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Background There is a lack of specificity of the analgesic agents used to treat headache and underlying acute carbon monoxide poisoning. Objective To compare effectiveness of “oxygen alone” vs “metoclopramide plus oxygen” vs “metamizole plus oxygen” therapy in treating carbon monoxide–induced headache. Design A prospective, multicenter, double-blind, controlled trial. Setting Three emergency departments in Turkey. Population Adult carbon monoxide poisoning patients with headache. Methods A total of 117 carbon monoxide-intoxicated patients with headache were randomized into 3 groups and assessed at baseline, 30 minutes, 90 minutes, and 4 hours. Main Outcome Measure The primary outcome was patient-reported improvement rates for headache. Secondary end points included nausea, need for rescue medication during treatment, and reduction in carboxyhemoglobin levels. Results During observation, there was no statistical difference between drug type and visual analog scale score change at 30 minutes, 90 minutes, or 4 hours, for either headache or nausea. No rescue medication was needed during the study period. The reduction in carboxyhemoglobin levels did not differ among the 3 groups. Conclusion The use of “oxygen alone” is as efficacious as “oxygen plus metoclopramide” or “oxygen plus metamizole sodium” in the treatment of carbon monoxide–induced headache.

Objective: Suicide is a complex behavior concerning a number of psychological, biological, social and cultural factors. It is also an important public issue, as well as one of the leading causes of...

After a Turkish scientist took Nobel Prize due to his contributions to understand clock genes, melatonin, closely related to these genes, may begin to shine. Melatonin, a hormone secreted from the pineal gland at night, plays roles in regulating sleep-wake cycle, pubertal development and seasonal adaptation. Melatonin has antinociceptive, antidepressant, anxiolytic, antineophobic, locomotor activity-regulating, neuroprotective, anti-inflammatory, pain-modulating, blood pressure-reducing, retinal, vascular, anti-tumor and antioxidant effects. It is related with memory, ovarian physiology, and osteoblast differentiation. Pathologies associated with an increase or decrease in melatonin levels are summarized in the review. Melatonin affects by four mechanisms: 1) Binding to melatonin receptors in plasma membrane, 2) Binding to intracellular proteins such as calmoduline, 3) Binding to Orphan nuclear receptors, and 4) Antioxidant effect. Receptors associated with melatonin are as follows: 1) Melatonin receptor type 1a: MT1 (on cell membrane), 2) Melatonin receptor type 1b: MT2 (on cell membrane), 3) Melatonin receptor type 1c (found in fish, amphibians and birds), 4) Quinone reductase 2 enzyme (MT3 receptor, a detoxification enzyme), 5) RZR/RORα: Retinoid-related Orphan nuclear hormone receptor (with this receptor, melatonin binds to the transcription factors in nucleus), and 6) GPR50: X-linked Melatonin-related Orphan receptor (it is effective in binding of melatonin to MT1). Melatonin agonists such as ramelteon, agomelatine, circadin, TIK-301 and tasimelteon are introduced and side effects will be discussed. In conclusion, melatonin and related drugs is a new and promising era for medicine. Melatonin receptors and melatonin drugs will take attention with greater interest day by day in the future.Saat genlerini anlamamıza olan katkısından dolayı bir Türk bilim adamı Nobel ödülünü aldıktan sonra, bu genlerle yakın ilişkili olan melatoninin önemi arttı. Melatonin, pineal bezden gece salınan bir hormondur, uyku/uyanıklık döngüsünde, pubertal gelişimde ve mevsimsel adaptasyonda rol alır. Melatoninin antinosiseptif, antidepresan, anksiyolitik, antineofobik, locomotor aktiviteyi düzenleyici, nöroprotektif, antiinflamatuvar, ağrı düzenleyici, kan basıncını düşürücü, retinal, vasküler, tümör baskılayıcı ve antioksidan etkileri vardır. Hafıza, over fizyolojisi ve osteoblast diferansiasyonuyla ilişkilidir. Melatonin seviyelerinde artış veya azalışla seyreden patolojiler derlemede özetlenmiştir. Melatonin 4 mekanizmayla etkir: 1) Plazma membranında melatonin reseptörlerine bağlanma, 2) Kalmodulin gibi hücre içi reseptörlere bağlanma, 3) Yetim nükleer reseptörlere bağlanma, 4) Antioksidan etkiler. Melatoninle ilişkili reseptörler şunlardır: 1) Melatonin reseptör tip1a: MT1 (hücre zarında), 2) Melatonin reseptör tip1b: MT2 (hücre zarında), 3) Melatonin reseptör tip1c (balık, amfibiler ve kuşlarda bulunur), 4) Kuinon redüktaz-2 enzimi (MT3 reseptörü, bir detoksifikasyon enzimi), 5) RZR/RORα: Retinoid-ilişkili Yetim çekirdek hormon reseptörü (bu reseptörle melatonin çekirdekte transkripsiyon faktörlerine bağlanır), 6) GPR50: X-geçişli Melatonin-ilişkili yetim reseptör (melatoninin MT1’e bağlanmasında etkilidir). Ramelteon, agomelatin, sirkadin, TIK-301 and tasimelteon gibi Melatonin agonistleri tanıtılacak ve yan etkileri karşılaştırılacaktır. Sonuçta, melatonin ve ilişkili ilaçlar tıpta yeni ve umut vaat eden bir alandır. Melatonin reseptörleri ve ilaçları gelecekte de artan oranda ilgi çekmeye devam edecektir.

Burn is the tissue damage on body caused due to various reasons. Although all burns caused by hot liquids are investigated as scalding burns, dense liquid burns (DLB) caused by such as milk and oil are different from other burns. The aim of this study was to report the properties of DLB.Patients admitted to the Emergency Service of Atatürk University Hospital, with DLB from June 2003 to December 2008, were examined retrospectively.During the study, 28 DLB patients were admitted to the emergency service. The most common admission were found in autumn 28.6% (n=8), and in May and June, 17.9% (n=5). The frequency of burns on the right upper extremity was seen in 50% (n=14) of the patients. The burn degree of all patients was determined as 2(nd) degree. Seventy-five percent (n=21) of the patients were discharged, 14.3% (n=4) were hospitalized. None of the patients died.Dense liquid burns is a burn type that is commonly seen in women, absolutely causing 2(nd) degree burns, frequently reported in upper extremity and head/neck regions, and in contrast to other studies, in our region it is completely seen in patients living in city centre.Yanık sıklıkla sıcak suya bağlı (haşlanma) oluşan hayatı tehdit eden bir durumdur. Bununla birlikte, bizim deneyimlerimize göre, sıcak süt ve yağ gibi yoğun sıvılara bağlı yanıklar, klinik seyir ve taburculuk açısından farklılıkları sebebi ile ayrı değerlendirilmelidir. Burada yoğun sıvılara bağlı yanıkların özelliklerini sunduk.Acil servisimize 2003 ile 2008 yılları arasında yoğun sıvılara bağlı yanık sebebi ile başvuran hastaları retrospektif olarak inceledik.Toplam olarak, 28 hasta çalışmaya dahil edildi. Ortalama yaş 26,5 idi ve hastaların %75’i kadındı. Hastaların %89,3’ü acil servisimize direk başvurdu ve %10,7’si başka acil servislerden hastanemize sevk edilmiş idi. Hastaların %75’i acil servisteki tedavilerinin ardından taburcu edildi, %14,3’ü yanık merkezine yatırıldı, %7,1’i başka hastaneye sevk edildi ve %3,6’sı yatışı reddetti. Yanık merkezindeki ortalama yatış süresi 24,5 gündü. Ortalama yanık alanı %3 idi. Vücut bölümlerine göre yanık sıklığı yüzdeleri: Baş ve boyun %39,3, gövde ön yüzü %14,3, gövde arka yüzü %17,9, sağ üst ekstremite %50, sol üst ekstremite %35,7, sağ alt ekstremite %21,4, sol alt ekstremite %89,3. Yanıkların tümü 2. dereceydi.Sıcak süt ve yağa bağlı yoğun sıvı yanıkları sıklıkla kadınlarda görülür. Yanıkların tamamı 2. derecedir.

