ECG alterations suggestive of hyperkalemia in normokalemic versus hyperkalemic patients.

BACKGROUND: In periarrest situations and during resuscitation it is essential to rule out reversible causes. Hyperkalemia is one of the most common, reversible causes of periarrest situations. Typical electrocardiogram (ECG) alterations may indicate hyperkalemia. The aim of our study was to compare the prevalence of ECG alterations suggestive of hyperkalemia in normokalemic and hyperkalemic patients. METHODS: 170 patients with normal potassium (K+) levels and 135 patients with moderate (serum K+ = 6.0-7.0 mmol/l) or severe (K+ > 7.0 mmol/l) hyperkalemia, admitted to the Department of Emergency Medicine at the Somogy County Kaposi Mór General Hospital, were selected for this retrospective, cross-sectional study. ECG obtained upon admission were analyzed by two emergency physicians, independently, blinded to the objectives of the study. Statistical analysis was performed using SPSS22 software. χ2 test and Fischer exact tests were applied. RESULTS: 24% of normokalemic patients and 46% of patients with elevated potassium levels had some kind of ECG alteration suggestive of hyperkalemia. Wide QRS (31.6%), peaked T-waves (18.4%), Ist degree AV-block (18.4%) and bradycardia (18.4%) were the most common and significantly more frequent ECG alterations suggestive of hyperkalemia in severely hyperkalemic patients compared with normokalemic patients (8.2, 4.7, 7.1 and 6.5%, respectively). There was no significant difference between the frequency of ECG alterations suggestive of hyperkalemia in normokalemic and moderately hyperkalemic patients. Upon examining ECG alterations not typically associated with hyperkalemia, we found that prolonged QTc was the only ECG alteration which was significantly more prevalent in both patients with moderate (17.5%) and severe hyperkalemia (21.1%) compared to patients with normokalemia (5.3%). CONCLUSIONS: A minority of patients with normal potassium levels may also exhibit ECG alterations considered to be suggestive of hyperkalemia, while more than half of the patients with hyperkalemia do not have ECG alterations suggesting hyperkalemia. These results imply that treatment of hyperkalemia in the prehospital setting should be initiated with caution. Multiple ECG alterations, however, should draw attention to potentially life threatening conditions.

Extending knowledge of the clinical picture of Balkan adder (Vipera berus bosniensis) envenoming: The first photographically-documented neurotoxic case from South-Western Hungary.

We report a severe envenoming associated with minimal local symptoms following a Balkan adder (Vipera berus bosniensis) bite in South-Western Hungary. A 63-year-old male with a history of hypertension and sinus bradycardia (45/min) was bitten by a sub-adult specimen of V. b. bosniensis in Somogy County on 04 May 2017. The patient was transported to and treated at the Emergency Department of "Moritz Kaposi" General Hospital, Kaposvár. Locally only pain and minimal swelling with a small haematoma developed on the bitten finger. The abdominal muscles were very tender and guarding was detected upon palpation on the way to hospital. The patient, who had taken his telmisartan (80 mg) tablet in that morning, complained of nausea and dizziness during the first medical examination. The systemic signs included fluctuations in blood pressure (115/85-165/105 mmHg), ECG changes (transient horizontal ST depression in V5-6, and sinus tachycardia (90/min)), severe diarrhoea and vomiting (in 7 episodes). Descending neuromuscular paralysis appeared in the next morning, including complete bilateral ptosis with external ophthalmoplegia, and binocular diplopia. Single-fiber electromyography confirmed the neuromuscular block in the frontalis muscle innervated by the facial nerve. Intense dizziness with uncoordinated movement emerged on the 3rd day. The laboratory findings were mild, including anaemia, hypokalaemia, elevated glutamic-pyruvic transaminase and C-reactive protein levels. The absolute neutrophil count remained almost completely normal. Supportive care and monovalent antivenom (Viper Venom Antitoxin®, Biomed, Warsaw) were applied. The patient was discharged from hospital on the 4th day, although recovery was not complete until 9 days after the bite. This is the first photographically-documented case of neurotoxic envenoming from the South-Western Hungarian distribution range of V. b. bosniensis.

[Patient turnover in a multidisciplinary emergency department]. / Betegforgalmi trendek multidiszciplináris sürgosségi osztályon.

