Utility of HAPS for predicting prognosis in acute pancreatitis.

BACKGROUND: Acute pancreatitis (AP) is a common abdominal disorder, which requires early diagnosis and treatment. Several prognostic scoring systems introduced to clinical practice are not suitable in emergency department (ED) because these require much time and complex parameters. Recently, the harmless acute pancreatitis score (HAPS) has been introduced to identify AP with a nonsevere course. The aim of this study was to determine the utility of HAPS in predicting the severity of AP. METHODS: All patients aged >16 years who were diagnosed as AP in ED were enrolled in this retrospective study. The study included 144 patients with a mean age of 58.7±15.4 years, and 69 (47.9%) of them were males and 75 (52.1%) were females. Patient data were collected from hospital database. The utility of HAPS was analyzed and compared using the Ranson's score. RESULTS: HAPS was statistically significant for predicting mild disease (p=0.008) and has demonstrated a specificity of 81%, a positive predictive value (PPV) of 96%, and an odds ratio of 5.57 (1.51-20.50). The predictability of Ranson's scores was not significant. The measure of agreement (κ) between the two scores was 0.15, indicating a low agreement. CONCLUSION: HAPS is a simple and useful scoring algorithm to predict the non-severe course of AP in ED. HAPS-0 patients did not require early aggressive treatments and advanced radiological screening tools during the early stages of the disease.

Improvement in physician pain perception with using pain scales.

BACKGROUND AND AIMS: Acute pain is the most common reason for visits to the emergency department (ED). The underuse of analgesics occurs in a large proportion of ED patients. The physician's accurate assessment of patients' pain is a key element to improved pain management. The purpose of this study was to assess if physicians' perception of pain can improve with looking at the pain score of the patient marked on VAS. STUDY DESIGN: This was a single-center, cross-sectional prospective observational study, that took place in an academic ED. METHODS: All adult ED patients presenting with a painful condition were enrolled to the study. In the first phase of the study, the physician rated his/her opinion about the patient's pain on a 100 mm VAS, in a blinded fashion to the patient's pain score. In the second phase, the physician rated his/her opinion after looking at the pain scale marked by patient. RESULTS: 587 patients (295, in first and 292, in second phase) were enrolled. The groups were not statistically different for demographic data. The physician's perception of pain was lower than the patient's pain score at both phases of the study. Insight of the patient's pain score on VAS increased the physician's pain perception significantly (p = 0.03). During the second phase, physicians ordered significantly more analgesic medications to the patients (p = 0.03). CONCLUSION: The physicians' perception of the patients' pain differs significantly from the pain that the patient is experiencing. VAS helps to bring the physicians impression of pain perception to the level of pain that the patient is actually experiencing and resulted in ordering more analgesics to the patients. Implementation of a pain assessment tool can raise the physician's perception of the pain and may improve pain management practices and patient satisfaction.

Utility of 360-degree assessment of residents in a Turkish academic emergency medicine residency program.

OBJECTIVES: This study was designed to test a 360-degree assessment tool for four of the emergency medicine resident competencies as outlined by the Council of Residency Directors in Emergency Medicine on patient care, communication skills, professionalism and system based practice in an academic Emergency Department. MATERIAL AND METHODS: Using the competency framework of the American Accreditation Council for Graduate Medical Education, a 57 item-containing assessment tool was created. Based on the different exposure aspects of the involved evaluator groups, the items were integrated into seven different evaluation forms. All sixteen of 16 residents and members from each evaluator group voluntarily participated in the study. Internal consistency scores, multilayer and multilevel Kappa values were measured. Evaluator group scores and resident ranks in competency areas were compared. All evaluators were asked to comment on the applicability and usefulness of the assessment tool in emergency medicine. RESULTS: Seven groups completed a total of 1088 forms to evaluate 16 residents. The reliability coefficient for the faculty members was 0.99 while it was 0.60 for the ancillary staff. The interrater Kappa values for faculty members, nurses and peer assessment were relevant with a value of greater than 70%. DISCUSSION AND CONCLUSION: Our results showed that the 360-degree assessment did meet expectations by the evaluator group and residents, and that this method was readily accepted in the setting of a Akdeniz University Emergency Medicine residency training program. However, only evaluations by faculty, nurses, self and peers were reliable to have any value. Doing a 360° evaluation is time and effort consuming and thus may not be an ideal tool for larger programs.

