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Background/aim: To describe seasonal variations in epidemiology, management, and short-term outcomes of patients in Europe presenting to an emergency department (ED) with a main complaint of dyspnea. Materials and methods: An observational prospective cohort study was performed in 66 European EDs which included consecutive patients presenting to EDs with dyspnea as the main complaint during 3 72-h study periods. Data were collected on demographics, comorbidities, chronic treatment, prehospital treatment, mode of arrival of patient to ED, clinical signs at admission, treatment in the ED, ED diagnosis, discharge from ED, and in-hospital outcome. Results: The study included 2524 patients with a median age of 69 (53–80) years old. Of the patients presented, 991 (39.3%) were in autumn, 849 (33.6%) were in spring, and 48 (27.1%) were in winter. The winter population was significantly older (P < 0.001) and had a lower rate of ambulance arrival to ED (P < 0.001). In the winter period, there was a higher rate for lower respiratory tract infection (35.1%), and patients were more hypertensive, more hypoxic, and more hyper/hypothermic compared to other seasons. The ED mortality was about 1% and, in hospital, mortality for admitted patients was 7.4%. Conclusion: The analytic method and the outcome of this study may help to guide the allocation of ED resources more efficiently and to recommend seasonal ED management protocols based on the seasonal trend of dyspneic patients. © TÜBİTAK., Lietuvos Mokslo Taryba: MIP-049/2015, We would like to thank Toine van den Ende and Ans Kluivers for their assistance in collecting data in Europe. The work of Justina Motiejunaite was supported by the Research Council of Lithuania (Grant No. MIP-049/2015), as well as by training grants from the French government, the Embassy of France in Lithuania, and the Erasmus Program. The EuroDEM study protocol and informed consent was received and reviewed by the institutional review board and ethical committee for each country (and/ or institution), and all participants provided informed consent. The EuroDEM study was done under the supervision of the EUSEM Research Committee. Data management in Europe was facilitated by the Jeroen Bosch Hospital., The work of Justina Motiejunaite was supported by the Research Council of Lithuania (Grant No. MIP-049/2015), as well as by training grants from the French government, the Embassy of France in Lithuania, and the Erasmus Program.

Background/aim: This study aimed to evaluate oxidative stress markers of liver tissue in a mouse α-amanitin poisoning model with three different toxin levels. Materials and methods: The mice were randomly divided into Group 1 (control), Group 2 (0.2 mg/kg), Group 3 (0.6 mg/kg), and Group 4 (1.0 mg/kg). The toxin was injected intraperitoneally and 48 h of follow-up was performed before sacrifice. Results: Median superoxide dismutase activities of liver tissue in Groups 3 and 4 were significantly higher than in Group 1 (for both, P = 0.001). The catalase activity in Group 2 was significantly higher, but in Groups 3 and 4 it was significantly lower than in Group 1 (for all, P = 0.001). The glutathione peroxidase activities in Groups 2, 3, and 4 were significantly higher than in Group 1 (P = 0.006, P = 0.001, and P = 0.001, respectively). The malondialdehyde levels of Groups 3 and 4 were significantly higher than Group 1 (P = 0.015 and P = 0.003, respectively). The catalase activity had significant correlations with total antioxidant status and total oxidant status levels (r = 0.935 and r = -0.789, respectively; for both, P < 0.001). Conclusion: Our findings support a significant role for increased oxidative stress in α-amanitin-induced hepatotoxicity.

Background/aim: This study aimed to evaluate oxidative stress markers of liver tissue in a mouse α-amanitin poisoning model with three different toxin levels. Materials and methods: The mice were randomly divided into Group 1 (control), Group 2 (0.2 mg/kg), Group 3 (0.6 mg/kg), and Group 4 (1.0 mg/kg). The toxin was injected intraperitoneally and 48 h of follow-up was performed before sacrifice. Results: Median superoxide dismutase activities of liver tissue in Groups 3 and 4 were significantly higher than in Group 1 (for both, P 0.001). The catalase activity in Group 2 was significantly higher, but in Groups 3 and 4 it was significantly lower than in Group 1 (for all, P 0.001). The glutathione peroxidase activities in Groups 2, 3, and 4 were significantly higher than in Group 1 (P 0.006, P 0.001, and P 0.001, respectively). The malondialdehyde levels of Groups 3 and 4 were significantly higher than Group 1 (P 0.015 and P 0.003, respectively). The catalase activity had significant correlations with total antioxidant status and total oxidant status levels (r 0.935 and r 0.789, respectively; for both, P > 0.001). Conclusion: Our findings support a significant role for increased oxidative stress in α-amanitin-induced hepatotoxicity.

