Usability of a Web-based Software Tool for History Taking in the Emergency Department.

Medical history taking is an important step within the diagnostic process. This study aims to assess the quality and usability (effectiveness, satisfaction, efficiency) of a web-based medical history taking app in the emergency department. During three weeks, patients and junior physicians filled out study questionnaires about the app. Senior physicians rated the quality of medical histories taken by junior physicians and app. In 241 patients, the studied app showed excellent usability with patients not in need of immediate medical attention. Senior physicians rated medical histories as more complete when app was used by patients in comparison to conventional history taking alone (p<0.01). Current app could not substitute medical history taking by physicians, but could definitely rather be used to gather ancillary information.

Value of High-Sensitive Cardiac Troponin in Predicting Mortality in the Emergency Department.

BACKGROUND: The present study aimed to determine the validity of hs-cTnT in predicting the mortality among patients presented to the emergency department (ED) likely to be acute coronary syndrome (ACS). METHOD: Patients in whom hs-cTnT was tested in the ED for a possible ACS composed the study cohort. Hs-cTnT levels of the study patients were obtained from the hospital computerized database. The outcome and mortality of the study patients was detected using the digitalized national mortality registry. All-cause mortality and cardiac mortality at the end of one month was the primary outcome. RESULTS: 11795 patients were eligible for mortality detection and included into the final analysis. 1246 of 11795 patients were established to be dead during the study period and 358 of them supposed to be cardiac in origin. The Area Under the Curve (AUC) value of initial hs-cTnT for predicting one-month cardiac mortality was 0.869 (95% CI: 0.863 - 0.875) and 0.861 (95% CI: 0.855 - 0.867) for one-month all-cause mortality. The upper reference limit, 14 ng/L, has a sensitivity and specificity of 87% (95% CI: 77% to 94%) and 69% (95% CI: 68% to 70%), respectively, for predicting one-month cardiac mortality. CONCLUSIONS: The reference value of initial hs-cTnT does not have the ability to predict the cardiac mortality in a sufficient manner. However, reductions or increases in absolute or relative hs-cTnT levels are in concordance with mortality rates.

Oxidative Status and DNA Damage Following Analgesic Treatment in Patients with Acute Pancreatitis.

BACKGROUND: This study is designed to investigate the effect of three different analgesics, used to treat pain in AP, on oxidative stress, DNA damage in mononuclear leukocytes, and on oxidative status. METHODS: This parallel design randomized controlled trial is composed of three treatment arms, intravenous paracetamol, intravenous dexketoprofen, and intravenous tramadol. RESULTS: A total of 107 patients were diagnosed with acute pancreatitis within the study period in the ED. Seventyseven of them were included in the study; 26 patients for the paracetamol group, 24 patients for the dexketoprofen group, and 27 patients for the tramadol group. The mean age of study subjects was 52.73 ± 15.38 and 66% (n = 51) of them were men. At the beginning of the study (before treatment), mean levels of DNA damage, TOS, and OSI levels were significantly higher and TAS was significantly lower in the acute pancreatitis groups than in the control group. DNA damage and OSI in HAPS-positive patients were found to be significantly greater than HAPS-negative patients (p = 0.046). DNA damage and oxidative stress were compared between the three groups. There were no differences between the groups in terms of DNA damage (p = 0.42) and also for the oxidatif stress parameters (OSI,TAS,TOS had p-values of p = 0.26, p = 0.78, p = 0.35, respectively). CONCLUSIONS: There is no difference between the effects of paracetamol, dexketoprofen, and tramadol, which are commonly used to manage acute pain in AP, on DNA damage in human T-lymphocytes and on serine parameters of oxidative status.

QT dispersion in carbon monoxide poisoning.

