Tatd 2015 2 by KAREPUBLISHING

ISSN 1304-7361

Turkish Journal of Emergency Medicine T羹rkiye Acil T覺p Dergisi VOLUME 15

NUMBER 2

YEAR 2015

Citation Abbreviation: Turk J Emerg Med Visual Diagnosis Foreign Bodies Ingested by a Mentally Retarded Patient Cebicci H, Alpaslan M Pain, Tenderness, and Swelling of Right Thumb Gumustas SA, Hamcan S ORIGINAL ARTICLES The Factors Influencing Relapse in Patients Presenting to the Emergency Department with COPD Exacerbation Durmaz D, Goksu E, Yildiz G, Unal A, Kartal M, Oskay A, Simsek Y Inter-Observer Agreement on Diffusion-Weighted Magnetic Resonance Imaging Interpretation for Diagnosis of Acute Ischemic Stroke Among Emergency Physicians Oray D, Limon O, Ertan C, Ayd覺noglu Ugurhan A, Sahin E Demographic Properties of Civilians with Blast Injuries in Southeastern Anatolia Region Kacmaz O, Dursun R, Durgun HM, Akdag M, Orak M, Ustundag M, Gulloglu C Rising Threat; Bonsai Aksel G, Bozan O, Kayac覺 M, Guneysel O, Bahar Sezgin S Rabies Suspected Animal Contact Cases in a City with Animal Husbandry and the Appropriateness of Prophylactic Procedures Dagar S, Sahin S, Oray D, Akkaya A, Kama A, Ucan G CASE REPORTS Salbutamol Abuse is Associated with Ventricular Fibrillation Uysal E, Solak S, Carus M, Uzun N, Cevik E A Rare Cause of Sudden Ptosis: Posterior Communicating Artery Aneurysm Bozkurt MF, Dinc E, Eken E, Bozkurt S, Sundu C Weakness In The Emergency Department: Hypokalemic Periodic Paralysis Induced By Strenuous Physical Activity Dogan NO, Avcu N, Yaka E, Isikkent A, Durmus U A Rare Cause of Acute Abdominal Pain: Splenic Infarct (Case Series) Ozakin E, Cetinkaya O, Baloglu Kaya F, Acar N, Cevik AA REVIEW The Integration of Palliative Care into the Emergency Department Basol N @TurkJEmergMed

TurkJEmergMed

Issued by The Emergency Medicine Association of Turkey This Journal is indexed in Turkish Medical Index of TUBITAK-ULAKBIM, EBSCOhost, Index Copernicus, DOAJ, Gale/Cengage Learning, SCOPUS, EMBASE and Turkiye Citation Index.

www.trjemergmed.com

Turkish Journal of Emergency Medicine EDITORS Suleyman TUREDI, M.D. Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine

Orhan CINAR, M.D. Gulhane Military Medical Academy (GMMA), Department of Emergency Medicine

Arzu DENIZBASI, M.D. Marmara University, Faculty of Medicine, Department of Emergency Medicine

ASSOCIATE EDITORS Seyran BOZKURT, M.D.

Mersin University Faculty of Medicine, Department of Emergency Medicine

Cem ERTAN, M.D.

Izmir University Faculty of Medicine, Department of Emergency Medicine

Nurettin Ozgur DOGAN, M.D.

Kocaeli University, Faculty of Medicine, Department of Emergency Medicine

Nese COLAK ORAY, M.D.

Dokuz Eylul University Faculty of Medicine, Department of Emergency Medicine

Mehmet Ali KARACA, M.D.

Hacettepe University Faculty of Medicine, Department of Emergency Medicine

Ozlem KOKSAL, M.D.

Uludag University Faculty of Medicine, Department of Emergency Medicine

Serkan SENER, M.D.

Ac覺badem University, Faculty of Medicine, Department of Emergency Medicine

Ibrahim TURKCUER, M.D.

Pamukkale University, Faculty of Medicine, Department of Emergency Medicine

TECHNICAL REVIEW AND METHODOLOGY EDITOR Haldun AKOGLU, M.D.

Marmara University, Faculty of Medicine, Department of Emergency Medicine

www.trjemergmed.com

Turkish Journal of Emergency Medicine EDITORIAL CONSULTANTS (2015, Vol. 2) Ayhan OZHASENEKLER, M.D. Can AKTAS, M.D. Cemil KAVALCI, M.D. Deniz ORAY, M.D. Funda KARBEK AKARCA, M.D. Gokhan AKSEL, M.D. Gul PAMUKCU GUNAYDIN, M.D. Ibrahim IKIZCELI, M.D. Mehtap BULUT, M.D. Murat ERSEL, M.D. Murat YESILARAS, M.D. Mutlu KARTAL, M.D. Onder LIMON, M.D. Ozgur KARCIOGLU, M.D. Yalcin GOLCUK, M.D. Yusuf Ali ALTUNCI, M.D.

SCIENTIFIC ADVISORY BOARD Jeffrey ARNOLD, M.D. Elizabeth DEVOS, M.D. Geijsel FEMKE, M.D. C. James HOLLIMAN, M.D. Monseireus KOEN, M.D.

Mark LANGDORF, M.D. Frank LOVECCHIO, M.D. Matej MARINSEK, M.D. Resmiye ORAL, M.D. Pini RICARDO, M.D.

Petrina ROBERTA, M.D. Brown RUTH, M.D. Lemoyne SABIN, M.D. Selim SUNER, M.D. Judith E. TINTINALLI, M.D.

FORMER EDITORS Rifat TOKYAY, M.D. (2001-2003) Hamit HANCI, M.D. (2003-2004) Oktay ERAY, M.D. (2004-2007)

Sedat YANTURALI, M.D. (2006-2008) Murat PEKDEMIR, M.D. (2010-2013) Cenker EKEN, M.D. (2007-2010, 2012) Ersin AKSAY, M.D. (2009-2011)

Turkish Journal of Emergency Medicine ISSN 1304-7361

ISSUED BY THE EMERGENCY MEDICINE ASSOCIATION OF TURKEY

VOLUME 15 NUMBER 2 JUNE 2015

OWNER YILDIRAY CETE, M.D. on behalf of the Emergency Medicine Association of Turkey

CORRESPONDENCE Turkiye Acil Tip Dernegi, Cankaya Mah., Cinnah Cad., No: 51/10 Cankaya, Ankara, Turkey Tel: +90 - 312 - 438 12 66 • Fax: +90 - 312 - 438 12 68 e-mail: bilgi@tatd.org.tr, editor@trjemergmed.org Published four times a year.

PUBLISHER

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KARE YAYINCILIK | karepublishing Sogutlucesme Cad., No: 76/103, 34730 Kadikoy, İstanbul, Turkey Tel: +90 - 216 - 550 61 11 Fax: +90 - 216 - 550 61 12

Periodical

COORDINATION DESIGN PRESS DATE

English correction service by makaletercume.

Ali CANGUL Edibe COMAKTEKIN June 2015

This publication is printed on paper that meets the international standard ISO 9706: 1994. Free full-text articles in English are available at www.trjemergmed.com.

KARE @TurkJEmergMed

TurkJEmergMed

Turkish Journal of

Emergency Medicine Contents vii

57 58

Publishing with the Turk J Emerg Med

JUNE 2015

viii Instructions for Authors

Visual Diagnosis Foreign Bodies Ingested by a Mentally Retarded Patient Cebicci H, Alpaslan M Pain, Tenderness, and Swelling of Right Thumb Gumustas SA, Hamcan S

ORIGINAL ARTICLES

The Factors Influencing Relapse in Patients Presenting to the Emergency Department with COPD Exacerbation Durmaz D, Goksu E, Yildiz G, Unal A, Kartal M, Oskay A, Simsek Y

Inter-Observer Agreement on Diffusion-Weighted Magnetic Resonance Imaging Interpretation for Diagnosis of Acute Ischemic Stroke Among Emergency Physicians Oray D, Limon O, Ertan C, Ayd覺noglu Ugurhan A, Sahin E

Demographic Properties of Civilians with Blast Injuries in Southeastern Anatolia Region Kacmaz O, Dursun R, Durgun HM, Akdag M, Orak M, Ustundag M, Gulloglu C

Rising Threat; Bonsai Aksel G, Bozan O, Kayac覺 M, Guneysel O, Bahar Sezgin S

Rabies Suspected Animal Contact Cases in a City with Animal Husbandry and the Appropriateness of Prophylactic Procedures Dagar S, Sahin S, Oray D, Akkaya A, Kama A, Ucan G

CASE REPORTS Salbutamol Abuse is Associated with Ventricular Fibrillation Uysal E, Solak S, Carus M, Uzun N, Cevik E

A Rare Cause of Sudden Ptosis: Posterior Communicating Artery Aneurysm Bozkurt MF, Dinc E, Eken E, Bozkurt S, Sundu C

Weakness In The Emergency Department: Hypokalemic Periodic Paralysis Induced By Strenuous Physical Activity Dogan NO, Avcu N, Yaka E, Isikkent A, Durmus U

A Rare Cause of Acute Abdominal Pain: Splenic Infarct (Case Series) Ozakin E, Cetinkaya O, Baloglu Kaya F, Acar N, Cevik AA

100

REVIEW The Integration of Palliative Care into the Emergency Department Basol N

Turkish Journal of

Emergency Medicine Publishing with the Turk J Emerg Med

1. The Turkish Journal of Emergency Medicine (Turk J Emerg Med) is published four times per year. The total number of original research articles is 15 per year and research articles (including original research, case studies, letters to the editor and reviews) constitute at least 50% of the published material. Every issue published will contain a minimum of 4 research articles. Apart from the research articles, Turk J Emerg Med also publishes articles in the categories of case studies, case series, visual diagnoses in emergency medicine, letters to the editor, brief reports, reviews and evidence based emergency medicine in consultation with the editorial board. Reviews are presented upon invitation from the editor. 2. All reviewer comments, signed copies of manuscripts and corrections will be kept in digital format in the journal archives for a minimum period of 5 years. 3. The submitted manuscripts are first reviewed by the journal’s editor who determines whether the manuscript deserves further evaluation or not. For submissions that are granted further evaluation, the editor assigns the manuscript to one of the assistant editors. The editor and the assistant editor then forwards the manuscript to two reviewers or one reviewer and a member of the scientific board for evaluation. If both the editor and the assistant editor determines the manuscript is not scientifically valuable or not an original work, or if it does not relate to emergency medicine or does not address the journal’s target audience, then they reject the manuscript directly without forwarding it to the reviewers. 4. The goal of the Turk J Emerg Med is to notify the authors with the acceptance of their submission for peer review within 14 days, peer review period of 21 days and final evaluation and notification of 28 days from the receipt of the manuscript. The authors are given 10 days for minor revisions and 20 days for major revisions. The final page layout is provided to the authors

within 30 days of the acceptance of the manuscript for publication, for final review and proof. 5. The assistant editor may consult the research methodology editor to clarify any problems in the statistical design and evaluation of the study during the peer review process. Even if such consultation is not sought during the review process, it can be implemented upon request of the editor in chief prior to the final acceptance of the manuscript. 6. All manuscripts containing material written in English will be evaluated by the language editor before the manuscripts are considered for publication. 7. Manuscripts submitted to the Turk J Emerg Med are expected to conform with the Helsinki Declaration and meet the common requirements of the biomedical journals. 8. Articles are listed on the content page and are published in appropriate sections (original research, case report, review, etc.). 9. The journal is printed on acid-free paper. 10. Advertisements are not allowed within articles. 11. The editor(s) of the Turk J Emerg Med are elected by the Board of the Emergency Medicine Association of Turkey once a year in January. The Turk J Emerg Med board consists of editor(s), assistant editors, a research methodology editor and a language editor. 12. All material published in the Turk J Emerg Med are the property of the Emergency Medicine Association of Turkey. This material may not be referred without citation nor may it be copied in any format. Authors are responsible for all statements made in their articles.

Editors of the Turk J Emerg Med Assoc. Prof. Dr. Suleyman TUREDI Assoc. Prof. Dr. Orhan CINAR Prof. Dr. Arzu DENIZBASI

Turkish Journal of

Emergency Medicine Instructions for Authors SUBMITTING MANUSCRIPTS Turk J Emerg Med accepts online manuscript submission. Users should visit journalâ&#x20AC;&#x2122;s web site and create an account before submitting their manuscripts. Resources for Authors page includes manuscript writing guidelines, drafts, templates and many useful examples for different manuscript types, as well as ethical standards that you should follow. You may want to check the sections on Reporting Statistics and Preparing Figures in the Resources for Authors page before sending your manuscript for peer-review.

REQUIRED FILETYPES AND MINIMUM SUBMISSION REQUIREMENTS Before submission via electronic submission system, a number of separate MS Word (.doc) and Adobe (.pdf) files should be prepared with the following formatting properties. No submissions will be accepted without a Cover Letter and a Title Page. 1. Cover Letter: A Cover Letter file should be included in all types of Manuscript submissions. On the Cover Letter, the author(s) should present the Title, Manuscript Type and Manuscript Category of the submission, and whether the submitted work had previously been presented in a scientific meeting. The Cover Letter should contain a statement that the manuscript will not be published or evaluated for publication elsewhere while under consideration by Turkish Journal of Emergency Medicine. In addition, the Full Name of the Corresponding Author and his/her Contact Information including the Address, Phone number and E-mail Address should be provided at the bottom of the Cover Letter. The Cover Letter should be signed by corresponding author, scanned and submitted in .jpg or .pdf format with other manuscript files. The order of a Cover Letter should be as follows: a. Title, Manuscript Type b. Statement that the manuscript will not be published or evaluated for publication elsewhere while under consideration c. Corresponding Author(s) Full Name, contact information including address, phone, and e-mail address d. Signature of the Corresponding Author 2. Title Page: A Title Page file should be included in all types of Manuscript submissions. Please prepare your title page as a separate electronic file, including the following elements: a. Title of the manuscript Generally nondeclarative, not a question, begins with main concept if possible, and without causal language, eg, "effect of," unless the study is an RCT b. Author(s) List, please list their full names and up to 2 academic degrees per author; do not include honorary affiliations, such as fellow status in an organization. c. Affiliation(s) of each author, including department or division, institution, city, state, country. d. Corresponding Author(s) Full Name, contact information including address, phone, and e-mail address e. Funding or other financial support should be acknowledged. f. Conflict of interest statement: A conflict of interest statement should be provided in bottom of the Title Page. Please list of all potential conflicts of interest for each author, in accordance with ICMJE Recommendations. In case of no conflicts of interests, please provide a statement such as: "Conflicts of Interest: None declared". g. We will assume that you will not make reprints available unless you specify otherwise. 3. Abstracts: On the Abstracts Page, the author(s) should present Abstract and Keywords (at least three) in this order. Keywords must be chosen carefully from MeSH Database (http://www.ncbi.nlm.nih.gov/mesh) websites. Number of Words and Structure requirements of Abstracts regarding to different Manuscript Types are listed below the Instructions for each Manuscript Type. 4. Main Text: A Main Text file should be included in all types of Manuscript submissions. This file should include Title, Abstracts Page, Main Text of your manuscript, and the References Section combined into a single electronic file. Tables can be included in this file as separate pages after References section, or may be uploaded separately as you prefer. Structure of the Main Text differs between Manuscripts types. Please refer to the Instructions for each Manuscript Type. a. This combined file with the sections of Abstracts, Keywords, Main Text, References with/without Tables should be a blinded version of the original manuscript. The names of the authors', and any identifying information including the academic titles, institutions and addresses must be omitted. Apart from the stage of the manuscript evaluation process, manuscripts submitted with any information pertaining to the author(s) will be rejected as soon as it is noticed. 5. Tables: Tables summarizing the data should be clearly formatted without using any templates. Data presented in the tables should not be included in its entirety in the text.

should be uploaded in MS Word (.doc) format and the electronic file should be named accordingly (Tables_xxx_vx.doc; see below). Tables should not be uploaded as pdf, jpeg or else. e. Arrange tables so that the primary comparisons of interest are horizontal, leftto-right (the standard reading order). Provide the N for each column or row and marginal totals where appropriate. 6. Figures: If the manuscript includes Figures then each Figure should be uploaded as a separate file in all types of Manuscript submissions. The information contained in the figure/image should not be repeated in its entirety, however reference to the figure/ image must be referred in the text. a. Technical reqirements i. Figure legends should be appear on a separate page after the References section. ii. During submission, all figures must be uploaded in a separate file from the text file and should be named accordingly (Figure1_xxx; Figure2_xxx; see below section: Electronic Filenames). iii. No legends or titles should be included in the Figures. iv. Pictures should be saved in JPEG, EPS or TIF format. v. Please submit photographs and figures with a resolution of at least 300 dots per inch. Figures are easiest for us to process if submitted in TIFF or EPS format. b. Content requirements i. We prefer graphics that show the distribution of data (eg, scatterplots, 1-way plots, box plots) to those showing summaries of data (eg, pie charts, bar graphs of means). Pie charts generally should not be used for research results. ii. If the data collected are paired (eg, pre and post, or 2 different measures on the same subject), then choose a graphical format that conveys the inherent pairing of the data. If data are paired, they should be displayed as such iii. Avoid background gridlines and other formatting that do not convey information (eg, superfluous use of 3-dimensional formatting, background shadings). Graphs should not be 3-D unless the data are. iv. Omit internal horizontal and vertical rules. v. If measurements are discrete, display as discrete points rather than a continuous line. vi. 95% CIs should be provided whenever appropriate (rather than SE) vii. For graphs, axes should begin at zero; if they do not, a break should be shown in the axis viii. Odds ratios should be displayed on a logarithmic scale ix. Survival curves should include number at risk below x axis x. Please check the references in the Resources for Authors page for many useful examples and guidelines for figure creation. c. Ethical requirements i. The owner and/or subject of the photograph must sign the Patient Consent Form, regardless of identifying material which can be found at Forms, Templates and Examples page under Resources Menu. ii. Figures should not be reproduced from other sources without permission 7. Statements, permissions, and signatures: a. Author Contribution Form: Designated authors should meet all four criteria for authorship in theICMJE Recommendations. All authors, and all contributors (including medical writers and editors), should specify their individual contributions and should complete a standard form, which is available at Forms, Templates and Examples page under Resources Menu. b. Conflict of Interest Form: A conflict of interest exists when professional judgment concerning a primary interest (such as patientsâ&#x20AC;&#x2122; welfare or validity of research) may be influenced by a secondary interest (such as financial gain). Financial relationships are easily identifiable, but conflicts can also occur because of personal relationships or rivalries, academic competition, or intellectual beliefs. A conflict can be actual or potential, and full disclosure to The Editor is the safest course. Failure to disclose conflicts might lead to publication of an Erratum or even to retraction. All submissions to Turk J Emerg Med must include disclosure of all relationships that could be viewed as presenting a potential or actual conflict of interest. All authors are required to provide a Conflict of Interest Statement and should complete a standard form, which is available at Forms, Templates and Examples page under Resources Menu. c. Patient Consent Form: Publication of any personal information about an identifiable living patient requires the explicit consent of the patient or guardian We expect authors to use a standard patient consent form which is available at Forms, Templates and Examples page under Resources Menu. d. Copyright Transfer Form: All authors are required to provide a Copyright transfer from with complete a standard form, which is available at Forms, Templates and Examples page under Resources Menu.

a. Tables must be numbered consecutively. b. Each Table must be referred to in the text. c. Number and Title of each Table should be written at the top of each page before MANUSCRIPT FORMATTING the Table. d. Tables can be included in Main text file as separate pages after References section, Manuscript format must be in accordance with the ICMJE-Recommendations for the or may be uploaded separately as you prefer. If you prefer a separate file, Tables Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals

Turkish Journal of

Emergency Medicine Instructions for Authors (updated in August 2013). Papers that do not comply with the format of the Journal will be experimental animal trials, or any other clinical or experimental studies. Maximum 8 authors, returned to the author for correction without further review. Therefore, to avoid loss of time 4000 words (including references, tables, and figure legends), 30 references, 6 tables and/or and work, authors must carefully review the submission rules. figures. Submission of research articles should include below mentioned pages, sections and Manuscript structure should be complient with the guidelines of WAME . Please check this files as defined above in required filetypes section: guideline and Resources for Authors page for more information if you are not sure how to write a manuscript. Extensive number of resources, drafts, templates and articles are provided for you so you can create an excellent manuscript. General Format 1. General Style: a. The manuscript should be typed in a Microsoft Word™ file, single-column format, double-spaced with 2.5 cm margins on each side, text should be justified on both the right and left margins of the page in Times New Roman, 12pt. b. Main text should include page numbers at the right bottom and consecutive line numbers. c. Every effort should be made to avoid medical jargon. 2. For the Blind Initial Review: The names of the authors', and any identifying information including the academic titles, institutions and addresses must be omitted. Manuscripts submitted with any information pertaining to the author(s) will be rejected. 3. Use of English: Proper use of English terminology and grammar should be employed. 4. Statistical Analysis: All studies should be analyzed in consultation with those experienced in statistical analysis. 5. Units of Measure: Measurements should be reported using the metric system according to the International System of Units (SI). Laboratory values should be presented with normal limits. Consult the SI Unit Conversion Guide, New England Journal of Medicine Books, 1992. Please check Resources for Authors page for more information. 6. Drugs: Generic names for drugs should be used. Doses and routes for the drugs should be stated. When a drug, product, hardware, or software mentioned within the main text product information, including the name of the product, producer of the product, city of the company and the country of the company should be provided in parenthesis in the following format: “Discovery St PET/CT scanner (General Electric, Milwaukee, WI, USA)” 7. Abbreviations: We discourage the use of any but the most necessary of abbreviations. They may be a convenience for an author but are generally an impediment to easy comprehension for the reader. All abbreviations in the text must be defined the first time they are used (both in the abstract and the main text), and the abbreviations should be displayed in parentheses after the definition. Abbreviations should be limited to those defined in the AMA Manual of Style, current edition. Authors should avoid abbreviations in the title and abstract and limit their use in the main text. 8. Decimal points or commas: Decimal numbers should be separated from the integers with points. Commas should not be used in decimals throughout the manuscript. 9. Use of percentages: Percent sign should be located after the percentages. 10. References: References should be numbered consecutively in the order in which they are first mentioned in the text, and should be formatted in AMA style (3 authors then "et al"). Avoid referencing abstracts, or citing a "personal communication" unless it provides essential information not available from a public source. Examples of Referencing are as follows: i. Article: Raftery KA, Smith-Coggins R, Chen AHM. Gender-associated differences in emergency department pain management. Ann Emerg Med. 1995;26:414-21. ii. Book: Callaham ML. Current Practice of Emergency Medicine. 2nd ed. St. Luis, MO:Mosby;1991. iii. Book Chapter: Mengert TJ, Eisenberg MS. Prehospital and emergency medicine thrombolytic therapy. In: Tintinalli JE, Ruiz E, Krome RL, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York, NY:McGraw-Hill;1996:337-343. iv. Courses and Lectures (unpublished): Sokolove PE, Needlesticks and high-risk exposure. Course lecture presented at: American College of Emergency Physicians, Scientific Assembly, October 12, 1998, San Diego, CA. v. Internet: Fingland MJ. ACEP opposes the House GOP managed care bill. American College of Emergency Physicians. Web site. Available at: http://www.acep.org/ press/pi980724.htm. Accessed August 26,1999. vi. Personal Communication: Use of personal communications should be avoided. If necessary, the person's name, academic title, and the month and year of the communication should be included in the reference. A letter of permission from the person referred to should accompany the manuscript. vii. Please check Resources for Authors page for more information.

MANUSCRIPT TYPES AND SPECIFIC FORMATTING GUIDELINES Identification of article type is the first step of manuscript submission because article type dictates the guidelines that should be used, including formatting and word limits of the manuscript. The main categories are outlined below: Research Article: Original studies of basic or clinical investigations in emergency medicine. These articles can include randomized controlled trials, observational (cohort, case-control or cross-sectional) studies, destructive studies, diagnostic accuracy studies, systematic reviews and meta-analyses, nonrandomized behavioral and public health intervention trials,

1. Abstracts Page: Both English and Turkish (if relevant) abstracts are required. Abstracts should not exceed 250 words and should be structured with the following subheadings: Objectives, Material and Methods (with design), Results, and Conclusion (case control study, cross sectional study, cohort study, randomized controlled trial, diagnostic accuracy study, meta-analysis and systemic review, animal experimentation, non-randomized study in behavioral sciences and public health, etc.). In your results emphasize the magnitude of findings over test statistics, ideally including the size of effect and its confidence intervals for the principal outcomes.