Introduction. In this paper, we aimed to present five Papaver rhoeas intoxication cases, which is very rare in the literature. Case 1. A 35-year-old female patient was admitted to our emergency room with the complaints of nausea, restlessness, and dyspnea developing 3 hours after eating Papaver rhoeas. On physical examination, her general condition was moderate; she was conscious and the vital findings were normal. The pupils were myotic. She was transferred to the toxicology intensive care unit as she experienced a generalized tonic clonic seizure lasting for three minutes. Case 2. A 41-year-old female patient was brought to our emergency room by 112 ambulance as she had contractions in her arms and legs, unconsciousness, and foam coming from her mouth two hours after Papaver rhoeas ingestion. On physical examination, she was confused, the pupils were myotic, and she was tachycardic. Arterial blood gases analysis revealed lactic acidosis. Case 3. A 38-year-old female patient was admitted to our emergency room with complaints of nausea and vomiting two hours after ingestion of Papaver rhoeas. Her physical examination and tests were normal. Case 4. A 34-year-old male patient was admitted to our emergency room with complaints of numbness and loss of power in his arms and legs one hour after Papaver rhoeas ingestion. He was hospitalized at the toxicology intensive care unit for follow-up and treatment. Dyspnea and bradycardia developed on the follow-up. The oxygen saturation without oxygen support was 90%. ECG revealed sinus bradycardia. The cardiac enzymes did not increase. Case 5. A 42-year-old female patient was brought to our emergency room by 112 ambulance with contractions in her arms and legs and unconsciousness two hours after Papaver rhoeas ingestion. On her physical examination, she was confused and the pupils were myotic. Arterial blood gases analysis revealed lactic acidosis. Conclusion. All patients were followed up for a few days and then discharged from the hospital with recovery. Unconscious consumption of Papaver rhoeas leads to a clinical condition resembling morphine intoxication, CNS depression, and epileptic seizures.

Brusellozis, dünya çapında en yaygın zoonozlardan biri olmayı sürdürmektedir. İnsan brusellozu bir çoklu sistem hastalığıdır ve çok çeşitli klinik bulgularla karşımıza gelebilir. Bazen enfeksiyon serolojik olarak pozitif olmasına rağmen asemptomatik olabilir. Burada 26 yaşında mezbaha işçisi bir erkek hastada, brusellozisi takiben gelişen derin ven trombozu (DVT) olgusu sunuldu. Hasta bir haftadır devam eden halsizlik, ateş ve sağ bacağında ağrı ve şişlik şikayeti ile başvurdu. Renkli doppler ultrasonografisinde sağ femoral ve popliteal venlerin trombüsle tıkalı olduğu görüldü. Brusella tanısı Rose-Bengal, tüp aglütinasyon, brucellacapt and enzim immunoassay anti-brucella abortus Ig M, G testleri ile, başka bir kurumda konmuştu. Nadiren de olsa bazı enfeksiyöz ajanların vasküler patolojilere neden olabildiği bildirilmiştir. Bunlar bazan hayatı tehdit edici olabilmektedir. Bu enfeksiyonların seyri esnasında vasküler komplikasyonlar gelişebileceği akılda tutulmalıdır ve hasta yakından izlenmelidir. Yine DVT ve benzeri patolojilerle başvuranlarda, diğer risk faktörleri yanında brusella ve salmonella gibi enfeksiyon ajanları da araştırılmalıdır., Brucellosis continues to be one of the most widespread zoonoses worldwide. Human brucellosis is a multisystem disease that may present with a broad spectrum of clinical manifestations, but it may also be asymptomatic with only serological evidence of infection. In this paper, a case report is presented of deep venous thrombosis (DVT) developing after a diagnosis of acute brucellosis in a young slaughterhouse worker. A 26-year-old man was diagnosed with DVT which had presented with the complaints of weakness and fever and a one-week history of pain and swelling in the right leg. Ultrasound revealed that the right femoral and popliteal veins were occluded with thrombi. Brucella was diagnosed using Rose-Bengal, tube agglutination, the Brucellacapt test and an enzyme-linked immunoassay using anti-Brucella abortus IgM/G antibody detection at another institution. Although rare, some infectious agents may cause vascular pathologies. These conditions may be life-threatening. Thus, it should be kept in mind that vascular complications may occur during infectious disease and patients should be monitored. Additionally, patients presenting with symptoms of DVT or similar vascular pathologies should be assessed for infectious agents, particularly Brucella and Salmonella, as well as other risk factors

