The impact of a heat wave on mortality in the emergency department.

Extreme heat wave increases the number of emergency department (ED) admissions and mortality rates. The purpose of our study is to investigate the effects of the heat wave experienced in Izmir province of Turkey on mortality.During a 9-day period between 17th and 25th June 2016 (study period), air temperature values were higher than the seasonal norms in Izmir, Turkey. In this cross-sectional study, nontraumatic admissions and in-hospital mortality rates were compared this historical interval of the extreme heat wave with the same period of the previous year and the other 21 days of June 2016.The average air temperature between 17th and 25th June 2016, was higher than the average air temperature of the previous year's same period and the average air temperature from the other 21 days of June 2016 (27.8 ±â€Š3.6 °C, (24.5 ±â€Š1.9°C, 24.1 ±â€Š2.1°C, respectively) (P <.01)During the study period, the mean number of ED visits and mortality rates were significantly higher than the previous year's same period (320 ±â€Š30/day vs 269 ±â€Š27/day, [P <.01], and 1.6% vs 0.7%, [P <.01]).Although the admission rate was similar between the study period and the other 21 days of June 2016 (320 ±â€Š30/day vs 310 ±â€Š32/ day, [P = .445]); in-hospital mortality rate was significantly higher during study period (1.6% vs 0.7%, [P <.01]).During the extreme heat waves, ED admissions and in-hospital mortality rates are increased. Precautions should be addressed for adaptation of people to extreme hot weather.

A rare entity in ED: Normal lipase level in acute pancreatitis.

Acute pancreatitis can have a variable presentation and diagnosis is based on clinical presentation, serum amylase and lipase levels and computed tomography. Negative predictive value of serum lipase in diagnosing acute pancreatitis is approximately to 100 percent and a normal blood lipase level in acute pancreatitis is an extremely rare condition. Here we reported two cases with normal serum amylase and lipase levels.

Utility of Computed Tomography in Elbow Trauma Patients with Normal X-Ray Study and Positive Elbow Extension Test.

BACKGROUND: Elbow fractures are a common injury seen among emergency department trauma patients. Despite its high frequency, there is no standardized method of diagnosis using conventional x-ray imaging for trauma patients presenting with elbow pain and restricted elbow movement. OBJECTIVE: We aimed to assess trauma patients, using computed tomography (CT), who present with a positive elbow extension test and have no evident fracture on x-ray study. METHODS: Patients presented to our emergency department with elbow trauma and were evaluated between April 2010 and March 2011. A CT scan of the injured elbow was ordered for patients with pain on elbow extension (a positive elbow extension test) and no evidence of fracture on x-ray study. All CT and x-ray images were evaluated by a designated radiologist. RESULTS: One hundred and forty-eight patients presented to our emergency department with elbow trauma. Two patients were excluded from the study, one with former motion disability and another with an open fracture. In the remaining patients, there were 32 fractures in total. Forty-three of 114 patients without fracture signs had a positive elbow extension test and 4 of these patients refused CT imaging. Fractures were found in 5 (12.8%) of the 39 patients assessed with CT. CT imaging found that two of these patients had a radial head fracture, two others had an olecranon fracture, and one patient had a coronoid fracture. CONCLUSIONS: We recommend CT as an additional evaluation imaging study for trauma patients who have a positive elbow extension test and who present with no apparent fracture on x-ray imaging.

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.

Rabies Suspected Animal Contact Cases in a City with Animal Husbandry and the Appropriateness of Prophylactic Procedures.

OBJECTIVES: This study aims to evaluate the features of rabies suspected animal contact cases in the emergency department and the appropriateness of administering post-exposure prophylaxis procedures according to World Health Organization (WHO) instructions. METHODS: Rabies suspected animal contact cases that applied to the emergency department between August 2012 and December 2013 were included in the study. Patients' data were obtained retrospectively from patient files, records of hospital automation system, and the "Rabies Suspected Animal Contact Cases Examination Form". The post-exposure prophylaxis recommended by the WHO were compared to the prophylactic applications administered by the emergency department. RESULTS: A total of 515 cases were included in the study. According to WHO classification, cases involving category 3 injuries (n=378, 73.4%) were more common than the others (p>0.0001). Compared to post-exposure prophylaxis recommendations by the WHO, 44.7% of all cases (n=230) were administered inappropriate prophylaxis. Thirty-seven percent of cases received less rabies Ig than recommended, despite category 3 contact. Six percent of cases with category 2 contact were given unnecessary rabies Ig and all cases with category 1 contact (1.5% of all cases) were given unnecessary rabies vaccine. CONCLUSIONS: We observed that in 44.7% of cases, post-exposure prophylaxis was applied inappropriately according to WHO instructions. Not only were there unnecessary vaccine and Ig applications, there were also missing prophylaxis procedures. Updating the current "Rabies Prevention and Control Directive" plus educating and controlling healthcare personnel on a regular schedule may help prevent inadequacies in prophylactic application.

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.

Determination of a predictive cutoff value of NT-proBNP testing for long-term survival in ED patients with acute heart failure.