2. Main Text: The main text should be structured with the following subheadings: Introduction, Material and Methods, Results, Discussion, Acknowledgments, References, Tables, and Figure Legends. a. Introduction: A three-paragraph structure should be used. Background information on study subject (1st paragraph), context and the implications of the study (2nd paragraph) and the hypotheses and the goals of the study (3rd paragraph). Background: Describe the circumstances or historical context that set the stage and led you to investigate the issue. Context: Describe why your investigation is consequential. What are its potential implications? How does it relate to issues raised in the first paragraph? Why is this specific investigation the next logical step? Goals of the study: Clearly state the specific research objective or hypothesis and your primary outcome measure. b. Material and Methods: The method section, is one of the most important sections in original research articles, and should contain sufficient detail. The investigation method, study sample, analyses performed, commercial statistical programs used, details of measurement and evaluation (e.g.: make and model of biochemical test devices and kits) should all be clearly stated. The names of local ethics committee or other approving bodies should be provided in Methods section for prospective studies. The Methods section should be organized with logical and sequential subheadings. The optimal subheading choices will vary with the analysis, but the following examples applicable to most clinical research: i. Study design and setting: Describe the study design using standard terms, and describe the study setting in a fashion that conveys characteristics that could affect the external validity (generalizability) of the findings. ii. Sample size estimation: Describe how you performed the sample size estimation, which tests and assumptions were used, and which sample size estimation software was used (if relevant). iii. Selection of Participants: Describe how participants were identified, screened, and enrolled. Remember to consider all participants including patients, providers, and outcome assessors, as appropriate. There should be a list of the inclusion and exclusion criterion with descriptions. In survey studies, information concerning who implemented the survey and how it was performed should be specified. iv. Interventions: Describe any interventions in sufficient detail to permit replication. Describe any blinding of subjects, providers, outcome assessors, or data analysts. Describe methods for determining whether the intervention was actually received. v. Methods and Measurements: Discuss how and when measurements were made. Discuss the precision and reliability of the measurements. How were spurious or missing measurements handled? Discuss who collected the data and how they collected it. Discuss how data were entered, checked, and processed. vi. Outcomes: Describe the study's primary and secondary outcome measures, and if needed explain why they were chosen to address the study objective. When possible, use outcomes that have been previously validated, or provide evidence of your own efforts to validate the measure. Emphasize patientcentered outcomes (eg, pain, days off from work, death) over intermediate outcomes (eg, change in forced expiratory volume, change in asthma score). vii. Power of the study: Provide the achieved power of the study according to the primary outcome that you used to calculate the sample size. viii. Analysis: Detail the primary analysis and specify any software that was used, including the name of the software and the company that produces it. Provide references for any non-routine analytic methods. If appropriate, detail sensitivity analyses that explore how results change when assumptions about the investigation are modified. c. Results: The demographic properties of the study population, the main and secondary results of the hypothesis testing must be provided. Commenting on the results and discussing the literature findings should be avoided in this section. Present as much data as possible at the level of the unit of analysis, graphically if possible. Emphasize the magnitude of findings over test statistics, ideally using size of effect and associated confidence intervals for each outcome. d. Discussion: The main and secondary results of the study should briefly presented and compared with similar findings in the literature. Providing intensive background information should be avoided in this section. Consider only those

Turkish Journal of

Emergency Medicine

Instructions for Authors published articles directly relevant to interpreting your results and placing them in context. Do not stress statistical significance over clinical importance. Avoid extrapolation to populations or conditions that you have not explicitly studied in your investigation. Avoid claims about cost or economic benefit unless a formal cost-effectiveness analysis was presented in the Methods and Results sections. Do not suggest "more research is needed" without stating what the specific next step is. Optionally, you may include a paragraph "In retrospect, . . ." to candidly discuss what you would do differently if given the opportunity to repeat the study, so others can learn from your experience. e. Limitations: The limitations of the study should be mentioned in a separate paragraph subtitled as the "Limitations" in the end of the discussion. Explicitly discuss the limitations of your study, including threats to the internal and external validity of your results. When possible, examine the magnitude and direction of each bias and how it might affect the interpretation of results. f. Conclusion: A clear conclusion should be made in the light of the results of the study. The potential effects of the results of the study on the current clinical applications should be stated in a single sentence. Inferences that are not supported by the study results should be avoided. g. Acknowledgments: h. References: References section should be in a separate page. i. Figure Legends: Figure Legends should be included in the Main Text in a separate page and this page should be the at the end of the Main text file. 3. Tables: At the end of the Main Text file as separate pages or as a separate file.

tables and/or figures. The authors should also submit copies of the articles proposed as supporting evidence. Visual Diagnosis: These are short case reviews with interesting and educative visual material. Visual Diagnosis is to be presented in two parts. In the first part, the case is summarized and the image is presented. In the second part, the diagnosis is provided in the heading, followed by a discussion of the management of the case and the specifications of the images. Maximum 2 authors, 500 words (including references), 5 references, 2 figures. No tables are allowed. There is no need for an abstract. Letter to the Editor: Opinions, comments and suggestions made concerning articles published in Turkish Journal of Emergency Medicine or other journals. Letters should contain a maximum of 1,000 words and 5 references are allowed for these single author submissions. No abstract is required.

GUIDELINES FOR SPECIFIC RESEARCH STUDY DESIGNS Randomized controlled trials (RCTs) RCTs must be reported in accordance with the CONSORT statement, summarized as follows: 1. Title includes the phrase "randomized controlled trial" 2. Clear depiction of the three elements of randomization: sequence generation, allocation, and concealment 3. Clear description of which outcome assessments were and were not blinded 4. A figure summarizing participant flow through the trial 5. Protocol deviations described, and whether analysis is intention to treat 6. Outcomes each reported with size of effect and associated confidence intervals.

4. Figures: Should not be included in the Main text file and should be uploaded as separate files as with the properties describes above in required filetypes section: Chart reviews 5. Ethics or Review Board Approval: If your manuscript involves original research, Least methodological elements that Turkish Journal of Emergency Medicine seek in you will be asked to verify approval or exemption by an institutional review or ethics retrospective research are as follows: board. Turkish Journal of Emergency Medicine will be unable to further consider 1. Trained and monitored abstractors use explicit protocols, precisely defined variables, manuscripts without approval or formal exemption. (The only exceptions are for and standardized abstraction instruments. analyses of third party anonymized databases which already have pre-existing IRB 2. Authors clearly describe how missing, conflicting, and/or ambiguous chart elements approval or exemption.) were coded. 6. Compliance with manuscript writing guidelines: If your manuscript involves 3. Interrater agreement assessed by having a sample of charts reviewed independently original research, you will be asked to verify compliance with guidelines for each by two or more abstractors. corresponding study design. Please check Resources for Authors page for checklists 4. When possible, abstractors are blinded to the study hypothesis and/or study group and relevant documents. assignment, particularly for chart elements that are not wholly objective. Case Reports: Brief descriptions of clinical cases or the complications that are Observational studies seldom encountered in emergency medicine practice and have an educational value. We prefer observational studies to be compliant with the latest STROBE guidelines. Consideration will be given to articles presenting clinical conditions, clinical manifestations or complications previously undocumented in the existing literature and unreported side Studies on diagnostic tests of adverse effects of the known treatment regimens or scientific findings that may trigger Weprefer studies on diagnostic tests to be compliant with the latest STARD guidelines. further research on the topic. Abstracts of case reports should mainly include information Clinical Decision Rules about the case, should not exceed 150 words, must be on a separate page and should be unstructured. The main text of Case Series should be structured with the following Weprefer clinical decision rules performed and reported in compliance with Green: subheadings: Introduction, Case Presentations, Discussion and References. Maximum Methodologic standards for interpreting clinical decision rules in emergency medicine: 5 authors, 1500 words (including references, tables, and figure legends), 15 references, 2014 update. 2 tables and/or figures. Case reports should be compatible with The CARE Guidelines: Meta-analyses Consensus-based Clinical Case Reporting Guideline which can be found on the Resources Meta-analyses of therapeutic trials should be compliant with the PRISM-P 2015 guidelines, for Authors Page. while meta-analyses of observational studies should be compliant with the MOOSE Case Series: Brief descriptions of clinical cases or the complications that are seldom guidelines. encountered in emergency medicine practice and have educational value. Abstracts POLICY FOR THE REPORTING OF METHODOLOGY AND STATISTICS should not exceed 250 words and be unstructured as case reports. Maximum 6 authors, 2500 words (including references, tables, and figure legends), 15 references, 3 tables Reporting Size of Effect and Its Confidence Intervals and/or figures. The main text of Case Series should be structured with the following Turkish Journal of Emergency Medicine strongly prefers that each comparative study outcome be reported with an estimated size of effect and its confidence intervals. Such subheadings: Introduction, Case Presentations, Discussion and References. reporting is advocated by the CONSORT statement, and lets readers to understand the Brief Report: Original reports of preliminary data and findings or studies with small approximate power and clinical importance of the observed magnitude of effect. numbers demonstrating the need for further investigation. Abstracts should not exceed 250 words and structured as research articles. Limitations include: maximum 6 authors, An example for the un-preferred type of reporting without size of effect: 4000 words (including references, tables, and figure legends), 15 references, 4 tables 1. A successful outcome was noticed in 98% of patients given Drug X versus 88% of and/or figures. Besides these constraints, all the formatting, approval, ethics and writing patient given Drug Y. guidelines of research articles also applies to brief reports. 2. In categorization of EF, the agreement (Weighted Kappa) between EPs and the Concept: Clinical or non-clinical articles related to the field of emergency medicine and cardiologist was 0.861 and 0.876, respectively. detailing improvements to emergency medicine practice. Abstracts should not exceed 3. For men, the average CWT on the right 5th intercostal space at the mid-axillary line 250 words with free structure. Maximum 3 authors, 4000 words (including references, was 32.7 mm and for women it was 39.3 mm (p=0.04)â&#x20AC;Ś tables, and figure legends), 15 references, 3 tables and/or figures. Examples for the preferred type of reporting with size of effect and confidence intervals: Review Article: Comprehensive articles reviewing national and international literature 1. A successful outcome was noticed in 98% of patients given Drug X versus 88% of related to current emergency medicine practice. Generally Turkish Journal of Emergency patients given Drug Y (difference 10%, 95%CI -2%, 17%). Medicine publishes only invited review articles. Other authors should contact the editor 2. In categorization of EF, the agreement (Weighted Kappa) between EPs and the prior to submission of review articles. Maximum 2 authors, 4000 words (including cardiologist was 0.861 (SE: 0.045, 95% CI: 0.773, 0.948) and 0.876 (SE:0.042, 95% CI: references, tables, and figure legends). There is no limit to the number of references. 0.793, 0.959), respectively. Evidence-Based Emergency Medicine: Articles seeking to detail clinical and medical practices should present a clinical scenario followed by the research question(s), followed by a selection of the best available evidence, analysis of the evidence and the application of the evidence. Abstracts should not exceed 250 words with free structure. Maximum of 4 authors, 4000 words (including references, tables, and figure legends), 15 references, 3

3. For men, the average CWT on the right 5th intercostal space at the mid-axillary line was 32.7 mm (SD 13.9; 95% CI: 30.3, 35.1) and for women it was 39.3 mm (SD 15.9; 95% CI: 32.4, 46.1). The average CWT on the right 5th intercostal space at the mid-axillary line was significantly higher in women than in men (p=0.04)

VISUAL DIAGNOSIS

Foreign Bodies Ingested by a Mentally Retarded Patient Huseyin CEBICCI, Mustafa ALPASLAN Department of Emergency Medicine, Kayseri Training and Research Hospital, Kayseri, Turkey

A mentally retarded patient was brought to the emergency department by his mother due to abdominal pain and the occasional vomiting of blood during the previous weekend. The patient claimed that he had swallowed nails approximately 1 month prior. However, the patientâ&#x20AC;&#x2122;s history of reliability was low. His vital signs were stable, and there was no melena upon rectal examination. There was no tenderness, defense or rebound in the abdominal examination. Chest X-ray was normal, while there were intensive radiopaque images in the abdominal X-ray (Figure 1a). An abdominal CT scan was performed to assess the position of the foreign bodies and to determine any other intra-abdominal complications (Figure 1b). The patient was admitted to a general surgery ward, and foreign bodies were removed from the small intestine (Figure 1c). The patient was discharged without complications after 3 days. [see page 85 for future explanation]

(a)

(b)

(c)

Figure 1. (a) X-ray showed radiopaque bodies. (b) Abdominal CT showed radiopaque bodies. (c) The nails and screws were removed from the small intestine of the patient.

Submitted: May 12, 2014 Accepted: July 04, 2014 Published online: October 17, 2014 Correspondence: Huseyin Cebicci, M.D. Kayseri Egitim ve Arastirma Hastanesi, Acil Tip Klinigi, Kocasinan, Kayseri, Turkey. e-mail: huseyincebicci@gmail.com

Turk J Emerg Med 2015;15(2):57 [85]

doi: 10.5505/1304.7361.2014.34635

VISUAL DIAGNOSIS

Pain, Tenderness, and Swelling of Right Thumb Seyit Ali Gumustas,1 Salih Hamcan2 Department of Orthopaedic Surgery, Balikesir Military Hospital, Balikesir

1 2

Department of Radiology, Balikesir Military Hospital, Balikesir, both in Turkey

A 21-year-old patient who was fell during a ball game presented with pain, tenderness, and swelling of the base of his right thumb. Clinical examination revealed a deformity and restricted joint motion. Anteroposterior (AP) wrist and thumb X-ray is shown in the Figure 1. [see page 86 for diagnosis]

Figure 1. Anteroposterior and oblique radiographs of the right hand.

Submitted: July 26, 2014 Accepted: August 19, 2014 Published online: February 17, 2015 Correspondence: Seyit Ali Gumustas, M.D. Yavuz Selim Kemik Hastaliklari ve Rehabilitasyon Hastanesi, 61030 Trabzon, Turkey. e-mail: seyitali_gumustas@yahoo.com

Turk J Emerg Med 2015;15(2):58 [86]

doi: 10.5505/1304.7361.2015.27132

ORIGINAL ARTICLE

The Factors Influencing Relapse in Patients Presenting to the Emergency Department with COPD Exacerbation Dilek DURMAZ,1 Erkan GOKSU,2 Gunay YILDIZ,2 Aslihan UNAL,2 Mutlu KARTAL,2 Alten OSKAY,3 Yeliz SIMSEK4 Department of Emergency Medicine, Akdeniz University, Antalya Department of Emergency Medicine, Denizli State Hospital, Denizli 3 Department of Emergency Medicine, Bursa Sevket Yilmaz Training and Research Hospital, Bursa 4 Department of Emergency Medicine, Adana Numune Training and Research Hospital, Adana, all in Turkey 1

SUMMARY Objectives Chronic Obstructive Pulmonary Disease (COPD) is associated with high mortality and morbidity and is projected to be the third most common cause of death worldwide by 2020. For a variety of reasons, there is a drive to manage a greater number of individuals as outpatients. Preventing readmissions can reduce associated morbidity and subsequent healthcare costs. Methods The aim of the present study was to determine the factors affecting the relapse of COPD exacerbated patients in the emergency department (ED). This study combines data from two prospective cohort studies. Patients included in the study were above 18 years of age, had a previous diagnosis of COPD, and presented to the ED for the treatment of acute exacerbation. All the information relevant to the study was collected during the patient’s visit to the ED. Relapse was defined as an unscheduled visit to an ED or primary physician within 2 weeks of initial ED visit for worsening COPD symptoms. Telephone follow-up was done on all patients at the end of 2 weeks. Results The cohort consists of 196 patients. Relapse rate in this study was 27%. Mean respiratory rate, exacerbations in previous year, home nebulizator therapy, home oxygen therapy, admission to intensive care or hospital ward due to COPD exacerbation, previous intubation and abnormal chest x-ray were associated with increased re-visit in univariate analysis. However, after multivariate analysis, exacerbations in previous year (OR: 1.08, 95%CI: 1.01– 1.15) and abnormal chest X-ray (OR: 2.5, 95%CI: 1.10–6.11) were still significant. Conclusions In conclusion, the number of ED visits previous year and abnormal chest x-ray can predict the revisit of a COPD exacerbated patient within 14 days of an ED visit. Key words: Emergency medicine; COPD; relapse.

Introduction Chronic Obstructive Pulmonary Disease (COPD) is a chronic disorder characterized by irreversible airway obstruction and is an important problem of public health. COPD mainly

occurs due to cigarette smoking, environmental and occupational exposure. This is a costly disease due to frequent exacerbations in addition to being a major cause of mortality and morbidity.[1] Exacerbation of COPD is one of the most

Submitted: February 21, 2014 Accepted: May 13, 2014 Published online: 12 June, 2015 Correspondence: Dr. Erkan Goksu. Dumlupinar Bulvari, 07059 Antalya, Turkey. e-mail: erkangoksu@akdeniz.edu.tr

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doi: 10.5505/1304.7361.2014.37791

Turk J Emerg Med 2015;15(2):59–63

common reasons for presenting to emergency departments (ED). Some of those patients repeatedly present to EDs with continuing complaints. Medical doctors have restricted parameters concerning which patient will present to hospital with unending complaints and increasing dyspnea. Although it has been reported in various studies that the patients would be presenting to hospital again in case of frequent hospital visit within previous year and increasing dyspnea, there are not any objective parameters.[2] The present study is designed to research the factors influencing relapse in patients diagnosed with COPD and presenting to the emergency department with exacerbation.

Materials and Methods This prospective cross sectional and clinical study was conducted through the data collected during two separate time periods in Akdeniz University, Faculty of Medicine Hospital, Emergency Department between November 2007-May 2008 and December 2011-July 2012. The study included the patients over 18, presenting to ED with COPD acute attack and who were later discharged. Exacerbation of COPD as an acute event was considered as defined in GOLD 2013 guidelines ‘a worsening of the patient’s respiratory symptoms thait is beyond normal day-to-day variations and leads to a change in medication’.[3] The patients with the suspicion of active pulmonary tuberculosis, with cystic fibrosis diagnosis, with a diagnosed bronchiectasis history, and with lung cancer were excluded from the study. The form used in the study included the following information: age, gender, date of presenting, cigarette use (past smoker, still smoker, non-smoker), vital findings upon arrival and departure from ED (blood pressure, oxygen saturation, respiratory rate, pulse wave velocity, temperature), whether arterial blood gas (ABG) values are abnormal or not (pH<7.35 or PaO2>60 mmHg or PCO2>45 mmHg accepted as abnormal), co-morbid conditions (Hypertension, Diabetes Mellitus, Coronary Heart Disease, Congestive Heart Failure, Chronic Renal Failure, Chronic Liver Disease), oxygen and nebulizer therapy receiving at home or not, history of hospitalization or intensive care requirements, having been intubated or not, systemic steroid use, number of presenting to ED during the last one year, body mass index, chest radiography abnormality (previous or recent changes in chest radiography accepted as abnormal), treatment in ED (ß2 mimetic, ipratropium bromide, steroid and dose), presence of Anthonisen criteria, possible factor inducing exacerbation (infection, wrong drug use), discharge with an unknown reason or pre-hospitalization treatment (antibiotic treatment, steroid treatment), discharge/hospitalization status, telephone numbers.

Anthonisen criteria are a classification used for the severity of COPD exacerbation. Those criteria are divided into two as major and minor. Increased dyspnea, increased sputum volume, and increased sputum purulence are considered as major criteria. Minor criteria are the presence of an upper respiratory tract infection in the past 5 days, fever without any other apparent cause, increased cough or wheezing. Type I have all three major criteria, and Type II exhibit two major criteria, Type III exacerbations (mild) have one major criterion plus one of the minor criteria. The patients discharged from ED were called back after 15 days and were inquired whether they had visited any health institution with the same complaints and their responses were recorded. First group data of the study were published in ‘European Journal of Emergency Medicine’ in 2010 and approval for reuse of some of the data was received from the concerning journal.[2] Also, approval from Faculty of Medicine Research Ethics Committee was obtained for the second group data. Statistical Analysis Statistical analyses were performed with SPSS Statistics version 16.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were presented as mean ± standard deviation; for non-normally distributed variables, median values and interquartile range were given; variable frequencies were stated as percentage. Normality distribution of variables was examined via both visual (histogram and probabilistic graphs) and analytic methods (Kolmogorov-Smirnov). In order for group comparison, Student t-test for normally distributed variables, Mann-Whitney U test for non-normally distributed variables, and χ2 (Chi-square) tests for categorical variables were performed. In multivariate analysis, logistic regression analysis was performed by employing probable factors determined in previous analyses. The conditions of type I error level under 5% were accepted as statistically significant.

Results The present study evaluated 196 patients. Development of relapse were observed in 54 (27%) of the patients. The study group consisted of 92 (47%) males, 104 (53%) females with a mean age of 67±10. Demographic details of the patients were displayed in Table 1. Arterial blood gas values were normal in 107 (55%) and abnormal in 65 (34%) of the patients while in 24 (11%) of the patients arterial blood gas measurement was not demanded. As a result of co-morbid disease evaluation; it was established that of the patients 84 (43%) were with hypertension, 35 (18%) with diabetes mellitus, 41(%21) with coronary

Durmaz D et al.

Relapse of COPD exacerbations in the ED

Table 1. Demographic attributes Variables

Population

Relapse (+)

Relapse (–)

Number of patients

196

142

Mean age (year±SD)

67±10

66±10

69±11

p 0.13

Sec Male

0.66

Female

104

Respiratory rate/min

29±7

28±6

31±8

0.03

25±6.4

24±6.2

0.40

Body mass index (kg/m2) Exacerbation number in last year

24 30

0.00

Oxygen therapy at home

55/196

32/142

23/54

0.005

Nebulation therapy at home

94/196

59/142

34/54

0.007

Intensive care unit admission

47/196

26/142

21/54

0.003

Ward admission

136/196

92/142

44/54

0.024

Previous intubation

17/196

7/142

10/54

0.003

Chest X-ray

115/179

75/127

40/52

0.002

Antibiotic use

147/196

105/142

42/54

0.58

SD: Standard deviation.

Table 2. The variables included in logistic regression model in predicting relapse Variables

OR°

(%95 CI)

Respiratory rate/min

1.05

0.99-1.11

0.06

Exacerbation number in last year

1.08

1.01-1.15

0.02

Oxygen therapy at home

0.64

0.22-1.84

0.41

Nebulation therapy at home

1.62

0.58-4.46

0.34

Intensive care unite admission

1.21

0.43-3.36

0.71

Ward admission

1.87

0.65-5.37

0.24

Previous intubation

1.24

0.27-5.70

0.77

Chest x-ray

2.59

1.10-6.11

0.02

OR: Odds ratio.

heart disease, 31 (16%) with congestive heart failure, 4(%) with chronic renal failure, 2 (2%) with chronic liver disease.

sive care requirements, having been intubated due to COPD exacerbation, and chest radiography abnormality were found out to have relationship with relapse in univariate analysis. On the other hand, in multivariate analysis, frequency of exacerbation in previous year (OR:1.08, 95%CI: 1.01–1.15) and chest radiography abnormality (OR:2.5, 95%CI: 1.10– 6.11) were significant (Table 2).

During discharge of the patients, 83 (42%) were prescribed modification in treatment, 45 (25%) were prescribed antibiotics, and 71 (36%) were prescribed systemic steroid. According to Anthonisen criteria which are used for the severity of symptoms,[4] 45 patients type 1 (severe), 42 patients type 2 (moderate) and 109 patients were evaluated as type 3 (mild) exacerbation.

