The importance of routine bedside biliary ultrasonography in the management of patients admitted to the emergency department with isolated acute epigastric pain

Background/aim: The aim of our study was to emphasize the importance of routine bedside biliary ultrasonography (USG) for the differential diagnosis of biliary tract disorders in patients admitted with acute isolated epigastric pain. Materials and methods: Adult patients who were admitted to the emergency department with acute isolated epigastric pain were included in the study. Emergency residents (ERs) were asked whether they planned to perform biliary USG during the initial evaluation and following diagnosis/treatment (secondary evaluation) of these patients. Bedside biliary USG examinations were performed by a sonologist and a radiologist evaluated the video recordings. Results: A total of 103 patients were enrolled, 29 of whom were diagnosed with biliary tract disease (BTD). In the 29 patients diagnosed with BTD, 27 had gallstones (biliary colic, 18; acute cholecystitis, 7; acute pancreatitis, 2) and two had biliary sludge. USG was not ordered by the ERs for 44.8% of the 29 patients with a final diagnosis of BTD, 58.8% of 17 patients with normal liver function tests and BTD, and 35.3% of the 17 hospitalized patients. Conclusion: Emergency physicians should routinely use biliary USG along with clinical judgement and laboratory studies in order to rule out BTD in patients with acute isolated epigastric pain.

Recognizing acute appendicitis criteria on abdominal CT: do emergency physicians need a preliminary report?

BACKGROUND: Computed tomography (CT) is invaluable for the diagnosis of acute appendicitis (AA) in the emergency setting when used appropriately with proper risk stratification. The aim of this study is to investigate the capability and accuracy of emergency physicians (EPs) at recognizing AA criteria in intravenous contrast-enhanced abdominal CT and to investigate the level of interobserver agreement among them. METHODS: Consecutive patients who presented to Izmir University Hospital from January 1, 2014, to December 31, 2014, were evaluated. Patients with histopathologically confirmed AA and had intravenous contrast-enhanced abdominal CT were enrolled. Abdominal CT were interpreted by 4 EPs in a blind fashion. To compare differences in performances between observers, sensitivity, specificity, positive predictive value, negative predictive value, and κ values were calculated. The results were then compared with the radiology department's official reports. RESULTS: There were 48 patients eligible for the study. Among these patients, 19 were male (41%), with a mean age of 34.4 years (±11.3 years). Five patients were CT-negative appendicitis according to official radiology reports that were accepted as the criterion standard. The best sensitivity and negative predictive values were achieved at criterion "enlargement of the appendix," whereas the least sensitivity was for criterion "lack of opacification in an enlarged appendix." CONCLUSIONS: The recognition of the CT criteria for AA among EPs is substantial at best, and their ability to recognize the primary criteria for diagnosing AA is good. Emergency physicians have to gain a higher level of expertise to use this invaluable diagnostic tool more efficiently.

Inter-Observer Agreement on Diffusion-Weighted Magnetic Resonance Imaging Interpretation for Diagnosis of Acute Ischemic Stroke Among Emergency Physicians.

OBJECTIVES: Diffusion-weighted magnetic resonance imaging (DW-MRI) is a highly sensitive tool for the detection of early ischemic stroke and is excellent at detecting small and early infarcts. Nevertheless, conflict may arise and judgments may differ among different interpreters. Inter-observer variability shows the systematic difference among different observers and is expressed as the kappa (Κ) coefficient. In this study, we aimed to determinate the inter-observer variability among emergency physicians in the use of DW-MRI for the diagnosis of acute ischemic stroke. METHODS: Cranial DW-MRI images of 50 patients were interpreted in this retrospective observational cross-sectional study. Patients who were submitted to DW-MRI imaging for a suspected acute ischemic stroke were included in the study, unless the scans were ordered by any of the reviewers or they were absent in the system. The scans were blindly and randomly interpreted by four emergency physicians. Inter-observer agreement between reviewers was evaluated using Fleiss' Κ statistics. RESULTS: The mean kappa value for high signal on diffusion-weighted images (DWI) and for reduction on apparent diffusion coefficient (ADC) were substantial (k=0.67) and moderate (k=0.60) respectively. The correlation for detection of the presence of ischemia and location was substantial (k: 0.67). There were 18 false-positive and 4 false-negative evaluations of DWI, 15 false positive and 8 false-negative evaluations of ADC. CONCLUSIONS: Our data suggest that DW-MRI is reliable in screening for ischemic stroke when interpreted by emergency physicians in the emergency department. The levels of stroke identification and variability show that emergency physicians may have an acceptable level of agreement.

Traumatic central cord syndrome in a 2-year-old child: minor trauma but major complication.

BACKGROUND: Traumatic central cord syndrome (TCCS) is the most frequently encountered incomplete spinal cord injury, and it is a relatively rare situation in children younger than 15 years, but may have serious consequences. METHODS: We report the case of a 2-year-old female child with upper extremity weakness following a simple fall. All vitals and systemic examination findings were normal, except for 2/5 muscular strength in the upper extremities. While radiographic imaging showed no pathologic findings, MRI exposed spinal injury. The patient was treated conservatively with medication only. The medical treatment of the patient consisted of anti-edema treatment with methylprednisolone in the first 24 hours; 330 mg of methylprednisolone infused in the first hour, followed by 59 mg per hour during the next 23 hours. Along with pharmacological treatment, she received physiotherapy sessions during her 11-day hospitalization period. RESULTS: The child had full recovery within 6 months after conservative treatment. CONCLUSION: Neurological deficit without plain radiographic evidence in pediatric spinal trauma patients is a rare but significant incident.

Spontaneous Bladder Rupture and Pelvic Fracture Due To Bladder Cancer.

Bladder rupture is a rare complication following bladder cancer, but has a high mortality rate. Since bladder rupture is an emergency, the diagnosis and treatment of the cancer is usually delayed. Here we report a 56-year-old male patient who presented to our emergency department with severe abdominal pain, abdominal distension, left leg pain and difficulty in walking without history of significant trauma and ended up with diagnoses of spontaneous bladder rupture and non-traumatic pelvic fracture caused by bladder carcinoma.

Paediatric trauma patients and attention deficit hyperactivity disorder: correlation and significance.

INTRODUCTION: Trauma is one of the leading reasons for emergency department (ED) visits in children. Hyperactivity, inattentiveness and impulsiveness may contribute to injury proneness. The aim of this study was to evaluate the prevalence and role of attention deficit hyperactivity disorder (ADHD) in children with trauma. METHODS: Trauma patients aged 3-17 attending the ED were included in the study group. Parents were informed after medical care had been given to their children, and demographic data and information about the trauma were collected. Later, parents were asked to complete the Conners' Parent Rating Scales-Revised questionnaire for ADHD symptoms. The control group consisted of children of similar age and sociocultural characteristics who attended the hospital for reasons other than trauma. Cases in which the child apparently had no active role in the trauma or where the parents did not complete the Conners' Parent Rating Scales-Revised questionnaire were excluded from the study. RESULTS: Fifty-five children were included in the study group (mean age 7.49 (range 3-14; SD 3.3); 33 (60%) were male). The control group was statistically similar to the study group. The most common trauma mechanism was falls (n=31, 56.4%). All the subscale scores were significantly higher in the study group, and previous trauma-related ED visits were associated with significantly higher subscale scores. CONCLUSION: The data suggest that children who make repeated trauma-related ED visits have a predisposition to ADHD, and they may benefit from screening for this disorder while in the ED.