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Objective: Despite the favorable data concerning topical agents use in outpatient clinics, they are not commonly in emergency departments (EDs). The present study aimed to compare the effect of 2.5% topical ketoprofen (gel form) to placebo in children presenting with ankle sprain to the ED. Study Design: Children between 7 and 18 years old presenting with ankle sprain composed the study population. Study patients were randomized into 2 study arms: 2.5% ketoprofen gel and placebo administered in a 5-cm area locally. Pain improvements at 15 and 30 minutes were measured by visual analog scale. Results: Median pain reductions at 15 minutes for ketoprofen and placebo groups were 27.5 (16-39) and 5 (4-10), respectively. Median changes in pain intensity at 30 minutes for ketoprofen and placebo gel groups were 48 (43-52) and 9 (6-16), respectively. When compared 2 arms for the pain improvement at 15 and 30 minutes, the differences between 2 study drugs were 20 (13-28) and 35 (29-41), respectively. There were 7 (12.7%) rescue drug needs in the placebo group and 1 (1.7%) in the ketoprofen group ( difference, 10.9%; 95% confidence interval, -6% to 7%; P = 0.83). There were no adverse effects in either group. Conclusions: Ketoprofen gel is superior to placebo in ceasing pain in children presenting with ankle sprain to the ED with a high safety profile. C1 [Serinken, Mustafa] Pamukkale Univ, Dept Emergency Med, Med Fac, Denizli, Turkey. [Eken, Cenker] Akdeniz Univ, Dept Emergency Med, Med Fac, Antalya, Turkey. [Tunay, Kamil] Afyon Kocatepe Univ, Dept Emergency Med, Med Fac, Afyon, Turkey. [Golcuk, Yalcin] Manisa Celal Bayar Univ, Dept Emergency Med, Med Fac, Manisa, Turkey.

BACKGROUND: Dysmenorrhea is one of the most common acute pain disorders among women of reproductive age. AIMS: To compare the effects of IV paracetamol with dexketoprofen in patients presenting with primary dysmenorrhea to the emergency department. STUDY DESIGN: Randomized controlled trial. METHODS: Patients over 18 years old presenting with pelvic pain related to menstruation were eligible for the study. Study patients received 1 g paracetamol or 50 mg dexketoprofen in 100 mL normal saline with a 4-5 minute infusion via the intravenous route. Pain intensity was measured by a visual analog scale at 15 and 30 minutes. Patients were randomized and assigned to either of two study arms via sealed envelopes. Study drugs were identical in color, and thus both personnel and patients were blinded to the study drug. The dexketoprofen group comprised 49 patients, and the paracetamol group had 50 patients in the final analysis. RESULTS: The mean age of the study subjects was 20.9±2.5 and the mean duration of the pain was 1.9±1.7 (median: 1, interquartile range: 1 to 2) hours. Both dexketoprofen (median change: 33, 95% CI: 24 to 38) and paracetamol (median change: 21, 95% CI: 12 to 32) effectively reduced the pain at 15 minutes, which was repeated at 30 minutes (median change: 63, 95% CI: 57 to 65 vs 55.5, 95% CI: 50 to 59, respectively). Pain improvement in the dexketoprofen group was better than in the paracetamol group at 15 (median difference: 8, 95% CI: 0 to 16, p=0.048) and 30 (median difference: 6, 95% CI: 1 to 12, p=0.028) minutes, which was statistically significant but not clinically significant. CONCLUSION: Dexketotoprofen has a better visual analogue scale score that is not clinically relevant compared to paracetamol.