BACKGROUND: Carbon monoxide (CO) poisoning are serious health problems, and effect of reducing the blood's oxygen carrying capacity. Deaths due to CO poisoning are mostly related to myocardial injury and central nervous system pathologies. AIM: The objective of this study was to determine the relationship between carbon monoxide intoxication, QT dispersion, and cardiac markers. MATERIALS AND METHODS: Patients with possible CO intoxication symptoms were evaluated to be eligible for the study. Patients' demographic data, carboxyhemoglobin levels, cardiac markers and QT interval measurements were recorded to the study form. RESULTS: A total of 127 patients (79 CO intoxicated and 48 controls) were included into the study with a mean age of 38.6 +/- 14.1 years and 62.2% of them were female. Average levels of patient's carboxyhemoglobin were 21.3 +/- 9. QT dispersion (39.0 +/- 10.8 vs 24.4 +/- 6.2; p < 0.001) and corrected QT dispersion (46.2 +/- 14.7 vs. 25.3 +/- 6.2; p < 0.001) were longer than the control group. Both QT dispersion (39.0 +/- 10.8 vs. 23.6 +/- 7.0; p < 0.001) or corrected QT dispersion (46.2 +/- 14.7 vs. 27.1 +/- 8.7; p < 0.001) were also decreased after one week later from the admission. CONCLUSION: Carbon monoxide intoxication is related to increased QT dispersion. Emergency physicians should measure QT dispersion in CO intoxicated patients in order to predict the electrical instability in myocardium and future adverse events.

Ectosomes as modulators of inflammation and immunity.

Vesicles released by cells have been described using various names, including exosomes, microparticles, microvesicles and ectosomes. Here we propose to differentiate clearly between ectosomes and exosomes according to their formation and release. Whereas exosomes are formed in multi-vesicular bodies, ectosomes are vesicles budding directly from the cell surface. Depending upon the proteins expressed, exosomes activate or inhibit the immune system. One of the major properties of exosomes released by antigen-presenting cells is to induce antigen-specific T cell activation. Thus, they have been used for tumour immunotherapy. By contrast, the major characteristics of ectosomes released by various cells, including tumour cells, polymorphonuclear leucocytes and erythrocytes, are the expression of phosphatidylserine and to have anti-inflammatory/immunosuppressive activities similarly to apoptotic cells.

Urinary retention, erectile dysfunction and meningitis due to sacral herpes zoster: a case report and review of the literature.

Zona zoster infection is often associated with painful erythematous vesicular eruptions of the skin or mucous membranes. Varicella zoster virus which stays latent in the sensorial root ganglia causes zona zoster infection. The most recognized feature of zona zoster is the dermatomal distribution of vesicular rashes. In the present case report, we state an unusual presentation of sacral zona zoster with urinary retention, erectile dysfunction and meningitis.

Contribution of goal-directed ultrasonography to clinical decision-making for emergency physicians.

OBJECTIVE: To determine the contribution of goal-directed right upper quadrant (RUQ) ultrasonography (US) on real-time decision-making of attending emergency physicians by evaluating their level of certainty for admission, surgery, medical treatment, additional laboratory and radiological investigations and discharge. METHODS: The study was conducted at an urban university tertiary care emergency department with an annual census of 60,000 adult patients. Patients with acute non-traumatic RUQ pain presenting to the emergency department during the 8-month study period were enrolled into the study. Primary outcome measures were level of certainty for admission to the hospital, emergency surgery, medical treatment, additional laboratory and radiological analyses and discharge from the emergency department. RESULTS: There was a significant difference between the pre-US and post-US certainty of the decision to perform additional diagnostic studies (56 vs 72, p = 0.01) but not in the other outcomes (treatment, admission, surgery and discharge). After categorising the physicians' decisions into low, intermediate and high, US had an effect on all primary outcomes and on all categories. This effect was most evident in the moderate category where the physicians were undecided for all primary outcomes. CONCLUSION: US performed by emergency department physicians affects the certainty of their decisions in patients presenting with RUQ pain. This effect is more evident on the decision to perform additional diagnostic studies and in patients about whom physicians are undecided.

End-of-life decisions in emergency patients: prevalence, outcome and physician effect.