Discussion

All in all, average respiratory rate, frequency of exacerbation in previous year, having oxygen and nebulizer therapy at home, having a previous history of hospitalization or inten-

As a result of the current study, increased application to ED due to COPD exacerbation within prior year and abnormality of chest radiography results found to be significant in

Turk J Emerg Med 2015;15(2):59â&#x20AC;&#x201C;63

terms of relapse prediction. Relapse rate was established as 27% in the study. In the previous studies, relapse rates ranging from 22% to 32% were reported.[5] Despite notable progress in health services, similar relapse rates have been observed since the last decade of 1980s.[6] Some studies showed that application to ED due to COPD exacerbation within prior year could be considered as a good parameter for relapse prediction.[7,8] For instance, a study by Bhowmik et.al, reported that patients with 3 or more frequent exacerbations had higher levels of interleukin 6 (IL-6) and IL-8 in sputum and those patients also had more increased airway inflammation.[9] Besides, another study by Gompertz et.al, displayed that in sputum of patients experiencing frequent inflammation, an anti-protease concentration called secretory leukopro-teinase inhibitor was at low level, which may explain the weakness of antibacterial and viral activities in patients being exposed to frequent inflammation.[10] Also, in another study by Patel et.al, it was established that in the airways of patients presenting with frequent inflammation, bacterial colonization and IL-6 levels had been higher.[11] These results might explain why relapse is more frequent in those patient group having increased inflammation and decreased inflammatory response. Global Initiative for Chronic Obstructive Lung Disease 2013 (GOLD 2013) Guidelines declared frequent exacerbation as a hospitalization criterion.[3] In order to prevent relapse, the patients with frequent exacerbation should be assessed for hospitalization. In a study carried out with the patients hospitalized owing to COPD exacerbation and with pre-existent severe COPD, hospital mortality was found out to be very high.[12] Even though it is difficult to reach the records about disease stages in ED conditions, the classification by GOLD 2013 might be indicative for medical doctors. In a prospective study by Kim and colleagues, it was stated that respiratory rate predicted relapse during admission to ED.[8] The study reported that average respiratory rate of patients per minute in relapse group (n=30) had been 25 while it had been 23 in non-relapse group (n=110). Though the results are statistically significant, clinical significance and indicative strength for medical doctors is debatable. Even though in our study average respiratory rate was significant in univariate analysis, no difference could be established between two groups in multivariate analysis. Dewan and colleagues found out in their retrospective study (n=107) that oxygen therapy at home and the frequency of exacerbation in prior year were the parameters which could predict relapse.[13] Although utilizing oxygen therapy at home was significant in univariate analysis in our study, it was not significant in multivariate analysis. It might be thought that

the patients receiving oxygen therapy at home have advanced stage COPD and even that difference could not have been established due to the fact that those patients were hospitalized through ED more than others. As mentioned before, in the study by Dewan and colleagues, it was found out that first group or second group antibiotic intake had not influenced relapse. GOLD 2013 guidelines suggest that antibiotic should be prescribed in the case of increase in dyspnea, sputum volume, and sputum purulence and that the choice of the antibiotic should be based on the local bacterial resistance pattern. In our study the antibiotic class was not recorded but usually second generation antibiotics were preferred; however, the findings displayed that they were ineffective on relapse. In a prospective study evaluating the patients presenting to family physician due to COPD exacerbation and the examining the factors influencing relapse within 30 days, ischemic heart disease, the degree of dyspnea and, history of hospital admission due to exacerbation were found significant.[14] However, the results in that study might have been affected by the foreseen period of 30 days. In our previous study related to COPD and relapse, the assessment performed by using two different visual analog scales for the degree of dyspnea including the time of ED admission and of pre-discharge showed that the degree of dyspnea was not significant in predicting relapse.[2] Besides, in patients presenting to family physician and to ED due to COPD exacerbation, the severity of exacerbation might not be equal. Because of the similar pace of COPD exacerbation rates during the last 30 years and high hospital bed occupancy rate during winter months when exacerbation density is high, establishment of observation units may be an effective alternative for the care period of those patients. In relation to that, in a study by Salazar and colleagues, inpatient treatment (n=1961) and follow-up at observation unit (n=545) were compared retrospectively and it revealed that the duration of hospital stay for inpatient treatment was 12 days while it was 3.4 days for follow-up at observation unit (p<0.001). In the same study, hospital admission rates for the second time within 10 days were 7% for inpatient treatment and 9.9% for follow-up at observation unit (p=0.02). Although in this study second time hospital admission was based on 10 days, very low level of relapse rate in both conditions and 3.4 days average stay duration in observation unit might be beneficial for the care process of those patients.[15] As a surprising result of this study, some of the objective parameters (respiratory rate at the time of presenting to ED, blood pressure, pulse rate, blood gas, chest radiography, body mass index) were not found useful in predicting relapse within two weeks. This might be explained by much more

Durmaz D et al.

Relapse of COPD exacerbations in the ED

hospitalization of patients with abnormal vital findings. In conclusion, it might be said that the patients presenting to ED with COPD exacerbation, with frequent COPD exacerbation in previous year, and with abnormal chest radiography are more likely to have relapse. Hence, it will be advantageous for the ED physicians to keep this condition in mind during the caring of those patients. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Murray CJL, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: global burden of disease study. Lancet 1997;349:1498–504. 2. Goksu E, Oktay C, Kartal M, Oskay A, Sayrac AV. Factors affecting revisit of COPD exacerbated patients presenting to emergency department. Eur J Emerg Med 2010;17:283-5. 3. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013. p:42. Available from: http://www.goldcopd.org/ 4. Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 1987;106:196–204. 5. Adams SG, Melo J, Luther M, Anzueto A. Antibiotics are associated with lower relapse rates in outpatients with acute exacerbations of COPD. Chest 2000;117:1345-52. 6. Murata GH, Gorby MS, Chick TW, Halperin AK. Use of emergency medical services by patients with decompasated obstructive lung disease. Ann Emerg Med 1989;18:501-6.

7. Murata GH, Gorby MS, Kapsner CO, Chick TW, Halperin AK. A multivariate model for the prediction of relapse after outpatient treatment of decompasated chronic obstructive pulmonary disease. Arch Intern Med 1992;152:73-7. 8. Kim S, Emerman CL, Cydulka RK, Rowe BH, Clark S, Cmargo CA, MARC investigators. Prospective multicenter study of relapse following emergency department treatment of COPD exacerbation. Chest 2004;152:473-81. 9. Bhowmik A, Seemungal TA, Sapsford RJ, Wedzicha JA. Relation of sputum inflammatory markers to symptoms and lung function changes in COPD exacerbations. Thorax 2000;55:114-20. 10. Gompertz S, Bayley DL, Hill SL, Stockley RA. Relationship between airway inflammation and the frequency of exacerbations in patients with smoking related COPD. Thorax 2001;56:36-41. 11. Patel IS, Seemungal TA, Wilks M, Lıoyd-Owen SJ, Donaldson GC, Wedzicha JA. Relationship between bacterial colonization and the frequency character and severity of COPD exacerbations. Thorax 2002;57:759-64. 12. Sen E, Ciloglu SO, Önen Z, Gülbay B, Yıldız OA, Saryal SB, et al. Long-term outcome and predictors of survival in patients hospitalized for an acute exacerbation of chronic obstructive pulmonary disease. Turkiye Klinikleri J Med Sci 2010;30:104654. 13. Dewan NA, Rafique S, Kanwar B, Satpathy H, Ryschon K, Tillotson GS, et al. Acute exacerbation of COPD, factors associated with poor treatment outcome. Chest 2000;117:662-71. 14. Miravitlles M, Murio C, Guerrero T. Factors associated with relapse after ambulatory treatment of acute exacerbations of chronic bronchitis. Eur Respir J 2001;17:928-33. 15. Juan A, Salazar A, Alvarez A, Perez JR, Garcia L, Corbella X. Effectiveness and safety of an emergency department shortstay unit as an alternative to standard inpatient hospitalisation. Emerg Med J 2006;23:833-7.

ORIGINAL ARTICLE

Inter-Observer Agreement on Diffusion-Weighted Magnetic Resonance Imaging Interpretation for Diagnosis of Acute Ischemic Stroke Among Emergency Physicians Deniz Oray,1 Onder LImon,1 Cem Ertan,1 Asli AydınoGlu UGurhan,1 Erkan SahIn2 Department of Emergency Medicine, Izmir University School of Medicine, Izmir Department of Radiodiagnostics, Izmir University School of Medicine, Izmir, both in Turkey 1

SUMMARY Objectives Diffusion-weighted magnetic resonance imaging (DW-MRI) is a highly sensitive tool for the detection of early ischemic stroke and is excellent at detecting small and early infarcts. Nevertheless, conflict may arise and judgments may differ among different interpreters. Inter-observer variability shows the systematic difference among different observers and is expressed as the kappa (κ) coefficient. In this study, we aimed to determinate the interobserver variability among emergency physicians in the use of DW-MRI for the diagnosis of acute ischemic stroke. Methods Cranial DW-MRI images of 50 patients were interpreted in this retrospective observational cross-sectional study. Patients who were submitted to DW-MRI imaging for a suspected acute ischemic stroke were included in the study, unless the scans were ordered by any of the reviewers or they were absent in the system. The scans were blindly and randomly interpreted by four emergency physicians. Inter-observer agreement between reviewers was evaluated using Fleiss’ κ statistics. Results The mean kappa value for high signal on diffusion-weighted images (DWI) and for reduction on apparent diffusion coefficient (ADC) were substantial (k=0.67) and moderate (k=0.60) respectively. The correlation for detection of the presence of ischemia and location was substantial (k: 0.67). There were 18 false-positive and 4 false-negative evaluations of DWI, 15 false positive and 8 false-negative evaluations of ADC. Conclusions Our data suggest that DW-MRI is reliable in screening for ischemic stroke when interpreted by emergency physicians in the emergency department. The levels of stroke identification and variability show that emergency physicians may have an acceptable level of agreement. Key words: Emergency department; diffusion weighted magnetic resonance imaging; inter-observer agreement, ischemic stroke.

Introduction Clinical diffusion neuroimaging, introduced in the early 1990s, was quickly adopted in the evaluation of suspected acute ischemic brain injury.[1] Diffusion-weighted magnetic resonance imaging (DW-MRI) is a highly sensitive tool for the detection of early changes in water diffusion that characterize many brain pathologies, including acute ischemic

stroke and is excellent at detecting small and early infarcts. These changes represent variations in the random motion of water molecules in tissues. They are expressed, in diffusionweighted images (DWI), as changes in MRI signal intensity or as variations in the apparent diffusion coefficient (ADC) of water.[2–5] Acute ischemic stroke is characterized by very high signal on DWI and marked reduction in ADC values. In stroke

Submitted: August 09, 2014 Accepted: October 10, 2014 Published online: February 17, 2015 Correspondence: Deniz Oray, M.D. Izmir Universitesi Tip Fakultesi, Izmir Medical Park Hastanesi Acil Tip Anabilim Dali. Izmir, Turkey. e-mail: deniz.oray@yahoo.com

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doi: 10.5505/1304.7361.2015.32659

Oray D et al.

Inter-Observer Agreement on dMRI Interpretation for Diagnosis of AIS Among Emergency Physicians

patients, reduced diffusion can be observed within minutes to less than 1 hour after witnessed ictus, before any ﬁndings are apparent on conventional MRI.[5] The appearance of DWI/ADC depends on the timing. Acute (0–7 days) findings of ischemic stroke in DWI are; a decrease in ADC value with maximal signal reduction at 1 to 4 days (hypo-intensity on ADC images), marked hyperintensity on DWI (a combination of T2 and diffusion weighting), and less hyperintensity on exponential images.[5,6]

two hours. Also, the emergency medicine residency program in xxx have at least a one month mandatory radiology rotation. Most of the hospitals do not have a radiologist and neurologist for 24 hours in xxx, therefore many emergency physicians have to interpret their patients’ scans and activate the stroke protocol themselves according to the local hospital protocols.

DW-MRI can show hyperacute ischemic stroke which cannot be seen on computed tomography (CT); moreover, it only takes few minutes to scan and should be considered when the emergency physician evaluates a patient with acute ischemic stroke.[7] Lövblad et al reported a sensitivity of 88% and a specificity of 95% for DW-MRI.[8]

a- High signal on DWI

As high as these values are, there are also reports of negative DW-MRI studies in cases of clinically proven ischemic stroke.[9,10] Sylaja et al reported a 25% false negative report rate of DW-MRI in stroke and stroke like deficits.[11] Additionally, as in all imaging modalities, DW-MRI is also interpreter dependent to some degree, especially when evaluated by non-radiologist interpreters. Inter-observer variability is the reflection of this dependency and is defined as the systematic differences among different observers and expressed as the kappa (κ) coefficient.[12] The primary aim of this study was to determine the interobserver variability among emergency physicians in the use of DW-MRI for the diagnoses of acute ischemic strokes.

The following parameters were taken into consideration:

b- Marked reduction on ADC values c- Location of these findings The reviewers noted on the mentioned parameters as present or absent. Inter-observer agreement between reviewers was evaluated using Fleiss’ κ statistics. The kappa coefficient measures pairwise agreement among a set of interpreters making category judgments, correcting for expected chance agreement.[13] The agreement on interpreter opinions are supposed to be acceptable beginning at a correlation co-efficient of 0.41–0.60 (Table 1).[14,15] Later, reviewers’ interpretations were compared to official radiology reports; the radiologists had more than 10 year experience in cranial radiology. MRI Protocol All MRI scans were performed on a Siemens 1.5 Tesla Avanto© MRI scanner using 4-mm slice thickness; B-0, B-1000 mm2/ sec images and ADC.

Materials and Methods

Statistical Analysis

This retrospective observational cross-sectional study was performed in xxx University xxx Hospital. Images selected from all cranial DW-MRI examinations that were referred to the Radiology Department of xxx University School of Medicine with suspected acute ischemic stroke from 01.06.201301.01.2014. Local ethics committee approval was obtained prior to data collection. Data were obtained from Medin© v3.1.24.115 software. The inclusion criterion was suspected acute ischemic stroke in patients who were submitted to DWMRI imaging. The exclusion criterion was absence of DW-MRI imaging or DW-MRI scans ordered by any of the reviewers. The scans were interpreted by four emergency physicians separately in a blind and random fashion under emergency departments (ED) conditions, where actual cases were being evaluated. Reviewers were unaware of the official radiology report and patients’ clinical status at the time of imaging. All reviewing physicians were emergency physicians and have the designation of assistant professor and more than 5 years’ experience in their specialty. The reviewers were trained by the radiology department for interpretation of DWI-MRI for

Kappa statistics on https://www.statstodo.com were used to evaluate the inter-observer agreement. StatsToDo© website provides free statistics calculators for clinical research and quality control.

Results There were 97 patients who underwent DWI-MRI between 01.06.2013-01.01.2014. Images of 47 patients were ordered by one of the reviewers and these were excluded from the study, leaving 50 patients for further evaluation. The mean kappa value for high signal on DWI and for reduction on ADC were κ=0.67 (0.56-0.78) and κ=0.60 (0.49-0.71) respectively. The inter-observer agreement between reviewers was substantial for high signal on DWI and moderate for reduction on ADC respectively. Accuracy of diagnosis for reviewers one to four, according to the official radiologist’s reports, were 88%, 90%, 80% and 86% for ischemic stroke (mean accuracy rate: 86%) respectively. Correlation between the reviewers was substantial (κ: 0.67) in detecting the presence of ischemia

Turk J Emerg Med 2015;15(2):64–68

Table 1. The interpretation of kappa value ranges[14] Kappa Interpretation (Level of agreement) <0 Poor 0.01–0.20 Slight 0.21–0.40 Fair 0.41–0.60 Moderate 0.61–0.80 Substantial 0.81–1.00

Almost perfect

Table 2. Numbers of false-negative and false-positive comments for high signal on DWI and ADC respectively FN1 FP2 DWI/ADC DWI3/ADC4 Observer 1

1/2

2/2

Observer 2

1/2

3/2

Observer 3

1/1

9/9

Observer 4

1/3

4/2

FN: False negative; 2FP: False positive; 3DWI: Diffusion weighed images; ADC: apparent diffusion coefficient.

1 4

and location. On the other hand, 14% of ischemic strokes related changes on DWI and ADC were missed by interpreters. In total, observers recorded 18 false-positive high signals on DWI, 15 false positive marked reductions on ADC, 4 falsenegative high signals on DWI and 8 false-negative marked reductions on ADC (Table 2). Six of the false-positive stroke lesions (33.3%) were located at the posterior cerebral region (5 at the brainstem and one at the cerebellum) and the rest were equally distributed. Of the 12 false-negative stroke lesions; 8 were located in the brainstem (66.7%), 2 were located in the cerebellum (16.3%), one was periventricular (8.3%) and one was at the occipital lobe (8.3%). In one case, a large hematoma (10 cm) was defined by all observers, and it was interpreted to be a non-ischemic lesion despite the diffusion deficiency findings; in another, a cortical mass <1 cm was falsely interpreted as an ischemic lesion; all four observers misinterpreted a mass with surrounding edema as a positive finding for ischemia and an artifact was misinterpreted as lacunar infarct by all the reviewers. Since all observers expressed the same opinions about the same images, these misinterpretations did not affect the inter-observer agreement, which is the main objective of our study. Our results also showed that a great majority of the false negative high signals in DWI and reduction in ADC were located at the posterior cerebral area or the brain stem.

Discussion Ischemic stroke is the fourth leading cause of death in United States.[16] Diagnoses of stroke in the ED depend on clinical evaluation and imaging studies. Although most EDs use (CT) as the imaging modality of choice due to factors such as availability and low costs, it’s a fact that 30% to 60% of ischemic lesions are not visible on CT in the acute stage of stroke.[3] DW-MRI is successfully being used in the evaluation of suspected acute ischemic brain injury due to the fact that reduced diffusion of brain tissue can be observed within the first hour following the ischemic event.[1] Gonzalez et al re-

ported that DW-MRI is highly accurate for diagnosing stroke within 6 hours of symptom onset and is superior to CT and conventional MRI.[17] Recently, DW-MRI has been preferred over CT in many EDs due to the same reasons, and the literature suggests the benefits of this choice.[16] Despite the well reported benefits of the DW-MRI, the interpretation of the imaging studies is still dependent on the reviewing physician, who is often not a radiologist, but an emergency physician practicing within the routine circumstances of an ED.[18] Although the diagnostic criteria for ischemia on DWI studies are well known, the effects of personal experience, differences in MRI devices, patients and even the screens which reviewers evaluate the images cannot be ignored.[19] Thus, the inter-observer agreement is a very important issue on this life threatening diagnosis. However, we could not find any studies on inter-observer variability for DW-MRI interpretation of ischemic brain injury at the ED in the literature. We therefore designed this study to determinate the inter-observer variability among emergency physicians in the use of DW-MRI for the diagnosis of acute ischemic strokes. Inter-observer agreement gives a score of the homogeneity or consensus in the ratings given by the reviewers. The level of agreement is shown by means of kappa values, and classified as shown in Table 1.[12,15] In our study, the mean kappa values for high signal on DWI and reduction on ADC were found to be substantial and moderate respectively, meaning that four reviewers had an acceptable to high levels of understanding and agreement on ischemic lesions on DW-MRI. The evaluation of radiologic work-up by non-radiologist physicians, although inevitably necessary, is continuously an issue of debate. The presence of false negative CT and DWMRI studies is manifested in the literature by many researchers. In a study, Kothari et al proposed that misdiagnosis rates for ischemic stroke by emergency physicians ranged from about 5% to 33%.[19] In their study, Ferro et al reported a 9%

Oray D et al.

Inter-Observer Agreement on dMRI Interpretation for Diagnosis of AIS Among Emergency Physicians

rate of misdiagnosis of stroke for non-neurologist physicians.[18] Savits et al also reported that DW-MRI and CT scans which were initially interpreted as negative in the ED, but were reported to be positive for ischemic findings by radiologists.[20] In our study, 14% of ischemic stroke related findings in DW-MRI were missed by emergency physicians.

emic stroke when interpreted by emergency physicians in the ED. Our results also showed that false-negative DW-MRI studies are not uncommon, especially if findings are suggestive of a stroke in the posterior circulation and brain stem.

Several case series have shown that false-negative DW-MRI results are not rare in brain stem strokes.[8,21–23] Sylaja et al also reported that 30% of their patients with negative DWI scans had either an imaging or clinical diagnosis of stroke located at the brain stem.[11] Our results also showed that a great majority of the false negative high signals in DWI and reductions in ADC were located at the posterior cerebral area or the brain stem.

The authors declare that there is no potential conflicts of interest.

There were four cases in which all observers misinterpreted some lesions or artifacts as ischemic findings. Although these false positive interpretations did not affect the overall interobserver agreement, they also pointed the fact that some technical or non-ischemic pathology may mimic ischemia. Sylaja et al suggested that technical concerns including the magnetic susceptibility artifacts might cause misinterpretations.[11] Löveblad et al also reported the misinterpretation of a cerebral abscess and a cranial tumor as ischemic lesions in their study.[8] We observed in our study that false positive diffusion deficiency judgments were commonly expressed for posterior cerebral area. This may be due to the small volume of the area as well as a higher rate of artifacts. Limitations Four reviewers have different medical education backgrounds from different medical schools; therefore the qualitative levels of radiological evaluation based on this background may differ in perspective. The evaluation of the DW-MRI images were performed under ED circumstances to mimic original judgment conditions. This also might have negatively affected the reviewers’ quality of decisions due to the level of illumination of the environment, distractive issues and the image quality of the monitors. Conclusion DW-MRI evaluation is an invaluable tool for ischemic stroke diagnosis in the ED. There is no question that diffusionweighted imaging is an important diagnostic tool in stroke management. Emergency physicians have to be capable of identifying stroke findings in DW-MRI images for timely diagnosis and the initiation of the appropriate treatment. The levels of stroke identification and variability show that emergency physicians may have an acceptable agreement on DW-MRI interpretation for stroke. According to our data, DW-MRI seems to be a reliable method in screening for isch-

Conflict of Interest

References 1. Maas LC, Mukherjee P. Diffusion MRI: Overview and clinical applications in neuroradiology. Applied Radiology 2005;34:44–60. 2. Lutsep HL, Albers GW, DeCrespigny A, Kamat GN, Marks MP, Moseley ME. Clinical utility of diffusion-weighted magnetic resonance imaging in the assessment of ischemic stroke. Ann Neurol 1997;41:574–80. 3. van Everdingen KJ, van der Grond J, Kappelle LJ, Ramos LM, Mali WP. Diffusion-weighted magnetic resonance imaging in acute stroke. Stroke 1998;29:1783–90. 4. Srinivasan A, Goyal M, Al Azri F, Lum C. State-of-the-art imaging of acute stroke. Radiographics 2006;26 Suppl 1:75–95. 5. Allen LM, Hasso AN, Handwerker J, Farid H. Sequence-specific MR imaging findings that are useful in dating ischemic stroke. Radiographics 2012;32:1285–99. 6. Chung SP, Ha YR, Kim SW, Yoo IS. Diffusion-weighted MRI as a screening tool of stroke in the ED. Am J Emerg Med 2002;20:327–31. 7. Keyik B, Yanık B, Bakdık S, et al. Difüzyon ağırlıklı manyetik rezonans görüntülemenin akut iskemik inmede tanı değeri. (The diagnostic value of diffusion weighed magnetic resonance imaging in ischemic stroke) Yeni Tıp Dergisi 2009;26:42–5. 8. Lövblad KO, Laubach HJ, Baird AE, Curtin F, Schlaug G, Edelman RR, et al. Clinical experience with diffusion-weighted MR in patients with acute stroke. AJNR Am J Neuroradiol 1998;19:1061–6. 9. Wang PY, Barker PB, Wityk RJ, Uluğ AM, van Zijl PC, Beauchamp NJ Jr. Diffusion-negative stroke: a report of two cases. AJNR Am J Neuroradiol 1999;20:1876–80. 10. Lefkowitz D, LaBenz M, Nudo SR, Steg RE, Bertoni JM. Hyperacute ischemic stroke missed by diffusion-weighted imaging. AJNR Am J Neuroradiol 1999;20:1871–5. 11. Sylaja PN, Coutts SB, Krol A, Hill MD, Demchuk AM; VISION Study Group. When to expect negative diffusion-weighted images in stroke and transient ischemic attack. Stroke 2008;39:1898–900. 12. Gwet KL. Computing inter-rater reliability and its variance in the presence of high agreement. Br J Math Stat Psychol 2008;61(Pt 1):29–48. 13. Carletta J. Squibs and Discussions Assessing Agreement on Classification Tasks: The Kappa Statistic. Computational Linguistics 1996;22:248–54. 14. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74. 15. Sim J, Wright CC. The kappa statistic in reliability studies:

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use, interpretation, and sample size requirements. Phys Ther 2005;85:257–68. 16. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870–947. 17. González RG, Schaefer PW, Buonanno FS, Schwamm LH, Budzik RF, Rordorf G, et al. Diffusion-weighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset. Radiology 1999;210:155–62. 18. Ferro JM, Pinto AN, Falcão I, Rodrigues G, Ferreira J, Falcão F, et al. Diagnosis of stroke by the nonneurologist. A validation study. Stroke 1998;29:1106–9. 19. Kothari RU, Brott T, Broderick JP, Hamilton CA. Emergen-

cy physicians. Accuracy in the diagnosis of stroke. Stroke 1995;26:2238–41. 20. Savitz SI, Caplan LR, Edlow JA. Pitfalls in the diagnosis of cerebellar infarction. Acad Emerg Med 2007;14:63–8. 21. Oppenheim C, Stanescu R, Dormont D, Crozier S, Marro B, Samson Y, et al. False-negative diffusion-weighted MR findings in acute ischemic stroke. AJNR Am J Neuroradiol 2000;21:1434–40. 22. Ay H, Buonanno FS, Rordorf G, Schaefer PW, Schwamm LH, Wu O, et al. Normal diffusion-weighted MRI during stroke-like deficits. Neurology 1999;52:1784–92. 23. Küker W, Weise J, Krapf H, Schmidt F, Friese S, Bähr M. MRI characteristics of acute and subacute brainstem and thalamic infarctions: value of T2- and diffusion-weighted sequences. J Neurol 2002;249:33–42.