Introduction: Pneumatosis cystoides intestinalis (PCI) is a rare condition with an unknown origin, defined as the appearance of gas-filled cysts in the intestinal wall. It usually occurs due to other clinical origins. Radiological imaging has been suggested for diagnosis. The treatment varies according to the patient’s clinical condition and radiological imagings from conservative treatment to the intestinal resection.Case Report: A 77 year-old female patient presented to the emergency room with abdominal pain, nausea, vomiting, constipation, and abdominal distention. The patient’s vital signs were in the normal range. Physical examination revealed an abdominal distention with inspection and general abdominal tenderness in all quadrants, especially the right upper side, with palpation. Intestinal-type air-fluid level was seen on direct abdominal radiography; therefore, we performed abdominal CT. CT detected the gall stone with free air around the stone and PCI view on the intestinal wall Conclusion: An emergency physician should keep PCI in mind; they should not misinterpret findings with intestinal obstruction and mesenteric ischemia on radiological scans and clinical signs. An emergency physician should keep PCI in mind. They should not misinterpret findings with intestinal obstruction and mesenteric ischemia on radiological scans and clinical signs

The main aim of this diagnostic case-control study of 136 patients with ovarian cysts (44 patients with ovarian torsion and 92 controls) was to determine the diagnostic value of haematologic inflammatory markers (neutrophil/lymphocyte ratio [NLR], red cell distribution width [RDW] and platelet distribution width [PDW]) for torsioned ovarian cysts. The presence of a torsioned ovarian cyst was identified by a 1.18-fold increase in the NLR (95%CI: 1.04-1.34, P = 0.009), a 1.22-fold increase in the RDW (95%CI: 1.04-1.43, P = 0.023) and a 1.93-fold increase in the PDW (95%CI: 1.19-3.14, P = 0.007). The NLR was the best predictor of a torsioned ovarian cyst (AUC: 0.74; 95% CI: 0.68-0.83). When an NLR cut-off value of 2.44 was used to determine ovarian torsion, the sensitivity, specificity, + LR and -LR were 70.5%, 70.7%, 2.40 and 0.42, respectively. In conclusion, the NLR may have diagnostic and prognostic value in determining torsioned ovarian cysts.

We aimed to determine the frequency of mutations, carrier rates and the association of rare mutations with Familial Mediterranean Fever (FMF) symptoms. There is a need to evaluate as many different populations as possible in order to determine either specific rare mutations or a range of disease-associated mutations. The demographic data and FMF symptoms related to MEFV gene mutations were collected from 731 participants. Exon 2 and exon 10 of the MEFV gene were tested by DNA sequencing. The rare mutations were identified as: M694I (1.1%, n = 12), E148V (0.6%, n = 6), T267I (0.5%, n = 5), L110P (0.2%, n = 2), E167D (0.2%, n = 2), K695R (0.1%, n = 1) and an insertion G (Guanine) mutation (0.4%, n = 4) at the 777th codon of exon 10. We used routine comprehensive detection systems such as Sanger sequence that can catch rare mutations, for definite diagnosis and treatment of FMF disease. © 2015.

1 , Bunyami Ozogul 2 , Umit Avsar 3 Abstract Aim: Electrical burns may develop because of the direct effect of electric current on the cell membrane and smooth muscle of blood vessels and because of the transformation into heat energy when passing through body tissues. Electrical burns account for 3%-5% of all cases of burns. Materials and Methods: A total of 213 patients with electrical burns who were admitted to our emergency department (ED) between 2001 and 2011 were retro- spectively analyzed. Results: The mean age of patients was 33.7±10.8 (min: 18, max: 72 years), and 86.9% (n=185) of the patients were male. The majority of patients (63.4%; n=135) were living in city centers, followed by patients in the village (22.5%; n=48) and the countryside (14.1%; n=30) respectively. The most common occurrence times of the burns were 14:00 (5.6%; n=12) and 10:00-11:00 (4.2%; n=9). Of the patients, 39.4% (n=84) were admitted to our ED between 18:00 and 24:00. Third degree burns were seen in 57.9% (n=127) patients, second degree in 39.4% (n=84), and first degree in 0.9% (n=2). Subarachnoid hemorrhage was accompanied in one patient and acute abdomen in another. Mortality was 1% (n=2) in the burn center. Electrical burns were most frequently seen in August (14.1%; n=30), June (11.3%; n=24), and July (10.3%; n=22). However, it was rarely seen during winter months (16%; n=34). The average days of hospitalization were 26.4±24.8 (min: 1, max: 141 days).

OBJECTIVE: In this study, we aimed to assess the epidemiology of suicide attempts, especially focusing on rates and trends in Northeastern Turkey. MATERIALS AND METHODS: This is a cross-sectional study including 893 parasuicide events recorded prospectively in 17 emergency rooms of state hospitals in two neighboring counties over three years. Information on each case was recorded on a standardized monitoring form that covered a series of sociodemographic and psychosocial features. RESULTS: In 2007, parasuicide rates per 100,000 inhabitants were 47.7 for females, 17.7 for males, and 32.5 for both genders. Suicide attempts were more common in women in all age groups except ≥50 years. The most common methods of deliberate self-harm were as follows: medical drug/toxic substance ingestion (93.3%), hanging (1.7%), and cutting or stabbing (3.6%). Housewives (53.8%) formed the largest group among women. Physical domestic violence was a common reason for suicide attempts in women aged 15-34 years. The only cited reason for suicide attempts that was predominant in males was financial difficulties. A previous psychiatric diagnosis was present in 19.5% of parasuicide cases, and the rate of seeing a doctor for psychiatric reasons in the last 6 months prior to the suicide attempt was 15.8%. CONCLUSION: Self-poisoning is the most common method for attempted suicide. The risk groups in our region appeared to be younger and married females. The epidemiology of suicide attempt cases in our region resembles a mixture of both European and Asian communities' parasuicide patterns. KEYWORDS: suicide attempt, parasuicide, sociodemographic findings, epidemiology. Language: en

We investigated the utility of the red cell distribution width (RDW) in diagnosing acute mesenteric ischemia (AMI) in patients with abdominal pain.The patients were divided into two groups in this retrospective case-control study: patients with AMI and patients with abdominal pain who did not require urgent surgery. Venous blood was collected from the patients upon admission to the emergency department, and abdominal computed tomography angiography was performed. The RDW and hematological and biochemical parameters of the groups were compared. The primary outcome was AMI among the patients with abdominal pain. The secondary outcome was mortality, complaint period, and size of ischemia/necrosis among the AMI patients.The RDW, white blood cell lactate dehydrogenase, and blood urea nitrogen of the patients with AMI were significantly different from those of the control group. When the average RDW (15.04 %) of the patients with AMI was used as a cut-off value, the sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood (-LR) were 40.8 %, 81.2 %, 2.17, and 0.73, respectively. When patients with AMI and anemia were included in the group, the sensitivity and specificity values did not change. There was no relation between the RDW and mortality, size of the ischemia/necrosis, and complaint period. Furthermore, there was no significant difference in the average RDW between the patients with ischemia/necrosis in the small intestine only and those with ischemia/necrosis in the colon.The RDW on admission is of marginal help to diagnose AMI among patients with abdominal pain.