INTRODUCTION: More than twenty emergency departments were opened across Hungary in the past years. Data deficiency on patient flow, trends and lack of knowledge of indicators could raise numerous logistical and organisational problems. AIM: Collection, analysis and provision of data to facilitate successful operations of emergency medical care services. METHOD: During a three-year period investigated, at the multidisciplinary Emergency Department of "Moritz Kaposi" Teaching Hospital, data on patient flow (n = 106,203), epidemiology, triage and international classification of diseases were analysed. RESULTS: Analysis showed 73% of patients were suitable for medical discharge within 24 hours. Predominantly internal medicine, paediatric and neurological diseases indicated hospitalisation (21%). Patients in critical condition were found to be low (<2%). Distinct diurnal, weekly, monthly variations were found. Majority of cases were injuries and intoxications (40%). Low mortality rate (0.3%) validates the effectiveness of stabilisation. CONCLUSIONS: The patient safety value of the examined emergency medical care is great, and could exempt the hospital wards from unjustified hospitalisations of the patients. Orv Hetil. 2017; 158(21): 811-822.

[Analysis of the data of patients presenting for emergency treatment with vertigo]. / A sürgosségi ellátásban szédüléssel jelentkezo betegek adatainak elemzése.

OBJECTIVE: Analyzing the medical record data of patients with the main symptom of vertigo in "Kaposi M6r" Hospital's Emergency Department. METHOD: Retrospective evaluation of patients's medical history with vertigo related diagnoses according to BNO classification. RESULTS: In the year of 2010, 18 000 patients were presented to ED. In 471 cases the symptoms were vertigo related which makes up 3% of the total. Almost half, 46% of these patients were brought in by ambulance medical car. The ratio of women was twice as high as of the men. One fifth, 19% of patients with vertigo gained admission to the ward and 81% of them were discharged in 24 hours. According to the interviews, 4 types of vertigo have been identified: "whirling style" vertigo in 37% of the cases, dizziness in 33% of the cases, presyncope in 12% and "light headedness" in 9%. The remaining 9% couldn't be classified. CONCLUSION: Vertigo is common presenting symptom in emergency department, however it rarely indicates severe condition. The diagnostic value of vertigo classification based on history and brain CT result in identifying the severity of the background condition is questionable. We found that in recognizing the cases which need prompt intervention, thorough neurological examination and the clarification of the vertigo's circumstances proved to be helpful.

[The simultaneous appearance and treatment of diffuse maxilla and mandible cyst with autotransplantatum. Case report]. / Kiterjedt maxilla és mandibula cysta egyideju elofordulásának esete és kezelése autotranszplantátummal.

The authors have observed 3 simultaneously but independently occurring cysts in the mandible and the maxilla at a 45 years old male patient. A plum sized follicular cyst around the non erupted maxillary # 23 canine and a bean sized follicular cyst around the mandibular # 33 tooth in residual retention and also an infectious, diffuse root cyst developed around the # 35 retained root was found in the mandibular corpus. The surgical extraction of the # 23, 33 residual retention canines, the # 35 retained root and the excision of the cysts were performed in intubation narcosis by two medical teams. For the filling up of the cyst cavities cortical cancellous bone blocks and particulated trabecular bone grafts were used harvested from the coxa. In the case of the infectious mandibular cyst the author's have also used local antibiotic perfusion. This complex therapy resulted in a successful recruitment within a short period of time.

[The combination therapy of an upper permanent impacted canine. Case report]. / Retineált felso maradó szemfog kombinált kezelése. Esetismertetés.

The impaction of the upper canine is the second most common type of developmental anomaly following the impaction of the third molars. The authors have diagnosed the impaction of the left upper canine in the case of a 17 year-old female patient. The failure of the eruption resulting in tooth spacing of the 23 teeth mainly caused esthetical problems for the young patient and her firm request was the treatment of the spacing caused by the residual canine. The authors on the basis of the clinical and radiological examinations prepared the plans of combination therapy of oral surgery and orthodontic therapy, which were welcomed both by the patient, and her parents. The authors by describing the individual steps of the combination therapy and with the presentation of the achieved results' illustrations will review the good esthetical and functional achievements.

[Comparison of wound infection rates after colon and rectal surgeries using triclosan-coated or bare sutures -- a multi-center, randomized clinical study]. / Sebfertozések gyakoriságának összehasonlítása colon- és rectummutétek után triclosan bevonatú varróanyag (PDS plus®) és azonos alapanyagú nem bevont varróanyag (PDS II®) felhasználása esetén - multicentrikus, randomizált, klinikai tanulmány.