ORIGINAL ARTICLE

Demographic Properties of Civilians with Blast Injuries in Southeastern Anatolia Region Omer KaCmaz,1 Recep Dursun,1 Hasan Mansur Durgun,1 Mehmet AkdaG,2 Murat Orak,1 Mehmet UstUndaG,1 Cahfer GUlloGlu1 Department of Emergency Medicine, Dicle University Medical Faculty, Diyarbakir Department of Ear Nose and Throat, Dicle University Medical Faculty, Diyarbakir, both in Turkey 1

SUMMARY Objectives The present study conducted demographic analysis of blast injuries, with the authors aiming to guide the determination of groups and regions at risk, helping hospitals take preventive measures and providing information for accurate triage, rapid intervention, multidisciplinary approach, and lowering workforce losses. Methods This study retrospectively examined the demographic properties of civilians who presented to the Emergency Department of Dicle University after being injured in explosions of various origins between January 2005 and September 2013 in the Southeastern Anatolia Region of Turkey. Results Of the study population, 85.50% were male and 14.50% were female. The explosive responsible for injury was a mine in 20.51% of the cases, a bomb in 29.06%, a squib in 14.53%, dynamite in 7.69%, and some other explosive in the remaining 28.31%. Of those injured, 35.90% were students, 21.36% were farmers, 11.10% were shepherds or drivers, and 31.62% were from other occupational groups. Conclusions In conclusion, injuries resulting from explosions are associated with higher morbidity and mortality rates, making it necessary to increase the number of trauma centers and emergency action teams in that region, as well as demining the region and educating the native population about explosives. Key words: Amputation; blast injury; explosives.

Submitted: October 24, 2014 Accepted: November 18, 2014 Published online: February 18, 2015 Correspondence: Recep Dursun, M.D. Dicle Universitesi Tip Fakultesi, Acil Tip Anabilim Dali, 21280 Diyarbakir, Turkey. e-mail: drrecepdursun@hotmail.com

Turk J Emerg Med 2015;15(2):69â&#x20AC;&#x201C;74

doi: 10.5505/1304.7361.2015.25993

Turk J Emerg Med 2015;15(2):69–74

Introduction Southeastern Anatolia Region is one of seven geographical regions in Turkey. It is the smallest, but most densely populated region. Syria and Iraq border to the south and Iran to the east. This region has the highest terrorism and smuggling rates in Turkey and its borders with neighboring countries have not been cleared of land mines. Hence, blast injuries due to explosions are common. Among civilians, explosions are encountered mostly due to terrorist activities. Although bombs are used during war, they may also rarely cause multiple blast injuries in peacetime as well. Nevertheless, substances with explosive properties other than bombs are also encountered in daily life, albeit rarely.[1] These include propane cylinders, automobile LPG systems, oil barrels, lighters, or even everyday tools that are seemingly harmless, such as pressure cookers, fireworks, squibs, vehicle power supplies, and electric panels.[2] In places where terrorist activities take place, explosives are used and when terrorist activities scale up, use of explosives shows a parallel increase.[3,4] Mines are laid during wars or for security reasons during peacetime and have enormous explosive power. They potentially remain underground or on soil for years after wars because land mines are not regularly mapped.[3,4] Land mines reduce the use of farmland,[5] delay infrastructure and government investments, and prevent the inflow of foreign capital due to the fear and threat experienced in these regions. It is reported that the cost of clearing mines is a hundred times their production cost[6,7] and that treatment costs for a mine victim are more than a thousand times their production cost. Unfortunately, thousands of new land mines are laid each year, most of which will never be cleared.[6] Fertile lands and historical places also suffer from land mines, harming agriculture and tourism. In our country, no clinical scoring or triage technique is widely used for occupational accidents, blast injuries due to domestic appliances, or certain explosives used for terrorist activities. Moreover, injury and mortality rates remain high due to lack of regulatory restrictions. This study aimed to guide the determination of groups and regions at risk, helping hospitals take preventive measures and providing information for accurate triage, rapid intervention, multidisciplinary approach, and lowering workforce losses by conducting demographic analysis of blast injuries.

Materials and Methods This study retrospectively examined the demographic properties of 117 civilians who presented to the Emergency Department of Dicle University, Faculty of Medicine, after being injured in explosions of various origins between January 2005 and September 2013 in the Southeastern Anatolia Region of the Republic of Turkey. This article is a crosssectional observational study. All patients were examined,

resuscitated in compliance with ATLS (Advanced Trauma Life Support), and treated per available protocols for diagnosis and treatment in the emergency department. Inclusion criteria 1- Injuries to civilians with materials meeting the criteria set for explosives 2- Injuries caused by explosions occurring in peacetime 3- Injuries with hospital records which were accessible from the Dicle University Faculty of Medicine, Emergency Department. Exclusion Criteria 1- Injuries to security or military personnel 2- Blast injuries during wartime 3- Other traumatic injuries (firearm wounds, traffic accidents, and falls from a height, etc.) Data Analysis Patient data recorded in sociodemographic forms included age, sex, site of incident (rural/urban/abroad), distribution of injured body parts (extremity, head, thorax, abdomen, other), location and distribution of extremity amputation, clinic of admission, type/site of explosion, distribution of clinical outcome of explosion, and distribution of occupation by type of explosive materials (mines, bombs, squibs, dynamites). Statistical analyses were performed using SPSS for Windows Ver. 15.0. Univariate analyses were performed using the Chi-Square test (χ2) for categorical variables and the student’s t test for continuous variables. The study data were expressed as Mean±SD. A p value less than 0.05 was considered statistically significant.

Results This study retrospectively examined 117 patients who presented to the emergency department of Dicle University, Faculty of Medicine, after a blast injury between January 2005 and September 2013 and met the inclusion criteria. (Tables 1, 2, 3, 4) The rate of dynamite explosions was 7.69%. Of these patients, 6.84% (n=8) were farmers. Dynamite-induced injuries affected significantly more farmers than any other occupation (p<0.05). Although statistically non-significant, some explosives affected particular worker classes more frequently, with shepherds being more affected by mines and dynamite and the majority of those injured by squibs were students (8.55%) and craftsmen (3.42%). The majority of our patients injured by bombs were students (11.97%) and craftsmen (6.84%).

Kacmaz O et al.

Demographic Properties of Civilians with Blast Injuries in Southeastern Anatolia Region

Table 1. Demographic properties by sex of the patients Demographic property

Male n=100 (85.5%)

Age (Years: Mean+SD)

Female n=17 (14.5%) n

23.50+13.47

Total n=117 n

20.18+09.44

23.02+12.98

Place of residence Town

Village

37.60

9.40

47.01

23.08

0.85

23.93

Country

19.66

4.27

23.93

Abroad

5.12

—

5.12

4.27

35.90

Occupation Student

31.62

Other*

22.22

9.40

31.62

Farmer

20.51

0.85

21.36

5.98

—

5.98

5.12

—

5.12

Driver

Shepherd

Site of incident

City center

48.72

13.67

62.39

Rural area

30.77

0.85

31.62

5.98

—

5.98

27.35

1.71

29.06

Abroad

Type of explosive Bomb

Mine

17.95

2.56

20.51

7.69

28.21

Squib

11.97

2.56

14.53

Dynamite

7.69

—

7.69

Other**

Other*: Craftsmen (n=17), children <7 years of age (n=7), housewives (n=7), state officials (n=5), and workers (n=1); Other**: Improvised explosive device (n=14), shell casing explosion (n=6), propane cylinder explosion (n=3), Petroleum barrel explosion (n=2), Gas bomb (n=2), Firework explosion (n=1), Automobile LPG (liquefied petroleum gas) tank explosion (n=1), Lighter explosion (n=1), Pressure cooker explosion (n=1), vehicle power supply explosion (n=1), and Transformer explosion (n=1).

Discussion A total of 117 cases of blast injuries presented to our hospital within an eight year time period. The seemingly low number of cases is the result of inclusion of only civilians, because injured military personnel or members of illegal terrorist organizations are usually not brought to our hospital. In addition, victims that were killed at the site of incident or in an ambulance while being transported to the hospital were also excluded.[1,8] A review of the literature on injuries with explosive materials revealed that most victims were young males, while women, children, and the elderly were injured less frequently.[9-14] Our study similarly demonstrated that the victims of blast injuries were mostly young people and males. Land mines usually harm military personnel during wartime, whereas they primarily affect poor, rural people during peacetime. Thus, the weakest and poorest are the victims of these weapons.[5] Previous studies in the literature usually compared explosives

and firearm injuries, or they provided information on a specific type of explosive material.[1,5,15,16] In a study from Cambodia that studied 863 firearm injuries, land mines were the cause of injuries in 37% of cases.[15] On the other hand, most of the victims in our study were injured by bombs or mines. In rural areas, dynamite injuries also existed along with mine injuries. This is because dynamite is commonly used in rural areas of our region for fishing in brooks or ponds. Terrorist organizations generally target crowded public places and young people.[1,4,11,13,16,17] The primary goal of these attacks is to create a state of fear and chaos.[1,4,17] The attacks usually have political motives and are performed for the interests of a religious or nationalist group.[4] A study performed in Israel revealed that 54% of people injured in explosions were injured in public places while 36% were injured in attacks to commercial buildings and main roads. Another study from Israel showed that most attacks targeted buses and bus routes.[9] In our study, blast injuries mostly occur-

Turk J Emerg Med 2015;15(2):69–74

Table 2. Distribution of patients by injured body parts Injured body part

Male n=100 (85.5%)

Extremity

73 62.39 7 5.98 80 68.38

Female n=17 (14.5%) n

Total n=117 n

Head and neck

46.15

7.69

53.85

Eyes only

30.77

5.13

35.90

Thorax

15 12.82 4 3.42 19 16.24

Penetrating

9 7.69 3 2.56 12 10.26

Lung only

Abdomen

8 6.84 1 0.85 9 7.69

Mild skin injury

Non-penetrating

6 5.13 1 0.85 7 5.98

5.98 4.27

2.56

3.42

8.55

7.69

Table 3. Distribution of the patients by the locations of amputation after explosion Location of amputation

Male n=100

Female n=17 %

None

64 54.70 16 13.68 80 68.38 21.37

13 11.11 1 0.85 14 11.96

Lower extremity

10 8.55 — — 10 8.55

Knee

5 4.27 — — 5 4.27 —

—

22.22

Wrist

3.42

—

Upper extremity

—

0.85

Finger

9.40

Total n=117

9.40

Toe

Shoulder

1 0.85 — — 1 0.85

3.42

Ankle

1 0.85 — — 1 0.85

Elbow

1 0.85 — — 1 0.85

Hip

0.85

red in public areas or by explosions due to victims manual handling explosive material. A study reported from Madrid, Spain revealed that explosions mostly occurred at the end of the business day and on the way home. It appears that such attacks usually target working class people.[16] However, students and farmers were injured most frequently in our study. Students were affected because explosions took place in city centers, in the vicinity of schools. Farmers, on the other hand, were affected by land mines. Literature data suggest that the majority of explosions occur either in public transportation vehicles or crowded public places.[1,4,16,17] Husum et al. reported that injuries from land mine explosions primarily occurred in rural areas.[5] Although the majority of our patients were affected in city centers, land mine explosions occurred in rural areas. This indicates that our results were in agreement with literature data.

—

0.85

Ron Golan et al. from Israel studied the distribution of body parts affected by explosion and found that the face, neck, thorax, and upper extremities were affected most.[9] In contrast, Karaca et al. reported that lower extremities were most commonly affected. Extremity injuries resulted in amputation in most cases.[18] The reasons for a higher rate of upper extremity injuries in the present study were manual handling of squibs and raking up discovered bombs and land mines. Not surprisingly, amputations mainly affected upper extremities, with hand and wrist regions being the most affected body parts. The most important aspects of blast injuries include their economic burden on a society, high treatment costs, and patient difficulties during the rehabilitation process.[7,19,20] Land mineassociated injuries require more hospital resources, an increased number of transfusion products and operations, and lon-

Kacmaz O et al.

Demographic Properties of Civilians with Blast Injuries in Southeastern Anatolia Region

Table 4. Distribution of the patients by the clinic of admission Clinic of admission

Male n=100

Emergency service

Female n=17 %

19.66

Total n=117

5.98

25.64

Orthopedics

30 25.64 — — 30 25.64

Plastic surgery

Ophthalmology

13 11.11 4 3.42 17 14.53

Neurosurgery

5 4.27 1 0.85 6 5.13

Chest surgery

16.24

2.56

1.71

2.56

17.95

5.13

General surgery

4.27

—

4.27

Cardiovascular surgery

1.71

—

1.71

ger rehabilitation and reintegration processes.[21] As a result of high treatment costs, 85% of affected persons suffer financial problems.[22] A quarter of our patients were discharged after a 24-hour follow-up period in the emergency department. The remaining three quarters had extremity injuries or amputations and, as expected, were admitted to the departments of Orthopedics and Traumatology, Plastic, Eye, Reconstructive, and Aesthetic Surgery , or the intensive care unit. Literature data suggest that explosions mostly occur in summer months.[1,4,11,13,17] In our study, blast injuries most commonly occurred in July and August (Figure 1). Attacks with explosives are dependent on the internal dynamics of countries or regions. Therefore, it would be erroneous to reach a conclusion with regard to yearly distribution of explosions. In our region, due to shifts in the political climate, 2008 was the calmest year while 2012 had the highest number of explosions (Figure 2).

Many studies have reported that land mine explosions occur in rural areas.[19-21] The majority of patients coming from rural areas were victims of land mine or dynamite explosions. Consequently, farmers were by far the most affected worker class. In non-rural regions, on the other hand, students led other social classes, most being injured by bombs and squibs. Although mortality rates differ in individual studies, they have usually been high. Some studies reported that 35% to 50% of deaths occurred during the prehospital period due to delays in accessing healthcare.[7,22] Husum et al. reported a prehospital death rate of 75%.[20,21] They emphasized that with timely response and first aid performed by mobilized healthcare teams, the mortality rate could be reduced by half in four years. The mean mortality rates in different studies reportedly ranged from 36% to 52%.[11,21] In our study, only two patients died in the hospital. Among those who survived long enough to reach the hospital, the mortality

Male Female

15 10

3 1

Figure 1. Distribution of patients by the month of incident.

5 3

0 October

September

June

1 August

2 May

April

1 March

1 February

January

July

December

November

1 0

2005

1 2006

1 2007

2008

2 0 2009

2010

3 1

1 2011

2012

2013

Figure 2. Distribution of the patients by years of presentation.

Turk J Emerg Med 2015;15(2):00-00

rate was 1.7%. This rate was lower than previous studies, since patients who died at the site of incident or during transport were excluded. The mortality rate of those injured in mine explosions was 8.33%. Limitations Records of those who died at the site of incident or during transport and those referred to other hospitals could not be reached. We could not access the records of all patients with blast injuries and were missing some data about injury mechanisms. We do not know the exact number of these missing patients. Other limitations are the study’s retrospective nature, the fact it was conducted in a single center, and the exclusion of military personnel.

Conclusion In conclusion, blast injuries have high mortality and morbidity rates. Therefore, the number of trauma centers and emergency teams in the region should be increased. In addition, mined lands should be cleared of mines and the local community should be educated about explosives. Further large-scale studies will be beneficial to prevent future injuries and their sequelae. They will also aid in prevention of blast injuries and ensure correct triage, rapid intervention, and a multidisciplinary approach. Finally, they will prevent further workforce losses after blast injuries. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Frykberg ER, Tepas JJ 3rd. Terrorist bombings. Lessons learned from Belfast to Beirut. Ann Surg 1988;208:569-76. 2. Eşsizoğlu A, Yaşan A, Bülbül I, Onal S, Yildirim EA, Aker T. Factors affecting the diagnosis of post-traumatic stress disorder after a terrorist attack. Turk Psikiyatri Derg 2009;20:118-26. [Article in Turkish] 3. Klamkam P, Jaruchinda P, Nivatwongs S, Muninnobpamasa T, Harnchumpol P, Nirattisai S, et al. Otologic manifestations from blast injuries among military personnel in Thailand. Am J Otolaryngol 2013;34:287-91. 4. Mirza FH, Parhyar HA, Tirmizi SZ. Rising threat of terrorist bomb blasts in Karachi--a 5-year study. J Forensic Leg Med 2013;20:747-51. 5. Jahunlu HR, Husum H, Wisborg T. Mortality in land-mine accidents in Iran. Prehosp Disaster Med 2002;17:107-9.

6. Andersson N, da Sousa CP, Paredes S. Social cost of land mines in four countries: Afghanistan, Bosnia, Cambodia, and Mozambique. BMJ 1995;311:718-21. 7. Husum H, Gilbert M, Wisborg T, Van Heng Y, Murad M. Land mine injuries: a study of 708 victims in North Iraq and Cambodia. Mil Med 2003;168:934-40. 8. Coupland RM. The effect of weapons on health. Lancet 1996;347:450-1. 9. Golan R, Soffer D, Givon A; Israel Trauma Group, Peleg K. The ins and outs of terrorist bus explosions: injury profiles of onboard explosions versus explosions occurring adjacent to a bus. Injury 2014;45:39-43. 10. Pyper PC, Graham WJ. Analysis of terrorist injuries treated at Craigavon Area Hospital, Northern Ireland, 1972-1980. Injury 1983;14:332-8. 11. Aharonson-Daniel L, Waisman Y, Dannon YL, Peleg K; Members of the Israel Trauma Group. Epidemiology of terror-related versus non-terror-related traumatic injury in children. Pediatrics 2003;112:e280. 12. Yavuz MS, Asirdizer M, Cetin G, Yavuz MF, Cansunar FN, Kolusayin RO. Deaths due to terrorist bombings in Istanbul (Turkey). J Clin Forensic Med 2004;11:308-15. 13. Bilukha OO, Becknell K, Laurenge H, Danee L, Subedi KP. Fatal and non-fatal injuries due to intentional explosions in Nepal, 2008-2011: analysis of surveillance data. Confl Health 2013;7:5. 14. Centers for Disease Control and Prevention (CDC). Homemade chemical bomb incidents - 15 states, 2003-2011. MMWR Morb Mortal Wkly Rep 2013;62:498-500. 15. Meddings DR, O’Connor SM. Circumstances around weapon injury in Cambodia after departure of a peacekeeping force: prospective cohort study. BMJ 1999;319:412-5. 16. Turégano-Fuentes F, Caba-Doussoux P, Jover-Navalón JM, Martín-Pérez E, Fernández-Luengas D, Díez-Valladares L, et al. Injury patterns from major urban terrorist bombings in trains: the Madrid experience. World J Surg 2008;32:1168-75. 17. Mayo A, Kluger Y. Terrorist bombing. World J Emerg Surg 2006;1:33. 18. Karaca MA, Erbil B, Karakılıç E, Kunt MM, Kavalcı C, Akpınar E, et al. ‘‘Evaluation of Injuries Due to a Terrorist Bombing in Ankara, 20 September 2011”, Eur J Surg Sci 2014;5:20-6. 19. Aharonson-Daniel L, Peleg K; ITG. The epidemiology of terrorism casualties. Scand J Surg 2005;94:185-90. 20. Jeffrey SJ. Antipersonnel mines: who are the victims? J Accid Emerg Med 1996;13:343-6. 21. Husum H, Resell K, Vorren G, Heng YV, Murad M, Gilbert M, et al. Chronic pain in land mine accident survivors in Cambodia and Kurdistan. Soc Sci Med 2002;55:1813-6. 22. Ascherio A, Biellik R, Epstein A, Snetro G, Gloyd S, Ayotte B, et al. Deaths and injuries caused by land mines in Mozambique. Lancet 1995;346:721-4.

ORIGINAL ARTICLE

Rising Threat; Bonsai Gokhan Aksel,1 Oner Bozan,1 Mine Kayacı,1 Ozlem GUneysel,2 Seckin Bahar SezgIn1 Department of Emergency Medicine Clinic, Umraniye Training and Research Hospital, Istanbul Department of Emergency Medicine Clinic, Dr. Lutfi Kirdar Kartal Training and Research Hospital, Istanbul, both in Turkey 1

SUMMARY Objectives In recent years, and especially in the past few months, the number of synthetic cannabinoid (bonsai) users has increased in our country. The aim of this study was to draw attention to the consumption of bonsai among young people and reveal the demographic and basic clinical characteristics of these users. Methods This was a retrospective study conducted at the Ümraniye Training and Research Hospital. All of the adult patients (≥18 year old) with synthetic cannabinoid intoxication who presented to the Emergency Department throughout the two years of the study (July 1st 2012–June 30th 2014) were enrolled. The frequencies were given as the median and inter-quartile range). Results 197 patients were included in this study, with 190 male patients (96.4%) and 7 (3.6%) female patients. Two of the four hospitalized patients were exitus, 52 left on their own will and a total of 141 patients were discharged after 6-12 hours of observation in the ED. Conclusions The use of synthetic cannabinoids (bonsai) in the recent years, especially in the summer months of 2014 was investigated in this study. Although these patients can have a benign clinical course, the process can also be fatal. It should especially be noted that patients with depressed respiration, low GCS scores and high PaCO2 values are at higher risk for mortality and the necessity of early intubation should be kept in mind. Key words: Cannabinoid receptor agonists; emergency medicine.

Introduction Synthetic cannabinoids (SC) first emerged in 2004 and became rapidly popular, especially among adolescents.[1,2] SC’s have various names worldwide, with the most common one being “spice”. However, in Turkey they are commonly known as “bonsai”.[3]

In recent years, especially in the last months, the number of bonsai users has increased in our country. In this study we aim to draw attention to the consumption of bonsai among young people and reveal the demographic and basic clinical characteristics of these users. This study was the sole study, which mentions the role of synthetic can-

Submitted: November 02, 2014 Accepted: November 26, 2014 Published online: March 02, 2015 Correspondence: Gokhan Aksel, M.D. Umraniye Egitim ve Arastirma Hastanesi, Acil Tip Klinigi, Elmalikent Mahallesi, Adem Yavuz Caddesi, No: 1, Umraniye, Istanbul, Turkey. e-mail: aksel@gokhanaksel.com

Turk J Emerg Med 2015;15(2):75–78

doi: 10.5505/1304.7361.2015.80388

Turk J Emerg Med 2015;15(2):75–78

nabinoids as a public health problem in Turkey.

Materials and Methods This was a retrospective descriptive cross-sectional study conducted at Ümraniye Training and Research Hospital. All of the adult patients who were over 17 years old with synthetic cannabinoid intoxication and presented to the Emergency Department (ED) throughout two years of the study (July 1st 2012–June 30th 2014) were enrolled. Patient records

were obtained through the hospital information system (HIS). ICD codes F12.2, Z72.2, T40 and X44 were searched and charts that presented with “bonsai intoxication” were included. Other drug intoxications and patients less than 18 years old were excluded from the study. Suspicious abuse, patient data that was lacking and patients with a history of trauma were also excluded from the study. For the statistical analysis, SPSS for Windows ver. 11.0 (Chicago, IL, USA) was used. The frequencies were given as median and inter-quartile range.

Results There were 197 patients who were included in this study; 190 patients (96.4%) were male and 7 (3.6%) were female. Two of hospitalized 4 patients (all were intubated) died, 52 left refusing treatment, and a total of 141 patients were discharged after 6–12 hours of observation in the ED. Patients’ median systolic blood pressure (SBP) SBP was 120 mmHg, diastolic blood pressure (DBP) was 70 mmHg and pulse rate was 89 beats/min. Median SBP of the four patients who were intubated was 110 mmHg, DBP was 69 mmHg and pulse rate was 71 beats/min. Demographic specifications of the patients and clinical characters are shown in Tables 1–3. During this two-year study the number of abuses rose significantly in the second year, especially in June 2014 as shown in Figures 1 and 2.

Table 1. Demographical findings and vital signs of all of the patients Variable

Median (IQR)

Age (year)

22 (19-27)

Male (n, %)

190 (96.4)

Pulse (beats/min)

89 (78-105)

SBP (mmHg)

120 (110-126)

DBP (mmHg)

70 (62-80)

SaO2 (%-%)

98 (97-99)

GCS

15 (15-15)

IQR: Inter quartile range; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; SaO2: Saturation of oxygen; GCS: Glasgow coma scale score.

Discussion

Table 2. Demographical findings and vital signs of the patients who were intubated Variable

Median (IQR)

Age (year)

29 (23-24)

Male (n, %)

4 (100.0)

Pulse (beats/min)

71 (45-125)

SBP (mmHg)

110 (83-125)

DBP (mmHg)

68 (45-77)

SaO2 (%-%)

41 (15-41)

GCS

Cannabinoids are separated into three main groups: endogen, natural and synthetic. SC’s were natural-synthetic mixtures sold as legalized marijuana in some countries and smoked in the form of cigarettes.[3] The most common form of natural cannabinoid is 9-tetrahydrocannabinol (THC).[3,4] Cannabinoids affect the CB1 and CB2 receptors in the body and they show these effects generally based on a CB1 like mechanism of action, impaired consciousness, sleep changes and cardiovascular effects. Whereas the role of CB2 is poorly understood, it is known that THC acts only through CB1. This is different than SC’s, which act both through the CB1 and CB2 receptors and are more effective than THC.[5–7]

3 (3-4)

IQR: Inter quartile range; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; SaO2: Saturation of oxygen; GCS: Glasgow coma scale score.