Nasal bone is the most common broken bone of the face. Incorrect assessments of nasal trauma are frequently encountered in forensic evaluations. Here, we aimed to determine the reasons and frequency of erroneous assessments of nasal trauma in emergency department (ED). This is a cross-sectional multicentric study analyzing the Forensic Medical Department archive retrospectively. Epidemiologic features, type of fracture (depressed or non-depressed), and specialty of the doctor examining the cases in ED were studied. Forensic evaluation was reported by analyzing all radiologic examinations (CT and X-ray), medical records, and after repeated physical examination of nasal trauma by the forensic council, consisting of a forensic expert, a radiologist and an otolaryngologist. Nasal fracture was diagnosed when at least two of three physicians agreed. A total of 535 cases (mean age 31.7 ± 14.4, 87.1 % males) were analyzed. The most common causes of injuries were assault (81.8 %), followed by traffic accident (15.3 %) and falls from a height (2.1 %). There were misdiagnoses in ten patients (1.9 %) and overdiagnosis in 135 (24.5 %). The possibility of fracture overdiagnosis was 13.5 times higher than missing it. General practitioners and emergency physicians have 19.7 times (95 % CI 5.5–22. 3) and 3.4 times (95 % CI 1.5–7.8) the tendency to report soft tissue nasal injuries as non-depressed fractures, respectively. We found that nasal fractures are rarely missed while the overdiagnosis was very common. Examination of patients by a general practitioner or an emergency physician without consultation with a specialist and using only plain radiographs were found to be independent parameters affecting overdiagnosis.

Background: Diagnosing cerebral venous sinus thrombosis (CVST) in patients referring to emergency service or neurology outpatient unit with complaints of headache is a challenging task. Magnetic resonance (MR) venography is the gold standard, but there are limitations regarding its use. Aim: To evaluate the validity of red cell distribution width (RDW) in CVST diagnosis in patients presenting with headache. Methods: A total of 138 patients comprising 37 patients with CVST and 101 control primer headache cases were included in this retrospective cross-sectional study. Control group consists of hospitalized patients with primary headache. Venous blood hemoglobin (Hb), platelet, mean corpuscular volume (MCV), RDW, fibrinogen, and vitamin B12 levels of the patients were recorded at the first referral. Diagnosis of CVST was established by MR venography. Results: The RDW ratio of patients with a diagnosis of CVST was significantly higher than that in patients with primary headache (15.3 ± 1.4 vs 13.3 ± 0.5; P Conclusion: We suppose that among patients presenting with the complaint of headache, RDW value may lead to diagnose CVST.

Objective: To determine whether or not wave/interval dispersions in electrocardiography (ECG) are increased, and to define whether wave and interval dispersions are correlated with carboxyhemoglobin (COHb) levels. Methods: ECG, complete blood count, and biochemical parameters were taken from 87 patients with carbon monoxide (CO) poisoning as well as 90 control patients with similar age, gender, and body mass index distribution. COHb levels were recorded in CO-poisoning patients. The COHb levels and the relationships with ECG parameters were studied. Results: Pmax, Pmin, Pd, PRmax, PRmin, PRd, QTmax, QTmin, QTd, cQTmax, cQTmin, cQTd, Tmax, Tmin, and Td in ECG were higher in intoxicated patients than the control group ( p < 0.05 for all). Pearson’s correlation analyses showed moderately significant positive correlations between COHb level and Pmax ( r = 0.224; p = 0.037) and Pd ( r = 0.222; p = 0.039). The receiver–operator characteristic (ROC) curve showed that a Pd value of 38 ms determined by ECG separates patients with a COHb ≥ 20% with area under the ROC curve of 0.78 (95%CI = 0.71–0.83), a sensitivity of 67.9% (95%CI = 59.4–75.6), a specificity of 95% (95%CI = 83.0–99.2], a positive predictive value of 97.9% (95%CI = 92.5–99.7), and a negative predictive value of 46.3% (95%CI = 35.3–57.7.) Conclusion: A significant increase in wave/interval dispersions in the ECG of CO-poisoning patients compared with controls may show that not only a part is affected but both atrium and the ventricles as a whole are affected by hypoxic ischemia. When COHb levels of the patients are unavailable, P dispersion on ECG may show CO poisoning level of the patient.

Trauma is one of the foremost causes of death in children and young adults (1). A decrease in the time between trauma and hospital arrival has reduced mortality rates (2), and ambulance design is an important factor in patient and staff safety (3,4). Stretchers, chairs, and wheelchairs are the primary means of transporting patients in emergency departments (5). After a patient arrives in the emergency room, treatment priority is determined using a triage system, and a patient may receive treatment immediately or wait for days (6). Thus, emergency department stretchers must be ergonomic, safe, and reliable (7). Furthermore, it is important that patients can be easily transferred to a stretcher with a minimal amount of movement; thus, an appropriate stretcher makes the job easier for the emergency medical personnel. Stretchers must serve a number of functions, and several investigations have been undertaken to design ergonomic transport devices (8). Customer satisfaction is critical for service providers, and the provision of quality products and services is an important way to increase customer satisfaction. Customer demand for quality service has increased competition among service providers, and the demand for quality in the health sector is no different (9). Emergency departments are the hospital showcase and, as such, their services should be of the highest quality. Stretchers are an indispensable piece of emergency department equipment. Many factors play a role in the choice of stretchers. They can be expensive, particularly with added features in terms of material, utility, ergonomic design, and safety.The present study examined the relationship of stretcher ergonomics and cost with emergency department staff satisfaction and their ratings of patient safety and treatment.

Background: Despite the developments in medicine in recent years, people in many regions of the world still tend to use alternative, or non-medical, folkloric treatment methods for many different health problems. One of these methods is “rope wrapping to the back,” which is considered to be therapeutic for patients with lumbar disc hernias or low back pain. This method is practiced by local individuals without medical training. Case Report: Over the course of 3 years, 14 patients, 8 women and 6 men, presented to Ataturk University and Erzurum state hospitals in eastern Turkey after undergoing the folk treatment known as “rope wrapping to the back” for low back pain. One of the patients, who had symptoms of systemic infection, later died. Of the other patients, 4 had local infections, 6 had unresolved complaints, and 3 had other complaints. Nine of the patients were treated in the emergency department and 4 required surgery. Two case reports are provided as examples. Conclusion: Improvements are needed to increase the accessibility of health care, improve physician–patient communication, and provide information to people, so as to prevent the use of folk remedies, which can have serious complications, sometimes resulting in death.

