Injuries related to pets, exotic animals, and falconry in Qatar.

INTRODUCTION: Pets and exotic animals are increasingly popular all over the world. Some of these animals may cause injuries to their owners or other people during interactions. Both injuries and systemic infections always present diagnosis and treatment challenges. Emergency physicians´ clinical experience in managing patients with injuries caused by pets and exotic animals, in particular, is limited; hence, we believe that it is a domain to explore in a Middle Eastern country to help raise awareness and provide reminders as to the best evidence-based medical practice. METHODS: Hamad Medical Corporation's hospital records of patients treated between 2015 and 2022 were analyzed retrospectively. Cases whose diagnosis was recorded as injuries caused by animals kept as pets were included in the study. Patients were evaluated in terms of demographic characteristics, type of injury, injury locations, injury severity, treatments applied, and complications. Descriptive statistics were carried out, and findings were expressed as percentages in a frequency table. RESULTS: Following a search of the electronic patient records during the period of interest, 43 patients were found to have sought treatment following an injury caused by a pet or domestic exotic animal. The mean age of the patients was 23.5 years; about three-quarters were male, and approximately half were children. All injuries were minor, and 74.4% were skin abrasions. The most commonly injured body parts were the hand, the leg, and facial injuries. It was observed that cats caused 53.5% of the injuries, whereas falcons were involved in 11.6% of the cases. All patients were prescribed prophylactic antibiotics, and 60.5% were administered a tetanus injection. CONCLUSION: Despite our study spanning over seven years, a relatively low number of patients reported to the government hospitals´ emergency departments. The injuries are most commonly caused by cats and often involve children and animal bites to hands. The key recommendations are for parents or childminders to always supervise children when interacting with animals, be particularly cautious, and wear some form of protection when handling pets and domestic, exotic animals. Whether it is a bite or a scratch, healthcare professionals should always anticipate the potential risk of infection, treat the patient accordingly, and prescribe prophylactic antibiotics.

Comparison of self versus expert-assisted feedback for cricothyroidotomy training: a randomized trial.

BACKGROUND: The self-video feedback method may have the potential to provide a low-cost alternative to physician-driven simulation-based training. This study aimed to assess the utility of two video feedback methods by comparing the improvement in performing cricothyroidotomy procedure following self video feedback (trainees review their performance by themselves) and expert-assisted video feedback (trainees review their performance while an emergency physician provides additional feedback). METHODS: This study was pretest-posttest and two-group designed research performed at a university simulation center with 89 final-year medical students and used a cricothyroidotomy simulation model. After seeing an educational presentation and a best practice video, trainees were randomized into two groups; self video feedback group (SVFG) and expert-assisted video feedback group (EVFG). They performed the cricothyroidotomy before and after the feedback. The procedures were also recorded and scored by two emergency physicians. RESULTS: There was a statistically significant improvement between pre-feedback and post-feedback assessments in terms of scores received and time needed for the procedures in both SVFG and EVFG groups (p < 0.05). Additionally, the post-feedback assessment scores were higher and time needed for the procedure was lower in the EVFG when compared with SVFG (p < 0.05 for both). CONCLUSIONS: Results demonstrated significant improvement in cricothyroidotomy performance with both types of video feedback method. Even though the improvement was better in the EVFG compared to the SVFG, the self video feedback may have value especially in situations where expert-assisted feedback is not possible.

Integrating patient management, reflective practice, and ethical decision-making in an emergency medicine intern boot camp.