The popularity of these drugs is growing since they cannot Table 3. Outcomes of intubated patients and their blood gas results Patient

Age/sex

Clinical result

pO2 (mmHg)

PCO2 (mmHg)

HCO3 (mmHg)

Patient 1

34/male

Intubated+Exitus

6.91

128

Patient 2

26/male

Intubated+Exitus

6.58

173

Patient 3

19/male

Intubated+Discharged

7.06

Patient 4

24/male

Intubated+Discharged

6.90

119

Aksel G et al.

Rising Threat; Bonsai

Number of patients

60 50 40 30 20

Jun. 14

Apr. 14

May. 14

Mar. 14

Jan. 14

Feb. 14

Dec. 13

Oct. 13

Nov. 13

Sep. 13

Jul. 13

Aug. 13

Jun. 13

May. 13

Apr. 13

Mar. 13

Jan. 13

Feb. 13

Dec. 12

Oct. 12

Nov. 12

Sep. 12

Jul. 12

Aug. 12

Figure 1. Number of patients presented to ED with bonsai consumption according to months.

be detected with routine screening tests and they are cheap and especially appealing to young people. In our study the median age was 22 years and there was a male gender predominance. These results were similar to the results of previous studies. Hoyte et al found the median age as 22.5 years and with a male gender predominance, although this was slightly lower than our results (cases reported in males was 74.3%).[1] Though it remains undetected through routine screening, they can be detected with new immunoassay methods and research is ongoing in this field.[8] Psychoactive effects of the SC’s are similar to the effects of THC, but they are more potent. These drugs can cause anxiety or panic as well as opposing effects like repressed anxiety. The most frequent cardiovascular effects are hypertension and tachycardia, but effects such as bradycardia and hypotension have also been reported.[4,9] In our study, patients’ median SBP was 120 mmHg, DBP was 70 mmHg and pulse rate 89/min, and these values were considered the normal range. Although 4 intubated patients had pulse rates and blood pressures (BP) that were slightly 180

Number of patients

160

153

140 120 100 80 60

Conclusion

20 0

lower with respect to all other patients pulse rates and BPs, they were still in the normal range. However, in our study the patients GCS was an average of 15 and there was no obvious hypoxia, with the SO2 average of the intubated patients measured as low as 41%. These patients had 3-4 GCS scores and their high PaCO2 in the blood gas was noteworthy. These four patients were intubated due to their low GCS scores, low PaO2, and high paCO2 levels although they had normal pulse rates and normal BPs. The respiratory suppression state of these patients was thought to have gotten worse due to secondary hypercapnia, respiratory and metabolic acidosis. The death of 2 of the 4 intubated patients doesn’t mean that the cannabinoids are harmless, but rather it can be seen as evidence that may change widely accepted assumptions about the safety of these drugs. Deaths caused by cannabinoids were not expected but that the fact that the SC’s have a wide clinical spectrum from benign to death is quite remarkable. In recent months, especially in June 2014, the high patient admission rate is conspicuous. Again in these months the use of bonsai and the bonsai related deaths frequently announced in the media has increased public awareness. The answer of why patient numbers increased so dramatically in the last month is unclear but according to police officers’ declarations, the usage of bonsai rises each day. The Turkish Monitoring Centre for Drugs and Drug Addiction 2013 report results revealed that the number of people that used SCs were 20 times higher in 2012 than in 2011. The report for 2014 has not been published yet but we think that SC consumption rose much more this year than in the previous years.[10]

1.Jul.12-30.Jun.13

1.Jul.13-30.Jun.14

Figure 2. Number of patients presented to ED with bonsai consumption according to years.

The use of synthetic cannabinoids (bonsai) in the recent years, especially in the summer months of 2014 is stated in this paper. Although patients can have a benign clini-

Turk J Emerg Med 2015;15(2):75–78

cal course, the process can also be fatal. It should be noted that especially patients with depressed respiration, low GCS scores and high PaCO2 values are at increased risk and the necessity of early intubation should be kept in mind. Limitations The major limitation of the study was its retrospective nature. The second limitation was the absence of screening tests for the synthetic cannabinoid. Confirmation of bonsai consumption was based on the medical history learned from the patients or their relatives. However, it is known that detection of these substances with routine screening tests is not possible in most medical care centers in Turkey, so anamnesis was the only method for confirmation. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Hoyte CO, Jacob J, Monte AA, Al-Jumaan M, Bronstein AC, Heard KJ. A characterization of synthetic cannabinoid exposures reported to the National Poison Data System in 2010. Ann Emerg Med 2012;60:435–8. 2. Harris CR, Brown A. Synthetic cannabinoid intoxication: a

case series and review. J Emerg Med 2013;44:360–6. 3. Gurdal F, Asirdizer M, Aker RG, Korkut S, Gocer Y, Kucukibrahimoglu EE, et al. Review of detection frequency and type of synthetic cannabinoids in herbal compounds analyzed by Istanbul Narcotic Department of the Council of Forensic Medicine, Turkey. J Forensic Leg Med 2013;20:667–72. 4. Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J Psychiatry 2001;178:101–6. 5. Pertwee RG, Howlett AC, Abood ME, Alexander SP, Di Marzo V, Elphick MR, et al. International Union of Basic and Clinical Pharmacology. LXXIX. Cannabinoid receptors and their ligands: beyond CB₁ and CB. Pharmacol Rev 2010;62:588–631. 6. Murray RM, Morrison PD, Henquet C, Di Forti M. Cannabis, the mind and society: the hash realities. Nat Rev Neurosci 2007;8:885–95. 7. Jerry J, Collins G, Streem D. Synthetic legal intoxicating drugs: the emerging ‘incense’ and ‘bath salt’ phenomenon. Cleve Clin J Med 2012;79:258–64. 8. Jang M, Yang W, Choi H, Chang H, Lee S, Kim E, et al. Monitoring of urinary metabolites of JWH-018 and JWH-073 in legal cases. Forensic Sci Int 2013;231:13–9. 9. Hohmann N, Mikus G, Czock D. Effects and risks associated with novel psychoactive substances: mislabeling and sale as bath salts, spice, and research chemicals. Dtsch Arztebl Int 2014;111:139–47. 10. http://www.kom.pol.tr/tubim/SiteAssets/Sayfalar/TürkiyeUyuşturucu-Raporu/2013(İNGİLİZCE).pdf (Accessed on 22th November 2014)

ORIGINAL ARTICLE

Rabies Suspected Animal Contact Cases in a City with Animal Husbandry and the Appropriateness of Prophylactic Procedures Seda Dagar,1 Sibel Sahın,2 Deniz Oray,3 Arif Akkaya,4 Ahmet Kama,1 Gulsah Ucan1 Department of Emergency, Kars State Hospital, Kars Department of Emergency, Artvin State Hospital, Artvin 3 Department of Emergency Medicine, Izmir University Faculty of Medicine, Izmir 4 Department of Emergency Medicine, Erzurum Regional Training and Research Hospital, Erzurum, all in Turkey 1

SUMMARY Objectives This study aims to evaluate the features of rabies suspected animal contact cases in the emergency department and the appropriateness of administering post-exposure prophylaxis procedures according to World Health Organization (WHO) instructions. Methods Rabies suspected animal contact cases that applied to the emergency department between August 2012 and December 2013 were included in the study. Patients’ data were obtained retrospectively from patient files, records of hospital automation system, and the “Rabies Suspected Animal Contact Cases Examination Form”. The post-exposure prophylaxis recommended by the WHO were compared to the prophylactic applications administered by the emergency department. Results A total of 515 cases were included in the study. According to WHO classification, cases involving category 3 injuries (n=378, 73.4%) were more common than the others (p<0.0001). Compared to post-exposure prophylaxis recommendations by the WHO, 44.7% of all cases (n=230) were administered inappropriate prophylaxis. Thirty-seven percent of cases received less rabies Ig than recommended, despite category 3 contact. Six percent of cases with category 2 contact were given unnecessary rabies Ig and all cases with category 1 contact (1.5% of all cases) were given unnecessary rabies vaccine. Conclusions We observed that in 44.7% of cases, post-exposure prophylaxis was applied inappropriately according to WHO instructions. Not only were there unnecessary vaccine and Ig applications, there were also missing prophylaxis procedures. Updating the current “Rabies Prevention and Control Directive” plus educating and controlling healthcare personnel on a regular schedule may help prevent inadequacies in prophylactic application. Key words: Post-exposure prophylaxis; rabies; World Health Organization contact category.

Submitted: October 18, 2014 Accepted: December 15, 2014 Published online: February 23, 2015 Correspondence: Seda Dagar, M.D. Kars Devlet Hastanesi, Acil Servis, Kars, Turkey. e-mail: sddagar@msn.com

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Turk J Emerg Med 2015;15(2):79–84

Introduction Rabies is a viral infection with a high mortality rate that spreads from animals and is currently seen in underdeveloped and developing countries.[1] Approximately 80,000 rabies suspected animal contact cases are reported to the Ministry of Health in our country each year.[2] Even though mortality has been reduced with precautions over the last twenty years, our country is the only European country where dog rabies still occurs.[3] Due to more intensive animal husbandry and lower socioeconomic level compared to other regions, the East Anatolia Region is at critical risk.[4] In our country, it has been reported that rabies vaccine and rabies immunoglobulin (Ig) usage is unnecessarily high for rabies post-exposure prophylaxis applications.[2,4-6] The World Health Organization (WHO) has categorized rabies suspected animal contacts into three categories and stated the recommended prophylactic approaches to be administered for each category.[7] In our country, post-exposure prophylaxis is administered according to the “Rabies Prevention and Control Directive” published by Basic Health Care General Management, Ministry of Health.[8] There are local studies that have evaluated post-exposure applications for rabies vaccine centers in our country, especially in the last decade. However, there are limited studies evaluating prophylactic applications according to WHO prophylaxis instructions. This study aims to evaluate the features of rabies suspected animal contact cases which applied to the emergency department and the appropriateness of post-exposure prophylaxis procedures applied to these cases in light of the WHO instructions.

Material and Methods This study was performed at the second base emergency department of Kars State Hospital, where approximately 210,000

patients are admitted per year. Approval from the local ethical committee was obtained before the study began. Rabies suspected animal contact was defined as all wild and domestic animal bites and scratches, and also contamination of mucous membrane or broken skin with saliva. All patients who applied to the emergency department between August 2012 and December 2013, and were assessed as rabies suspected animal contact cases were included in the study. Patients’ data were obtained by a retrospective scan of patient files, records from the hospital automation system named Sisoft HBYS, and “Rabies Suspected Animal Contact Cases Examination Form”. Patients with missing data were excluded from the study. Demographic information, legal domiciles of patients, time till application to the hospital, kind of animal contacted, facts about animal’s vaccines and owner, forensic notification requirements of the case, type of contact, number and localization of injuries, treatments, and prophylaxis applications were all recorded on the data collection form. Recommended post-exposure prophylaxis depended on contact categories suggested by the WHO are given in Table 1. The post-exposure prophylaxis measures recommended by the WHO were compared to the prophylactic applications which were actually administered to the patients in the emergency department. Statistical analyses were performed with “Statistical Package for Social Sciences (SPSS) for Windows version 21.0” (SPSS Inc., IL. USA). Quantitative data were described as the number of observations and their percentages (%), and qualitative data were marked with their mean±standard deviation (SD) or median (minimum-maximum). Statistical analyses were performed by chi-square test. In our results, p<0.05 was considered significant.

Results During the study, of 515 rabies suspected animal contact cas-

Table 1. Rabies suspected animal contact categories by WHO and recommended post-exposure prophylaxis applications Categories of contact with suspect rabid animal

Post-exposure prophylaxis measures

Category 1

Touching or feeding animals, licks on intact skin

None

Category 2

Nibbling of uncovered skin, minor scratches

or abrasions without bleeding

Immediate vaccination and local treatment of the wound

Category 3

Single or multiple transdermal bites or scratches,

Immediate vaccination and administration

licks on broken skin; contamination of mucous

of rabies immunoglobulin;

membrane with saliva from licks, contacts with bats.

local treatment of the wound

Dagar S et al.

Rabies Suspected Animal Contact Cases and the Appropriateness of Prophylactic Procedures

Table 2. Range of rabies suspected animal contact cases according to age groups

Table 4. The features of injuries after rabies suspected animal contact

Age groups

Age 0-5

16.3

Depth of the wound

Age 6-10

18.6

Surface

335

Age 11-18

125

24.3

Deep

180

Age 19-35

147

28.5

Part of the injury

Age 36-65

7.6

Head-Neck

7.8

Age 66 and older

4.7

Torso

10.1

Upper extremity

271

52.6

Lower extremity

224

43.5

Bite

307

59.6

Abrasion

119

38.6

Kind of injury

Table 3. The features of contacted animals

Species of contacted animals

Laceration

17.1

Ecchymosis

2.9

Amputations

0.4

Dogs

438

Cats

10.7

Mice

1.2

Cows

Horses

0.8

Others

1.3

Table 5. Treatments applied to rabies suspected animal contact cases in the emergency department

Known

281

54.6

Treatments

Unknown

234

45.4

Wound suture

Vaccination of animals

Required

16.7

9.5

429

83.3

466

90.5

Tetanus prophylaxis Applied

320

62.1

195

37.9

Owner of animals

Vaccinated

Unknown

es who applied to the emergency department, 383 (74.4%) were male and the average age of all patients was 28.5Âą20.1 years old (range: 1-99-years-old). The number of cases according to age groups is given in Table 2. We found that rabies suspected animal contact subgroup eighteen-years-old and younger (n=305, 59.2%) was more than the subgroup over eighteen-years-old (n=210, 40.8%) (p=0.0001). Of all the cases, 248 (48.2%) were from urban areas and 267 (51.8%) were from rural areas (p=0.466). In 336 cases (65.2%), the patient applied in the first 24 hours after contact and in 131 cases (25.4%), the patient was not seen until at least 24 hours after animal contact. We could not determine the length of time that passed between contact and application for 48 cases (9.3%). In the rural subgroup, applications within the first 24 hours (n=176, 65.9%) after the contact were more than the ones after 24 hours (n=67, 25.1%) (p<0.0001). In the subgroup of patients eighteen-years-old and younger, 154 (70.3%) applied in the first 24 hours after contact and 52 (23.7%) applied after 24 hours (p<0.0001). Only seventeen

Not required

Not applied

n %

Rabies prophylaxis

Only Rabies vaccine

299

58.1

Rabies vaccine and rabies Ig

216

41.9

cases (3.3%) needed forensic notification. The features of contacted animals are given in Table 3 and the features of injuries sustained after rabies suspected animal contact are given in Table 4. In 12.8% of cases (n=66), the patient had multiple injuries on one or more body parts. Treatments applied to rabies suspected animal contact cases in the emergency department are listed in Table 5. Upper extremity injuries (n=46, 53.5%) needed sutured most frequently. All rabies suspected animal contact cases which applied to the emergency department received the rabies vaccine. Cases in the subgroup aged between 19 and 35-years-old (n=59, 27.3%) were most commonly administered both the rabies vaccine and rabies Ig.

Turk J Emerg Med 2015;15(2):79–84

Table 6. Comparison of prophylaxis approaches suggested by WHO and those performed in the emergency department after rabies suspected animal contact

Applied prophylactic treatments

Classification by WHO

Rabies Vaccine

Rabies Ig

Category 1

Applied in 8 cases (1.5%) unnecessarily

Applied in 1 case (0.2%) unnecessarily

Category 2

—

Applied in 31 cases (6%) unnecessarily

Category 3

—

Not applied in 191 cases (37%)

When cases were categorized according to the rabies suspected animal contact categories suggested by the WHO, 8 cases (1.6%) had category 1 injuries, 129 cases (25%) had category 2 injuries, and 378 cases (73.4%) had category 3 injuries. There were far more category 3 cases than the others (p<0.0001). The comparison of prophylactic applications recommended by the WHO and what was performed in the emergency department are given in Table 6. In light of postexposure prophylaxis approaches suggested by the WHO, 230 of all cases (44.7%) were administered inappropriate prophylaxis.

Discussion Rabies is a fatal viral encephalitis that is contagious from infected animals.[8] Post-exposure prophylactic procedures include wound disinfection, vaccination, and Ig applications.[9] In developed countries, rabies is only found in wild animals, so vaccination rates and Ig applications are very low.[10] But in developing countries, due to pets passing on the disease, there are differences in prophylaxis applications.[11] In terms of standardizing applications, especially for developing countries, the WHO suggests deciding on prophylactic procedures after classifying injuries.[7] This study aims to evaluate the features of rabies suspected animal contact cases in the emergency department of a city with animal husbandry, and the appropriateness of applied prophylaxis approaches compared to WHO recommendations. In 44.7% of the cases in our study, prophylaxis was inappropriately applied with respect to WHO recommendations. Unnecessary rabies Ig applications (6%) for category 2 injuries were the most common unnecessary applications. Gülaçtı et al. reported that 9.8% of cases had unnecessary rabies vaccine and 6.2% had unnecessary rabies Ig.[5] Song et al. found that category 1 cases (12% of all cases), received unnecessary rabies vaccine.[12] In our study, all suspected contact cases received the rabies vaccine. This result means that all the category 1 injury cases (1.5%) received an unnecessary rabies vaccine. The rate of contact cases being in-

even though they needed it

cluded in a vaccination program was very low in developed countries. Moran et al. reported 6.7% of cases and Long et al. reported that 1.7% of cases were included in a vaccination program in their studies.[10,13] This rate has been reported at 95% or more in our country.[2,4,6,11] We thought that unnecessary rabies vaccines and Ig applications were administered because of the expectation of contact cases and so health personnel would feel secure against the disease. Another reason might be incorrect information, given by cases about prophylactic applications administered to people and animals in the past. Each rabies vaccination program costs between 50 and 100 US dollars.[11] If rabies Ig costs are added, unnecessary prophylaxis applications bring huge economic losses in developing countries such as ours. At the same time, each unnecessary application poses a risk of side effects, which include serious anaphylactic reactions.[8] Song et al. reported incomplete prophylactic approaches in 27.6% of all cases.[12] Kamoltham et al. found that just 4% of category 3 injuries received rabies Ig, and that result was supported by the fact that there is not enough Ig in Asian countries.[14] We found that 37% of cases had inadequate rabies Ig, in spite of having a category 3 contact. Because the Ministry of Health provides enough rabies Ig in our country, lack of information and the inexperience of health personnel might be the cause of missing rabies Ig administrations. Category 3 injuries were more common than the other injuries in this study and the difference was statistically significant (p<0.0001). Song et al. found that category 3 injuries were 63.3% of total cases, while category 1 injuries were only 6.3%.[12] In literature, the rate of category 3 injuries is higher in countries where animal husbandry is common. Kamolthom et al. observed that 73% of all cases in Thailand were category 3 injuries and Chhabra et al. found the rate was 78.8% in India.[14,15] Gülaçtı et al. reported in their study (which was the only one in our country containing WHO classifications), that 76.8% of cases were category 3 injuries. [5] Many people work with animals for long periods of time in our city, where animal husbandry is a source of income,

Dagar S et al.

Rabies Suspected Animal Contact Cases and the Appropriateness of Prophylactic Procedures

which could explain why category 3 injuries were so common in our study. In this study, we found that men (74.4%) and children (59.2%) experience rabies suspected animal contact most frequently. According to data from the WHO, boys under fifteen-years-old generate 40% of the suspected contact cases in developing countries.[7] Song et al. found this rate was 25%.[12] Eslamifar et al. reported that the rate of cases in those younger than twenty-years-old was 28.8%.[16] In a study conducted in the middle region of Anatolia, Gündüz et al. found the rate of cases for those under eighteen-yearsold was 45.5%.[17] Kılıç et al. found the rate of cases for those under twenty-years-old was 43.5% in their study, performed in Western Anatolia.[18] But in Eastern Anatolia, where animal husbandry is more common, rates for those under eighteenyears-old (50% or more) was even higher than WHO data.[6,11] Like other studies in our region, we found that patients under eighteen comprised 59.2% of all cases. We believe that educational and socioeconomic differences of countries and regions cause different data in age ranges. The WHO specifies that people living in rural area have more risks involving rabies and rabies suspected animal contact. [7] Song et al. related this to crowded population, low rate of animal vaccination, inadequacy of education, and poor economic conditions.[12] In our country, when socioeconomic levels decrease and animal husbandry increases, rabies application rates from rural areas increase. Erkal et al. found in their study, performed in the capital city, that 7% of applicants were from rural areas.[19] Temiz et al. found this rate was 47% in their study, which was performed in the eastern side of our country.[11] Like other studies in our region, 51.8% of our cases were from rural areas. Göktaş et al. observed in their study, performed in a western city, that 73.9% of cases applied to the emergency department within 24 hours after animal contact. [20] But in the study, performed by Temiz et al. in a city where animal husbandry was very common, this rate increased to 85.2%.[11] These rates made us think that regional differences affect social sensitivity. In our study, there were significantly more cases that applied to the emergency department from rural areas within 24 hours after contact (n=176, 65.9%) than those that applied more than 24 hours after contact (p<0.0001). This result shows that despite inadequate education in rural areas, people are more sensitive to rabies there. Increased exposure and possibility of animal contacts due to intensive animal husbandry in rural areas gives people more experience with diseases related to animals. This could explain why people are more sensitive to rabies there. In this study, dog contacts (85%) were far more common than other animal contacts. In prior studies in our country, it was revealed that approximately half of all rabies suspected

contact cases applied to hospitals after contact with animals, especially dogs with no owner.[4,5,20] In our study 45.4% of contacted animals had no owner. This shows that those animals, especially dogs, pose huge risks for public health in our region. Although 54.6% of contacted animals had owners, just 9.5% of them were vaccinated. Pets are the main source of disease in developing countries such as ours, so pet owners should be educated about this subject and diligent in administering vaccines for their pets on a regular basis. Limitations Because of our study was retrospective, there may be incorrect or missing data. Also, because there are differences in educational, socioeconomic, and cultural levels in various regions, we cannot generalize our results for the entire country. This is the most important limitation in our study.

Conclusion We observed that 44.7% of cases received inappropriate post-exposure prophylaxis according to WHO instructions. Besides unnecessary vaccine and Ig applications, there were also missing prophylaxis procedures. Updating the current “Rabies Prevention and Control Directive”, plus educating and controlling healthcare personnel on a regular schedule may help prevent inadequacies in prophylactic applications. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Haznedarolu T. Kuduz. In: Topçu Willke A, Söyletir G, Doğanay M: İnfeksiyon hastalıkları. 1. baskı, Ankara: Nobel Tıp Kitabevi; 1996. s. 885–901. 2. Özsoy M, Yakıştıran S, Özkan E. Evaluation Of The Patients Admitted To Rabies Vaccination Department In 2000. Türk Hij Den Biyol Derg 2002;59:1–6. 3. Kuduz Şüpheli Isırık Görülme ve Kuduz Mortalite Hızları, Türkiye, 1980-2006. Sağlık Bakanlığı Temel Sağlık Hizmetleri Genel Müdürlüğü Çalışma Yıllığı, 2006. 4. Tunç N, Temiz G, Aras E, Bilgiç A, Onat S. The evaluation of the patients who admitted to a regional hospital emergency service with suspect of rabies. J Clin Exp Invest 2012;3:383–6. 5. Gülaçtı U, Büyükaslan H, İçer M, Şahan M. The Comparison of Post-exposure Prophylaxis Recommended by World Health Organization with the Application of the Prophylaxis after Rabies Suspected Contact in Emergency Service. Düzce Tıp Derg 2013;15:46–9. 6. Söğüt Ö, Sayhan MB, Gökdemir MT, Kara HP. A Preventable Public Health Challenge in Southeastern Turkey: Rabies RiskContact Cases. JAEM 2011;10:14–7. 7. Rabies fact sheet no: 99 updated September 2014. Accessed

Turk J Emerg Med 2015;15(2):79–84

September 30,2014 at http://www.who.int/mediacentre/ factsheets/fs099/en/ 8. T.C. Sağlık Bakanlığı Temel Sağlık Hizmetleri Genel Müdürlüğü Kuduz Korunma ve Kontrol Yönergesi 2005. 2. Baskı, Ankara, Sağlık Bakanlığı Yayınları 2005. 9. Rupprecht CE, Hanlon CA, Hemachudha T. Rabies re-examined. Lancet Infect Dis 2002;2:327–43. 10. Moran GJ, Talan DA, Mower W, Newdow M, Ong S, Nakase JY, et al. Appropriateness of rabies postexposure prophylaxis treatment for animal exposures. Emergency ID Net Study Group. JAMA 2000;284:1001–7. 11. Temiz H, Akkoç H. Evaluation of 809 Cases Applicated to A Rabies Vaccination Center of Diyarbakır Government Hospital. Dicle Tıp Derg 2008;35:181–4. 12. Song M, Tang Q, Wang DM, Mo ZJ, Guo SH, Li H, et al. Epidemiological investigations of human rabies in China. BMC Infect Dis 2009;9:210. 13. Lang ME, Klassen T. Dog bites in Canadian children: a fiveyear review of severity and emergency department management. CJEM 2005;7:309–14. 14. Kamoltham T, Singhsa J, Promsaranee U, Sonthon P, Mathean

P, Thinyounyong W. Elimination of human rabies in a canine endemic province in Thailand: five-year programme. Bull World Health Organ 2003;81:375–81. 15. Chhabra M, Ichhpujani RL, Tewari KN, Lal S. Human rabies in Delhi. Indian J Pediatr 2004;71:217–20. 16. Eslamifar A, Ramezani A, Razzaghi-Abyaneh M, Fallahian V, Mashayekhi P, Hazrati M, et al. Animal bites in Tehran, Iran. Arch Iran Med 2008;11:200–2. 17. Gündüz T, Elçioğlu O, Balcı Y. An evaluation of dog and cat bites over a five-year period: a sample case from Eskişehir. [Article in Turkish] Ulus Travma Acil Cerrahi Derg 2011;17:133–40. 18. Kilic B, Unal B, Semin S, Konakci SK. An important public health problem: rabies suspected bites and post-exposure prophylaxis in a health district in Turkey. Int J Infect Dis 2006;10:248–54. 19. İlhan Erkal S, Sancar B, Bulut C. Research On First Aid Attempts After Contact With Rabies Suspicious Animals. Ankara Sağlık Bilimleri Derg 2012;1:101–14. 20. Göktaş P, Ceran N, Karagül E, Çiçek G, Özyürek S. Summary: Evaluation of 11,017 cases applicated to a rabies vaccination center. Klimik Dergisi 2002;15:12–15.