Background: Suicidal behavior represents a serious public health problem. Studies about twins, adoption, and family conflicts have shown a relationship between genetics and suicide. CB1 receptors a...

Correspondence to / Yazisma Adresi: Atif Bayramoglu, Erzurum Bolge Egitim ve Arastirma Hastanesi, Acil Servisi, Cat Yolu 25170 Erzurum, Turkiye Phone: +90 442 317 27 92 e.mail: atifbay@gmail.com doi:10.5152/jaem.2012.016 Zeynep Gokcan Cakir1, Atif Bayramoglu2, Ayhan Akoz1, Sule Esen Turkyilmaz1, Mucahit Emet1, Mustafa Uzkeser1 1Erzurum Ataturk Universitesi Tip Fakultesi, Acil Tip Anabilim Dali, Erzurum, Turkiye 2Erzurum Bolge Egitim ve Arastirma Hastanesi, Acil Servisi, Erzurum, Turkiye

To find out the predictors of scapula fractures in high-impact blunt trauma patients and the predictors of missing them in the emergency department (ED).This is a retrospective descriptive review of patients treated at a single hospital over a 3.5-year period. The study included 1,039 high-impact blunt trauma patients of any age. The patients were divided into two groups: patients with scapula fractures (the patient group) and others (the control group). The patient group was re-assessed into two subgroups: patients with and without missed scapula fractures. Logistic regression analysis was used to assess the predictors of a scapular fracture in the ED.The incidence of scapula fractures was 4%. The Injury Severity Scores (ISS) of the scapula fracture group were significantly higher than those of the control group (P 0.0001). Patients with scapula fractures were significantly older (P 0.001). Patients with scapular body fractures stayed for significantly longer in the intensive care unit (ICU) (P = 0.039) and their mean Abbreviated Injury Scale (AIS)face score was higher (P = 0.04) compared to scapular fractures without body parts. Scapula fractures were missed in 35.7% of patients. All bilateral scapula fractures were missed. Computerized tomography showing shoulder region or scapula was obtained in 26.7% of missed injuries.After matching for ISS, the mortality of patients with scapula fracture was significantly higher than the control group. We observed that fractures in the glenoid and scapular neck occurred higher than in the body region. We found that the seniority of the ED doctor, consultation ratio for orthopedics in ED, and the existence of brain contusion were important parameters for missing scapula fractures in ED.

A 25-year-old man who suffered a traffic accident was admitted to our emergency department. Computer tomography was performed. Computer tomography images showed an osseous structure mimicking avulsion fracture at the level of C5–C6 (Fig. 1). There was no bone defect corresponding to spinous process and so, the diagnosis was consistent with sesamoid ossicles of the nuchal ligament. Sesamoid ossicles of the nuchal ligament are an anatomical variant that are usually asymptomatic. Prominent differential diagnosis includes avulsion fractures of the spinal processes and myositis ossificans. Focal well-defined osseous masses, well-circumscribed with regular shape, are in favor of sesamoid ossicle of nuchal ligament, whereas triangular dense bony fragment with bony defect of the adjacent spinous process are in favor of spinous process fracture. Ihsan Yuce, MD Berhan Pirimoglu, MD Gokhan Polat, MD Recep Sade, MD Mucahit Emet, MD Mecit Kantarci, MD, PhD Department of Radiology, School of Medicine Ataturk University 25100 Erzurum, Turkey Department of Emergency Medicine, School of Medicine Ataturk University 25100 Erzurum, Turkey

To the Editor,We are honored to see that our published article aboutthe relationship between acute mesenteric ischemia (AMI)and red cell distribution width (RDW) took attention [1].Zhang et al. [2] shared their opinions about the topic, andthey deservedly pointed out some blurred details. It is ourmission to clarify these issues:First, RDW is not a specific marker, but a clue thatsomething wrong is going on in the body leading to anincrease in reticulocytes in the blood. There are hundreds ofdifferent physiologic and pathologic conditions that maycauseRDWrise.Inourmethodssection,weclearlyidentifiedthat our exclusion criteria included ‘‘patients with any illnessthat could affect RDW levels, such as thalassemia trait,hereditary elliptocytosis, and hemoglobin C disease’’ [1].Neither the patients with AMI nor control group had renal/hepatic dysfunction, thyroid or bone marrow disease, previ-ous history of transfusion within 3 months, or malnutrition.ThestudygroupsconsistedofTurkishethnicitywithoutusingmedications that may influence RDW. However, we couldnot stabilize some of the comorbidities that were also knownas etiologic factors in AMI such as atrial fibrillation, chronicheartfailure, arterialhypertension, anddiabetesmellitus.Wementioned this point in our limitations section [1].Second, as the study groups were gathered from theemergency department (ED), there were no delay betweenblood sampling and RDW measuring. After the bloodsamples are sent via pneumatic system in our ED, theparameters are measured in a special part of the laboratoryto prevent delays: emergency laboratory part. Thus, wethink that our laboratory procedure has got no influence inRDW measurements.Third, in our first table, there were 13 parameters thatwere significantly different between AMI patients andcontrols. We were analyzing the laboratory parameters ofstudy population, and thus we did not take into accountdemographic features and comorbidities in multivariateanalysis. As some of these laboratory parameters wereassociated with each other, we carefully chosen sevendifferent parameters in the multivariate analysis. Studyingseven parameters as multivariate analysis in a population of159 is very acceptable and enough for the statistical power[1]. In the logistic analysis, we only gave statistically sig-nificant results. The odds ratio of RDW was 1.058 (95 %CI 0.754–1.485; wald: 0.106, p = 0.745).Fourth, Zhang et al. kindly requested the reason ofconflicting results about RDW levels and ischemia/necrosissize and mortality between our study and Bilgic et al.’sstudy [1–3]. Our study has got superiorities discussed to thearticle by Bilgic et al. We measured the size of ischemia/necrosis in centimeters, while they just grouped the patientsaccording to approximate necrosis length without measur-ing the exact size. Moreover, we did not need resectionsurgery in the first look for all the patients with AMIcontrary to their study population. Most important, weexcluded patients with comorbidities that may affect RDW,and for the etiologic factors that may affect this parameter(atrial fibrillation, chronic heart failure, hypertension, anddiabetes mellitus), we discussed them with univariateanalyses between patients with and without mortalities. Wewere unable to see these exclusion criteria and discussionsin the study by Bilgic et al.