BACKGROUND: Integration of clinical skills, ethical decision-making, and reflection skills have emerged as cornerstones of clinical teaching in medical schools. This study aimed to detect whether a multimodal learning environment approach consisting of lectures, a drill, post-drill video debriefing, and written reflection in an emergency medicine rotation boot camp improves interns' patient management skills, ethical decision-making, and reflection skills. METHODS: A multimodal learning environment was created by the collaboration of emergency medicine, ethics, and medical education specialists. Multiple educational techniques involving lectures, case discussions, and role-playing a crisis scenario were applied. Pre-test and post-test, debriefing on performances on video records, video-recorded performance assessment, and reflective essays about their own and group's performances were used to assess various aspects of the student performances. Additionally, a meeting was organized with the presence of the authors to create qualitative data obtained through the program evaluation meeting conducted on three themes: influences of teaching methods, students' performances, and common achievements and mistakes of students. RESULTS: 133 students participated. Post-test multiple-choice question (MCQ) test scores were slightly higher than pre-test. A low and medium correlation was detected among pre-test and post-test patient management problem (PMP) and reflection scores, which was more prominent for female students. Multiple linear regression showed that pre-test and post-test PMP scores significantly contributed to reflection scores. These results might support that better patient management predicts more robust reflective practice. Teachers observed that students appreciated being inspired by well-performing peers, particularly noting the empathic needs of patients, companions, and other health professionals. However, students overlooked summoning forensic or social services and were inhibited by the pressure of the contextual traits of the drill. CONCLUSION: The multimodal learning environment created by multidisciplinary collaboration contributed to the improvement of components of situational awareness of the interns: patient management skills, ethical decision-making, and reflective practice. During this research, we created a toolbox better to capture the richness and diversity of student interactions. Considering the scarcity of context-specific assessment methods and widespread use of MCQs or generic scales for higher-order thinking skills in medicine, this study might be regarded as a step forward in that context.

Developing Cricothyroidotomy Skills Using a Biomaterial-Covered Model.

INTRODUCTION: Cricothyroidotomy is an advanced and life-saving technique, but it is also a rare and a difficult procedure. The purpose of the present study was to produce a low-cost simulation model with realistic anatomic features to investigate its effectiveness in developing cricothyroidotomy skills. METHODS: This study was performed at a university simulation center with 57 second-year student paramedics and a cricothyroidotomy simulation model. Total scores were assessed using a checklist. This consisted of 13 steps and was scored as misapplication/omission=0, correct performance and timing with hesitation=1, and correct performance and timing without hesitation=2. One of these steps, local anesthesia of the area if time is available, was not performed owing to time limitations. The highest possible score was 24. Data are presented as mean±SD with range, as appropriate. Normal distribution was evaluated using the Kolmogorov-Smirnov test, Student t test, and Mann-Whitney U test, and correlation analysis was used for statistical analysis. RESULTS: Students completed the cricothyroidotomy procedure steps in 116±46 (55-238) s. At performance assessment, the score achieved was 12±5 (2-24). The highest total score of 24 was achieved by 3 students (5%). Total scores exhibited negative and significant correlation with procedure time (r=-0.403, P=0.002). CONCLUSIONS: The model developed in this study is an inexpensive and effective method that can be used in cricothyroidotomy training for student paramedics. We think that repeating the cricothyroidotomy procedure on the model will increase success levels.

A Comparison of the Effects of Grayanotoxin-Containing Honey (Mad Honey), Normal Honey, and Propolis on Fracture Healing.

OBJECTIVES: Delayed healing and non-union of fractures have a significant effect upon patient morbidity. Studies have therefore largely concentrated on accelerating fracture healing. This study was intended to compare the effect of "mad honey" and propolis on fracture healing using radiological and histopathological analysis. SUBJECTS AND METHODS: Femur fracture was surgically performed on 48 rats, followed by fixation. Animals were then divided into 8 groups: 2 control groups (15- and 30-day) and 6 treatment groups (15- and 30-day normal honey, 15- and 30-day "mad honey," and 15- and 30-day propolis). Rats were sacrificed at the end of these periods, and radiological and histological examinations were performed. RESULTS: Radiological healing in the propolis group after 15-day therapy was statistically better than in the control (p = 0.004) and normal honey (p = 0.006) groups. After 30-day therapy, healing in the propolis group (p = 0.005) and grayanotoxin-containing "mad honey" group (p = 0.007) were significantly better than in the control group. Histologically, there was a statistically significant difference between the 15-day propolis group and the other groups (control, honey, mad honey: p = 0.003, p = 0.003, and p = 0.002, respectively). We also found a statistically significant difference when the 30-day propolis group (p = 0.005) and "mad honey" group (p = 0.007) were compared to the control group. CONCLUSIONS: This study shows that grayanotoxin-containing "mad honey" and propolis can accelerate fracture healing.

A retrospective analysis of nebulized versus intravenous fentanyl for renal colic.