VISUAL DIAGNOSIS [see page 57]

DIAGNOSIS: Gastrointestinal Tract Foreign Bodies The detection of gastrointestinal tract (GI) foreign bodies has been possible for about 70 years.[1] The majority of the foreign bodies in the body occur by ingestion.[2] Ninety percent of them are excreted from the GI spontaneously, 10% - 20% of them need endoscopic management, and about 1% of them require surgery.[2–4] Eighty percent of ingested foreign bodies are ingested by the pediatric population.[3] In adults, foreign body ingestion can also occur, especially in people with intellectual disabilities, alcoholics, and in those without teeth, but it also can result from accidental swallowing.[2,4] Neck, chest and abdominal radiography (X-ray) reveal metal objects and bone, as well as the presence of any perforation.[2] Foreign bodies larger than 2 cm in diameter cannot pass the pyloric canal and the ileocecal valve, and those larger than 5 cm cannot pass the duodenal lobe.[2,5] Radiopaque bodies are often easily detected, while non-radiopaque bodies are not. All foreign bodies can be detected by X-ray, and it may also reveal their characteristics, such as location, size and contour. Computed tomography (CT) is often used for screening and for detecting complications of foreign bodies. However, artifacts may be seen when using CT to image metallic foreign bodies.[5] If cases with obstruction have bleeding and perforation, and if the foreign body cannot pass the iliocecal region for two weeks, or if it does not move for more than 72 hours, surgery should be performed.[4] In our case, although the patient has mental retardation and therefore has low reliability, he stated that he had swallowed nails. In cases with a history of low reliability, more detailed physical examinations and imaging techniques should be performed. Radiopaque foreign bodies were seen at the level of the small intestine in the X-ray (Figure 1). Although there are artifacts in the abdominal CT scan, no complications were observed (Figure 1b, c). In our case, the foreign bodies, which were ingested about 1 month prior, were still present, and the patient was hospitalized and underwent surgery after surgical consultation. Conclusion Foreign body ingestion can be seen in adults, especially in those with intellectual disabilities. In spite of their low reliability, any medical history taken from the patients should be taken into account. More detailed physical examinations should be performed, and the threshold for the use of imaging techniques in these patients should be low. References 1. BEST RR. Management of sharp pointed foreign bodies in the gastrointestinal tract. Am J Surg 1946;72:545–9. 2. Telford JJ. Management of ingested foreign bodies. Can J Gastroenterol 2005;19:599–601. 3. Zhang S, Cui Y, Gong X, Gu F, Chen M, Zhong B. Endoscopic management of foreign bodies in the upper gastrointestinal tract in South China: a retrospective study of 561 cases. Dig Dis Sci 2010;55:1305–12. 4. Ribas Y, Ruiz-Luna D, Garrido M, Bargalló J, Campillo F. Ingested foreign bodies: do we need a specific approach when treating inmates? Am Surg 2014;80:131–7. 5. Lee JH, Kim HC, Yang DM, Kim SW, Jin W, Park SJ, et al. What is the role of plain radiography in patients with foreign bodies in the gastrointestinal tract? Clin Imaging 2012;36:447–54.

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doi: 10.5505/1304.7361.2014.34635

VISUAL DIAGNOSIS

[see page 58]

DIAGNOSIS: Carpometacarpal (Cmc) Joint Dislocation Anteroposterior (AP) wrist and thumb x-ray revealed a dislocation of the CMC joint (Figure 1). No bone fracture signs were identified. The patient was treated with open reduction, pinning and capsuloraphy, and a short thumb spica cast was applied (Figure 2a, b). At 4â&#x20AC;&#x201C;month follow-up, radiographic examination revealed normal joint anatomy without any signs of subluxation or early osteoarthritis.

carpal bone fractures.[2] Joint capsule and ligaments, including intermetacarpal, anterior oblique, dorsoradial, and posterior oblique ligaments, play a significant role in stabilization.[1] Joint capsule and/or ligaments are frequently damaged during dislocation.[3]

Routine AP and oblique x-ray radiographs are sufficient to evaluate the CMC joint. Computed tomography may be used in the diagnosis of complex injuries Dislocation of the thumb carpometacarpal (CMC) and preoperative planning. joint is a rare injury in the hand. This injury is usually the result of an axial transmitted force through a Treatment aims to accomplish reduction and stabilpartially flexed thumb.[1] The patient complained of ity, with the goals of reducing pain, maintaining joint swelling and tenderness over the CMC joint. Mecha- motion, and preserving strength and function. Treatnisms of injury including sudden, strong impacts, fall ment options include closed reduction and casting, from tall heights, motor vehicle accidents, and fight- open or closed reduction with pinning and reconstruction of dorsal ligament and capsulorrhaphy.[4] ing must attract attention for this injury. Inadequate treatment may induce recurrent instabilDislocation of the CMC joint of the thumb is a rare in- ity, joint degeneration, and chronic pain and reduce jury and may be associated with other injuries such as functional capability of the joint.[5] (a)

References

(b)

Figure 2. (a) Intraoperative photograph of the dorsalateral aspect of carpometacarpal joint shows the thumb CMC joint percutaneous pinning, capsule damage and capsuloraphy. (b) Postoperative anteroposterior radiograph of carpometacarpal joint shows thumb CMC joint reduction and percutaneous pinning.

Turk J Emerg Med 2015;15(2):58 [86]

1. Strauch RJ, Behrman MJ, Rosenwasser MP. Acute dislocation of the carpometacarpal joint of the thumb: an anatomic and cadaver study. J Hand Surg Am 1994;19:938. 2. Tolat AR, Jones MW. Carpometacarpal dislocation of the thumb associated with fracture of the trapezium. Injury 1990;21:411-2. 3. Fotiadis E, Svarnas T, Lyrtzis C, Papadopoulos A, Akritopoulos P, Chalidis B. Isolated thumb carpometacarpal joint dislocation: a case report and review of the literature. J Orthop Surg Res 2010;5:16. 4. Sohail A, Kevin DP. Carpometacarpal dislocations of the fingers. Operative Techniques in Sports Medicine 1996;4:257-67. 5. Simonian PT, Trumble TE. Traumatic dislocation of the thumb carpometacarpal joint: early ligamentous reconstruction versus closed reduction and pinning. J Hand Surg Am 1996;21:802-6.

doi: 10.5505/1304.7361.2015.27132

CASE REPORT

Salbutamol Abuse is Associated with Ventricular Fibrillation Emin UYSAL,1 Suleyman SOLAK,1 Murat CARUS,1 Nedim UZUN,1 Erdem CEVIK2 Department of Emergency Medicine, Bagcilar Training and Research Hospital, Istanbul 2 Department of Emergency Medicine, Van Military Hospital, Van, both in Turkey

SUMMARY Salbutamol-induced cardiac complications are well-established. Herein, we describe a case of a 24-year female who was admitted to the emergency department because of a suicide attempt with salbutamol (76 mg). Salbutamol abuse induced the development of supraventricular tachycardia and ventricular fibrillation. Regular sinus rhythm was restored with defibrillation. The hypokalemic patient who stayed in the intensive care unit was discharged after 48 hours of hospitalization. Key words: Salbutamol; suicide; ventricular fibrillation.

Introduction Short-acting β-agonists are used in the management of intermittent asthma or chronic obstructive pulmonary disease (COPD) exacerbation.[1] Salbutamol shortens both the sinus cycle length and sinus node recovery time. In addition, it increases atrioventricular (AV) nodal conduction and reduces the AV nodal refractory time as well as myocardial refractoriness.[2] Over the past 40 years, it has been well-documented that β adrenergic agonists are associated with several cardiovascular adverse effects including ischemia, myocardial depression, atrial fibrillation (AF), ventricular arrhythmia, fatal myocardial band necrosis, and sudden cardiac death.[3] In this article, we report a 24- year-old female case of suicide attempt with salbutamol, which caused ventricular fibrillation (VF) in the light of β adrenergic agonist-related side effects.

Case Report A 24-year-old female case was admitted to the emergency department by her relatives due to a suicide attempt with

salbutamol 76 mg (Ventolin 4 mgx19) four hours post attempt. The patient history revealed no known chronic disease. Upon admission, the patient had mild anxiety with a normal overall status and a Glasgow Coma Scale score of 15. Her arterial blood pressure was 110/60 mmHg, while her pulse rate, respiratory rate, and SPO2 was 126 bpm, and 18 min, 96%, respectively. The patient’s heart sounds were rhythmic and tachycardic. Pulmonary auscultation revealed no rales or rhonchi and systemic examination indicated no pathology. The patient was monitored and an intravenous (I.V.) route was restored. Nasogastric decompression was performed and activated charcoal (50 g) was administered. Baseline electrocardiography (ECG) showed sinus tachycardia. Blood samples were collected for biochemistry tests and 0.9% NaCl was infused. Supraventricular tachycardia (SVT) developed at 30 minutes (Figure 1). A metoprolol tartarate-5 mg I.V. push was initiated to the patient without a history of bronchospasm. The patient was unresponsive to β blocker therapy and lost consciousness and developed ventricular fibrillation (Figure 2). Biphasic defibrillator at 200 Joules was used to restore regular heart rhythm. Spon-

Submitted: May 28, 2014 Accepted: June 20, 2014 Published online: March 07, 2015 Correspondence: Erdem Cevik, M.D. Van Asker Hastanesi, Acil Servisi, Van, Turkey. e-mail: cevikerdem@yahoo.com

Turk J Emerg Med 2015;15(2):87–89

doi: 10.5505/1304.7361.2015.33230

Turk J Emerg Med 2015;15(2):87–89

diovascular medications.[6] Similarly, our case was a female adult and admitted to the emergency service with suicide attempt with salbutamol.

Figure 1. Electrocardiography showing supraventricular tachycardia.

Figure 2. Electrocardiography showing ventricular fibrillation.

taneous circulation was returned. The patient was in sinus rhythm following defibrillation. Biochemistry test results on admission were as follows: glucose 230 mg/dL, blood urea nitrogen 23.5 mg/dL, creatinine 0.74 mg/dL, aspartate aminotransferase 19 U/L, alanine amino transaminase 20 U/L, amylase 62 U/L, lipase 27 U/L, total bilirubin 0.24 mg/dL, sodium 139 mmol/L, potassium 2.7 mmol/L, chlorine 107 mmol/L, calcium 9.25 mg/dL, prothrombin time 11.7 sec, partial thromboplastin time 21.3 sec, international normalized ratio 1.05, white blood cells 12.76x103, hemoglobin: 12 g/dL, hematocrit: 37.2 RU, platelets 304.000, pH 7.38, HCO3std 21.6 mmol/L, K+ 2.3 mmol/L lactate 3 mg/ dL, glucose 231 mg/dL, osmolarity 281 mOsm/kg. The hypokalemic patient was administered potassium infusion and hospitalized in the intensive care unit (ICU) for 48 hours. No malignant arrhythmia was observed during hospitalization. The patient followed in intensive care unit and discharged with the psychiatric consultation.

Discussion In recent years, the incidence of suicide has been increasing worldwide. Infact, suicide is more prevalent among girls and young adults than males. Consistent with this, the incidence of suicide is 3.53/100 in men and 2.31/100 in women with rates in young adults (aged 15 to 24 years) of 4.58/100 in male individuals and 5.22/100 in female individuals according to the Turkish Statistical Institute (TurkStat).[4] Kose et al.[5] also reported that women have a higher rate of suicide than men and the most commonly used method was drug or toxic agent use. In addition, some authors reported that the most frequently preferred agents for suicide attempt were analgesics followed by antidepressants, antipsychotics, and car-

Case-control studies showed that β-2 adrenergic agonists increased the risk of myocardial infarction (MI), congestive heart failure (CHF), cardiac arrest, and sudden cardiac death at varying degrees (odds ratio [OR] 1.3 to 3.4).[7,8] Single dose β-2 adrenergic agonist produced an increased heart rate by 9.12 bpm (confidence interval [CI] 95%, 5.32 to 12.92) compared to placebo. The cardiovascular side effects including major ones such as increased risk of sinus tachycardia (risk ratio [RR] 3.06; 95% CI; 1.7 to 5.5), ventricular tachycardia, AF, syncope, CHF, and sudden cardiac death were also increased with a β-2 adrenergic agonist than placebo (RR 2.54%; 95% CI; 0.18 to 0.54). The risk of major cardiovascular side effects was estimated as 1.61 (95%, CI 0.76 to 3.42), however; it did not reach statistical significance. In another study, β-2 adrenergic agonist was associated with ventricular and atrial ectopic heart beats and prolonged Q Tc interval.[8] Furthermore, sinus tachycardia and tachyarrhythmias were defined in several case reports.[9] In our case, we observed sinus tachycardia on admission and SVT followed by VF development. Fortunately, the patient responded to defibrillation. In another study, single dose β-2 adrenergic agonist produced 0.36 mmol/L decrease in blood potassium level (95% CI, 0.18 to 0.54).[7] Hyperglycemia and hypotension were also among the side effects of the treatment. Additionally, hypokalemia was associated with increased risk of ventricular tachycardia and VF in susceptible patients.[10] Similarly, our case developed hypokalemia and hyperglycemia. After SVT, ventricular fibrillation developed during treatment. This can most likely be attributed to the hypokalemia of the patient. We believe that the increased adrenergic activity and hypokalemia combined facilitated the ventricular fibrillation. Conclusion In conclusion, β-2 adrenergic agonists at therapeutic doses may cause cardiac and metabolic side effects. Such effects may be considerably evident in patients with drug abuse. The patients with salbutamol abuse should be under medical supervision for the management of electrolyte disturbances and malignant arrhythmias. Acknowledgments The authors would like to thank Dr Hakan Sari for his contribution. Conflict of Interest The authors declare that there is no potential conflicts of interest.

Uysal E et al.

Salbutamol Abuse is Associated With Ventricular Fibrillation

References 1. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08–4051). www. nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on March 21, 2011 ). 2. Kallergis EM, Manios EG, Kanoupakis EM, Schiza SE, Mavrakis HE, Klapsinos NK, et al. Acute electrophysiologic effects of inhaled salbutamol in humans. Chest 2005;127:2057–63. 3. Lulich KM, Goldie RG, Ryan G, Paterson JW. Adverse reactions to beta 2-agonist bronchodilators. Med Toxicol 1986;1:286– 99. 4. Coskun M, Zoroglu S, Ghaziuddin N. Suicide rates among Turkish and American youth: a cross-cultural comparison. Arch Suicide Res 2012;16:59–72. 5. Köse A, Eraybar S, Köse B, Köksal Ö, Akköse Aydın Ş, Armağan E, et al. Patients Over the Age of 15 Years Admitted for Attempted Suicide to the Emergency Department and the Psy-

chosocial Support Unit. JAEM 2012;11:193–6. 6. Andersen UA, Andersen M, Rosholm JU, Gram LF. Psychopharmacological treatment and psychiatric morbidity in 390 cases of suicide with special focus on affective disorders. Acta Psychiatr Scand 2001;104:458–65. 7. Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a metaanalysis. Chest 2004;125:2309–21. 8. Cazzola M, Imperatore F, Salzillo A, Di Perna F, Calderaro F, Imperatore A, et al. Cardiac effects of formoterol and salmeterol in patients suffering from COPD with preexisting cardiac arrhythmias and hypoxemia. Chest 1998;114:411–5. 9. Boucher A, Payen C, Garayt C, Ibanez H, Dieny A, Doche C, et al. Salbutamol misuse or abuse with fatal outcome: a casereport. Hum Exp Toxicol 2011;30:1869–71. 10. Nordrehaug JE, Johannessen KA, von der Lippe G. Serum potassium concentration as a risk factor of ventricular arrhythmias early in acute myocardial infarction. Circulation 1985;71:645–9.

CASE REPORT

A Rare Cause of Sudden Ptosis: Posterior Communicating Artery Aneurysm Merve Fatma Bozkurt,1 Erdem DÄąnc,1 Emis Eken,2 Seyran Bozkurt,3 Cem Sundu1 Department of Ophthalmology, Mersin University, Mersin 2 Clinic of Neurology, Silifke State Hospital, Mersin 3 Department of Emergency, Mersin University, Mersin, all in Turkey 1

SUMMARY A forty-seven-year-old female patient was admitted to our clinic with sudden ptosis and diplopia without pain. She had no trauma or systemic disease history. Ptosis and mydriasis were observed in her left eye. Eye movement was restricted all directions without lateral. Isolated oculomotor nerve paralysis was diagnosed based on clinical findings, and posterior communicating artery aneurysm was observed in magnetic resonance angiography. Key words: Aneurysm; isolated oculomotor nerve paralysis; posterior communicating artery.

Introduction Diabetes mellitus, hypertension, multiple sclerosis, trauma, and compressive lesions such as neoplasms and aneurysms can cause oculomotor nerve paralysis (ONP).[1] Nerve paralysis may also be associated with various neurological syndromes. Clinical findings of ONP show differences according to the affected nerve segment. Also, systemic findings can be seen with nerve paralysis.[2] Isolated ONP associated with aneurysm or compressive lesions is characterized by sudden onset, pain, and pupilla involvement.[2] We report a case admitted the emergency clinic with sudden ptosis in her left eye that was diagnosed as isolated ONP related to a posterior communicating artery aneurysm.

or systemic disease history. Best-corrected visual acuity was 10/10 in her right eye and 7/10 in her left eye. Total ptosis and mydriasis were seen in her left eye (Figure 1). While direct and indirect light reflex was normal in her right eye, light reflex could not be observed in her left eye. Also, eye movement was restricted to all directions without lateral (Figure 1). Approximately 30 prism diopters exotropia was seen in the primary position. Anterior and posterior segment examination was normal in both eyes. Computer tomography (CT) and diffusion magnetic resonance imaging (MRI) was observed as normal. However, a posterior communicating artery aneurysm was seen in enhanced MRI and MRI angiography (Figure 2). Isolated ONP was diagnosed based on clinical and radiological findings and endovascular treatment was planned.

Case Report

Discussion

A forty-seven-year-old female patient was admitted to the clinic with sudden ptosis and diplopia without pain. Her complaints had begun three days prior. She had no trauma

The oculomotor nerve supplies the motor innervation of levator palpebrae superior, rectus superior, rectus inferior, oblique inferior musculi and parasymphatic innervation of the

Submitted: May 22, 2014 Accepted: June 23, 2014 Published online: June 15, 2015 Correspondence: Merve Fatma Bozkurt, M.D. Faculty of Medicine, Department of Ophthalmology, Ciftlikkoy Campus, Mersin University, 33110 Mersin, Turkey. e-mail: fmerveb@gmail.com

Turk J Emerg Med 2015;15(2):90â&#x20AC;&#x201C;92

doi: 10.5505/1304.7361.2015.90001

Bozkurt MF et al.

A Rare Cause of Sudden Ptosis: Posterior Communicating Artery Aneurysm

Figure 1. Total ptosis and mydriasis were seen in her left eye. Eye movement was restricted to all directions except lateral. Also, exotropia was observed at the primary position.

Figure 2. Posterior communicating artery aneurysm, which is the millimetric nodular gadolinium enhancement, was seen in enhanced MRI (T2 sequence) and MRI angiography (arrows).

iris and ciliary body.[3] The basiler section of the nerve passes between the posterior cerebral and superior cerebellar arteries laterally parallel to posterior communicating artery. Intracranial aneurysms in this area are the primary cause of the insulating ONP that is determined in approximately 20-30% of the cases as underlying etiologic factor.[4] The primary location of the aneurysms that cause the nerve paralysis is the posterior communicating artery; we presented a case reporting an aneurysm in a similar region. As is known, hypertension or trauma are important risk factors for aneurysm, but in our case study there was no systemic disease or trauma history.[6] Insulting ONP that is caused by aneurysm or mass effect is usually characterized by acute pain and pupillary involve-

ment.[2] In our case study, nerve paralysis emerged acutely at the same time as pupillary involvement was detected. But as there was no pain history in our case, it does not suit the classical clinical picture, but similar cases have been reported.[7] However pupillary involvement may not be detected in 8-15% of patients with aneurysm caused ONP but pupillary involvement may occur by following patients.[8] The existence of pupillary involvement may give an idea about the underlying etiologic factor. If there is pupillary involvement, aneurysms or mass-like lesions that occupy an area should be considered, but if there is no pupillary involvement, vascular pathologies lead by diabetes mellitus should be thought of. This situation occurs because of the position of the fibers that lie in the nerve. While the infact caused by the

Turk J Emerg Med 2015;15(2):90–92

vascular pathologies such as diabetes mellitus affects the center of the nerve, mechanical causes affect the fibers that are close to the area.[9] As the parasymphatic fibers of the nerve lie superficially, pupillary involvement is detected in these cases because of the impression. At the same time, other than the lateral rectus and superior oblique musculi, extraocular motor innervation is damaged so that ptosis and scantiness of eye movements except the exterior view are detected.[2] Also, as we presented in our case, study patients develop diplopia and the affected eye slides to the exterior. Clinically insulting ONP-like cases should be examined for trauma and systemic vascular disease. In that case, differential diagnosis about the underlying etiologic factor can be done. Intracranial visualization should be performed. As occurred in the case we presented, normal intracranial visualization should not eliminate the clinical diagnosis of aneurysm, and angiography should be performed urgently. As treatment of cases with unruptured aneurysms endovascular techniques has recently become more popular, it is also planned in our case study.[10] Consequently similar clinical patients consulting to emergency service should be diagnosed differentially for intracranial aneurysms. Otherwise rupture of the aneurysm resulting in subarachnoid bleeding with subsequent high mortality and morbidity and the clinical situation of the patient may become worse.

References 1. Kissel JT, Burde RM, Klingele TG, Zeiger HE. Pupil-sparing oculomotor palsies with internal carotid-posterior communicating artery aneurysms. Ann Neurol 1983;13:149–54. 2. Kanski JJ. Third nerve. In: Kanski JJ, ed. Clinical ophthalmology: a systematic approach. 5th ed. New York: Butterworth Heinemann; 2006. p. 631–5. 3. Bruce BB, Biousse V, Newman NJ. Third nerve palsies. Semin Neurol 2007;27:257–68. 4. Motoyama Y, Nonaka J, Hironaka Y, Park YS, Nakase H. Pupilsparing oculomotor nerve palsy caused by upward compression of a large posterior communicating artery aneurysm. Case report. Neurol Med Chir (Tokyo) 2012;52:202–5. 5. Chang SI, Tsai MD, Wei CP. Posterior communicating aneurysm with oculomotor nerve palsy: clinical outcome after aneurysm clipping. Turk Neurosurg 2014;24:170–3. 6. Evliyaoğlu Ç. Pathophysiology and genetics of intracranial aneurysms. Turkish Neurosurgery 2012;22:189–96. 7. Alim S, Demir AK, Hamzaoğlu V. Isolated oculomotor nerve palsy due to compression by a large intracranial aneurysm after blunt head trauma. Journal of Contemporary Medicine 2013;3:203–6. 8. Atilla H. Paralitik şaşılıklar ve supranükleer göz hareketleri. In: O’Dwyer PA, Akova YA, editör. Temel göz hastalıkları. 2. basım. Ankara: Güneş Tıp Kitabevleri; 2011. s. 817–826.

Conflict of Interest

9. Fukushima Y, Imai H, Yoshino M. Ptosis as partial oculomotor nerve palsy due to compression by infundibular dilatation of posterior communicating artery, visualized with three-dimensional computer graphics: case report. Neurol Med Chir 2014;54:214–8.