Amaç: Resusitasyon tam donanımlı bir bilgiyle yapılması gereken bir işlemdir. Bu çalışmamızda hekimlerimizin resüsitasyonu ne kadar bildiğini ve güncel kılavuzların kardiyopulmoner resüsitasyon (KPR) sırasında ne kadar uygulana- bildiğini araştırmayı planladık. Gereç ve Yöntemler: Çalışmamıza eğitim araştırma hastanesi, üniversite has- tanesi ve 112 komuta merkezinde çalışan toplam 134 hekim katıldı. Yaş, uz- manlık dalı, mezun oldukları üniversite, uyguladıkları aylık KPR sayısı gibi so- ruların yanında resüsitasyona dair bir anket uygulandı. Çalıştıkları hastaneye göre devlet hastanesi, üniversite hastanesi ve 112 komuta sisteminde çalışan hekimlerin bilgi düzeyleri karşılaştırıldı. Bulgular: Katılımcıların %24.6’sının (n33) ILCOR protokollerini doğru uygu- larken, %38.8’inin (n52) protokolleri yanlış ya da eksik uyguladığı, %24.6’sı- nın (n33) ise bilmediği tespit edildi. Hekimleri çalıştıkları birime göre yapılan değerlendirmede en iyi sonuçlar üniversite hastanesinde çalışan hekim grubunda elde edildi ve ancak başarı oranı sadece %50 civarındaydı. 112 komuta merkezi ve eğitim araştırma hastanesi grubunda bu oran daha da düşüktü. Sonuç: Türkiye’deki kardiyopulmoner resüsitasyona yönelik eğitim sistemi tekrar gözden geçirilerek resüsitasyon protokollerinin daha güncel bilgilerle uygulanmasının sağlanması ve günlük pratikte bu bilgilerin daha fazla kul- lanılabilmesi için acil tıp sisteminin de içinde bulunduğu, hizmet içi eğitim programlarının oluşturulması gerektiği kanaatindeyiz., Objective: Resuscitation is a procedure which needs to be done with fully- equipped knowledge. In this study, we aimed to investigate how much the physicians knew about resuscitation and the current guidelines were applied during the resuscitation. Materials and Methods: A total of 134 physicians working in the training and research hospitals, the university hospitals and 112 emergency medical ser- vices. A survey including questions about the participants’ resuscitation knowl- edge, age, specialty, the university graduated from and the number of cardio- pulmonary resuscitations (CPR)carried out in a month was performed. The level of knowledge of the physicians working in the training and research hospitals, the university hospitals and 112 emergency medical services were compared. Results: We determined that, while 24.6% (n33) of the participants applied the ILCOR protocols correctly, 38.8% (n52) of them applied the protocols incorrectly or incompletely and 24.6% (n33) of them did not know the pro- tocols. The evaluation was performed according to the physician’s work place and the best results were obtained from the university hospital physicians, but the success rate was achieved in only around 50%. This rate was even lower in the training and research hospital and 112 emergency medical ser- vices groups. Conclusion: By reviewing the cardiopulmonary resuscitation training system in Turkey, implementation of resuscitation protocols with more current information should be provided. We believe that it is necessary to establish the in service training programs, including the emergency medical system, as a part of training for using current information in daily practice.

Giriş: Pulmoner emboli, tanısı genellikle klinik şüpheye dayanan ve hayatı tehdit eden bir hastalıktır. Epidural kanama kafa travması olan hastalarda cerrahi ile kolayca tedavi edilebilen prognozu iyi bir klinik durumdur. Olgu sunumu: 34 yaşında erkek hasta dispne ve senkop şikayetiyle başka bir sağlık kuruluşuna başvurmuş ve yapılan değerlendirme sonrası epidural kanama tanısıyla acil operasyona alınmıştı. Operasyon sonrası kontrol altına alınamayan taşikardi ve nefes darlığı olması üzerine ileri tetkik için kurumumuza sevk edilmişti. Elektrokardiografi, ekokardiyografi ve toraks bilgisayarlı tomografi bulguları masif pulmoner emboli ile uyumluydu. Epidural kanama operasyonu geçirmesi nedeniyle hastaya teşhis sonrası trombolitik veya antikoagülan tedavi başlanamadı. Hastanın destek tedavisine operasyon sonrası 72. saatte düşük molekül ağırlıklı heparin ve 96. saatte varfarin eklendi. Takiplerinde klinik durumu düzelen hasta yatışının 15. gününde taburcu edildi. Sonuç: Hasta yönetiminde zamanla yarışan acil servis hekimi, yaşamı tehdit edebilecek birden fazla patoloji ile aynı hastada karşılaşabileceğini hatırından çıkarmamalıdır, Introduction: Pulmonary embolism is a life-threatening condition and its diagnosis is generally based on clinical suspicion. Case report: A 34-years-old male had been admitted to another hospital with acute dyspnea and syncope. After initial evaluation he had immediately been undergone an operation due to epidural hematoma and occipital fracture. ECG, Echocardiogram and Thorax CT findings complied with pulmonary embolism. Thrombolytic or anticoagulant medication could not be started because of epidural hematoma operation. At postoperative 72 hours low molecular weight heparin and at 96 hours warfarin was administered. He discharged from hospital at day 15. Conclusions: The emergency room physician who race with time in patient management, has to keep in mind that physician could experience more than one life-threatening pathology in the same patient.