STUDY OBJECTIVE: To assess the effectiveness of nebulized fentanyl used for analgesia in renal colic. MATERIALS/METHODS: This research was planned as a randomized, blinded study in which prospectively collected data were analyzed retrospectively to compare nebulized and intravenous (iv) fentanyl therapies. Patients with renal colic with 'moderate' or worse pain on a four-point verbal pain score (VPS) or with pain of 20mm or above on a 100-mm visual analogue score (VAS) at time of presentation were randomized into iv fentanyl (n=62) or nebulized fentanyl (n=53) study groups. Decreases in VAS and VPS scores at 15 and 30min compared to baseline, rescue analgesia requirements and side-effects between the groups were compared. RESULTS: Both iv fentanyl and nebulized fentanyl provided effective analgesia in renal colic patients at the end of 30min. However, iv fentanyl provided more rapid and more effective analgesia than nebulized fentanyl. Patients receiving iv fentanyl had lower rescue analgesia requirements than those receiving nebulized fentanyl (37.1% vs 54.7%), although the difference was not statistically significant (p=0.058). In addition, side-effects were more common in the iv fentanyl group compared to the nebulized fentanyl group (22.1% vs 9.4%), although the difference was also not significant (p=0.058). CONCLUSION: Nebulized fentanyl provides effective analgesia in patients with renal colic. However, iv fentanyl exhibits more rapid and more powerful analgesic effects than nebulized fentanyl. Nonetheless, due to its ease of use and few potential risks and side-effects the nebulized form can be used as an alternative in renal colic.

The diagnostic value of serum pentraxin 3 levels in pulmonary contusion.

PURPOSE: To investigate the difference in pentraxin 3 (PTX 3) levels between patients with pulmonary contusion and healthy volunteers. MATERIALS AND METHODS: This study was conducted with a group of 20 trauma patients diagnosed with pulmonary contusion and 30 healthy individuals enrolled as a control group in a tertiary university hospital. RESULTS: Median PTX 3 levels were 7.05 (3.29-13.1), ng/ml in the contusion group and 1.03 (0.7-1.58) ng/ml in the control group. PTX 3 titers were significantly higher in patients with pulmonary contusion compared to those of the control group (p<0.001). An area under the curve (AUC) value of 0.968 investigated using ROC analysis to determine the diagnostic value of the PTX-3 in pulmonary contusion patients was measured. A PTX-3 cut-off value of 2.06 produced 95.5% sensitivity and 86.7% specificity. CONCLUSION: PTX 3 levels in pulmonary contusion increased significantly compared to the healthy control group. If supported by wider series, PTX 3 may be expected to be capable of use as a marker in pulmonary contusion.

The effect of ethyl pyruvate and N-acetylcysteine on ischemia-reperfusion injury in an experimental model of ischemic stroke.

INTRODUCTION: Reperfusion therapies play an important role in early-period treatment for patients presenting to the emergency department due to stroke. However, the ischemia-reperfusion injury that may occur with reperfusion must then be considered. The purpose of this study was to determine the effectiveness of N-acetylcysteine (NAC) and ethyl pyruvate in preventing ischemia-reperfusion injury. METHOD: This study is a randomized, controlled experimental study. In group 1, rats' left main carotid arteries were clamped. Reperfusion was established by releasing the clamp after 1.5 hours. In group 2, the left main carotid artery was clamped, and 20 mg/kg intraperitoneal NAC was administered after 1 hour. The clamp was released 0.5 hour after NAC administration. In group 3, rats' left carotid arteries were clamped, and 50 mg/kg ethyl pyruvate was administered intraperitoneally after 1 hour. The clamp was released 0.5 hour after ethyl pyruvate administration. All tissue samples were collected 2.5 hours after reperfusion. Brain tissues were compared histopathologically. RESULTS: A higher percentage of degenerative neurons was determined in group 1 compared with groups 2 and 3 (P values: P(a) = .003 and P(c) = .003, respectively). A significant difference was also observed between groups 2 and 3 (P(b) = .003), with the percentage of degenerative neurons being lower in the NAC group than in the ethyl pyruvate group. CONCLUSION: The use of NAC and ethyl pyruvate reduces injury resulting from ischemia-reperfusion in an experimental animal model of acute ischemic stroke and subsequent reperfusion.