BACKGROUND: End-of-life decisions (EOLD) represent potentially highly consequential decisions often made in acute situations, such as 'do not attempt resuscitation' (DNAR) choices at emergency presentation. AIM: We investigated DNAR decisions in an emergency department (ED) to assess prevalence, associated patient characteristics, potential medical and economic consequences and estimate contributions of patients and physicians to DNAR decisions. DESIGN: Single-centre retrospective observation, including ED patients with subsequent hospitalization between 2012 and 2016. Primary outcome was a DNAR decision and associated patient characteristics. Secondary outcomes were mortality, admission to intensive care unit and use of resources. METHODS: Associations between DNAR and patient characteristics were analysed using logistic mixed effects models, results were reported as odds ratios (OR). Median odds ratios (MOR) were used to estimate patient and physician contributions to variability in DNAR. RESULTS: Patients of 10 458 were attended by 315 physicians. DNAR was the choice in 23.3% of patients. Patients' characteristics highly associated with DNAR were age (OR = 4.0, 95% CI = 3.6-4.3) and non-trauma presentation (OR = 2.3, 95% CI = 1.9-2.9). In-hospital mortality was significantly higher (OR = 5.4, CI = 4.0-7.3), and use of resources was significantly lower (OR = 0.7, CI = 0.6-0.8) in patients choosing DNAR. There was a significant effect on DNAR by both patient (MOR = 1.8) and physician (MOR = 2.0). CONCLUSIONS: DNAR choices are common in emergency patients and closely associated with age and non-trauma presentation. Mortality was significantly higher, and use of resources significantly lower in DNAR patients. Evidence of a physician effect raises questions about the choice autonomy of emergency patients in the process of EOLD.

Ketamine may be related to reduced ejection fraction in children during the procedural sedation.

OBJECTIVE: Ketamine is a dissociative anesthetic agent with sympathomimetic effects used commonly for procedural sedation in emergency department. The present study aimed to reveal the effect of ketamine on myocardium by measuring ejection fraction (EF). METHODS: Patients less than 9 years old undergoing procedural sedation with ketamine secondary to minor trauma composed the study population by convenience sampling. Study patients received ketamine at a dose of 1.5 mg/kg. A cardiologist performed the measurements of cardiac contractility pre-ketamine and 10 min after the ketamine administration. RESULTS: A total of 22 patients were enrolled into the study. Patient recruitment has been ceased after the 22nd patient because of the thought that more patients would not provide additional information. The study subjects had a mean age of 3.5 ± 2.2 years and 14 (64%) of them were male. EF reduced in 14 (63.6%) patients (mean: 5.6 ± 3.1; median: 5; interquartile range (IQR): 3.75-7; minimum-maximum (min-max): 1-14). Systolic blood pressures reduced in 10 of 14 patients with decreased EF and increased in 8 of 10 patients without decreased EF. The changes in systolic blood pressure in patients with decreased EF ( n = 14) were as follows: -7.6 ± 10.9; median: -7.5; IQR: -16.5 to 1.75; and min-max: -30 to 9. There were two patients with elevated high-sensitive troponin. CONCLUSION: Ketamine may reduce EF and systolic blood pressure in children less than 9 years old undergoing procedural sedation.

First Report of Leaf Spot of Smooth Bromegrass Caused by Pithomyces chartarum in Nebraska.