Traditional Kehr's sign: Left shoulder pain related to splenic abscess.

Kehr’s sign was originally described by the German surgeon Hans Kehr (1862-1916). It is a classical example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the clavicle. We present a case of a 21-year-old woman admitted to the emergency department with the chief complaint of left shoulder pain related to splenic abscess.

Value of the swimming position and arm traction in visualizing the cervicothoracic junction over the standard lateral cervical X-ray.

BACKGROUND: The cervicothoracic junction (CTJ) is often inadequately visualized on lateral cervical X-rays due to anatomic variations and technical factors. AIMS: The aim of this study was to investigate whether the swimmer's view and arm traction could enhance the image field on the standard lateral cervical (SLC) X-ray. METHODS: The study was conducted in a university hospital in October 2007 with 40 volunteers. SLC X-ray, lateral cervical X-ray in the swimming position, and lateral cervical X-ray with arm traction were performed in the supine position. The enhancements in the image fields were analyzed. RESULTS: There was a statistically significant difference for the increases in the view of cervical spines between SLC X-ray (12.60 +/- 7.48) and either lateral cervical X-ray with arm traction (21.73 +/- 9.78; p = 0.000) or in the swimming position (21.20 +/- 14.19; p = 0.001). Both arm traction and swimming position increased the field of view by approximately 9 mm. Increased visualization of the cervical spine occurred for 24 of the 40 participants using the arm traction view (60.0%) and 23 participants (57.5%) using the swimming position view-results found to be statistically similar according to the >/= 1/3 caudal vertebral height visualized (p = 0.902). Using the lateral cervical X-ray view, the number of cervical vertebrae visualized differed according to body mass index (BMI)-seven cervical vertebrae were visualized in participants with a BMI < 25 and six vertebrae were visualized in participants with a BMI >/= 25 (p = 0.007). CONCLUSION: Lateral cervical X-rays with arm traction and swimming position enhance the view of SLC X-rays. An initial SLC X-ray including the lower third of the cervical spine (with C7), arm traction, and swimming position may be beneficial in visualizing the CTJ. However, patients with an increased BMI are unlikely to benefit from all three methods.

Oral deltamethrin ingestion due in a suicide attempt.

Deltamethrin intoxication is uncommon throughout the world. The toxicity of insecticides containing pyrethroids is considered relatively lower than that of other insecticides such as compounds containing organophosphate. Acute deltamethrin poisoning due to oral ingestions is relatively rare. This report describes a case of a 32-year-old woman admitted to the emergency department (ED) with irritability, muscle cramps, discomfort, sensation of burning, loss of sensation in her feet and arms and dyspnea due to deltamethrin ingestion. Deltamethrin intoxication should be considered as a differential diagnosis in patients presented to ED with nonspecific neurological symptoms. The supportive treatment in acute phase of intoxication is critical in the management of these patients since higher doses of deltamethrin ingestion may cause severe symptoms (Tab. 2, Ref. 16). Full Text (Free, PDF) www.bmj.sk.

Anxiety and depressive disorders in patients presenting with chest pain to the emergency department: a comparison between cardiac and non-cardiac origin.

OBJECTIVE: The aim of this study was to determine the prevalence of anxiety and depressive disorders in patients presenting with chest pain to the Emergency Department (ED) and determine if there is a relationship between these and cardiac vs. non-cardiac chest pain. METHODS: This prospective cross-sectional study was performed in an urban tertiary care hospital between March and October 2005. Consecutive patients presenting with chest pain were enrolled in the study. The prevalence of anxiety and depressive disorders in patients with chest pain were determined by using the Hospital Anxiety and Depression Scale. RESULTS: A total of 324 patients presented to the ED with chest pain during the study period. The mean age of the patients studied was 50.5 +/- 14 years; 67% were men and 33% were women. Of the 324 study patients, 194 (59.9%) patients were diagnosed with non-cardiac chest pain, 16 (4.9%) with stable angina, 84 (25.9%) with unstable angina, and 30 (9.3%) with acute myocardial infarction. No statistically significant differences were determined between patients with cardiac and non-cardiac chest pain both for anxiety (40% vs. 38.1%, respectively; p = 0.737) and depressive disorders (52.3% vs. 52.1%, respectively; p = 0.965). CONCLUSION: Anxiety and depressive disorders are common among patients presenting with chest pain to the ED. However, the prevalence of anxiety and depressive disorders is similar between patients with chest pain of cardiac and non-cardiac origin. Chest pain should not be attributed to an anxiety or depressive disorder before organic etiologies are excluded.