Cost-effective use of cardiac markers for the evaluation of ischemic chest pain (CP) patients at the emergency department (ED) is attracting the attention of researchers. The aim of this study is to define how cost-effective an approach should be for evaluate CP patients and to evaluate whether testing for cardiac markers is done cost-effectively in CP patients.In this retrospective study, 1028 ischemic CP patients (aged from 17-89 years, 389 female, 639 male) with non-diagnostic electrocardiography (ECG) who were admitted to the ED between September 2002 and September 2003 were enrolled into the study.The conditions of how diagnostic tests were actually ordered for these patients and how they should have been ordered cost-effectively were assessed and both the cost and effectiveness were compared. The actual total cost of the diagnostic tests ordered to investigate ischemic CP was $42,476. The cost would have been $32,342 if they had been ordered in the most cost-effective manner, for a total savings of $10,134. The ED cost, the calculated cost-effective cost and the lost amount were compared with the Student's t-test, and the differences between them was found to be statistically significant (p0.001). The effectiveness was compared using the chi-square test and was found to be significant (χ(2)= 12.20, SD= 1, p0.001).In conclusion, fast and effective evaluation of ischemic CP in the ED and correct management of patients by correct determination of the risk factors provides a high level of cost-effectiveness. Every ED should determine an algorithm for patients admitted with CP and physicians should obey this algorithm.Acil servislerde iskemik göğüs ağrılı (GA) hastaların değerlendirilmesinde kardiyak belirteçlerin bedel etkin kullanımı araştırıcıların dikkatini çekmektedir. Bu çalışmanın amacı, iskemik GA’lı hastalarda bedel etkin yaklaşımın nasıl olması gerektiğini belirlemek ve bu hastalarda kardiyak belirteçlerin bedel etkin olarak istenip istenmediğini değerlendirmektir.Bu retrospektif çalışma eylül 2002 eylül 2003 tarihleri arasında acil servise kabul edilen tanısal olmayan EKG’si olan 1028 iskemik göğüs ağrılı hasta (17–89 yaş arası, 389 kadın, 639 erkek) dahil edilmiştir. Bu hastalara tanısal testlerin nasıl istendiği araştırılmış, bedel-etkin yöntemle nasıl test isteneceği belirlenerek iki yöntemin bedeli ve etkinliği ayrı ayrı kıyaslanmıştır.Başvuran hastalara iskemik göğüs ağrısı yönünden istenen tetkiklerin toplam bedelinin 42476$ olduğu görülmüştür. Bedel etkinlik kurallarına göre tetkik istenmiş olsa idi 32342$ olacağı hesaplanmış ve ikisi arasındaki fark 10134$ bulunarak acil servis bedeli, bedel-etkin olacağı düşünülen bedeli ve bedel kaybı Student’s t testi ile kıyaslanmış anlamlı bulunmuştur (p0,001). Hastaların acil servis etkinliği, bedel-etkin olduğu düşünülen etkinlikle Chi-Square testi ile kıyaslanmış olup χSonuç olarak, akut travmatik olmayan göğüs ağrısının acil servislerde değerlendirilmesinde hızlı ve etkin bir hasta triajıyla, doğru risk ayrımı yapılarak hastaların doğru bir şekilde yönlendirilmesi, üst seviyede bedel-etkinlik sağlayabilir. Göğüs ağrılı hastaların acil serviste bedel-etkin değerlendirilmesi için, her acil servisin önceden belirlenmiş bir algoritimi olması gerektiğini göstermektedir.

Lisfranc yaralanması nadir görülür, teşhisi zordur ve sıklıkla atlanan bir yaralanmadır. Kalıcı sekele yol açan bu yaralanmada gecikmiş sevk veya yetersiz tedavi nedeniyle artan bir şekilde acil hekimlerine malpraktis davaları açılmaktadır. Bu vaka sunumunda, buz pateni yaparken düşmesine bağlı ayaktaki lisfranc ligament yaralanması ile ilişkili tibia ve fibula spiral kırığı olan bir erkek hakkında bilgi sunmak istedik. Acil hekimleri ayak orta bölümünde şişme ve/veya hassasiyeti olan hastada Lisfranc yaralanmasından yüksek oranda şüphelenmelidirler. Orta ayak bölümünde genellikle lateral deviasyon veya belirgin çıkık görülmediği için bazı lisfranc yaralanmaları ilk bakışta atlanabilir. Ayak ön bölümü normal olarak görülebilir veya lisfranc ekleminde tek başına akut hassasiyet olması bizim vakamızda olduğu gibi eşlik eden kırıklara bağlı atlanabilir., Lisfranc injury is a rarely seen, hardly diagnosed and frequently missed injury. Emergency physicians are increasingly exposed to malpractice lawsuits due to delayed referral or inadequate management of this injury that leads to permanent sequelae. We report here the case of a boy with spiral fractures of both the tibia and fibula due to an ice-skating injury, who additionally had Lisfranc ligament injury of the foot. Emergency physicians should maintain a high index of suspicion for a Lisfranc injury in a patient with midfoot swelling and/or tenderness. Many Lisfranc injuries are missed at first glance as gross luxation or lateral deviation of the midfoot is usually not present. The forefoot may appear normal; or acute tenderness along the Lisfranc joint may be mistakenly attributed to co-existing fractures as it was in our case

We report a 20-year-old woman with blunt chest trauma because of a motor vehicle injury who has traumatic asphyxia and hypotension. The diagnosis of blunt cardiac injury was put by using dual-energy computed tomography in the emergency department because other laboratory and imaging modalities were useless. After hospitalization in intensive care unit, she was treated with supportive and antiedema therapy. The patient was extubated on the fifth day and discharged on the ninth day without any sequel. Coexistence of traumatic asphyxia with blunt cardiac injury is rare. Several imaging techniques such as transthoracic and transesophageal echocardiography, contrast-enhanced multislice thorax computed tomography or initial electrocardiogram, and troponin I levels are used to detect the myocardial damage, but diagnostic capability is low. Dual-energy computed tomography is a promising new technology with the ability of defining blunt cardiac injuries and may have an indication in the emergency setting in patients with hemodynamic instability to rule in traumatic cardiac complications especially when electrocardiogram and transthoracic echocardiography are useless in the emergency department.

Open fractures are not so obvious sometimes, and in the case of multiorgan injuries, they may be misdiagnosed in emergency department. Here, we report a 48-year old man with motor vehicle crash injury. There were ominous facial, vertebral, thoracic, and abdominal injuries as well as distal femoral shaft fracture and multiple skin lacerations in different parts of the body in the initial examination. On the tertiary examination, we incidentally caught an important finding showing an open fracture: oily (greasy) bleeding from the wound (Video 1, Fig. 1 and 2). We think that the characteristic of the blood, namely, the spotted lipid sign floating on the blood, is a unique and pathognomonic finding differentiating between simple wound lacerations and obscured open fractures.

Introduction Current diagnostic measurements used to assess myocardial involvement in Kounis syndrome, such as electrocardiography (ECG), cardiac enzymes, and troponin levels, are relatively insensitive to small but potentially significant functional change. According to our review of the literature, there has been no study using magnetic resonance imaging (MRI) on Kounis syndrome except for one case report. Aim To identify the findings of dynamic contrast-enhanced magnetic resonance imaging (CE-MRI) in patients with Kounis syndrome (KS) type 1. Material and methods We studied 26 patients (35 ±11.5 years, 53.8% male) with known or suspected KS type 1. The patients underwent precontrast, first-pass, and delayed enhancement cardiac MRI (DE-MRI). Contrast enhancement patterns, edema, hypokinesia, and localization for myocardial lesions were evaluated in all KS type 1 patients. Results Contrast-enhanced magnetic resonance imaging demonstrated an early-phase subendocardial contrast defect, and T2-weighted images showed high-signal intensity consistent with edema in lesion areas. None of the lesion areas was found upon contrast enhancement on DE-MRI. The area of early-phase subendocardial contrast defect was reported as follows: the interventricular septum in 14 (53.8%) patients, the left ventricular lateral wall in 8 (30.7%), and the left ventricular apex in 4 (15.4%). Conclusions Dynamic cardiac MR imaging is a reliable tool for assessing cardiac involvement in Kounis syndrome. Delayed contrast-enhanced images show normal washout in the subendocardial lesion area in patients with Kounis syndrome type 1.