Background: Dysmenorrhea is one of the most common acute pain disorders among women of reproductive age. Aims: To compare the effects of IV paracetamol with dexketoprofen in patients presenting with primary dysmenorrhea to the emergency department. Study Design: Randomized controlled trial. Methods: Patients over 18 years old presenting with pelvic pain related to menstruation were eligible for the study. Study patients received 1 g paracetamol or 50 mg dexketoprofen in 100 mL normal saline with a 4-5 minute infusion via the intravenous route. Pain intensity was measured by a visual analog scale at 15 and 30 minutes Patients were randomized and assigned to either of two study arms via sealed envelopes. Study drugs were identical in color, and thus both personnel and patients were blinded to the study drug. The dexketoprofen group comprised 49 patients, and the paracetamol group had 50 patients in the final analysis. Results: The mean age of the study subjects was 20.9 +/- 2.5 and the mean duration of the pain was 1.9 +/- 1.7 (median: 1, interquartile range: 1 to 2) hours. Both dexketoprofen (median change 33, 95% CI: 24 to 38) and paracetamol (median change: 21, 95% CI: 12 to 32) effectively reduced the pain at 15 minutes, which was repeated at 30 minutes (median change: 63, 95% CI: 57 to 65 vs 55.5, 95% CI: 50 to 59, respectively). Pain improvement in the dexketoprofen group was better than in the paracetamol group at 15 (median difference 8, 95% CI: 0 to 16, p=0.048) and 30 (median difference: 6, 95% CI: 1 to 12, p=0.028) minutes, which was statistically significant but not clinically significant. Conclusion: Dexketotoprofen has a better visual analogue scale score that is not clinically relevant compared to paracetamol.

Objective: Ketamine is a dissociative anesthetic agent with sympathomimetic effects used commonly for procedural sedation in emergency department. The present study aimed to reveal the effect of ketamine on myocardium by measuring ejection fraction (EF). Methods: Patients less than 9 years old undergoing procedural sedation with ketamine secondary to minor trauma composed the study population by convenience sampling. Study patients received ketamine at a dose of 1.5 mg/kg. A cardiologist performed the measurements of cardiac contractility pre-ketamine and 10 min after the ketamine administration. Results: A total of 22 patients were enrolled into the study. Patient recruitment has been ceased after the 22nd patient because of the thought that more patients would not provide additional information. The study subjects had a mean age of 3.5 +/- 2.2 years and 14 (64%) of them were male. EF reduced in 14 (63.6%) patients (mean: 5.6 +/- 3.1; median: 5; interquartile range (IQR): 3.75-7; minimum-maximum (min-max): 1-14). Systolic blood pressures reduced in 10 of 14 patients with decreased EF and increased in 8 of 10 patients without decreased EF. The changes in systolic blood pressure in patients with decreased EF (n = 14) were as follows: -7.6 +/- 10.9; median: -7.5; IQR: -16.5 to 1.75; and min-max: -30 to 9. There were two patients with elevated high-sensitive troponin. Conclusion: Ketamine may reduce EF and systolic blood pressure in children less than 9 years old undergoing procedural sedation.

OBJECTIVE: The objective was to compare intravenous morphine and intravenous acetaminophen (paracetamol) for pain treatment in patients presenting to the emergency department with sciatica. METHODS: Patients, between the ages of 21 and 65 years, suffering from pain in the sciatic nerve distribution and a positive straight leg-raise test composed the study population. Study patients were assigned to one of three intravenous interventions: morphine (0.1 mg/kg), acetaminophen (1 g), or placebo. Physicians, nurses, and patients were blinded to the study drug. Changes in pain intensity were measured at 15 and 30 minutes using a visual analog scale. Rescue drug (fentanyl) use and adverse effects were also recorded. RESULTS: Three-hundred patients were randomized. The median change in pain intensity between treatment arms at 30 minutes were as follows: morphine versus acetaminophen 25 mm (95% confidence interval [CI] = 20 to 29 mm), morphine versus placebo 41 mm (95% CI = 37 to 45 mm), and acetaminophen versus placebo 16 mm (95% CI = 12 to 20 mm). Eighty percent of the patients in the placebo group (95% CI = 63.0% to 99%), 18% of the patients in the acetaminophen group (95% CI = 10.7% to 28.5%), and 6% of those in the morphine group (95% CI = 2.0% to 13.2%) required a rescue drug. Adverse effects were similar between the morphine and acetaminophen groups. CONCLUSION: Morphine and acetaminophen are both effective for treating sciatica at 30 minutes. However, morphine is superior to acetaminophen.