A study to develop clinical decision rules for the use of radiography in wrist trauma: Karadeniz wrist rules.

INTRODUCTION: The aim of this study was to evaluate patients presenting to the emergency department (ED) with wrist trauma using physical examination findings and functional tests and to identify findings with high sensitivity and specificity among the parameters assessed in patients with fracture in the wrist. The ultimate objective was thus to establish a reliable and widely usable clinical decision rule for determining the necessity of radiography in wrist trauma. METHODS: This prospective, multicenter study was performed in 8 hospitals. The relation between radiologically determined fracture and clinical findings consisting of physical examination findings and functional tests was assessed in terms of whether or not these were markers of radiography requirement, with the aim of identifying predictive values for fracture. RESULTS: A total of 603 eligible trauma patients presented to the participating EDs during the study period. Fracture was identified in 24.5% of patients (n = 148). The 4-way combination with the highest sensitivity was identified as axial compression and the positive distal radioulnar drawer test, and pain with radial deviation and dorsal flexion. Sensitivity at distal ulna palpation was added as a fifth parameter, and sensitivity and negative predictive value thus increased to 100%. CONCLUSION: With their 100% sensitivity and 100% negative predictive values, the Karadeniz wrist rules may represent a clinical decision rule that can be used in practice in EDs. If all 5 findings are negative, there is no indication for wrist radiography.

Determination of radiography requirement in wrist trauma.

OBJECTIVES: The purpose of this study was to evaluate predetermined physical examination and function tests recommended to identify severe injury among patients presenting with wrist injury to the emergency department and to establish a reliable clinical decision rule capable of determining the need for radiography in wrist injuries. MATERIALS AND METHODS: This was a multicenter prospective derivation study of wrist injuries. All patients were assessed in terms of mechanism of trauma, inspection findings, heart rate, sensitivity at palpation, presence of pain with active movement, grasp strength, and functional tests using an examination form under main headings. Sensitivity, specificity, and positive and negative predictive values were expressed for each sign and each examination finding. RESULTS: One hundred nineteen adult patients were enrolled during the 6-month study period. Fracture was identified in 24.3% (n = 29). Presence of pain on the radial deviation, dorsal flexion, distal radioulnar drawer, and axial compression tests exhibited high sensitivity (82.8%, 89.7%, 82.8%, and 86.2%, respectively) and high negative predictive values (88.6%, 81.3%, 87.5%, and 93.6%, respectively) for wrist fracture. Sensitivity of 96.6% was observed when these 4 tests were evaluated together. CONCLUSIONS: The presence of one of these examination findings increases the likelihood of fracture and is adequate to recommend wrist radiography. In addition, there is a strong possibility of radiography being unnecessary if all 4 test results are negative in patients presenting with wrist injury, potentially preventing many nonessential radiographs being performed.

Diagnostic value of plasma signal peptide-Cub-Egf domain-containing protein-1 (SCUBE-1) in an experimental model of acute ischemic stroke.

OBJECTIVES: This study was intended to examine possible diagnostic value of plasma Signal Peptide-Cub-Egf domain-containing protein-1 (SCUBE1) levels in an experimental model of acute ischemic stroke. METHODS: Twenty-four female Sprague Dawley rats were divided into four groups. Blood and brain tissue specimens were collected immediately following artery ligation (control; Group 1), 1h after ligation (Group 2), 2 h after ligation (Group 3) and 6h after ligation (Group 4). SCUBE1 levels were investigated in the serum specimens. The brain samples were examined histopathologically. Correlation analysis was performed between the values. RESULTS: Median SCUBE1 values were 1.75 ng/ml in the control group, 3.80 ng/ml, 3.71 ng/ml and 4.19 ng/ml in the groups 2, 3 and 4, respectively (n=6 for each, P=0.004, for each group compared to control values). Histopathological analysis revealed median atrophic neuron percentages of 16% (in group 1), 42%, 55% and 76% in group 2, 3 and 4 respectively (n=6 for each, P=0.004, for each group compared to control group). A higly significant correlation was determined between SCUBE-1 levels and percentage of atrophic neurons (r=0.744 P=0.000). CONCLUSIONS: In this experimental model of acute ischemic stroke plasma SCUBE1 levels rose from the 1st hour of induced stroke and remained high up to 6th hour tested. Results of this experimental study has a potential to become the basis for a clinical study to confirm whether SCUBE1 can be used as a biomarker in the early diagnosis of acute ischemic stroke patients.