The authors declare that there is no potential conflicts of interest.

10. Yavuz K, Geyik S, Saatci I, et al. Endovascular treatment of cerebral aneurysms. Turkiye Klinikleri J Radiol-Special Topics 2012;5:84–90.

CASE REPORT

Weakness in the Emergency Department: Hypokalemic Periodic Paralysis Induced By Strenuous Physical Activity Nurettin Ozgur DOGAN, Nazire AVCU, Elif YAKA, Ali ISIKKENT, Ugur DURMUS Department of Emergency Medicine, Kocaeli University Faculty of Medicine, Kocaeli, Turkey

SUMMARY Hypokalemic periodic paralysis is a rare but serious disorder that is typically caused by a channelopathy. Thyrotoxicosis, heavy exercise, high carbohydrate meal and some drugs can trigger channelopathy in genetically predisposed individuals. A 33-year-old male patient presented to the emergency department with weakness in the lower extremities. He stated that he had done heavy physical activity during the previous week. The patient exhibited motor weakness in the lower extremities (2/5 strength) during the physical examination. Initial laboratory tests showed a potassium level of 1.89 mEq/L. The initial electrocardiogram demonstrated T wave inversion and prominent U waves. The patient was treated in the emergency department with oral and intravenous potassium. The physical and ECG symptoms resolved within 16 hours of potassium supplementation and biochemical tests showed normal serum potassium levels. The patient was discharged shortly after the resolution of the symptoms. Weakness is an important but nonspecific symptom that may be brought on by a number of underlying physiological processes. Hypokalemic periodic paralysis is a rare disease that may be triggered by heavy physical activity and presents with recurrent admissions due to weakness. Key words: Emergency department; hypokalemic periodic paralysis; muscle weakness.

Introduction Hypokalemic periodic paralysis (HPP) is a rare and episodic disorder presenting with muscle weakness and fatal dysrhythmias secondary to deep hypokalemia.[1-3] HPP occurs as a result of both primary (hereditary) and secondary causes, some of the which are preventable. Primary causes are familial with autosomal dominant inheritance of point mutations in the calcium channel subunit CACNA1S, whereas secondary causes include thyrotoxicosis, hyperaldosteronism, renal tubular acidosis, barium intoxication, and either legal or illicit drug use (laxatives, diuretics, corticosteroids, thyroid hormone pills).[2,4,5]

Regardless of the underlying etiology, acute attacks may be triggered by heavy exercise, viral infection, insomnia, high carbohydrate diet, cold and other stress factors.[2] Although the primary goal of treatment is to restore serum potassium to normal physiologic levels, fatal dysrhythmia secondary to rebound hyperkalemia has been reported in patients with HPP as a result of the delayed release of potassium stores.[6] Here we report a case of hypokalemic periodic paralysis presenting with symptoms of hypokalemia and electrocardiographic manifestations.

Submitted: May 25, 2014 Accepted: June 23, 2014 Published online: March 04, 2015 Correspondence: Nurettin Ozgur Dogan, M.D. Kocaeli Universitesi Tip Fakultesi, Acil Tip Anabilim DalÄą, Umuttepe Kampusu, Kocaeli, 41000 Izmit, Turkey. e-mail: nurettinozgurdogan@gmail.com

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doi: 10.5505/1304.7361.2015.57984

Turk J Emerg Med 2015;15(2):93–95

Case Report A 33-year-old male patient presented to the emergency department with weakness and spasms in the lower extremities. His primary complaint was weakness and the inability to walk in the morning hours. The patient was free of systemic illnesses and denied the use of medications or illicit/herbal drugs. The patient’s diet had not changed recently. The patient reported having a similar episode five years ago during which time he was admitted to the neurology department. He was discharged from the hospital after potassium supplementation restored the patient’s muscular strength. During this prior episode biochemical tests showed that thyroid function, vitamin B12, and folic acid levels were in the normal range. The patient stated that he had been conducting heavy physical activity during the previous week. In the emergency department, the patient was conscious and oriented. His vital signs included a temperature of 35 °C, blood pressure of 140/77 mm Hg, respiratory rate of 24 breaths/ minute, and pulse rate of 73 beats/minute. In the physical examination, the patient had motor weakness in both the lower extremities (2/5 strength) and upper extremities (4/5 strength). Deep tendon reflexes were diminished. Sensorial examination and cerebellar tests were normal. Initial laboratory tests showed deep hypokalemia

(K: 1.89 mEq/L; normal range 3.5-5.5 mEq/l) and hyperchloremia (Cl: 117 mEq/L; normal range 98–107 mEq/L). Other electrolytes, renal, liver function tests, complete blood count, and coagulation parameters were within normal ranges. In 12- lead electrocardiogram, a sinus rhythm with marked T wave inversion and prominent U waves was demonstrated (Figure 1). The patient was treated in the emergency department with oral and intravenous potassium (4.68 g oral and 120 mEq/L intravenous potassium) with the goal of achieving a serum potassium level greater than 3.0 mEq/L. Intravenous potassium replacement was achieved with intermittent infusion of potassium to avoid cardiac side effects. Sixteen hours after the start of the treatment the physical examination findings improved and the patient started to walk again. The patient was referred to endocrinology and continuation of the treatment was advised. At discharge, serum potassium levels had increased to 4.91 mEq/L and motor strength in the extremities was 5/5. The electrocardiogram was normal and hypokalemia symptoms had completely resolved (Figure 2). Regarding the patient’s previous admissions to the ED for similar episodes of weakness, a diagnosis of hypokalemic periodic paralysis was established and an outpatient followup was advised.

Figure 1. ECG at the presentation to the ED (U-waves were shown with black arrows).

Figure 2. ECG at discharge from ED.

Dogan NO et al.

Weakness In The Emergency Department: Hypokalemic Periodic Paralysis Induced By Strenuous Physical Activity

Discussion Hypokalemic periodic paralyses are a heterogenous group of diseases that are more prevalent in young men of Asian origin. Although channellopathies resulting from genetic predisposition play an important role in development of the disease, a considerable number of cases are diagnosed as idiopathic.[5] The present case was previously evaluated for secondary causes of hypokalemia, however the diagnosis of HPP was not established at that time. Therefore the patient did not recognize the signs and symptoms of the disease and the association with potentially precipitating factors. Patients with hypokalemic periodic paralysis usually present with symmetric motor weakness, which was noted by the present case in the early morning hours.[1,4,7] A differential diagnosis with a broad spectrum of diseases including Guillain-Barre syndrome, myasthenia gravis, spinal cord diseases, and proximal myopathies, is necessary to rule out other causes of the periodic paralysis. In addition, endocrinologic andnephrologic disorders including thyrotoxicosis, Gitelman syndrome, renal tubular acidosis, and hyperaldosteronism should be considered.[5] These disorders may be distinguished based upon clinical presentation, acid-base status, and accompanying electrolyte disorders. In the absence of objective motor deficits, electrocardiographic manifestations including ST-segment depression, T-wave inversion, and prominent U waves may indicate severe underlying hypokalemia. The present case presented with prominent U waves in the precordial leads and ST-segment depression in the initial ECG. At the initial presentation, the patient had paraparesis and the medical team initially considered disorders involving the spinal cord such as spinal tumor, transverse myelitis, or pathologic fractures of the vertebrae. However the repetitive nature of the symptoms, the ECG features, and low potassium levels suggested a metabolic disorder rather than a neurologic problem. In conjunction with ECG findings, the episodic character of his paraparesis suggested a possible diagnosis of hypokalemic paralysis. Thyrotoxicosis has been proposed as one of the important secondary causes of HPP as a result of increased potassium influx into the cells via the sodium/potassium ATPase pump. [4,6-9] Total body potassium stores may be inherently sufficient and vigorous potassium replacement can cause significant harm, including hyperkalemia-associated dysrhythmias.[6] Thyroid hormone levels may contribute to diagnosis in cases of thyrotoxic HPP, however this patient was previously evaluated for hyperthyroidism during the prior hypokalemic episode. Nevertheless, the medical team cautiously replaced potassium using both oral and intravenous routes.

Strenuous physical activity is widely accepted as an important trigger of HPP. A case series conducted by Wong reported that three of ten patients with thyrotoxic HPP experienced physical exhaustion prior to the onset of symptoms.[7] Patients with HPP may report a high carbohydrate meal, lack of sleep, and physical or psychological stress as precipitating factors. Although the present patient was previously evaluated for secondary causes for hypokalemia, heavy exercise is likely to have precipitated the attack. Hypokalemic periodic paralysis predominantly affects patients of Asian descent; etiological causes remain heterogenous and unclear. Before a diagnosis with HPP can be established, secondary causes, including various endocrinologic disorders, should be evaluated. If HPP is suspected, careful repletion of potassium with cardiac monitoring reduces the incidence of fatal arrhytmogenic complications. Emergency physicians should be aware of the signs and symptoms of HPP and its manifestations. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Alkaabi JM, Mushtaq A, Al-Maskari FN, Moussa NA, Gariballa S. Hypokalemic periodic paralysis: a case series, review of the literature and update of management. Eur J Emerg Med 2010;17:45–7. 2. Incecik F, Hergüner MO, Altunbaşak S, Lehman-Horn F. Hypokalemic periodic paralysis due to the SCN4A R672H mutation in a Turkish family. Turk J Pediatr 2010;52:409–10. 3. Fraer M. A mask and many faces: hypokalemic periodic paralysis. South Med J 2008;101:887. 4. Doğan NÖ, Doğru C, Demircan A, et al. Thyrotoxic hypokalemic periodic paralysis presenting with paraparesis. Nobel Med 2013;9:118–20. 5. Maurya PK, Kalita J, Misra UK. Spectrum of hypokalaemic periodic paralysis in a tertiary care centre in India. Postgrad Med J 2010;86:692–5. 6. Ahmed I, Chilimuri SS. Fatal dysrhythmia following potassium replacement for hypokalemic periodic paralysis. West J Emerg Med 2010;11:57–9. 7. Wong P. Hypokalemic thyrotoxic periodic paralysis: a case series. CJEM 2003;5:353–5. 8. Antonello IC, Antonello VS, de Los Santos CA, de Almeida N, d’Avila DO. Thyrotoxic hypokalemic periodic paralysis: a lifethreatening syndrome. Eur J Emerg Med 2009;16:43–4. 9. Gorchynski J, Nwosu H, Frame J. Acute ascending paralysis presenting as an endocrine emergency. Am J Emerg Med 2009;27:371.e1–371.e3.

CASE REPORT

A Rare Cause of Acute Abdominal Pain: Splenic Infarct (Case Series) Engin OZAKIN, Osman CETINKAYA, Filiz BALOGLU KAYA, Nurdan ACAR, Arif Alper CEVIK Department of Emergency, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir

SUMMARY Splenic infarcts are rare cases. It may not be noticed in the emergency department because the clinical picture is likely to mimic various acute abdominal pains. The splenic infarct is often the result of systemic thromboembolism associated with cardiovascular disorders. The aim of this study is to present an evaluation of the patients that presented to the emergency department (ED) with abdominal pain and were diagnosed with splenic infarct. Key words: Emergency department; D-dimer; infarct; spleen.

Introduction Splenic infarction is a rare clinical condition. The presentation can mimic other causes of acute abdominal pain. The diagnosis is based on clinical presentation and imaging studies. İt is mostly seen in conjunction with hematologic diseases, vascular and thromboembolic disorders. İn this cases series we reported splenic infarcts presented with abdominal pain in emergency department.

Case Report In this study, patients that presented to the adult ED (for patients over 18) of our hospital and were diagnosed with a splenic infarct between January 1, 2009 and January 1, 2013 were analyzed retrospectively. Age, gender, case history, triage category, complaints, pain characteristics, time when the pain started, vital and physical examination findings as well as the results of electrocardiogram (ECG), laboratory tests and radiological imaging were recorded. Three female and three male patients were included in this study. The average age of patients was 62.17±12.28 (range:

22–90). Table 1 provides the details of case history, examination, laboratory tests, imaging and clinical results. All patients had abdominal pain when they first presented to the ED. Abdominal pain was accompanied by nausea and vomiting in four patients, and by constipation in three patients. The pain started on average 7±4.64 (range: 1–30) days before the patients presented to the hospital. The evaluation of vital findings showed that four patients had tachypnea and one patient had a high fever. The medical history of patients included chronic obstructive pulmonary disease, congestive heart failure, mitral valve replacement, diabetes mellitus, asthma and brucella. According to the ECG results, one patient had atrial fibrillation. The abdominal examination showed three patients had sensitivity throughout, two patients had epigastric sensitivity and one patient had sensitivity in the left upper quadrant while two patients had rebound tenderness and guarding. The laboratory test results of three patients revealed high leucocyte values. The D-dimer test was performed on two patients, which revealed high values (see Table 1). The bedside ultrasound imaging did not indicate any pathological results apart from a hypoechoic

Submitted: October 25, 2013 Accepted: January 05, 2014 Published online: March 02, 2015 Correspondence: Engin Ozakin, M.D. Eskisehir Osmangazi Universitesi Tip Fakultesi, Acil Tip Anabilim Dali, 26230 Eskisehir, Turkey. e-mail: enginozakin@hotmail.com

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doi: 10.5505/1304.7361.2015.16769

Ozakin E et al.

Splenic Infarct

Table 1. Demographic and clinical characteristics of patients Characteristics Age Sex Triage category Symptoms

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

79 26 90 83 22 73 Male Female Male Female Male Female 2

Abdominal pain,

Abdominal pain

Abdominal pain,

Abdominal pain

Abdominal pain,

constipation

nausea, vomiting

and constipation

Onset of the pain Medicine/drugs/other Tension arterial (mmHg) Pulse (/min.) Respiratory rate (/min.) Fever (‘C) Past medical history

4 hours

3 days

1 day

30 days

2 days

Smoke/alcohol

–

Smoke, Coumadin

5 days

140/80

110/80

120/70

110/70

80/50

110/60

101

36.3 36.5 36.1 36.4 39.6 36.3 Asthma, Hypertension

C/S operation

COPD, DM, CHF

Anaemia (AA)

(6 months ago),

Aorta valve

CHD, HT

replacement

rubella EKG Abdomen examination

Atrial fibrillation

NSR

NSR, LVH

Epigastric

Left upper

Diffuse

Diffuse tenderness

Epigastric

tenderness quadrant tenderness tenderness tenderness rebound and

tenderness

and defence

defence Leukocytes (/mm3) 22.000 3800 12800 19680 5600 6400 D-dimer (µg/dl) 2047 7780 – – – – Amylase (U/L)

109

–

316

164

CT findings

Infarct in upper

Splenomegaly,

Infarct in

Multiple infarcts

Infarct in middle

and middle pole

infarct in lower

middle pole

in parenchyma

inferior pole

upper pole

Admission time (day) Conclusion

and middle pole

Discharged

lesion in spleen in one patient. All patients underwent an abdominal computerized tomography (CT) scan in the ED, the results of which were evaluated in the same unit. As a result of the CT scan, the radiology specialists reported a significant number of hypodense lesions that were likely associated with an infarct, and these findings were considered to confirm the presence of a splenic infarct (Figure 1a, b). All patients diagnosed with a splenic infarct were hospitalized. The average period of stay in the hospital was 8.16±1.49 (range: 4–13) days. The patients were discharged after conservative treatment, since none of them developed severe complications or mortality.

Discussion Splenic infarction occurs as a result of tissue necrosis that develops due to parenchymal ischemia, which is a result of the interruption of arterial blood supply to the spleen. The infarct may occur in a segment of the spleen or in the comp-

lete spleen. Infiltrative hematologic disorders that cause the congestion of splenic circulation with abnormal cells or thromboembolism constitute the most common (88%) causes of an infarct.[1] It was reported that the rate of splenic infarction development ranges from 50 to 72% in CML and myelofibrosis patients.[1] Splenic infarction may also develop secondary to cardiovascular disorders, autoimmune/ collagen tissue diseases, trauma, surgery (pancreatectomy or liver transplantation) or an infection. In 16.6% of patients, it is the first symptom of an underlying disease.[2] In the present study, four patients had a risk factor for thromboembolism (patients taking warfarin due to coronary artery disease, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, hypertension and valve replacement). No hematological diseases were detected according to medical history or clinical follow-up of any patients. As reported in the literature as a rare occurrence, one patient had a active brucella infection.[3]

Turk J Emerg Med 2015;15(2):96â&#x20AC;&#x201C;99

(a)

(b)

Figure 1. (a, b) Splenic infarction.

In patients with a splenic infarct, the clinical presentation may be in the form of non-specific abdominal pain or hemorrhagic shock resulting from massive subscapular bleeding. In some cases, the clinical picture does not provide any indications, and the diagnosis is based on imaging, laparoscopy or laparotomy. The overall symptom is abdominal pain or abdominal pain in the left upper quadrant in two thirds of the patients.[2,4] Nausea and vomiting are also among early symptoms. Abdominal pain can be accompanied by fever, shivering, pleuritic chest pain and left shoulder pain (Kehr finding). Pain often has been occurring for at least one week in half of patients.[2] The most common symptom found on physical examination was left upper quadrant pain. All patients presenting to our clinics had abdominal pain and sensitivity in abdomen. In five patients, the pain lasted for less than one week. There is no disease-specific laboratory test used for diagnosis. The leucocyte count may be over 12000/m3 in 50% of patients, and 7% of patients may have thrombocytosis.[4,5] In concordance with the literature, the leucocyte values of three patients in our study were high. The D-dimer test was performed for two patients with the pre-diagnosis of mesenteric embolism, and the value was high for both patients. Given that there are a limited number of studies related to the link between D-dimer and splenic infarct in the literature, D-dimer values of cases seems to be high.[2,6] This result leads us to think that because etiology is generally secondary to thromboembolism, D-dimer, a fibrin degradation product found in clotting disorders, may be useful for excluding splenic infarction. However, there is a need for further research. The other laboratory test results did not present any pathological findings.

CT scan with contrast is the best method and option for the diagnosis of splenic infarct. It is also more advantageous than other diagnostic methods for the identification of other pathologies. The possibility of splenic infarct should be considered in patients at risk and with non-specified left upper quadrant pain, and a CT scan should be performed. Magnetic resonance imaging by intravenously injected gadolinium contrast medium is another option. Research on splenic infarcts indicates that ultrasound imaging is a method that may be preferred.[7] Ultrasound is useful if the spleen parenchyma can be identified.[8] In the acute phase of infarction, the incidence of negative imaging is high in B-mod ultrasound scan,[9] and another research puts that its diagnostic value is 18%.[1] In cases where the infarction area is large, color Doppler ultrasound may show the area without blood.[9] Recent studies suggest that in patients with suspected splenic infarct, the incidence of imaging the infarct increases up to 100% with the use of second-generation ultrasound contrast agents.[10,11] In the present case, an abdominal CT scan was used for imaging since the patientsâ&#x20AC;&#x2122; pain did not alleviate during the follow-up period; the left upper quadrant pain continued on physical examination and the laboratory findings did not provide any pathologies that explained the clinical situation. Before the CT, the patients underwent bedside ultrasound scan, which showed one patient had a hypoechoic lesion with an irregular contour. The results for the other patients did not present any pathological findings or abdominal free fluid. The fact that all patients were discharged from the hospital after conservative treatment may indicate that the clinical situation and lesions were in a mild form. This may explain why the ultrasound imaging failed to show the lesions in other five patients. The diagnosis of splenic infarct has increased because of using abdominal radiological imaging techniques more fre-

Ozakin E et al.

Splenic Infarct

quently[12] and opting for angiographic embolization more commonly in vascular injuries of the spleen.[13] The present guidance approaches suggest conservative follow-ups in cases of uncomplicated and asymptomatic splenic infarcts. Nevertheless, surgery is preferred in case of complications such as resistant symptoms, bleeding, rupture, abscess and pseudocyst. Conclusion Splenic infarction, a cause of abdominal pain, is rarely encountered and often unnoticed. The diagnosis is based on clinical suspicion and imaging. Abdominal CT is the first option for diagnosis. Splenic infarction should certainly be considered in differential diagnosis of patients presenting to the emergency department due to abdominal pain, in view of underlying and risk-posing diseases. A D-dimer test may be used for excluding the diagnosis of splenic infarct; however, there is a need for further research. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Nores M, Phillips EH, Morgenstern L, Hiatt JR. The clinical spectrum of splenic infarction. Am Surg 1998;64:182–8. 2. Antopolsky M, Hiller N, Salameh S, Goldshtein B, Stalnikowicz R. Splenic infarction: 10 years of experience. Am J Emerg Med

2009;27:262–5. 3. Jae Hoon Lee, Yu Min Lee, Chang Hoon Lee, Chang Soo Choi and Tae Hyeon Kim. Splenic Infarction Associated with Brucellosis in a Non-Endemic Area. Infect Chemother. 2010 Feb;42(1):48–50. 4. Jaroch MT, Broughan TA, Hermann RE. The natural history of splenic infarction. Surgery 1986;100:743–50. 5. Dahlberg PJ, Frecentese DF, Cogbill TH. Cholesterol embolism: experience with 22 histologically proven cases. Surgery 1989;105:737–46. 6. Tomoya Hara, Koji Yamaguchi and Masataka Sata. Massive splenic infarction due to left ventricular apical . Heart Asia 2012;4:53. 7. Goerg C, Schwerk WB. Splenic infarction: sonographic patterns, diagnosis, follow-up, and complications. Radiology 1990;174:803–7. 8. Goerg C, Schwerk WB. Splenic infarction: sonographic patterns, diagnosis, follow-up, and complications. Radiology 1990;174:803–7. 9. Caremani M, Occhini U, Caremani A, Tacconi D, Lapini L, Accorsi A, et al. Focal splenic lesions: US findings. J Ultrasound 2013;16:65–74. 10. Chen MJ, Huang MJ, Chang WH, Wang TE, Wang HY, Chu CH, et al. Ultrasonography of splenic abnormalities. World J Gastroenterol 2005;11:4061–6. 11. Görg C, Bert T. Second-generation sonographic contrast agent for differential diagnosis of perisplenic lesions. AJR Am J Roentgenol 2006;186:621–6. 12. Joshi SC, Pant I, Shukla AN, Anshari MA. Splenic infarct as a diagnostic pitfall in radiology. J Cancer Res Ther 2008;4:99–101. 13. Pachter HL, Guth AA, Hofstetter SR, Spencer FC. Changing patterns in the management of splenic trauma: the impact of nonoperative management. Ann Surg 1998;227:708–19.

REVIEW

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The Integration of Palliative Care into the Emergency Department Nursah Basol Department of Emergency Medicine, Gaziosmanpasa University Faculty of Medicine, Tokat, Turkey

SUMMARY Palliative care (PC) is a new and developing area. It aims to provide the best possible quality of life for patients with life-limiting diseases. It does not primarily include life-extending therapies, but rather tries to help patients spend the rest of their lives in the best way. PC patients often are admitted to emergency departments during the course of a disease. The approach and management of PC include differences with emergency medicine. Thus, there are some problems while providing PC in the ED. With this article, the definition, main features, benefits, and problems of providing PC are presented, with the primary aim of emphasizing the importance of PC integration into the ED. Key words: Emergency department; integration; palliative care; training.