Giriş: Siyanür çağlardan beri bilinen, çabuk etkili, küçük dozlarda bile dakikalar içinde ölüme neden olabilen güçlü bir zehirdir. Madencilik, kimya sanayi, ziraat gibi pek çok endüstriyel alanda kullanılmaktadır. Güncel olarak altın madenciliğindeki kullanımı ve çevresel toksisitesi ile ülkemizin gündemindedir. Olgu sunumu: 60 yaşında erkek hasta, kuyumcu dükkanında bulunan siyanürden yanlışlıkla bir yudum içmesinden sonra çağrılan 112 Acil ekibi tarafından kliniğimize getirildi. Olay yerinde entübe edilen hastanın geliş fizik muayenesinde genel durumu kötü, bilinci kapalı, TA: 80/60 mmHg, nabzı 60/dk, spontan solunumu yok, ışık refleksleri -/- ve GKS Skoru 3 idi. Olay yerinde mide lavajına başlanan hastanın servisimizde mide lavajına devam edildi, aktif kömür verildi. Yoğun Bakım Ünitesi’nde mekanik ventilatöre bağlanarak takibe alınan hastaya pozitif inotrop desteği başlandı. Kan siyanür düzeyi >2.0 mg/L idi. Çekilen beyin tomografisinde beyin ödemiyle uyumlu görüntü mevcuttu. Antidot olarak Ankara’dan getirtilen 5 gr hidroksikobalamin, ancak zehirlenmenin 9. saatinde verilebildi. İzlemde pozitif inotrop ve mekanik ventilasyon ihtiyacı ortadan kalkmayan hastanın kliniğinde belirgin düzelme görülmedi. Zehirlenmenin 4. gününde hasta kaybedildi. Yapılan otopside siyanür zehirlenmesine bağlı beyinde küçük noktasal kanamalar ve sağ akciğer üst lobda parankim içi kanama ile yoğun miktarda ödem mayiine rastlandı. Tartışma: Siyanür mitokondriyal sitokrom oksidaz enzimini inhibe ederek hücresel oksijenin kullanımını bozduğundan hücresel hipoksi ortaya çıkmaktadır. Ağız yoluyla alınmasında zehirlenme yavaş oluşmakta ve kişinin kurtarılması olanaklı olmaktadır. Bu nedenle hem destek tedavisinin hem de spesifik tedavinin erken başlatılması önemlidir. Ağır bir toksisitenin söz konusu olduğu vakada, destek tedavisi oldukça erken ve etkin biçimde başlatılmasına rağmen antidot spesifik tedavisi geç başlatılabilmiştir., Introduction: Cyanide is a rapid absorbable and powerful poison; even in small doses can cause death in minutes. It is used in many industrial fields; such as mining, chemical industries and agriculture. Recently, its use in gold mining and its enviromental toxicity is on the agenda of our country. Case Report: 60 years old male patient was brought to our clinic after drinking a sip of cyanide in his jewelry shop by 112 emergency team. In physical examination of patient, who was intubated at the scene of accident, general condition was poor, he was unconsciousness, arteriyal blood pressure was 80/50 mmHg and there was no spontaneous respiration. GCS score was 3. Patient’s gastric lavage had started at the scene and contuined in our service, then active charcoal was given. The patient was taken to our intensive care unit and mechanically ventilation started with positive inotropic support. Blood cyanide level was >2.0 mg/L. 5 g hydroxycobalamin brought from Ankara could be given 9 hour after poisoning. The patient died at day 4. Discussion: Cyanide inhibits mitochondrial cytochrome oxidase enzyme and disrupts cellular utilization of oxygen lead to cellular hypoxia. Poisoning by oral consumption is a slow process and patient’s recovery is sometimes possible. Therefore, the initiation of support and specific treatment as quickly as possible is important. In this case, although effective support treatment was started quickly; the specific antidote treatment could not be begun