Our aims were, to clarify the blood lipid differences [Total serum cholesterol (TC), High-density lipoprotein (HDL), Low density lipoprotein (LDL), Triglyceride (TG)] between female patients who had attempted suicide and controls and to determine whether we could use the patients׳ initial lipid profiles to predict suicide re-attempt within the subsequent year. A total of 284 participants (110 cases and 174 controls) were recruited, with no differences in body mass index, age, blood sampling time and gender. Blood samples were collected from all participants for serum lipid profiles and assayed in an auto-analyzer. We divided the suicide re-attempter group into suicide attempters in the subsequent year (SSY) and suicide attempters after the subsequent year (SASY). The TC, LDL, and TG levels were significantly lower in the suicidal group than in the control group. HDL was significantly higher in the suicidal group than in the control group. Low TG (

AIM We examined whether there is a relationship between vagal nerve root injury and the severity of respiration disorders associated with subarachnoid hemorrhage (SAH). MATERIAL AND METHODS This study was conducted on 20 rabbits. Experimental SAH was induced by injecting homologous blood into the cisterna magna. During the experiment, electrocardiography and respiratory rhythms were measured daily. After the experiment, any axonal injury or changes to the arterial nervorums of the vagal nerves were examined. All respiratory irregularities and vagal nerve degenerations were statistically analyzed. RESULTS Normal respiration rate, as measured in the control group, was 30 ± 6 bpm. In the SAH-induced group, respiration rates were initially 20 ± 4 bpm, increasing to 40 ± 9/min approximately ten hours later, with severe tachypneic and apneic variation. In histopathological examinations, axon density of vagal nerves was 28,500 ± 5,500 in both control and sham animals, whereas axon density was 22,250 ± 3,500 in survivors and 16,450 ± 2,750 in dead SAH animals. The severity of axonal degeneration of vagal nerves was greater in the six dead animals than in the survivors. CONCLUSION If vagal nerves are lesioned, the muscles of respiration are paralyzed and respiratory reflexes are disrupted. That the ischemic and mechanical factors created by SAH cause vagal nerve root injury and respiration disorders may be inevitable and fatal.

Introduction Discrimination of stroke and stroke mimics is problematic in young patients. The aim of the study was to determine whether arterial ischemic stroke and stroke mimics can be differentiated via the red cell distribution width (RDW) value in young patients. Material and methods In this retrospective cross-sectional study, a total of 236 patients hospitalized at the neurology ward were investigated. The patients were divided into 3 groups: the 1st group included young stroke patients, the 2nd group included patients with epilepsy, and the 3rd group included patients with multiple sclerosis (MS). Complete blood count and computed tomographic brain imaging tests were performed in all patients, and magnetic resonance imaging was done when necessary. Results A total of 236 patients were included in this study. Ninety-five (40%) patients were young stroke patients, 71 (30%) had epilepsy and 70 (30%) had MS. The mean RDW values of young patients with stroke were significantly higher than patients with epilepsy or MS (14.9 ±1.2, 13.3 ±1.2, 13.4 ±0.6, p < 0.0001, respectively). The diagnostic power of RDW in the differentiation of patients with stroke is good (area under the curve (AUC) = 0.89). When an RDW cut-off value of 14.05% is accepted for differentiating young patients with stroke from other disorders, the sensitivity, specificity, positive predictive and negative predictive values were 73.7%, 87.9%, 6.1 and 0.043, respectively. Conclusions Red cell distribution width is a promising, rapid, easy and inexpensive parameter to distinguish young stroke from stroke mimics (such as epilepsy and MS) in young patients.

Introduction In the environment, there are hundreds of poisonous and injurious plants with a wide variety of toxicity. Among all plants with anticholinergic effect, Hyoscyamus reticulatus is a species whose clinicopathological effects have been poorly described in literature. The paper is especially aimed at drawing attention to the possibly fatal syndrome of prolonged QT, as well as to clinical and laboratory changes in six members of a single family poisoned with this plant. Cases Six female patients aged from 19 to 49 presented to our emergency room with a suspicion of being poisoned after having ingested a plant known as 'the mad axe plant' (Hyoscyamus reticulatus). At least one of anticholinergic symptoms including flushing, mydriasis, dry mouth and tachycardia was present in all of the patients. In addition, different levels of agitation were observed in four of the patients. A euphoric emotional state was present in two patients. The corrected QT distances were found to be prolonged in three of the patients. Discussion and conclusion Based on economical, social and cultural reasons, it is a very common habit in our country, especially in our region in spring and summer months, to consume some plants growing spontaneously in rural areas as food. Intoxication with Hyoscyamus reticulatus is a plant poisoning that is poorly described in literature. Its classical symptoms are predominantly anticholinergic. Although it is commonly self-limited and can be corrected with close observation and supportive treatments, it should be kept in mind that the prolongation of QT interval can accompany the symptoms of poisoning with this plant (Tab. 1, Fig. 3, Ref. 19).

To analyze the injury characteristics of younger and older adult trauma victims. Materials and methods: This was a prospective, cross-sectional, observational, and single-center study including both younger adult and geriatric trauma patients. The relationships between the age groups and the number of consultations in the emergency department (ED) were compared with analysis of covariance after adjusting for Injury Severity Score (ISS). Results: The data consisted of 779 patients, 131 (16.8%) of whom were elderly. The intensive care unit admission rate was 7.2%. Our results showed a significantly higher incidence of intracranial hemorrhage, fracture and/or dislocation of the femur, and fracture of the thoracic vertebra in the elderly patients, and acute abdomen, bowel injury, and pelvic fracture in younger adults. After adjusting for ISS and total consultations, the length of stay in the ED was significantly shorter in the elderly compared to the younger adults (115 min vs. 132 min; F = 24.2; P < 0.0001). After controlling for ISS, the total number of consultations among the elderly was significantly lower than that of the younger adults (2.07 ± 1.42 vs. 2.53 ± 1.44; P < 0.0001). Conclusion: The findings of this study suggest that the characteristics of seriously injured older adults admitted to our ED differ from those of their younger counterparts.

To the Editor: We read the article about Kounis syndrome published in an earlier issue of your journal with great interest. This letter is intended both to correct a mistake in the article and to emphasise its importance by sharing our own clinical experiences.

The Eurasian Journal of Medicine, which is the official journal of Ataturk University School of Medicine, started the publication life in Turkish in 1968, and it has been published as three issues per year in English since 2008 [1]. Change of the publication policy in 2008, aiming to reach the worldwide researchers and audience, bore its fruits, and it is now indexed in PubMed Central and Thomson Reuters’ Emerging Sources Citation Index (ESCI), as well as in some other indexes [2].