Smooth bromegrass (Bromus inermis Leyss.) is the most common perennial grass species cultivated for forage in North America. During late fall of 2004, smooth bromegrass plants in Lincoln, NE were observed to have brown lesions on leaf midveins that were several centimeters long. Symptomatic leaves were surface disinfested for 1 min in 2% NaOCl and incubated at 25°C on potato dextrose agar (PDA) and water agar. The fungus, Pithomyces chartarum (Berk. & Curt) Ellis, was isolated consistently and identified on the basis of morphological characteristics (1). Colonies were effused and black on PDA. Conidiophores measured 3.5 to 8 × 1.9 to 3.9 µm and were smooth and single. Conidia (7 to 25 × 9.5 to 14 µm) were broadly ellipsoidal, pale brown to dark brown, verrucose with mainly three transverse septa and one to two longitudinal septa. Pathogenicity tests were conducted on 50-day-old plants by spraying with a conidial suspension (2.5 × 105 spores per ml). Control plants were sprayed with sterile water. All plants were kept in a moist chamber (100% relative humidity) for 3 days and then transferred to a greenhouse (25°C, >70% relative humidity, and a 12-h photoperiod). One week after spraying, elongated lesions developed on leaf midveins of inoculated plants from which P. chartarum was consistently reisolated. No symptoms were observed on control plants. While P. chartarum has been described as a saprotroph or a parasite on a wide range of plants primarily in the tropics and subtropics, including the southern United States (2), it was reported previously on B. inermis only in Canada (3). This report expands the distribution and host range of P. chartarum as a pathogen in the United States. References: (1) M. B. Ellis. Dematiaceous Hyphomycetes. Commonwealth Mycological Institute, Kew, Surrey, England, 1971. (2) D. F. Farr et al. Fungal Databases, Systematic Botany and Mycology Laboratory, On-line publication. ARS, USDA, 2005. (3) J. H. Ginns. Compendium of Plant Disease and Decay Fungi in Canada 1960-1980. Res. Br. Can. Agric. Publ. 1813, 1986.

First Report of Crown and Stem Rot of Orchid (Orchis palustris) Caused by Sclerotinia minor.

Orchis palustris Jacq. is a wild orchid native to wetlands in eastern Anatolia. During June of 2003, near Erzurum, Turkey, a decline of this orchid was observed in several meadows that had been irrigated for forage production. Stems were chlorotic, wilted, and collapsed. There was a soft, watery rot at the crowns and lower stems. White mycelium and black sclerotia formed on necrotic stem and crown tissues. The fungus was isolated from sclerotia on potato dextrose agar (PDA) and identified as Sclerotinia minor Jagger on the basis of small sclerotia (0.5 to 2.5 mm long) scattered throughout the colonies (2). Pathogenicity was confirmed by inoculating stems of 8-week-old plants with mycelial plugs from 5-day-old PDA cultures and enclosing inoculated plants in transparent plastic bags for 3 days. After 2 weeks, symptoms similar to those in the field were observed, and S. minor was reisolated from inoculated plants. Noninoculated control plants remained asymptomatic. The disease was previously observed on O. laxiflora Lam. in Turkey (1), but to our knowledge, this is the first report of S. minor infecting O. palustris References: (1) C. Eken et al. Plant Pathol. 52:802, 2003. (2) L.M. Kohn. Phytopathology 69:881, 1979.

First Report of Colletotrichum truncatum on Alfalfa in Turkey.

During the summer of 1997 and 1998, a pathogen identified as Colletotrichum truncatum (Schwein.) Andrus & W.D. Moore was isolated from lesions on stems of alfalfa (Medicago sativa L.) plants in Erzurum, Turkey. Typical symptoms on stems of mature plants were large, sunken, irregularly shaped black lesions. Twenty-eight cultures of C. truncatum were isolated from stem lesions. Acervuli containing spores and dark setae were observed within lesions. Conidia were hyaline, one-celled, falcate to nearly straight with a prominent clear area in the center of highly granular cytoplasm, and measured 16.3 to 20.6 × 3.1 to 4.5 µm. These morphological characteristics were consistent with the description of C. truncatum (1). The pathogenicity of two isolates was determined on alfalfa cv. Bilensoy. Alfalfa seedlings (6-week-old) were inoculated with a conidial suspension of the fungus (1.4 × 107 conidia per ml), incubated in a moist chamber for 3 days, and subsequently transferred to growth chambers maintained at 25°C with a 12-h photoperiod. Ten plants were inoculated with each isolate. Symptoms first appeared on stems 12 days after inoculation. Sunken, irregularly shaped black lesions occasionally girdled stems of plants inoculated with C. truncatum. Symptoms did not appear on stems of control plants inoculated with sterile distilled water. C. truncatum was reisolated from symptomatic tissue. This is the first report of C. truncatum on alfalfa from Turkey. Reference: (1) B. C. Sutton. 1992. Pages 1-27 in: Colletotrichum Biology, Pathology and Control. J. A. Bailey and M. J. Jeger, eds. CAB International, Wallingford, U.K.