The relationship between oxidative stress and apoptosis of histopathological changes in the ovary made by mad honey containing grayanotoxin.

The purpose of this study is to determine the effects of grayanotoxin in mad honey on ovarian tissue folliculogenesis in terms of cell death and nitric oxide expression. Three groups of 18 female Sprague-Dawley rats were formed. The first group received mad honey (80 mg/kg), the second group received normal honey (80 mg/kg), and the third group was the control. The first and second groups received normal and mad honey by oral gavage for 30 days before being sacrificed under anesthesia. Caspase 3 immunostaining showed a moderate to strong response, particularly in the mad honey group. In the mad honey group, immunostaining for caspase 8 and caspase 9 revealed a moderate immunoreaction in the granulosa cells of the Graaf follicles. The majority of Graaf follicles exhibited TUNEL positive in the mad honey group. The iNOS immunoreaction revealed a high level of expression in the mad honey group. In all three groups, eNOS immunostaining showed weak reactivity. According to the findings of apoptotic and nitric oxide marker expression, it was determined that mad honey may result in an increase in follicular atresia in ovarian follicles when compared to normal honey and control groups.

Clinical assessment and risk stratification for prehospital use of methoxyflurane versus standard analgesia in adult patients with trauma pain.

Oligoanalgesia, the undertreatment of trauma-related pain using standard analgesics in prehospital and emergency departments, has been extensively documented as one of the major challenges affecting the effective treatment of trauma-related pain. When administered in low doses, methoxyflurane has been highlighted by numerous medical works of literature to provide an effective, nonopioid, nonnarcotic treatment alternative to standard analgesics for prehospital and emergency department use. Low-dose methoxyflurane has been associated with fast-pain relief in adult patients manifesting moderate-to-severe pain symptoms. This systematic review and meta-analysis aimed to assess the clinical implication of low-dose methoxyflurane use in prehospital and emergency departments in adult patients with moderate-to-severe trauma-related pain. Moreover, the review aimed at assessing the risk stratification associated with using low-dose methoxyflurane in prehospital and emergency departments. The systematic review and meta-analysis performed a comprehensive search for pertinent literature assessing the implications and risks of using low-dose methoxyflurane in adult patients exhibiting moderate-to-severe trauma-related pain in prehospital settings. A comparison between the use of low-dose methoxyflurane and standard-of-care analgesics, placebo, in prehospital settings was reported in four clinically conducted randomized controlled trials (RCTs). These RCTs included the STOP! trial, InMEDIATE, MEDIATA, and the PenASAP trials. A meta-analysis comparing the time taken to achieve first pain relief on initial treatment of patients with moderate-to-severe trauma-related pain favored the use of low-dose methoxyflurane to the standard-of-care analgesics (mean difference = -6.63, 95% confidence interval = -7.37, -5.09) on time taken to establish effective pain relief. Low-dose methoxyflurane has been associated with superior and faster pain relief in prehospital and emergency departments in adult patients exhibiting moderate-to-severe trauma-related pain compared to other standard analgesics.

Arteriovenous malformation presenting as a lip swelling.

Key Clinical Message: Arteriovenous malformations (AVM) are extremely rare on the face and especially on the lip. Lip can be more easily exposed to traumas due to their anatomical location. Especially superficial AV malformations are very susceptible to trauma and can bleed very seriously after being exposed to such effects. AVMs management generally based on their hemodynamic characteristics and growth modalities. The surgical treatment requires elaborate planning and multidisciplinary approach. When evaluating a mass with a clinical manifestation of lip swelling, ruling out a vascular anomaly before any intervention is also crucial. Abstract: Arteriovenous malformations (AVM) are abnormal fistulas between an artery and a vein, without an intervening capillary bed. AVM may occur everywhere in the body, with the brain being of particular concern, as AVM can be complicated by bleeding. Herein, we present the case of a patient with a very atypical AVM location consisting of a lip mass. Given the possibility of hemorrhage and airway obstruction, early detection and timely intervention are mandatory.