BACKGROUND: Surgical Site Infection (SSI) is the third most frequent nosocomial infection, and accounts for 14-16% of all infections. While the treatment of SSI can be very costly, previous results indicated that triclosan may reduce SSI rate. Therefore, we carried out a prospective randomised trial to further evaluate the effect of triclosan after elective colorectal surgery. METHODS: Seven surgical units in Hungary were involved in a prospective, randomised, multicentric clinical trial to compare triclosan coated (PDS plus®) and uncoated (PDS II®) sutures for abdominal wall closure in elective colorectal surgery. Pre- and perioperative variables were recorded in an online database. The primary aims of the study were to determine the incidence of SSI and the pathogens associated with it, as well as evaluation of additional cost of treatment. RESULTS: 485 patients were randomised. SSI occurred in 47 cases (12.5%), of those 23 (12.23%) from the triclosan group (n = 188) and 24 (12.18%) from the uncoated group (n = 197, p = 0.982). In 13 (27.66%) cases late appearance of SSI was detected, of those 4 patients with triclosan coated suture (8.51%) and 9 patients with uncoated suture (19.15%, p = 0.041). There was no difference between the type of incisions or elective colon and rectal resections in terms of incidence of SSI. CONCLUSION: Beneficial effect of triclosan against Gram positive bacteria could not be confirmed in our study due to the relatively low number of patients with SSI. Furthermore, triclosan did not influence the incidence of SSI due to Gram negative bacteria. SSI rate decreased by 50% compared to our previous study, however, it was regardless of the use of coated or uncoated PDS loop. Finally, operative factors were more important than patient's risk factors in terms of incidence of SSI. In case SSI developed, delayed discharge from hospital as well as special wound care significantly increased overall cost of treatment.

[CS circular staplers for rectal surgery--a multicenter prospective study]. / CS(R) körvarrógépek alkalmazása rectumanastomosisoknál--Multicentrikus prospektív klinikai vizsgálat.

While circular staplers are used worldwide - especially for rectal anastomoses - there are relatively few publications on the effectiveness of these instruments. Between May 2008 and March 2009 in a prospective multicenter surveillance study 136 patients were enrolled from nine surgical units in Hungary. Rectal anastomoses were performed mainly in the upper and middle third of the rectum. In 115 cases adenocarcinoma, in 16 patients other type of malignant tumors and in 5 cases with anastomosis in the distal third were estimated too. 20 laparoscopic and 116 "conventional" surgery was performed. 32 mm diameter type CS circular staplers were used in 50, 28 mm in 85, and 25 mm in one case. Intraoperative technical failure of the device occurred in four cases, immediate correction were performed successfully in all of these patients and they recovered without postoperative complications. Late anastomotic leaks were detected in five patients, of which three healed spontaneously and two required reoperation. In the whole series two patients died representing a 1.4 percent mortality rate. The CS circular staplers proved to be appropriate for infraperitoneal rectal anastomoses.

[Late complication after mesh repair of incisional hernias: pseudocyst formation]. / A hegsérvek hálóval történo rekonstrukcióját követo késoi szövodmény: a pseudocysta-képzodés.

INTRODUCTION: Using mesh for hernia repair is a very common procedure; they are particularly useful for postoperative incisional hernias. The most common complications of mesh repair are seroma, haematoma or abscess formation. Previous literature data suggested that fibrotic cyst formation appearing in the late postoperative period is relatively rare. However, more recent studies and our own experience indicate that its incidence is more common and we have to consider it in the differential diagnosis of the complications of hernia repair. PATIENTS: 148 incisional hernia mesh repairs were carried out between a period of 1st January, 2001 to 31st December, 2005. Fibrotic pseudocyst formation was observed in five cases. All developed as a late complication between 4 to 25 months postoperatively. An onlay polypropylene mesh was used in each case. All five patients underwent a wide excision of the pseudocyst wall and they recovered without complications. DISCUSSION: The etiology of pseudocyst formation is unclear. Nevertheless, a possible relationship between the development of seroma and haematoma can not be ruled out, despite no fibrotic pseudocyst formation was observed in the early postoperative period. There is no evidence whether the characteristics of the mesh or the way of implantation would have any effect on pseudocyst formation, as well. It is noted that the only treatment of this late complication is surgical excision. Pseudocyst formation might be prevented by the application of sublay and minimally invasive techniques.