First Report of Rhizoctonia zeae in Turkey.

In 1997, during a study to determine the pathogenic fungi on Johnsongrass (Sorgum halepense) in the Yusufeli District of Artvin Province, 10 isolates of a Rhizoctonia sp. were obtained from necrotic roots. In anastomosis tests, Johnsongrass isolates fused at low frequency with the Rhizoctonia sp. (teleomorph: Waitea circinata var. circinata) and R. oryzae (teleomorph: W. circinata var. oryzae), and at high frequency with R. zeae (teleomorph: W. circinata var. zeae). Test isolates of the Rhizoctonia sp. (W. circinata var. circinata), R. oryzae, and R. zeae (isolate nos. W616, 231, and 590, respectively) were provided by R. H. Leiner (University of Alaska Fairbanks). In addition, Johnsongrass isolates were identified as R. zeae based on colony morphology of the vegetative state. Pathogenicity of two isolates (JR-3 and JR-8) was determined on Johnsongrass seedlings at 25°C. Six seeds were sown in a 10-cm-diameter pot containing a sterile soil mixture of coarse sandy loam and sand (1:1, vol/vol). Each pot was a replicate and each treatment was replicated four times. Four-week-old Johnsongrass seedlings were inoculated by gently removing the soil mixture from one side of the stem, placing a colonized potato dextrose agar (PDA) 4-mm-diameter plug in direct contact with the base of the stem, and covering the inoculum with the soil mixture. A sterile, uncolonized PDA plug was used as a control. Disease symptoms were observed 2 weeks after inoculation. Brownish, sunken lesions were observed on the base of stems and roots of seedlings inoculated with R. zeae. Stems and roots of uninoculated seedlings were lesion free. Isolates JR-3 and JR-8 were reisolated from plants grown in their respective treatments. This is the first report of R. zeae from Turkey.

Ectosomes released by platelets induce differentiation of CD4+T cells into T regulatory cells.

Accumulating evidence suggests an immune-modulatory role for platelets (PLT) and PLT-derived microvesicles. In particular, ectosomes, i.e. vesicles budding from PLT surface, have been shown to exert immunosuppressive activities on phagocytes. Here we investigated the effects mediated by PLT-derived ectosomes (PLT-Ecto) on CD4+ T cells. Exposure of activated CD4+ T cells to PLT-Ecto decreased their release of IFNγ, TNFα and IL-6, and increased the production of TGF-ß1. Concomitantly, PLT-Ecto-exposed CD4+ T cells displayed increased frequencies of CD25high Foxp3+ cells. These phenomena were dose-dependent and PLT-Ecto specific, since they were not observed in the presence of polymorphonuclear- and erythrocyte-derived ectosomes. Analysis of specific T cell subsets revealed that PLT-Ecto induced differentiation of naïve T cells into Foxp3+ cells, but had no effect on pre-differentiated Foxp3+ regulatory T cells (Tregs). Importantly, PLT-Ecto-induced Foxp3+ cells were as effective as peripheral blood Tregs in suppressing CD8+ T cell proliferation. PLT-Ecto-mediated effects were partly dependent on PLT-derived TGF-ß1, as they were to some extent inhibited by PLT-Ecto pretreatment with TGF-ß1-neutralising antibodies. Interestingly, ectosome-derived TGF-ß1 levels correlated with Foxp3+ T cell frequencies in blood of healthy donors. In conclusion, PLT-Ecto induce differentiation of CD4+ T cells towards functional Tregs. This may represent a mechanism by which PLT-Ecto enhance peripheral tolerance.