Determination of difficult intubation in the ED.

OBJECTIVE: The aim of this study is to determine the predictors of difficult intubation in the emergency setting. METHODS: This prospective observational clinical study was conducted in the emergency department (ED) of a University Hospital with an annually census of 50 000 visits from May 2005 to May 2007. All patients requiring intubation in the ED were included into the study. During the study period, same airway management protocol was used all intubations. The study form included patient's demographic and variables according to intubation such as the Cormack-Lehane grade, modified LEMON score, Glasgow Coma Scale score, success rate, and associated complications. RESULTS: A total of 366 patients were included in the study. The mean age of the study patients was 46.8 +/- 22.8, and 68.6% (n = 251) of them were male. A total of 86 (23.5%) patients were classified in the difficult intubation group and 280 (76.5%) patients in easy intubation group. Logistic regression analysis performed by the variables found to be significant in the univariate analysis revealed thyroid-to-hyoid distance less than 2 fingers (odds ratio, 3.34; 95% confidence interval, 1.35-8.27; P = .009) as an independent factor complicating the intubation. Cormack and Lehane classification was strongly related to difficult intubation. Intubation was more difficult from grade 1 to 4 (11% vs 25.2% vs 34% vs 81.8%, respectively; P = .000). CONCLUSIONS: The thyroid-to-hyoid distance less than 2 fingers is the only independent variable in predicting difficult intubation. Mallampati classification is not a useful tool in classifying the difficult intubation in the ED that the "LEMON" acrostic can be modified to "LEON".

Intravenous paracetamol or morphine for the treatment of renal colic: a randomized, placebo-controlled trial.

STUDY OBJECTIVE: This randomized, placebo-controlled trial evaluates the analgesic efficacy and safety of intravenous single-dose paracetamol and morphine for the treatment of renal colic. METHODS: We conducted a randomized, double-blind, placebo-controlled clinical trial comparing single intravenous doses of paracetamol (1 g), morphine (0.1 mg/kg), and placebo (normal saline solution) for patients presenting to the emergency department (ED) with suspected renal colic. Subjects with inadequate pain relief at 30 minutes received rescue fentanyl (0.75 microg/kg). We compared changes in pain intensity 30 minutes after treatment among the 3 arms, as well as the need for rescue medication and the presence of adverse effects. RESULTS: Six hundred forty-five consecutive patients were screened for study and 165 were entered. Eight subjects were subsequently excluded from analysis because of protocol violations and 11 were excluded because of uncertain diagnoses, leaving 146 subjects available for analysis. The mean reduction in visual analogue scale pain intensity scores at 30 minutes was 43 mm for paracetamol (95% confidence interval [CI] 35 to 51 mm), 40 mm for morphine (95% CI 29 to 52 mm), and 27 mm for placebo (95% CI 19 to 34 mm). Statistically significant mean differences in pain intensity reductions compared with those for placebo were observed for paracetamol (16; 95% CI 5 to 27; P=.005) and morphine (14; 95% CI 0.4 to 27; P=.05); however, no difference was found between paracetamol and morphine (2; 95% CI -13 to 16; P=.74). Rescue analgesics at 30 minutes were required by 21 subjects (45%) receiving paracetamol, 24 subjects (49%) receiving morphine, and 34 subjects (67%) receiving placebo (P=.08). At least 1 adverse effect was experienced by 11 (24%) receiving paracetamol, 16 (33%) receiving morphine, and 8 (16%) in the placebo group (P=.14). There were no serious adverse events. CONCLUSION: Intravenous paracetamol is an efficacious and safe treatment for ED patients with renal colic.

Artificial neural network in predicting craniocervical junction injury: an alternative approach to trauma patients.

OBJECTIVE: The aim of this study is to determine the efficiency of artificial intelligence in detecting craniocervical junction injuries by using an artificial neural network (ANN) that may be applicable in future studies of different traumatic injuries. MATERIALS AND METHODS: Major head trauma patients with Glasgow Coma Scale

Portal vein thrombosis related to Cassia angustifolia.