Age-dependent structural and radiological changes in the larynx.

AIM: To define radiological physiological changes in the larynx by establishing an age-related scale. MATERIALS AND METHODS: The present retrospective study used radiological records of patients that had undergone lateral cervical imaging. Three hundred patients were included. Thyroid cartilage was divided into anatomical regions. The hyoid bone was evaluated as the body and greater horns. Cases were compared by grouping by age and gender. RESULTS: Thyroid tissue and cricoid cartilage only became visible after the second decade. Ossification in the thyroid cartilage began in the posterior inferior horn and progressed to the superior horn and central lamina. It also began in the posterior part of the cricoid cartilage and moved forward with age. In the first decade, the body and greater horn parts of the hyoid bone could be seen more distinctly, and after the third decade the hyoid bone appeared as a single bone. The hyoid bone was the only structure ossified in the laryngeal region below the age of 20 and formed an image on direct imaging. CONCLUSIONS: Age-related changes to the laryngeal tissues are evident on radiographs. Clinicians should bear this in mind when evaluating neck radiographs.

Pseudocholinesterase levels are not decreased in grayanotoxin (mad honey) poisoning in most patients.

BACKGROUND: The symptoms of mad honey poisoning resemble those of cholinergic toxidromes; however, it is not clear whether they share a common biochemical basis. OBJECTIVES: The aim of this study was to investigate a possible resemblance between mad honey poisoning and cholinergic toxidromes. METHODS: This is a descriptive study performed prospectively in patients presenting to a University Medical Faculty Emergency Medicine Department emergency service with mad honey poisoning over 1 year, from September 2008 to September 2009. Adult patients with clinical findings suggesting mad honey poisoning (i.e., bradycardia, hypotension, syncope, and vertigo) and with a history of honey consumption were enrolled. Pseudocholinesterase levels in blood samples taken from the mad honey-poisoned patients were analyzed to determine whether these were lower than normal pseudocholinesterase levels for adults (5400-13,200 U/L). RESULTS: The most common symptoms of the 30 patients enrolled in the study were vertigo and nausea. Low blood pressure and bradycardia were the most frequently observed physical examination findings. None of the patients enrolled had a history of disease that might cause low pseudocholinesterase. Mean pseudocholinesterase levels in our patients with mad honey poisoning were 7139.30 ± 2316.41 U/L (min-max: 1785-12,835). Blood pseudocholinesterase levels were within normal limits in 90% of patients and below normal in 10%. CONCLUSION: A low pseudocholinesterase level was found in 3 (10%) of our 30 patients. These biochemical data do not support the hypothesis that mad honey poisoning should be regarded as cholinergic poisoning.

A wild wolf attack and its unfortunate outcome: rabies and death.

Wild animal attacks are potential occurrences in rural areas of Turkey. Wolf attacks, however, are rare this century, but there are many anecdotal reports from previous times. Attacks by wolves are generally directed against animals, such as cows and sheep, and for feeding purposes. Wolf attacks on humans are a little known and unexpected phenomenon. A 60-year-old man was brought to the emergency department with facial injuries caused by a wolf emerging from a rural area and leaping at his face as he was sitting in his garden. During the incident, the patient strangled the wolf to death. Despite postexposure prophylaxis the patient likely died because of rabies.

Myocarditis following COVID-19 mRNA (mRNA-1273) vaccination.

In this case report, we presented a case of myocarditis as a rare complication that developed after Covid mRNA-1273 vaccine. Cases of post-vaccine myocarditis usually progress with mild symptoms. However, it should be a situation that healthcare workers should keep in mind, that myocarditis may develop after vaccination.

Gallbladder volvulus.

Gallbladder volvulus is a rare entity. The condition results in rotation of the gallbladder on its mesentery along the axis of cystic duct and artery. Gallbladder volvulus is a condition in which the organ twists on its long axis to the point where its vascular supply is compromised.

Rare cause of finger swelling.

Arteriovenous malformation at the finger and without trauma is a rare condition. Surface-located arteriovenous malformations are susceptible to trauma. Therefore, they can cause severe bleeding and, such bleeding can seriously endanger the blood supply and circulation of the limb.