Background: This study is designed to investigate the effect of three different analgesics, used to treat pain in AP, on oxidative stress, DNA damage in mononuclear leukocytes, and on oxidative status. Methods: This parallel design randomized controlled trial is composed of three treatment arms, intravenous paracetamol, intravenous dexketoprofen, and intravenous tramadol. Results: A total of 107 patients were diagnosed with acute pancreatitis within the study period in the ED. Seventy-seven of them were included in the study; 26 patients for the paracetamol group, 24 patients for the dexketoprofen group, and 27 patients for the tramadol group. The mean age of study subjects was 52.73 +/- 15.38 and 66% (n = 51) of them were men. At the beginning of the study (before treatment), mean levels of DNA damage, TOS, and OSI levels were significantly higher and TAS was significantly lower in the acute pancreatitis groups than in the control group. DNA damage and OSI in HAPS-positive patients were found to be significantly greater than HAPS-negative patients (p = 0.046). DNA damage and oxidative stress were compared between the three groups. There were no differences between the groups in terms of DNA damage (p = 0.42) and also for the oxidatif stress parameters (OSI, TAS, TOS had p-values of p = 0.26, p = 0.78, p = 0.35, respectively). Conclusions: There is no difference between the effects of paracetamol, dexketoprofen, and tramadol, which are commonly used to manage acute pain in AP, on DNA damage in human T-lymphocytes and on serine parameters of oxidative status.

Objective: Kidney stones are one of the most common disorders of the urinary tract. With increasing awareness, a larger proportion of patients are seeking medical knowledge from the Internet. In present study, the features, reliability and efficacy of videos on YouTube related to the treatment of kidney stones were evaluated. Material and methods: In December 2014, YouTube was searched using keywords "nephrolithiasis"; "renal calculi"; "renal stones"; and "kidney stones" for videos uploaded containing relevant information about the disease. Only videos in Turkish were included in the study. Two physician viewers watched each video and classified them as useful, partially useful and useless according to European Association of Urology (EAU) Guidelines. The source, length, number of views, number of favourable opinions, and days since uploaded date of the all videos were evaluated. Results: A total of 600 videos were analysed The median length of videos was 6.7 +/- 10.4 (median: 3, IQR: 0.03-58) minutes. Each video was viewed at an average of 2368 (min: 11, max: 97133) times. Most of the videos (32.8%) were created by academicians and physicians. Nearly half (47.4%) of the videos were uploaded in 2014. The majority of the videos (62.5%) contained information for treatment. Percutaneous nephrolithotomy and ureterorenoscopy were the most common treatment modalities (32.8% and 28.0%, respectively) in these videos. A statistically significant difference was not detected between view numbers and source of videos (p= 0.87). However, there was a statistically significant difference between usefulness to the viewers and source of videos. Hospital -based videos were detected to be more useful (p= 0.000). Conclusion: As a result, videos that would be prepared in internet environment by professional individuals or organizations in a way which would attract attention and be easily comprehended by the public could contribute to the knowledge and education of our society about the stone disease which is commonly seen in our country.