Introduction Palliative care (PC) is basically the complete active care of patients who have life-limiting diseases.[1] It aims to provide relief from distressing symptoms and to achieve the best possible quality of life. It was defined by World Health Organization in 2006 as “(PC is) an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.[2]” Historically, PC was developed for terminal stage cancer patients. The spectrum of diseases has widened, and it now includes cardiac, respiratory, metabolic, renal, and neurological (i.e. dementia) diseases.[3–5] Main Features of PC There are some main features of PC. First, it has a patientcentered culture.[6] This means that every patient is unique

and, additionally, every situation about the patient is unique as well. The most important thing is to assess the whole patient and to include the patient and family while making decisions. It is designed to meet all the physical, psychological, spiritual, and social needs of the patient. PC has a multidisciplinary, collaborative, and team-based approach. [7,8] It is important to have good communication skills that include breaking bad news.[9] The aim of PC is not limited to the end of the disease, but rather it aims to support the patient in the early stages of the life-limiting disease. It begins in early stages of the disease but it doesn’t end with death; it includes supporting families in bereavement. Misconceptions about PC There are some misconceptions about PC. First, it is not same as end-of-life care, although end-of-life care is a part of PC.[3,10] PC focuses on providing the best possible quality of life in patient’s remaining time. It does not aim to prolong the life span. However, PC does not mean that the patient has to give up curative treatments such as chemotherapy

Submitted: December 29, 2014 Accepted: January 12, 2015 Published online: March 03, 2015 Correspondence: Nursah BaSol, M.D. Gaziosmanpasa Universitesi Tip Fakultesi Hastanesi, Acil Tip Anabilim Dali, 60000 Tokat, Turkey. e-mail: drnursahbs@hotmail.com

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doi: 10.5505/1304.7361.2015.65983

Basol N

The Integration of Palliative Care into the Emergency Department

and their access to intensive care units or hospital beds. Recently, early identification of patients has gained importance. Thus, patients can be considered as a PC patient while curative treatment continues.[4,9] The Providers of PC As PC is not an approach that one health care provider can ensure, it cannot be supplied by only one health care institution. To apply PC with its full meaning requires all the structures of the health care system of a country. All providers of PC should be determined, and the communication between providers should be maintained. There may be variations according to health care system of a country. They can be PC units, PC home care teams, and/or PC consultants in hospitals, hospices, primary health care providers, and emergency departments (ED).[7] Emergency physicians should know these providers of PC, especially to refer these patients from ED. Hospice is planned for patients who can no longer be helped by curative treatment and are expected to live about 6 months or less, if the illness runs its usual course.[11] Hospice aims to celebrate, enable, and facilitate life and living by trained professional teams. It is designed to meet all physical, physiological, social, and spiritual needs.[12,13] Death is a part of life and is acceptable in the hospice approach.[14] The words of Cicely Saunders, who is the founder of the modern hospice movement, may explain the aims of hospice clearly: “You matter because you are you. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but also to live until you die.” [15] Referring the patients to hospice care is important decision in ED. Four steps were suggested as assessing hospice benefits eligibility, discussing hospice as a disposition plan with the patient’s physician, assessing whether the patient‘s goals are consistent with hospice care, and introducing hospice to the patient and family surrogates.[16] PC in the ED It is known that patients who need PC often visit EDs whether or not there are PC units, home care services and hospices, and ED visits will never lose importance due to the aging population and the increase in advanced diseases . It is obvious that adults with chronic illnesses often visit an ED several times in their last year of life. Unfortunately, high rates of ED visits in the last weeks of life are accepted indicators of poor-quality end-of-life care.[17] In a study which was called ‘the health and retirement study’, number of emergency admissions were evaluated according to age variable in the last months of life for fourteen years. It was found that 75% of patients older than age 65 years visited an ED in the last six months of life, and 51% of patients

visited an ED in the last month of life. They also found that repeated visits were common in these patients.[18] McNamara et al. evaluated ED admissions in the 90 days before death. They reported that 65.8% of patients with malignancies were admitted to ED in the last year of life, and 47% of patients in the 90 days before death visited ED many times.[17] In a study, patients with advanced malignancy were evaluated according to ED admissions, and it was reported that 26% of patients with advanced malignancy were admitted to ED more than five times in a two-year period.[19] There can be a lot of reasons for admission to ED. First, PC patients may have serious and variety of symptoms in a disease trajectory. Pain is the most common problem. In addition to pain, dyspnea, nausea, vomiting, nutritional deficiencies, fatigue, bleeding problems, and anemia may occur.[20–23] Moreover, acute function loss, acute anxiety, epileptic seizures, and delirium were reported symptoms of PC patients.[24] Shin et al. reported that pain, fatigue, nausea, and insomnia were the most common symptoms when referring acute PC patients from ED.[21] Also, they suggested that the patients who were referred from ED had more severe symptoms than other PC patients. In a study by Ahn et al., the reasons for ED admission for cancer patients were divided into four groups: disease progression (55.5%), infection (22.8%), treatment-related complications (14.7%), and non-cancer related problems (7%).[25] The ED may be an option for PC patients for hydration or intravenous medication, as well as a quick reach for acute imaging. The symptoms that the patient suffers are often bothersome and distressing, and it may cause anxiety in patients and families. It is known that psychological distress includes symptoms such as depression and anxiety. It was suggested that the prevalence of psychological distress in cancer survivors ranged from 0% to 44%.[26] It was found that many patients with advanced malignancy needed only simple procedures such as hydration, bladder catheterization, and oxygen therapy in ED in a study by Hjermstad et al.[27] They found the most common reasons for ED admissions were gastrointestinal problems (nausea, vomiting, diarrhea, etc.), lung problems (dyspnea, pleural effusion, pneumonia, etc.) and pain. It was suggested that somatic indications such as reduced performance status, frailty, loneliness, and psychological distress might be a reason for admissions to ED. Additionally, family distress and feeling safer in the hospital than at home were indicated as the causes of ED admission.[27] Next to those, the most common reason was the availability of EDs 24 hours a day and 7 days a week. The patients have access to physicians for all their needs. EDs will always be essential for PC patients with or without

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PC units, hospices, and PC consultants. The first important point for providing best care is to be aware of PC in ED. PC patients are on a long and distressed road. They are more vulnerable than other patients. Hence, symptom-oriented assessments cannot be enough for them. Problems There are some problems while providing PC in ED. Several studies from different countries report similar problems about these difficulties. According to a study by Grudzen et al., the limited knowledge and understanding about the main role of ED physicians in providing PC, problems in decision-making, a more defensive approach, and logistical challenges of ED were reported as difficulties while providing PC to patients in terms of the perspectives of ED physicians. [28] The thoughts of Australian ED clinicians were evaluated concerning problems while providing PC in ED. The free text responses were commented along three main headings The first one was about differences in expectations, and the most common response was ‘family or patient do not understand or agree with prognosis’; the second was about challenges for staff, and the most common response was ‘not enough experience to avoid the default treatment pathway’; and the last was about the challenges related to systemic issues, and the most common problem was ‘limited information was available about the patients’.[29] Additionally, the barriers on PC initiation in ED were defined as communication problems, ethical and legal issues, aggressive symptom management, and lack of clear guidelines.[28] Logistical Problems The logistical problems of ED were reported by Bradley et al. and included lack of time and space; overcrowding and workload; alarms, buzzers, and the yelling of agitated patients; and poorly designed departments.[30] It was shown in the literature that patients spent considerable time in ED before being transferred to an inpatient unit or a PC bed, services that may not be immediately available.[5,29] Time itself can be a problem for providing PC in ED. ED visits can distress and exhaust vulnerable patients at the end of life and their families, while being clinically challenging and time consuming for staff.[29] A study by Lamba et al., which evaluated differences between ED-initiated, intensive care-initiated, and floor-initiated PC consults, found that emotional and bereavement support was more required and communication with family was one of the major needs in ED.[31] Logistical problems, such as interruption to work flow, unclear whether ED can support this type of care, lack of patient follow-up, and lack of trust due to the lack of a long-term relationship were presented according to responses of ED physicians in Stone et al.’s study.[32]

Cultural Problems The main problem is differences between the cultures of two medical approaches. Emergency medicine aims to provide stabilization of acute medical urgencies as quickly as possible, whereas it is not necessary to draw immediate medical actions in PC[33] and it is less invasive in critical situations. Nauck et al. suggested that aggressive resuscitation might be inappropriate for every critical situation in ED, such as PC patients[20] because death is an expected outcome for most PC patients. The cultural problems suggested by Stone et al. were language barriers, differing religious and spiritual beliefs about illness, death, and dying, patient education, family needs at odds with patient needs, and patient informed decision-making.[32] Grudzen et al. claimed that it was not easy to match two different cultures and approaches between EM and PC. Thus, they suggested that PC consultation in ED might solve the problems while providing PC.[34] Inversely, it was reported that EM culture should change to patient-centered culture as in PC. However, it is obvious that patient goal-centered care matches the wishes of patients and families.[9] Training Problems Training about PC core competencies is very important. It is specified in the literature that there is a lack of training about PC in ED residency programs. In a survey study about PC in ED, most of the ED physicians (72%) stated only a working knowledge about PC, and they indicated a need for education about end-of-life communication and ethical issues particularly.[3] One hundred fifty-nine emergency residents from USA participated in the survey study by Meo et al., and it was reported that residents recognized the importance of PC competence. Most of the responders had indicated an interest in greater formal training in PC topics, and they reported a lack in their training program about PC.[33] Similarly, training problems such as PC being at odds with medical training and lack of communication skills training in EM were reported in a survey study that 42 emergency physicians participated in. It was indicated that residents were aware of the importance of PC, and they would like to have more training about PC skills.[35] Benefits of PC Integration into the ED The creation of a PC pathway in ED provides a better match for patient wishes with the care received, and it may provide an improvement in patient-centered care and a decrease in the intensity and invasiveness of care when appropriate. It was suggested that initiating PC in the ED had a unique opportunity to support PC interventions early in a patient’s disease trajectory, promoting quality of life as well as reducing costs associated with treatments.[5] Similarly, Wang et al. sug-

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gested that PC intervention in the ED provided numerous benefits in terms of timely provision of care, improved outcomes, direct referrals to hospice, reduced hospital length of stay (LOS), improved patient and family satisfaction, less utilization of intensive care, and cost savings.[36] The evaluation of emergency physicians’ perspectives on PC through a survey study presented the benefits of PC to patient and family as better pain management, better quality of life, and the preparation of family for death, and the benefits to ED physicians were broadened perspective in training and increased job satisfaction.[32]

Studies have suggested that palliative care might lead to cost savings through reduced use of avoidable health care services.[5,36] As an example, a hospital-based palliative care program helped reduce the utilization of intensive care, laboratory services, and pharmacy.[41] Devader et al. suggested that reducing the use of avoidable health care services, unnecessary tests and treatments, and decreasing LOS provides cost savings.[11] Patients with in-home palliative care were found to be less likely to visit emergency departments (EDs) or to be admitted to hospitals, and more likely to die at home, than those with usual care.[42,43]

The health care system should aim to reduce unnecessary ED admissions for PC patients. Wang et al. revealed that health services utilization was an important measure of palliative care effectiveness. Easier access to medical doctors outside the hospital and better lines of cooperation between hospitals and the primary healthcare services might reduce the need for ED admissions.[36] Similarly, Seow et al. reported that patients who spent more time with home care teams had reduced ED admissions.[37] It was suggested that patients who wished to die at home and patients who had advance directives with DNR orders had reduced ED admissions.[38,39] It was suggested that special PC programs in health care systems can reduce the psychosocial stress in families as well as the number of emergency calls, and it was reported that these programs make PC patients more likely to die at home.[40]

There are some studies that indicate the benefits of PC initiation in the literature. It has been found that early initiation of PC consultation in the ED was associated with a significantly shorter LOS for patients admitted to the hospital, and they indicated that the patient- and family-centered benefits of PC were complemented by reduced inpatient utilization.[5] Kandarian et al. suggested that early PC consultation in the ED impacted quality of life, health care utilization and survival, but not whether this was due to the supportive care aspect of PC teams alone.[8] Identification of PC Patients in the ED Early identification of PC patients is very important in ED. In the literature, there are some criteria in terms of defining PC patients on ED admission. The primary and secondary cri-

Table 1. The identification of PC patients Primary criteria

Secondary criteria

Global indicators that represent the minimum that hospitals

Specific indicators of a high likelihood of unmet palliative care needs

should use to screen patients at risk for unmet palliative needs The ‘‘surprise question’’: Would you be surprised if the patient

Admission from long-term care facility

died within 12 months? Frequent admissions (e.g., more than one admission for

Elderly patient, cognitively impaired, with acute hip fracture

same condition within several months) Admission prompted by difficult-to-control

Metastatic or locally advanced incurable cancer

(moderate-severe) physical or psychological symptoms Complex care requirements (e.g., functional dependency;

Chronic home oxygen use

complex home support for ventilator/feedings) Decline in function, feeding intolerance, or failure to thrive

Out-of-hospital cardiac arrest

Current or past hospice program enrollee

Limited social support (e.g., family stress, chronic mental illness)

No history of completing an advance care planning

discussion/document

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teria that were suggested by Lamba et al. are presented in Table 1.[44] A basic model was suggested for identification of PC patients in ED. First, the patient should have a serious and life-threatening disease and additionally should have one or more of the following criteria: ED physician would not be surprised if the patient died in the next 12 months, or if a pediatric patient, will not survive to adulthood; more than one ED visit or hospital admission for the same condition within several months; ED visit prompted by difficult-to-control physical or psychological symptoms, decline in function, feeding intolerance, unintentional weight loss or caregiver distress; and lastly, complex long-term care needs requiring more support.[45] PC integration models in the ED The integration of PC into ED is a new area of expertise. Thus, the ways of integration are not completely identified. In a study by Lamba et al., four clinical integrations are suggested. The first is a traditional consultation model.[44] When a PC patient comes to ED, the emergency physician calls a PM expert consultant in hospital. The second is called basic integration. The ED and PC work together on some goals/ objectives. The third, which is called advanced integration, requires that ED and PM work together on processes and protocols but ED locates in the forefront. The applicability of these models may be limited due to the availability of PM expert consultants in hospitals. In Turkey, PC is not a specialty and only a few physicians are interested in PC. The final model is an ED-focused advanced integration program. It needs a dual EM-palliative care board-certified physician. PC is a subspecialty of ED since 2008 in the USA, but in many countries including Turkey, PC is not a subspecialty, so the feasibility of this model is not possible for every country.[46] The study by Wu et al. that evaluated the effects of PC integration may be an example for the third explained model. The benefits of this model were presented as decreased LOS, greater patient satisfaction, reduced costs, and less invasiveness.[5] Some basic integration steps when getting started are

presented by IPAL-EM. According to one, four steps are suggested. The first step is to convene an interdisciplinary workgroup to plan and lead the effort; the second step is to assess the needs and resources for improving PC in the ED; the third one is to develop an action plan to map out work responsibilities and a time line; and last step is to engage the entire ED team to create a supportive culture for palliative care improvement.[47] Additionally, a list that briefly includes what could be done in a week for initiation of PC into ED is reported. It includes identify your ED “champions,” review the existing literature, identify local hospice and palliative care resources, and develop a plan to complete a needs assessment.[48] In a study by Rosenberg, an integration model that is called ‘LSMA (Life Sustaining Management and Alternatives)’ is presented.[4] It is an emergency-based PC program that includes a core team of one ED physician and one nurse coordinator for the initial consult. Nutritionists, chaplains, psychologists, social workers, physical therapists, occupational therapists, and other disciplines as required to meet the needs of each patient and family are the other members of the team. They reported increased patient and family satisfaction, reduction of costs, decreased length of stay (LOS), and reduction of the intensity of care and resuscitation rates with the LSMA program.[4] Every emergency department should find their own way on this issue. It should be organized according to the health care resources in the country, sources of hospitals with or without palliative consultants or units, and the circumstances of each individual ED. Thus, the methods might be different but the aim should be presenting high quality of care for PC patients. The Management of PC Patients in the ED The most important thing is to identify PC patients in ED and then to identify resources of possible health care facilities in terms of referral from ED. A PC team can be formed in ED that includes physicians and nurses.[49,50] It is not to be forgotten that to provide PC is only possible with a multi-disciplinary approach. This team can include social workers and chaplains in the hospital. If a team cannot beformed, the com-

Table 2. The first steps of assessment of PC patients in ED A

Does the patient have any advance directives in place regarding life-sustaining measures? If so, what are they?

How can you make the patient feel better? This is the symptom-management phase of the acute resuscitation while the ED physician tries to ascertain what level of resuscitation he or she should perform.

Are there caregivers at the bedside or who can be reached by phone? If so, take their needs and desires into consideration.

Does the patient have decision-making capacity?

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Table 3. The list of solution proposals for providing better PC in the ED Proposed Solutions Arrangements that include facilities to provide PC can be made in the existing health care system. Training programs that include core competencies of PC can be added to ED residency programs. Management guidelines that include PC emergencies can be prepared for ED staff. Educational materials and courses from the ED perspective can be added ongoing medical education. Arrangements intended to remove logistical barriers should be made in ED. Special palliative care teams can be formed in the ED. Arrangements that include providing legality of advance directives and DNR orders can be done in the existing health care system.

munication between ED physician and the rest of the team should be enabled. Also, the psychologist or psychiatrist can be ensured to contact or consult for PC patients and families. Devader et al. present the ABCD for rapid assessment of PC patients in ED.[11] It is shown in Table 2. When a PC patient comes to ED, the question should be “what is the appropriate treatment for this patient in this particular situation?” It is not forgotten that every patient and every situation is unique, and rapid assessment and meeting the needs of patients should be done in the ED. After assessment and treatment, ED physician, patient, family, and the patient’s primary physician should decide the best option among hospice, PC unit, hospital bed, or home care for the patient. The Proposed SolutionsWhen it is considered globally, EM residency programs should be organized according to PC knowledge and skills, with or without the health care structure of PC. Emergency physicians should know core competencies concerning PC.[51] The core competencies are indicated in a study by Meo et al.[33] According to that study, they are: assessing illness trajectory, formulating prognosis, difficult communication with patients and families, pain and symptom management, withdrawing or withholding nonbeneficial treatments, planning advanced care, PC systems referrals, and an understanding of ethical and legal issues. Additionally, Quest et al. added family presence during resuscitation, management of the imminently dying, spiritual/ cultural competency, and management of the dying child to the core competencies.[14] These core competencies can be added to ED residency programs. Additionally, some proposed solutions that are intended to solve the problems that occur while providing PC in ED are presented in Table 3. Furthermore, the main point for initiating PC in the ED is suggested that clinical awareness, a multi-professional team approach, communication skills, ethics expertise, close con-

tact with the patient and families, information and informed consent, and correct documentation can help manage crises in PC such that unforeseen and distressing acute emergencies should be rare.[24] Finally, PC is a new and rapidly evolving area and is a good approach that every patient with life-limiting disease deserves. Although there are some developments in the existing health care system that are supported by Ministry of Health in Turkey, there is not enough clinical awareness and embodiment in EDs. It is known that there are not enough PC units, hospices, or consultants in hospitals in Turkey. As a result, there will be inadequacy while providing PC to its whole meaning. However, giving best care and meeting the needs of patients are the responsibility of emergency physicians. In the beginning, the deficiencies in the training aspects of PC may be remedied due to good management of PC patients. Next, changing the overall approach to PC patients may be chosen. An increase in patient-centered care and a decrease in invasive approaches may be tried for these patients by emergency physicians. Communication with the patient as well as families is more important. Thus, ED physicians can try to give more time to these patients. If EDs begin to solve their problems and create a system for providing PC in the course of time, Turkey can be a country that presents good PC to patients completely by opening new units and hospices. Conflict of Interest The authors declare that there is no potential conflicts of interest.

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JA, et al. Characteristics and outcomes of patients admitted to the acute palliative care unit from the emergency center. J Pain Symptom Manage 2014;47:1028–34. 22. Radbruch L, Nauck F, Ostgathe C, Elsner F, Bausewein C, Fuchs M, et al. What are the problems in palliative care? Results from a representative survey. Support Care Cancer 2003;11:442–51. 23. Teunissen SC, de Graeff A, de Haes HC, Voest EE. Prognostic significance of symptoms of hospitalised advanced cancer patients. Eur J Cancer 2006;42:2510–6. 24. Schrijvers D, van Fraeyenhove F. Emergencies in palliative care. Cancer J 2010;16:514–20. 25. Ahn S, Lee YS, Lim KS, Lee JL. Emergency department cancer unit and management of oncologic emergencies: experience in Asan Medical Center. Support Care Cancer 2012;20:2205–10. 26. Economou D. Palliative care needs of cancer survivors. Semin Oncol Nurs 2014;30:262–7. 27. Hjermstad MJ, Kolflaath J, Løkken AO, Hanssen SB, Normann AP, Aass N. Are emergency admissions in palliative cancer care always necessary? Results from a descriptive study. BMJ Open 2013;3. 28. Grudzen CR, Richardson LD, Major-Monfried H, Kandarian B, Ortiz JM, Morrison RS. Hospital administrators’ views on barriers and opportunities to delivering palliative care in the emergency department. Ann Emerg Med 2013;61:654–60. 29. Marck CH, Weil J, Lane H, Weiland TJ, Philip J, Boughey M, et al. Care of the dying cancer patient in the emergency department: findings from a National survey of Australian emergency department clinicians. Intern Med J 2014;44:362–8. 30. Bradley V, Burney C, Hughes G. Do patients die well in your emergency department? Emerg Med Australas 2013;25:334–9. 31. Lamba S, Nagurka R, Walther S, Murphy P. Emergency-department-initiated palliative care consults: a descriptive analysis. J Palliat Med 2012;15:633–6. 32. Stone SC, Mohanty S, Grudzen CR, Shoenberger J, Asch S, Kubricek K, et al. Emergency medicine physicians’ perspectives of providing palliative care in an emergency department. J Palliat Med 2011;14:1333–8. 33. Meo N, Hwang U, Morrison RS. Resident perceptions of palliative care training in the emergency department. J Palliat Med 2011;14:548–55. 34. Grudzen CR, Richardson LD, Hopper SS, Ortiz JM, Whang C, Morrison RS. Does palliative care have a future in the emergency department? Discussions with attending emergency physicians. J Pain Symptom Manage 2012;43:1–9. 35. Lamba S, Pound A, Rella JG, Compton S. Emergency medicine resident education in palliative care: a needs assessment. J Palliat Med 2012;15:516–20. 36. Wang L, Piet L, Kenworthy CM, Dy SM. Association between palliative case management and utilization of inpatient, intensive care unit, emergency department, and hospice in medicaid beneficiaries. Am J Hosp Palliat Care 2015;32:216–20. 37. Seow H, Barbera L, Howell D, Dy SM. Using more end-oflife homecare services is associated with using fewer acute care services: a population-based cohort study. Med Care 2010;48:118–24. 38. Salam-White L, Hirdes JP, Poss JW, Blums J. Predictors of emer-

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gency room visits or acute hospital admissions prior to death among hospice palliative care clients in Ontario: a retrospective cohort study. BMC Palliat Care 2014;13:35. 39. Schonwetter RS, Clark LD, Leedy SA, Quinn MJ, Azer M, Kim S. Predicting emergency room visits and hospitalizations among hospice patients with cardiac disease. J Palliat Med 2008;11:1142–50. 40. Wiese CH, Vossen-Wellmann A, Morgenthal HC, Popov AF, Graf BM, Hanekop GG. Emergency calls and need for emergency care in patients looked after by a palliative care team: Retrospective interview study with bereaved relatives. BMC Palliat Care 2008;7:11. 41. Morrison RS, Penrod JD, Cassel JB, Caust-Ellenbogen M, Litke A, Spragens L, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med 2008;168:1783–90. 42. Brumley R, Enguidanos S, Jamison P, Seitz R, Morgenstern N, Saito S, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc 2007;55:993–1000. 43. Wye L, Lasseter G, Percival J, Duncan L, Simmonds B, Purdy S. What works in ‘real life’ to facilitate home deaths and fewer hospital admissions for those at end of life?: results from a realist evaluation of new palliative care services in two English counties. BMC Palliat Care 2014;13:37. 44. Lamba S, DeSandre PL, Todd KH, Bryant EN, Chan GK, Grudzen CR, et al. Integration of palliative care into emergency medicine: the Improving Palliative Care in Emergency Medicine (IPAL-EM) collaboration. J Emerg Med 2014;46:264–70. 45. Todd KH. Practically speaking: emergency medicine and the palliative care movement. Emerg Med Australas 2012;24:4–6.

46. Quest TE, Bryant EN, Waugh D, Grudzen C, Weissman DE for the IPAL-EM (Improving Palliative Care in Emergency Medicine) Project. Palliative Care ED Screening Tool: A Technical Assistance Resource from the IPAL-EM Project. Avaliable at: http://ipal.capc.org/downloads/ipal-em-palliative-care-edscreening-tool.pdf 47. Eric N. Bryant, MD,1 Tammie E. Quest, MD,2 Paul L. DeSandre, DO,3 David E. Weissman, MD, FACP, for the IPAL-EM (Improving Palliative Care in Emergency Medicine) Project. Getting Started: Organizing an ED Palliative Care Initiative A Technical Assistance Monograph from the IPAL-EM Project. Avaliable at: http://ipal.capc.org/downloads/ipal-em-getting-started.pdf 48. DeSandre PL, Stone S, Quest TE, Weissman DE, for the IPALEM (Improving Palliative Care in Emergency Medicine) Project. Four Things to Do in a Week: Integrating Palliative Care Services into the Emergency Department A Technical Assistance Monograph from the IPAL-EM Project. Avaliable at: http://ipal.capc.org/downloads/ipal-em-four-things-to-doin-a-week.pdf. 49. Grudzen CR, Quest TE, Spragens LH, Weissman DE, for the IPAL-EM (Improving Palliative Care in Emergency Medicine) Project. Evaluation of ED–Palliative Care Metrics & Quality A Technical Assistance Monograph from the IPAL-EM Project. Avaliable at: http://ipal.capc.org/downloads/ipal-em-evaluation-of-ed-palliative-care-metrics-quality.pdf. 50. Lamba S, Schmidt TA, Chan GK, Todd KH, Grudzen CR, Weissman DE, et al. Integrating palliative care in the out-of-hospital setting: four things to jump-start an EMS-palliative care initiative. Prehosp Emerg Care 2013;17:511–20. 51. Schears RM. Emergency physicians’ role in end-of-life care. Emerg Med Clin North Am 1999;17:539–59.

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