The aim of this study is to determine the percentage of intra-abdominal hemorrhage (PIAH) on computerized tomographic (CT) scan via the Cavalieri method and to define whether this is correlated with the outcome.Fifty-one patients (24 children and 27 adults) with blunt hepatic injury were studied in this Level III prognostic clinical cohort study. The stereologic method of point counting based on the Cavalieri approach was adapted to CT data so as to assess IAH and abdominal volume. PIAH was calculated as intra-abdominal fluid volume/whole abdominal volume × 100.Mean PIAHs in children and adults were 4.20% ± 2.85% and 6.28% ± 5.21%, respectively. Coexisting intra-abdominal injuries in children and in adults were as follows: splenic injury (29.2, 11.1%; p = 0.012), kidney (25, 11.1%), bladder (4.2, 14.8%), and pelvic fracture (12.5, 11.1%). PIAH was moderately negatively associated with hemoglobin levels (r = -0.301; p = 0.032), hematocrit levels (r = -0.322; p = 0.021), and GCS (Glasgow Coma Scale) score (r = -0.276; p = 0.05). Neither receiver operating characteristic curve analyses for PIAH nor outcomes were statistically significant in children. In adults, sensitivity and specificity of PIAH in predicting the prognoses when the cutoff levels were taken as 5.39%, 9.9%, and 12.4%, respectively, were as follows: operation (71, 84%), mortality (36, 93%), and intensive care unit admission (25, 94%).In patients with blunt hepatic injury, the Cavalieri principle of stereology can easily be added to the CT slices to calculate PIAH. This method is repeatable in other institutions and can be used as a guide to predict outcomes. It is suitable for a universal parameter to measure intra-abdominal fluid in blunt injury. PIAH has low sensitivity but high specificity to predict intensive care unit admission and mortality in cases of blunt hepatic injury in adults. Its specificity in predicting the need for operation is better than that of the anatomic liver injury grading systems in computerized tomography.Prognostic study, level III.

Sağ atriyal trombüs nadirdir fakat yaklaşık %30-40 ölüme neden olabilmektedir. Ekokardiyografi pulmoner embolinin kardiyak kökenli nedenlerinin belirlenmesinde önemlidir ve hareketli trombüs nadiren aynı anda sağ atriyum ve pulmoner arterde görüntülenebilir. Trombolitik tedavi sağ atriyal trombüs ve masif pulmoner emboli olan hastalarda hayat kurtarıcı girişimdir. Biz bu yazıda interatriyal septuma tutunan ve pulmoner emboliye yol açan yılanvari sağ atriyal trombüs olgusunu sunmayı amaçladık. Bu olgunun ilginç olan özelliği, hareketli trombüsler transtorasik ekokardiyografi ile sağ atriyum ve pulmoner arterde aynı anda görüntülenmiştir, Right atrial thrombi are rare but cause mortality in approximately 30-40% of cases. Echocardiography is important for determining the causes of the cardiac origin of pulmonary embolism, and, simultaneously, mobile thrombi can be rarely visualized in the right atrium and pulmonary artery. Thrombolytic therapy is a life-saving intervention in patients with a right atrial thrombus and massive pulmonary embolism. In this report, we present a case of a serpentine-like right atrial thrombus adhered to the interatrial septum, leading to pulmonary embolism. The interesting feature of this case is that mobile thrombi were simultaneously visualized in the right atrium and pulmonary artery by transthoracic echocardiography

Electrocardiographic (ECG) abnormalities and cardiac troponin I elevation are seen in addition to the classic clinical symptoms and signs of subarachnoid hemorrhage (SAH). We aimed to show that, in patients with ST elevation, troponin elevation, and altered consciousness, the reason may be SAH. A 36-year-old man presented to emergency service with ECG abnormalities, high level of cardiac troponin I, and neurologic symptoms. In the patient's initial ECG, there were sinus arrhythmia, bradycardia, T-wave inversions inferiorly, and concave ST elevations in V1 to V4. Three hours later, his ECG showed increased ST-segment elevations with normal heart rate. The patient's troponin I value was 10 mg/L. Ejection fraction was 60%, and there were no wall motion abnormalities on echocardiography. Computed tomographic scan of the brain demonstrated SAH with falx sign and midline cerebellar hematoma (3 × 4 cm in size) in the occipital region. The patient died on the 10th day of follow-up because of severe metabolic acidosis, multiorgan failure, and bradycardia. Cardiac evaluation is recommended in patients with intracranial hemorrhage in many studies. In our opinion, if there are neurologic symptoms or signs in patients diagnosed as acute myocardial infarction with ECG changes and troponin elevation, requesting threshold of brain computed tomography should be low before the thrombolytic therapy.

The aim of this study was to determine the relationship between ischemic neurodegeneration, of the petrosal ganglion of the glossopharyngeal nerve, and BP fluctuations, after subarachnoid hemorrhage (SAH).Twenty-four rabbits had their blood pressure and heart rhythms studied daily over 20 days. Then, the histopathology of the petrosal ganglion was examined in all animals. Normal and apoptotic neuron density of the petrosal ganglion and blood pressure values were compared statistically.Mean total volume of the petrosal ganglia was calculated as 0.9 ± 0.34/mm3. BP level of control group was 96.1 ± 2.1 mmHg; 116.5 ± 4 mmHg of mild hypertension (HT) group and 128.1 ± 3.6mmHg in the severe HT group. When the groups were compared to each other they were significantly different. The level of normal-apoptotic neuron in control group was 11,240 ± 802/mm³ -40 ± 6.3/mm³; 9730 ± 148.7/mm³ - 1560 ± 256.2/mm³ in the mild HT group and 6870 ± 378.8/mm³-4240 ± 628.2/mm³ in the severe HT group. When the groups were compared to each other there was significantly difference.Blood pressure variability observed in this study may be explained by ischemic neurodegeneration of petrosal ganglia caused by SAH. The results of this study suggest that petrosal ganglion ischemia has potential implications for the development of hypertension. These findings suggest that new treatment strategies should be considered for the treatment of SAH.

Kounis syndrome (KS) is an acute coronary vasospasm after exposure to an allergen due to mast cell degranulation and existing mediators. Various drugs, conditions, and environmental exposures can cause KS. We presented 2 cases, 1 of whom had taken an antiflu drug (containing paracetamol, pseudoephedrine, and dextromethorphan). His electrocardiogram (ECG) showed inferior ST elevations (2 mm) with normal cardiac biomarkers. His cardiac magnetic resonance imaging showed hypokinesis and myocardial hibernation on apical septum and on the left ventricle. The second patient took a pill of naproxen sodium. The ECG showed 1-mm ST elevation in leads DII, V5, and V6. His troponin was markedly elevated. These cases showed that there seems to be no correlation with ECG and troponin levels in KS. In addition, for patients in whom KS type 1 is expected without troponin elevation, noninvasive cardiac magnetic resonance imaging study seems to be appropriate for the diagnosis of KS.