Background: High blood pressure is still a challenge for emergency physicians to discern the patients that require further analysis to establish the existence of acute hypertensive target organ damage (TOD). The present study aimed to reveal that adropin levels are useful for detecting TOD in patients presenting with high blood pressure. Methods: Patients presenting with a blood pressure of more than 180/110 mm Hg were enrolled into the study. After a resting period of 15 minutes, patients' blood pressures were measured thrice at 5-minute intervals while the patients were sitting on a chair, and the average of these measurements was accepted as the baseline value. Blood samples were obtained for either adropin levels or possible TOD during the emergency department admission. Results: A total of 119 patients were included in the study. The mean systolic and diastolic blood pressures of study patients were 204.8 +/- 23.2 and 108.3 +/- 10.3, respectively, and 42% (n - 50) of the patients had TOD. Although the adropin levels were similar between the patients with or without TOD (TOD group = 195 pg/mL, interquartile range [IQR]: 178-201; no-TOD group = 196 pg/mL, IQR: 176-204 [P = .982]), it is significantly higher in normotensive patients (normotensive group = 289 pg/mL, IQR: 193-403) compared with the hypertensive ones (P < .001). Conclusions: Despite the significantly higher levels of adropin in normotensive patients compared with hypertensive ones, adropin could not be used as a decision tool for detecting TOD in patients presenting with high blood pressure to the emergency department. (C) 2016 Elsevier Inc. All rights reserved.

Background: Topical agents have been shown to be effective in soft tissue injuries and commonly used in outpatient clinics. However, the data regarding topical agents in the emergency department is insufficient, and they are not used often in the emergency department setting. The present study aimed to compare the effect of 2.5% topical ketoprofen (gel form) to placebo in patients presenting with ankle sprain to the emergency department. Methods: Patients presenting with ankle sprain composed the study population. Study patients were randomized into 2 study arms: 2.5% ketoprofen gel and placebo administered over a 5-cm area locally. Pain alleviation was measured by visual analog scale at 15 and 30 minutes. A total of 100 patients were included in the final analysis. Results: The median pain reduction in ketoprofen and placebo groups at 15 minutes was 27 (19.8-33.4) and 9 (7.6-17), respectively. The median pain reduction at 30 minutes for both groups was 42 (36-50.8) and 20 (17.6-24.4), respectively. Pain improvement either at 15 minutes (median difference: 16 [9-22]) or 30 minutes (median difference: 21 [15-27]) was better in the ketoprofen group than placebo. There were no adverse effects in either group. Conclusion: Ketoprofen gel was superior to placebo at 30 minutes in alleviating pain secondary to ankle sprain in the ED with a high safety profile. Further studies are needed concerning the effect of ketoprofen gel for long-term effects. Level of Evidence: Level I, high quality prospective randomized study.

Background: The present study aimed to determine the validity of hs-cTnT in predicting the mortality among patients presented to the emergency department (ED) likely to be acute coronary syndrome (ACS). Method: Patients in whom hs-cTnT was tested in the ED for a possible ACS composed the study cohort. Hs-cTnT levels of the study patients were obtained from the hospital computerized database. The outcome and mortality of the study patients was detected using the digitalized national mortality registry. All-cause mortality and cardiac mortality at the end of one month was the primary outcome. Results: 11795 patients were eligible for mortality detection and included into the final analysis. 1246 of 11795 patients were established to be dead during the study period and 358 of them supposed to be cardiac in origin. The Area Under the Curve (AUC) value of initial hs-cTnT for predicting one-month cardiac mortality was 0.869 (95% CI: 0.863 - 0.875) and 0.861 (95% CI: 0.855 - 0.867) for one-month all-cause mortality. The upper reference limit, 14 ng/L, has a sensitivity and specificity of 87% (95% CI: 77% to 94%) and 69% (95% CI: 68% to 70%), respectively, for predicting one-month cardiac mortality. Conclusions: The reference value of initial hs-cTnT does not have the ability to predict the cardiac mortality in a sufficient manner. However, reductions or increases in absolute or relative hs-cTnT levels are in concordance with mortality rates.

BACKGROUND: This study aimed to compare pantoprazole, a proton-pomp inhibitors (PPIs), and ranitidine, a H-2 receptor antagonists (H(2)RA), in ceasing dyspeptic symptoms in the emergency department (ED).

