Double-J stents are widely used in urology practice, and removal of these stents can sometimes be forgotten. AIMS: To investigate whether indwelling time of double-J stent can predict which treatment modality is required for removal of the stent from the body. STUDY DESIGN: A multicentre, retrospective observational study. METHODS: The data of 57 patients who were treated for forgotten ureteral stents between January 2007 and December 2014 were evaluated retrospectively. Patients were classified into four groups according to indwelling time of the stents: 6-12 months, 13-24 months, 25-36 months, and <36 months. Encrustation and associated stone burden of the stents were evaluated with non-contrast stone protocol computerised tomography. RESULTS: Patients were classified according to their duration of the stent indwelling time. Simple cystoscopic stent retrieval was performed in 71.4% of patients in the 6-12 months group, 44% of patients in the 13-24 months group, 6.2% of patients in the 25-36 months group, and 11.1% of patients in the <36 months group. A percutaneous or open surgery was required in no patients with an indwelling time of double-J stent shorter than 30 months. CONCLUSION: Transurethral and/or percutaneous combined endo-urological approaches are usually sufficient for the removal of forgotten double-J stents. Transurethral procedures are sufficient for the treatment of patients with double-J stent indwelling times less than 30 months.

Influences of "do-not-resuscitate order" prohibition on CPR outcomes.

OBJECTIVES: The aim of the study is to determine factors affecting the return of spontaneous circulation (ROSC) ratios, neurological outcomes at discharge, the ratio of living patients discharged from the hospital and due to Do not attempt resuscitation (DNAR) prohibition. MATERIAL AND METHODS: This is a retrospective observational study conducted on patients of cardiopulmonary resuscitation (CPR) performed in emergency department (ED) and intensive care units between February 2010 and February 2012. RESULTS: A total of 469 patients were evaluated, and 266 eligible patients who did not have DNAR orders were included in the study. Overall, 45.1% of the adult in-hospital cardiac arrest victims returned to spontaneous circulation, and 5.3% survived to hospital discharge. Of the patients who were discharged alive from the hospital, 33.3% were discharged in poor neurologic conditions of Cerebral Performance Category (CPC) score 3 or 4. The ROSC ratio was reduced for the patients with malignancies compared to the patients with other preexisting conditions (OR: 12.783; 95% CI 2.967-55.072; p = 0.000). None of the patients with malignancies were discharged alive from the hospital. Only one patient with end-stage disease was discharged alive from hospital, and this patient's CPC score was 4. DISCUSSION AND CONCLUSION: CPR has not increased the ROSC and alive discharge rates in patients with malignancy and end-state disease. DNAR order prohibition have been increased the futile CPR attempts. DNAR should be accepted as a human right that represents an honorable death option and whether a DNAR is order demanded should be specifically discussed with patients with malignancies and end-stage disease presenting to ED.

Pre-operative stool analysis for intestinal parasites and fecal occult blood in patients with acute appendicitis.

BACKGROUND: Etiology of acute appendicitis (AA) rarely involves parasitic infections of gastrointestinal (GI) tract. Preoperative diagnosis of parasitic infections in appendix remains difficult, although parasites can sometimes be observed inside the lumen during histopathological examination. The aim of the present study was to prospectively screen prevalence and species of intestinal parasites and adherence of fecal occult blood (FOB) in patients admitted to emergency department (ED) with clinical symptoms of AA who underwent appendectomy. METHODS: Demographic and stool analysis data of a total of 136 patients (≥13 years old) who underwent appendectomy between July 2009 and December 2014 were prospectively assessed, and histopathological data of all patients were retrospectively assessed. RESULTS: In histopathological examination after appendectomy, of 136 patients, 75.5% (n=103) had AA, 11.1% (n=15) had perforated appendicitis (PA), and 13.2% (n=18) had a negative appendicitis (normal appendix, NA). Pre-operative stool analysis revealed that 25% (n=34) had intestinal parasites and 14.7% (n=20) of patients had positive fecal occult blood test (FOBT). Those with positive FOBT represented 9.7% (n=10) of 103 AA patients, 53.3% (n=8) of 15 PA patients, and 11.1% (n=2) of 18 NA patients; this was statistically more significant for PA than other groups (p<0.001). CONCLUSION: Presence of intestinal parasites in stool might not be associated with appendicitis, but it can occasionally lead to pathological findings of appendicitis. A positive FOBT may be a predictor for PA.