OBJECTIVE: The main objective of this study was to determine a predictive cutoff value for plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) that could successfully predict the long-term (4-year) survival of patients with acute heart failure (HF) at the time of admission to the emergency department (ED). To our best knowledge, our study is the first research done to identify a predictive cutoff value for admission NT-proBNP to the prescriptive 4-year survival of patients admitted to ED with acute HF diagnosis. METHODS: NT-proBNP levels were measured in plasma obtained from 99 patients with dyspnea and left ventricular dysfunction upon admission to the ED. The end point was survival from the time of inclusion through 4 years. RESULTS: The mean age of the patients in this study was 71.1 ± 10.3 years; 50 of these patients were female. During the 4-year follow-up period, 76 patients died; survivors were significantly younger than non-survivors (64.26 ± 11.42 years vs 72.83 ± 11.07 years, P = .002). The optimal NT-proBNP cutoff point for predicting 4-year survival at the time of admission was 2300 pg/mL, which had 85.9% sensitivity and 39.1% specificity (95% confidence interval, area under the curve: 0.639, P = .044). CONCLUSION: Elevated NT-proBNP levels at the time of admission are a strong and independent predictor of all-cause mortality in patients with acute HF 4 years after admission. Furthermore, the optimal cutoff level of NT-proBNP used to predict 4-year survival had high sensitivity. However, especially in the case of long-term survival, additional prospective, large, and multicenter studies are required to confirm our results.

Predictive cutoff point of admission N-terminal pro-B-type natriuretic peptide testing in the ED for prognosis of patients with acute heart failure.

OBJECTIVE: The main objective of this study was to determine a cutoff level of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) that could successfully predict the short- and long-term prognosis of patients with acute heart failure at the time of admission to the emergency department. The results of our study are presented in context with previously published literature. We believe that the present study will be useful and salutary for the progress of literature. METHODS: N-terminal pro-B-type natriuretic peptide plasma levels were obtained from 100 patients with shortness of breath and left ventricular dysfunction upon admission to the emergency department. All patients underwent follow-up evaluations 30 days and 1 year after admission. The end point was defined as all-cause mortality. RESULTS: The mean age of the patients in this study was 70.8 ± 11.6 years, and 51% were female. All-cause mortality at the 30-day and 1-year follow-up evaluations was 21.2% and 53.5%, respectively. We determined that the optimal NT-proBNP cutoff point for predicting 30-day mortality at the time of admission was 9152.4 pg/mL, with a 71.4% sensitivity and an 81.3% specificity (95% confidence interval, area under the curve: 0.726; P = .002). The optimal NT-proBNP cutoff point for predicting 1-year mortality at the time of admission was 3630.5 pg/mL, with an 83.0% sensitivity and a 52.2% specificity (95% confidence interval, area under the curve: 0.644; P = .014). CONCLUSION: Elevated NT-proBNP levels at the time of admission are a strong and independent predictor of all-cause mortality in patients with acute heart failure at 30 days and 1 year after admission. Furthermore, the optimal cutoff level of NT-proBNP used to predict 30-day and 1-year mortality had high sensitivity.

Etofenamate associated with Lyell syndrome: a case report.

Toxic epidermal necrolysis (Lyell syndrome) is a rare, acute, and potentially life-threatening mucocutaneous disease that is most often triggered by drugs. This is the first case of toxic epidermal necrolysis because of treatment with etofenamate of which we are aware.

Sedative-hypnotic medication exposures and poisonings in Izmir,Turkey.

The aim of this study was to analyse intoxications concerning sedative-hypnotic medication patients admitted to the Department of Emergency Medicine in Dokuz Eylul University Hospital (EMDEU) between 1993 and 2005. Demographics of the patients, characteristics of sedative-hypnotic exposures, performed treatment attempts and outcome of the poisoned patients were recorded on standard data forms that were later entered into a computerized database programme. Related to the sedative-hypnotic exposures, 686 poisoning cases were admitted to the EMDEU. Mean age was 10.8 +/- 6.5 years among the paediatric age group (<17 years old, 169, 24.6%) and 30.3 +/- 12.8 years among the adult group (>17 years old,509, 74.2%). The most common sedative-hypnotic agents were benzodiazepines (286, 35.8%), alprazolam accounted for41.6% of them (119). Most of the patients admitted to EMDEU were asymptomatic (61.7%). Observation alone was recommended in 53.9% of EMDEU cases. Although prescription of benzodiazepines is restricted, benzodiazepine was the most common cause of sedative-hypnotic medication exposures. As only a minority of patients (3%) had clinically serious signs and symptoms, most of the overdoses might be under toxic levels or the decontamination methods might be efficient. In this study, the clinical outcome of the patients is relatively better than previous results described in literature.

Massive intracranial hemorrhage associated with the ingestion of dimethyl sulfoxide.

Dimethyl sulfoxide (DMSO) has been widely used in the treatment of arthritis and certain inflammatory diseases, and is also considered an alternative remedy for cancer even if not supported by concrete evidence. This report illustrates the first case of a fatal complication following the illicit use of this agent. A 55-y-old man who reportedly ingested 500 mg acetaminophen and approximately 1 ml DMSO solution was brought to the emergency department after experiencing 2 tonic-clonic seizures. He had been diagnosed with lung mesotelioma with brain metastases which caused no neurologic deficit. The ingested DMSO was the first dose within the last 3 mo. Examination revealed right-sided hemiplegia. Unenhanced computed tomography of the head showed 3 hemorrhagic areas with blood-cerebrospinal fluid at the left parietal, occipital and frontal regions accompanied by a midline shift. Despite initial resuscitation, 2 units of fresh frozen plasma and antiedema treatment, the patient experienced cardiac arrest that did not respond to resuscitative measures. DMSO can cause massive intrametastatic hemorrhage, and neurologic deterioration can be profound in patients with metastatic brain lesions.