Opposite effects of serotonin and interferon-alpha on the membrane potential and function of human natural killer cells.

In an earlier article, we reported that serotonin (5-hydroxytryptamine, 5-HT) inhibits the natural killer cell (NK) cytotoxicity of human whole blood in a dose-dependent manner and that natural human interferon-alpha (IFN-alpha) partially eliminates this effect. Because natural IFN-alpha might contain factors other than IFN, we repeated these experiments with recombinant human interferon-alpha (rhIFN-alpha) and separated blood lymphocytes enriched with NK cells and then demonstrated that IFN really is responsible for this effect. Furthermore, this investigation was carried out to clarify the mechanisms of the action of 5-HT and of rhIFN-alpha on NK cells. The inhibition of the cytotoxicity was pronounced when 5-HT was added at the onset of the cytotoxic assay, whereas the pretreatment of lymphocytes for 18 h only led to a slight inhibition. Moreover, rhIFN-alpha applied 1 h before or 1 h after the addition of 5-HT decreased the inhibitory effect of 5-HT. Flow cytometric analysis involving the use of a voltage-sensitive dye, oxonol, revealed that 5-HT depolarized, whereas rhIFN-alpha hyperpolarized the plasma membrane of the lymphocytes. Thus, it seems likely that the inhibitory effect of 5-HT on the cytotoxicity of peripheral human lymphocytes is due to the depolarization on the plasma membrane of the effector cells and that rhIFN-alpha antagonizes this ability via its hyperpolarizing activity.

Cross-reactivity between human adenoviruses in delayed-type hypersensitivity.

The aim of this study was to determine the antigen responsible for the induction of delayed-type hypersensitivity (DTH) by human adenoviruses (Ads). The estimation of DTH was based on measurement of the extent of swelling of the hind footpads of mice. CsCl density gradient-purified human Ad serotype 6 (Ad6) induced DTH in a dose-dependent manner. In Ad6-sensitized mice, DTH could be elicited by serotypes belonging to the same species of human Ads (types 1 and 5) and by a serotype (type 3) belonging to another species. Latex particles coated with purified hexon antigen prepared from Ad5 had the capacity to sensitize mice and elicit a DTH reaction. We suggest that, for serotypes belonging to species C, the cross-reactive highly conserved T cell epitope of the hexon protein might be responsible for the DTH induction, and furthermore the same epitope might result in the cross-reactivity between serotypes 3 and 6. The possible importance of these data is discussed in relation to human gene therapy through the application of Ad vectors.

[Esophageal operations with thoracoscopy]. / Thoracoscopos nyelocso mutétek.

Between 01.07.1992 and 30.06.1997 we performed thoracoscopic esophagomyotomies in seven patients suffering from achalasia cardiae, and 6 thoracoscopic mobilization of the esophagus because of esophageal cancer. The necessary background for thoracoscopic operations are: practice in minimally invasive surgery, isolated intubation, appropriate instrumentation and readiness for immediate thoracotomy. Following the myotomy, oral feeding started on the 2nd postoperative day. The mean discharge of the patients was on the 6th postoperative day. We compared the pre- and post-operative conditions 6 weeks following the operation x-ray, esophago-gastroscopy, manometry, pH-measurements were performed. Good result of the operations were: all examinations showed marked improvement and all patients had better swallowing and 3 to 9 kg increase of body weight. Thoracoscopic mobilization has been attempted on nine occasions. Thoracotomy was necessary in 3 patients because of a perforation of the left main bronchus, bleeding and tumor infiltration to surrounding areas. The mean mobilization time was 4 hours, but the time original 6 hours with practice was reduced to less than 3 hours. One patient died because of pulmonary complication, recovery of other patients was uneventful.

[The role of laparoscopy in the surgical treatment of colorectal cancer. Initial results]. / A laparoszkópia kezdeti eredményeinek szerepe a colorectalis carcinomák sebészi kezelésében.

The authors have carried out laparoscopically assisted abdomino-perineal rectal resections on a selected group of 8 patients during the past two years. The laparoscopic technique was not accompanied by any complications, while the patients enjoyed the benefits of the procedure. The bowel function of the patients were restored on the 2nd to 3rd day, the mean length of the hospital stay was 8.3 days. On the basis of their own favourable initial experience and recent literature data, the authors discuss the benefits, disadvantages and pitfalls of the laparoscopically assisted technique for surgical treatment of colorectal cancer. The problematics of oncological radicality is analysed.