The ED use and non-urgent visits of elderly patients.

OBJECTIVE: To evaluate the use of the emergency department (ED) by elderly patients, their non-urgent visits and the prevalence of main disease for ED visits. METHODS: This cross-sectional study was conducted on patients aged 65 years and over who visited the ED of a tertiary care university hospital in Turkey between January 2015 and January 2016 retrospectively. RESULTS: A total of 36,369 elderly patients who visited the ED were included in the study. The rate of ED visits by elderly patients was higher than their representation within the general population (p < 0.001). While the rate of elderly patients visiting polyclinics was 15.8%, the rate of elderly patients visiting the ED was 24.3% (p < 0.001). For both genders, the rates of ED visits for patients between 65 and 74 years old was higher than for other elderly age groups (p < 0.001). The prevalence of upper respiratory tract infection (URTI) was the highest within the elderly population (17.5%, CI: 17.1-17.9). The proportion of ED visits for non-urgent conditions was 23.4%. Most of the ED visits were during the non-business hours (51.1%), and they were highest in the winter season (25.9%) and in January (10.2%). The hospitalization rate was 9.4%, and 37.9% of hospitalized patients were admitted to intensive care units. CONCLUSION: The proportion of ED visits by elderly patients was higher than their representation within the general population. Elderly patients often visited the ED instead of a polyclinic. The rate of inappropriate ED use by elderly patients in this hospital was higher than in other countries.

The success of tubularized-incised plate urethroplasty in adults and children.

PURPOSE: Hypospadias repair is rarely performed in adults. It is believed that the success rate is lower in adulthood. We aimed to compare the success rate of primary hypospadias repair with tubularized-incised plate (TIP) urethroplasty in adults and children. PATIENTS AND METHODS: The databases of consecutive boys and adults who were treated with TIP urethroplasty for primary hypospadias between 2012 and 2015 were evaluated. All operations in the boys and adult patients were performed by a single surgeon. We considered urethroplasty complications to include a urethrocutaneous fistula, neourethral stricture, meatal stenosis, diverticulum, and glans dehiscence. Urine flow was also evaluated using uroflowmetry. RESULTS: Seventy-seven consecutive patients underwent surgery by a single surgeon in the last 3 years for hypospadias repair. Nineteen of these patients were adults. Urethrocutaneous fistulae developed in 2 of the 19 (10.5 %) adults, and 3 of the 58 (5.2 %) boys. In addition, there were urinary tract infections in 2 (3.4 %) children, meatal stenosis in 1 (1.7 %) child, and glans dehiscence in 1 (5.3 %) adult. Uroflowmetry was normal in all patients. There was no difference in outcomes between boys and adults. CONCLUSION: Our data showed that the success rate of hypospadias repair with TIP urethroplasty is similar in adults and children. TIP urethroplasty is associated with good results in adults and boys.

The use of latex foley catheter in repair of hypospadias the most common seen congenital penile anomaly.

OBJECTIVE: Hypospadias is the most common congenital penile anomaly occurring in 1/300 live births. Various surgery techniques are used in repair of hypospadias. Infant and children with hypospadias are usually admitted to emergency services by worried their parents for the first time. TIP urethroplasty is widely used in the repair of hypospadias, but the use of urethral catheters is still a matter for discussion. Herein, we described our experiences with the use of an unsutured latex foley catheter placed in the glans for 24 to 48 hours. METHODS: A retrospective chart review was performed on 38 patients who underwent Tubularized incised plate (TIP) hypospadias repair from 2009 to 2011. Of these, 35 patients who had two-way latex Foley catheters placed for 24 h to 48 hands were followed for at least 12 month. RESULTS: Excellent cosmetic results were obtained in all patients. Urinary tract infection developed in two patients (5.7%). one patient (2.8%) who had mild urethral repair breakdown was repaired in the office environment. CONCLUSION: We observed very low complication rates in application of a two-way latex Foley catheter in hypospadias surgery and found that this method can be used safely. Moreover, the catheter can be used for traction purposes during the procedure. At the end of the 24 to 48 h period, removal of the two-way latex urethral catheter with balloon does not harm the urethral repair. To reach a definite conclusion, larger studies are needed.