Objective: The objective was to compare intravenous morphine and intravenous acetaminophen (paracetamol) for pain treatment in patients presenting to the emergency department with sciatica. Methods: Patients, between the ages of 21 and 65 years, suffering from pain in the sciatic nerve distribution and a positive straight leg-raise test composed the study population. Study patients were assigned to one of three intravenous interventions: morphine (0.1 mg/kg), acetaminophen (1 g), or placebo. Physicians, nurses, and patients were blinded to the study drug. Changes in pain intensity were measured at 15 and 30 minutes using a visual analog scale. Rescue drug (fentanyl) use and adverse effects were also recorded. Results: Three-hundred patients were randomized. The median change in pain intensity between treatment arms at 30 minutes were as follows: morphine versus acetaminophen 25 mm (95% confidence interval [CI] = 20 to 29 mm), morphine versus placebo 41 mm (95% CI = 37 to 45 mm), and acetaminophen versus placebo 16 mm (95% CI = 12 to 20 mm). Eighty percent of the patients in the placebo group (95% CI = 63.0% to 99%), 18% of the patients in the acetaminophen group (95% CI = 10.7% to 28.5%), and 6% of those in the morphine group (95% CI = 2.0% to 13.2%) required a rescue drug. Adverse effects were similar between the morphine and acetaminophen groups. Conclusion: Morphine and acetaminophen are both effective for treating sciatica at 30 minutes. However, morphine is superior to acetaminophen. (C) 2016 by the Society for Academic Emergency Medicine

Objectives: Burnout syndrome is recognized as a major global problem among emergency healthcare workers as it causes prevalent fatigue, job separations, and disappointment. The objective of this study was to investigate the relationship of the glial marker S100B in sera of emergency physicians with burnout syndrome and depression. Methods: This was a prospective observational study of emergency medicine residents in three distinct university-based departments of emergency medicine. S100B levels were measured before and after the shifts. In addition, the resident completed the Maslach Burnout Inventory (MBI) and the Beck Depression Inventory (BDI) prior to starting the shift. S100B levels were compared to the occurrence of burnout syndrome and depression as measured by the MBI and BDI. Results: Forty-eight of 53 emergency medicine residents actively working in the three university-based EDs participated in the study. The majority of the sample had BDI scores compatible with severe depression (n = 37, 77.1%). The median scores of MBI for emotional exhaustion, depersonalization, and personal accomplishment were 29 (interquartile range [IQR] = 25 to 33), 14 (IQR = 12 to 18), and 26.5 (IQR = 22 to 31), respectively. S100B levels were found to correlate best with scores of BDI and emotional exhaustion in burnout syndrome. The difference between median S100B levels recorded in the residents with severe depression and moderate depression was found statistically significant (median [IQR] = 150 [145 to 151] vs. 135 [128 to 140]; p = 0.0005). This is also true for S100B levels detected before and after night shifts (median [IQR] = 146 [136.5 to 153.2] and 149.5 [139-158], respectively; difference = 3, 95% confidence interval = 2 to 4 [p = 0.001]). Conclusions: S100B levels correlate with depression scores and emotional exhaustion in burnout syndrome. The findings suggest that S100B can be used as a marker to screen emergency medicine residents and detect individuals with high risk for depression and burnout syndrome. (C) 2016 by the Society for Academic Emergency Medicine