The consistency of emergency physicians' and cardiologists' ECG interpretation and likelihood classification of chest pain patients.

Patients presenting to the emergency department with chest pain are evaluated by emergency physicians in hospitals without cardiology cover 24 h a day. The purpose of this study is to determine the consistency of electrocardiography (ECG) interpretation and chest pain likelihood classification between emergency physicians and cardiologists. This randomised prospective cross-sectional study was performed in a tertiary care university hospital emergency department. The study form included ECG interpretation and chest pain likelihood classification according to American College of Cardiology (ACC)/American Heart Association (AHA) guideline which were recorded by emergency physicians and cardiologists separately in a blinded fashion. All chest pain patients who consulted with a cardiologist were enrolled into the study during the study period. The consistency between the two groups and the kappa value were calculated. Recorded study forms of 133 patients with cardiology consultations were evaluated. The consistency in the interpretation of ECG between the emergency physicians and cardiologists was found to be 94.6% (kappa = 0.85) for ST segment elevation, 78.6% (kappa = 0.57) for ischaemic ECG findings and 79.3% (kappa = 0.36) for dynamic ECG changes. The consistency for the likelihood classification between two groups for predicting the pain as angina or non-cardiac was 90.8% (kappa = 0.30), for classifying as acute coronary syndrome or stable angina pectoris (SAP) was 95.6% (kappa = 0.26) and for classifying patients as low likelihood or intermediate-high likelihood was 86.3% (kappa = 0.61). A strong consistency was shown between the emergency physicians' and cardiologists' ECG interpretation especially in determining the ST segment elevation. And also, there is a strong concordance in the likelihood classification of chest pain patients.

Pathogenicity of Beauveria bassiana (Deuteromycotina: Hypomycetes) to larvae of the small poplar longhorn beetle, Saperda populnea (Coleoptera: Cerambycidae).

The small poplar longhorn beetle, Saperda populnea is an important pest of Lombardy poplars (Populus nigra L.) in Turkey. A survey for natural entomopathogenic fungi of S. populnea larvae was made in Erzurum, Turkey, during the period 2004-2005. Larvae (13.5%) infected with a strain of the fungus Beauveria bassiana were found. The pathogenicity of B. bassiana strain 46 was conducted with different concentrations of conidia (10(6), 10(7) and 10(8) conidia/ml) of this isolate on S. populnea larvae. The lowest concentration (10(6) conidia/ml) caused about 56% mortality within 6 days. One hundred percent mortality was achieved after median lethal time (LT(50)) of 4.6 and 4.4 days for 10(7) and 10(8) conidia/ml, respectively. There were no significant differences between median lethal times. This is the first record of natural infection of S. populnea larvae by B. bassiana.

Does awareness of diagnosis make any difference to quality of life? Determinants of emotional functioning in a group of cancer patients in Turkey.

The object of this study was to investigate how the information status with regard to diagnosis, in addition to social and clinical factors, influenced emotional functioning and quality of life in a group of cancer patients in Turkey. A consecutive sample of 100 cancer patients being treated for different diagnoses in a tertiary care centre were prospectively evaluated. Data on patient disease and social characteristics, clinical factors, and scores on the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) were analysed by logistic regression models. A significant proportion (44%) of the patients did not know of their diagnosis of cancer. The scores on functional and symptom scales and global health status/quality of life according to QLQ-C30 did not differ according to the information given or not given on diagnosis. However, the independently significant determinants of good emotional functioning were male gender (P=0.002), low serum alanine transferase levels (P=0.025), good social functioning (P=0.002), and the absence of constipation (P=0.005). In Turkey, it is still common for cancer patients not to be informed of their diagnosis, and there is a great need to improve this situation. Honest disclosure of the truth does not worsen any dimension of quality of life in general or emotional functioning in particular. On the contrary, those with hepatic dysfunction, female gender, poor social functioning and constipation are the ones at increased risk of poor emotional functioning, and these patients may benefit from psychological screening.