INTRODUCTION: Cassia angustifolia (Senna), used as a laxative, is a plant from the Fabaceae family. It includes hydroxyanthracene glycosides, also known as Senna Sennoside. These glycosides stimulate the peristalsis of the colon and alter colonic absorption and secretion resulting in fluid accumulation and expulsion. In the literature, there are reports illustrating the hepatotoxic effects of Cassia angustifolia but there is no report of portal vein thrombosis caused by Cassia Angustifolia. CASE REPORT: A 42-year-old woman was admitted to the emergency department with a five-day history of worsening epigastric pain, anorexia, episodic vomiting, and intermittent fever. She reported that she had boiled dried senna leaves she had bought from herbalists and drank approximately 200 mL daily for two years. Color Doppler screening found an echogen thrombus obliterating portal vein bifurcation and the right branch. The lumen was obstructed at this level and there was no blood flow through it. Treatment with thrombolytics was unsuccessful. DISCUSSION: Severe hepatotoxicity senna use is unusual. The cause of senna-related hepatotoxicity is unclear but could be explained by the exposure of the liver to unusual amounts of toxic metabolites of anthraquinone glycosides. CONCLUSION: Chronic use of Cassia angustifolia may rarely be associated with portal vein thrombosis.

[A second-degree burn related to air bag deployment: a case report]. / Hava yastigina bagli ikinci derece yanik: Olgu sunumu.

Although air bags have been shown to reduce mortality and morbidity in motor vehicle crashes, they are associated with specific injuries. Burns due to air bag deployment account for more than 5% of all air bag injuries and typically involve upper extremities or head and neck. Aside from friction burns, thermal and chemical burns are also seen resulting from the use of certain chemicals for the deployment mechanism. We reported a female patient who presented to the emergency department with a second-degree burn in her left breast, six days after a motor vehicle crash. She was treated with irrigation with saline solution and 2% sodium fusidate ointment. The burn area healed within a week, without any further treatment. Only a slight scar tissue remained after a six-month follow-up.

Appropriateness of emergency department visits in a Turkish university hospital.

AIM: To determine the patterns and appropriateness of patients' use of a university hospital emergency department. METHODS: During a 14-day period in November 1998, we collected demographic and socio-economic data, reasons for preferring emergency department care, and patient visit data from consecutive patients visiting our tertiary-care university hospital emergency department. The principle investigator reviewed the study information forms and classified visits according to the classification of Afilalo into three categories: category I--emergent emergency department visits; category II--needing evaluation within 6 hours, either in emergency department or elsewhere; or category III--needing evaluation after more than 6 hours. Three emergency medicine residency-trained physicians determined the appropriateness of emergency department evaluation. Patients in the categories II and III were retrospectively reclassified as appropriate or inappropriate, according to availability of care at the outpatient facility at the hour of initial emergency department presentation. RESULTS: Complete data were collected from 1,155 (96.2%) of 1,201 patients visiting our emergency department during the study period. There were 69% (n=795) appropriate of visits. The mean stay at emergency department of inappropriate users lasted 66 min. The main reasons of inappropriate users to prefer emergency department care were its proximity, satisfaction with care, worsening symptoms, and unavailability of care in a regular clinic. CONCLUSION: Although inappropriate emergency department usage was high, these patients had relatively short emergency department stays. The impact on emergency department resource utilization and "over-crowding" by these patients may not be as great as commonly perceived.

The efficacy of urinalysis, plain films, and spiral CT in ED patients with suspected renal colic.

We determined the diagnostic value of urinalysis and plain films in patients with suspected renal colic presenting to an emergency department (ED). Over a 1-year period, 138 patients presented to the ED during the daytime with suspected renal colic, but for technical reasons the diagnostic modalities used in the study could be completed for only 99 patients, and 34 patients were lost to follow-up. A urinalysis; kidney, ureter, and bladder film; and spiral computed tomography (CT) were performed on each patient. The presence of urinary tract stones was determined by their definite presence on helical CT and/or passage of a stone on clinical follow-up (average follow-up = 3 months). A urinary stone was visualized on spiral CT or passed in the urine in 54 of the patients. Using helical CT findings or passage of a stone as the gold standard, plain radiography had a sensitivity of 69% and specificity of 82%. Urinalysis had a sensitivity of 69% and specificity of 27%. The sensitivity increased to 89% if either test was positive, but the specificity remained low at 27%. The sensitivity and specificity of CT in the diagnosis of urinary stones was 91%. Urinalysis and plain films are much less accurate than helical CT for confirming the diagnosis of acute urolithiasis. Further evaluation of the clinical and cost-effectiveness of helical CT should be done to determine its role in the work-up of these patients.