Objective: Oligoanalgesia is common in emergency departments (EDs), and pain management is of concern for ED physicians. The aim of this study was to reveal the effect of ketoprofen gel in patients presenting with mechanical low back pain to the ED. Method: All the study patients received intravenous dexketoprofen additional to study drugs. After dexketoprofen, 2 g of 2.5% ketoprofen gel or placebo was administered to the site with pain and tenderness. Pain relief at 15 and 30 minutes was measured by visual analog scale scores. Rescue drug need and adverse effects were also recorded. Results: A total of 140 patients were enrolled into the study. The mean age of the study patients was 35 +/- 12, and 56% (n = 79) of them were male. The mean pain reduction at 30 minutes was 52 +/- 18 for ketoprofen gel and 37 +/- 17 for placebo, and ketoprofen gel was better than placebo at 30 minutes (mean difference, 16 mm; 95% confidence interval, 10-21). Ten patients (14%) in the placebo group and 2 patients (3%) in the ketoprofen gel group needed rescue drug (P =.35). Conclusion: Ketoprofen gel improves pain in patients presenting with mechanical low back pain to ED at 30 minutes in addition to intravenous dexketoprofen when compared to placebo. (C) 2016 Elsevier Inc. All rights reserved.

Objective The objective was to compare intravenous morphine and intravenous acetaminophen (paracetamol) for pain treatment in patients presenting to the emergency department with sciatica. Methods Patients, between the ages of 21 and 65 years, suffering from pain in the sciatic nerve distribution and a positive straight leg-raise test composed the study population. Study patients were assigned to one of three intravenous interventions: morphine (0.1 mg/kg), acetaminophen (1 g), or placebo. Physicians, nurses, and patients were blinded to the study drug. Changes in pain intensity were measured at 15 and 30 minutes using a visual analog scale. Rescue drug (fentanyl) use and adverse effects were also recorded. Results Three-hundred patients were randomized. The median change in pain intensity between treatment arms at 30 minutes were as follows: morphine versus acetaminophen 25 mm (95% confidence interval [CI] = 20 to 29 mm), morphine versus placebo 41 mm (95% CI = 37 to 45 mm), and acetaminophen versus placebo 16 mm (95% CI = 12 to 20 mm). Eighty percent of the patients in the placebo group (95% CI = 63.0% to 99%), 18% of the patients in the acetaminophen group (95% CI = 10.7% to 28.5%), and 6% of those in the morphine group (95% CI = 2.0% to 13.2%) required a rescue drug. Adverse effects were similar between the morphine and acetaminophen groups. Conclusion Morphine and acetaminophen are both effective for treating sciatica at 30 minutes. However, morphine is superior to acetaminophen. © 2016 by the Society for Academic Emergency Medicine.

OBJECTIVE: Ketamine is a dissociative anesthetic agent that has an increased frequency of usage in the last years particularly in emergency departments. In the present study, we aimed to determine whether ketamine is related to myocardial injury in children undergoing minor procedures. METHOD: Children younger than 18 years undergoing procedural sedation secondary to minor trauma composed the study population. Patients were administered ketamine with a dose of 1.5 mg/kg via intravenous route. QT interval was measured by Bazett's formula, and QT dispersion was determined by taking the average of 3 different QT intervals. High-sensitive troponin levels were measured before and 3 hours after the ketamine administration. RESULTS: A total of 30 patients were included into the study. Study subjects had a median age of 2 years (interquartile range, 1-4 years). There were 2 patients among the study patients who had troponin elevations 3 hours after the ketamine administrations. High-sensitive troponin levels of these 2 at the time of preketamine, 3, 5, and 24 hours after the ketamine administration were as follows: 5, 29, 15, and 5 ng/L and 3, 44, 41, and 4 ng/L, respectively. There was no difference before and after the ketamine administration for the corrected QT intervals and QT dispersions. CONCLUSION: Ketamine may be related to minor troponin elevations in children undergoing procedural sedation without a permanent cardiac dysfunction.

Takotsubo syndrome (TS) has been described as an acute cardiac condition precipitated by a stressful mental or physical condition. A majority of patients are presented with acute substernal chest pain. It is often difficult to differentiate TS from acute ST-elevation myocardial infarction (STEMI) on initial presentation. The electrocardiograph classically mimics STEMI and is generally accompanied by elevation of myocardial enzymes that warrants immediate cardiac catheterization. The present article reports a patient with TS referred to the emergency department because of symptoms suggestive of acute coronary syndrome.