Background The heart is innervated by several systems that contribute to the control of the heart's rhythm. The cardiac fibers of the vagus nerve have an important role in the regulation of heart rhythm under many emotional and physical conditions. Severe electrocardiographic disturbances have been reported following subarachnoid hemorrhage (SAH), but ischemic neuronal degeneration of the nodose ganglion of the vagus nerve has not been previously investigated. We examined if there is a relationship between ischemic injury of the nodose ganglion of the vagus nerve and the severity of heart rhythm disorders after subarachnoid hemorrhage. Methods This study was conducted on 20 rabbits. Four rabbits were used as a baseline group. Experimental subarachnoid hemorrhage was applied to half of the remaining animals (n = 8) by injecting homologous blood into the cisterna magna, and the others (SHAM group, n = 8) were injected with isotonic saline solution in the same manner. For 20 days after the injection, heart rhythm changes were observed daily. After the experiment, normal and ischemic neuron densities in the nodose ganglia of the vagus nerves were examined stereologically. The number of heart rhythm irregularities and the number of degenerated neurons in the nodose ganglia were compared statistically. Results The normal heart rhythm rate was 280 ± 45/min. At the beginning of the SAH, the average heart rate was 220 ± 30/min; about 10 hours later, it decreased to 189 ± 30/min, indicating severe bradycardia. However, after 7 days, the average heart rate had increased to 350 ± 30/min. Six animals died due to irregularities in cardiac function and respiration. Histopathological examinations showed that the average density of normal neurons in the nodose ganglion was 10,500 ± 2500 in the baseline animals and the SHAM group, but the normal neuron density was 8250 ± 1500 in survivors and 6450 ± 1330 in dead animals. The ischemic neuronal degeneration in the nodose ganglia was more severe in the dead animals than in the survivors (p Conclusion Afferent vagus nerves originating from the nodose ganglia have an important role in regulating heart rhythm via their afferent fibers and efferent connections. If neurons of the nodose ganglia are lesioned due to ischemic insult during subarachnoid hemorrhage, heart rhythm regulation by vagus afferent reflexes is disturbed. Vagus pathway paralysis may result in indirect sympathetic overactivity. The development of tachycardia causes depletion of the heart's reserves, and cardiac arrest may be inevitable following extensive subarachnoid hemorrhage.

To determine the extent of missed injuries in patients hospitalized with major trauma in a Turkish Level 1 emergency department. We also tried to identify the primary factors contributing to each missed injury and to determine their subsequent adverse short-term clinical outcomes. This is a retrospective analysis of prospectively collected data on a cohort of trauma patients. Trauma patients were divided into two groups: patients with missed injury and others. Logistic regression was used to define factors affecting “missed injury”. A total of 670 hospitalized trauma patients were included. The incidence of missed injuries in the patients and the rate of missed injury per patient were 13.3% (95% CI 6–20) and 1.64, respectively. The most frequently missed diagnosis was injuries of the musculoskeletal system (38%; 95% CI 30–46). It was “clavicle fracture and/or dislocation” (35%; 95% CI 16–53) when the rate of missed diagnosis according to the frequency of the specific injury was calculated. A multiple logistic regression analysis showed that the predictors of missed injuries were patient’s age (OR 0.74, 95% CI 0.63–0.87), total number of injuries (OR 1.74, 95% CI 1.38–2.20), and ISS (OR 1.10, 95% CI 1.03–1.18). Radiological errors were prominent in almost 90% (95% CI 85–95). Missed injury caused additional hospital stay (30%; 95% CI 21–40) and additional surgery was required (15%; 95% CI 8–23). The study highlights the need for a trauma team approach and the need for support of radiological report in the ED.

There has been difficulty in the appropriate determination of blunt cardiac injury (BCI) related to blunt thoracic trauma (BTT). The aim of this study is to assess BCI and the effectiveness of diagnostic tests in BTT in patients admitted to the emergency department (ED). Eighty-eight patients with suspected myocardial injury in BTT were enrolled. The diagnostic criteria for BCI were: elevation of troponin I, arrhythmia requiring treatment, unexplained low voltage on electrocardiography (ECG), unexplained hypotension requiring vasopressor, cardiogenic shock requiring inotropes, and transthoracic echocardiographic (TTE) findings suggestive of BCI. Patients with arrhythmia in the medical history, congestive heart failure, ischemic heart disease, history of cardiac surgery, and those

Hyponatremia is the most frequent electrolyte disorder of hospitalized patients and is associated with a longer hospital stay and serious symptoms. The syndromes of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting (CSW) are 2 potential causes of hyponatremia in patients with disorders of the central nervous system. In both syndromes, serum osmolality and plasma uric acid are decreased; blood antidiuretic hormone and urine sodium levels are increased; and plasma albumin concentration and plasma K+ levels are normal. This case report highlights the link between lightning-induced brain injury and CSW syndrome. A 16-year-old boy was admitted to our emergency department because of lightning injury and was unconscious. His Glasgow Coma Scale score was 13. Second-degree burns at the left knee and ankle, at the right leg, and at the occipitoparietal region with a 3-cm area of singed hair were noted. On the second day, the examination showed dry mucous membranes and slightly decreased skin turgidity. He had normal blood pressure throughout hospitalization, and excessive urine output was noted. A decrease in body weight (maximum of 0.450 kg) was observed. Biochemical examination found a rapid drop in serum sodium levels after admission. The diagnosis of central hyponatremia and CSW in the context of lightning injury was made owing to negative salt and water balance. Hypertonic saline solution was given. The patient was discharged home on the fifth day of hospitalization with normal serum chemistries and without the need for sodium supplementation.

This is a retrospective and registry-based descriptive study including animal- related injuries represented by the most crowded Emergency Department (ED) in Eastern Turkey over a period of two years. Animal-related injuries were 0.2% of all ED admittances; dominant in males and were high in summer. 68% of the subjects were exposed to mammalians. Most prominent injuries were dog bites (30%), horse (22%) and livestock-related injuries (12%). Hospitalization was significantly higher in mammalian animal injuries compared to non-mammalian injuries. The highest hospitalization rate was measured for equine-related injuries (15%). In our bite series, dogs were the primary source (69%) while horse-bites (17%) took the second place and they were more than two fold more when compared with cats (7.5%). Dog bites were prominent in children, thus both parents and children should be educated. Insect and snake-related injuries were both low in number and relatively silent in prognosis. Highest temperatures on site were determined for tick-bites, unspecified insect stings and bee stings, respectively. The highest humidity was determined for dog-bites, cat-bites and scorpion stings, respectively. Nonmammalian and sting injuries had higher temperature and lower humidity measurements compared to mammalian and bite injuries. Geographical and meteorological factors may directly affect descriptive epidemiology of animal-related injuries.

Although previous scientific articles claim that morbidity and mortality are low in pure skeletal muscle relaxant ingestion, this is the 10th leading cause of death recently; however, this represents only a 2.1% ratio in adult toxic exposures in the United States. We report the case of a patient with phenprobamate overdose whose neurologic and psychiatric symptoms were the dominant findings. We were unable to perform hemoperfusion because of insufficient equipment. Thus, the patient was taken to for hemodialysis for 3 hours. However, the clinical response was inadequate. Furthermore, plasmapheresis was applied using 12 U of fresh frozen plasma for the consecutive 2 days. This caused resolution of neurologic and psychiatric symptoms. The patient was released with no residual complication on the fifth day of admission. We conclude that in phenprobamate intoxication, if hemoperfusion is impossible, plasmapheresis seems to be the best modality.