Nontraumatic Massive Spontaneous Hemothorax with Concomitant Warfarin Use

Hemorrhagic complications due to warfarin use are frequently seen in emergency departments. However, nontraumatic massive hemothorax is an unexpected complication. We report a 59-year-old woman with warfarin overdose, who had massive hemothorax in right lung without any history of trauma. Her main complaint was significant dyspnea, which has gradually increased in three days. On her physical examination, she was tachypneic and had decreased lung sounds on her right hemithorax. She took warfarin regularly for aortic and mitral valve replacement for 18 years. Her INR level was 12.9 (0.8–1.2). Computed tomography of thorax revealed massive hemothorax with mediastinal shift. Fresh frozen plasma infusion was started immediately. Tube thoracostomy was performed for reexpansion of right lung and 2000 cc blood was drained in 5 minutes. Although hemorrhagic complications can be expected in warfarin therapy, thoracic hemorrhage related to warfarin therapy is relatively rare (3% of all hemorrhagic complications due to warfarin therapy). To our knowledge, massive hemothorax due to warfarin use is an extremely rare condition

Measurement of mean platelet volume in the diagnosis of acute ischemic cerebrovascular disease and transient ischemic attack

Platelet aktivasyonunun bir göstergesi olan ortalama trombosit hacminin (MPV) aterotrombotik hastalıklarda ve iskemik inmenin erken tromboembolik fazında yükseldiği gösterilmiştir. Fakat geçici iskemik atak ile ortalama trombosit hacmi arasındaki ilişki henüz yeterince araştırılmamıştır. Bu çalışma iskemik inme ve geçici iskemik atak hastalarında MPV düzeylerinin tanısal değerinin araştırılması amacıyla tasarlanmıştır. 182 hasta prospektif olarak değerlendirilerek 3 gruba ayrılmıştır: 88 kortikal infarkt hastası, 55 laküner infarkt hastası ve 39 geçici iskemik ataklı hasta. Çalışma populasyonu aynı zamanda 60 kişilik kontrol grubunu da içermektedir. İstatistiksel önemlilik için t-testi, tek yönlü ANOVA analizi ve korelasyon analizi uygulanmıştır ve p<0.05 değeri istatistiksel olarak anlamlı olarak kabul edilmiştir. Kontrol grubuyla karşılaştırıldığında, kortikal infarkt hastaları ve geçici iskemik atak hastalarının MPV sonuçları daha yüksek olarak bulunmuştur (p<0.001 ve p=0.002, ANOVA). Aynı zamanda hastaneye yatan hastalarda, acilden taburcu olan hastalara göre MPV düzeyleri istatistiksel olarak anlamlı ölçüde yüksektir (p=0.036, ANOVA). Hastaların NIHSS skorları ile MPV düzeyleri arasında zayıf pozitif korelasyon bulunmuştur (r=0.207, p=0.001). MPV düzeyleriyle geçirilmiş inme öyküsü arasında da ilişki tespit edilmiştir (p=0.005, t-testi). MPV düzeylerinin ölçümü, geçici iskemik atak ve iskemik inme hastalarıyla ilgilenen acil hekimleri için tanısal ve prognostik bilgi verebilir. Şüpheli nörolojik iskemik semptomları olan hastalarda tanıda MPV düzeyleri göz önünde bulundurulmalıdır

Bland-Altman analysis: A paradigm to understand correlation and agreement

The rapid increase in the number of new laboratory methods has led to the necessity of reliable verification methods. Validation of a new measurement method for application to medical practice requires comparison with gold standard techniques. The Bland-Altman analysis is a frequently applied technique in studies that investigate the agreement between two methods of the same medical measurement. In this review, potential areas of usage of Bland-Altman analysis is elaborated from a clinical viewpoint, and possible pitfalls in study designs are discussed in statistical perspective. Keywords: Bland-Altman analysis, Limits of agreement, Correlation analysis, Biostatistic

A Case of Laptop Computer-Induced Erythema Ab Igne

Erythema ab igne, also known as toasted skin syndrome, is a skin reaction characterized by reticulate erythema, brown pigmentation, and telangiectasia. In some cases, epidermal atrophy and scaling are also identified. The condition is usually caused by prolonged exposure to a source of heat or infrared radiation. Here, we report a case of erythema ab igne associated with laptop computer use

AKUT İSKEMİK İNME VE GEÇİCİ İSKEMİK ATAĞIN TANISINDA ORTALAMA TROMBOSİT HACMİNİN ÖLÇÜMÜ

Platelet aktivasyonunun bir göstergesi olan ortalama trombosit hacminin (MPV) aterotrombotik hastalıklarda ve iskemik inmenin erken tromboembolik fazında yükseldiği gösterilmiştir. Fakat geçici iskemik atak ile ortalama trombosit hacmi arasındaki ilişki henüz yeterince araştırılmamıştır. Bu çalışma iskemik inme ve geçici iskemik atak hastalarında MPV düzeylerinin tanısal değerinin araştırılması amacıyla tasarlanmıştır. 182 hasta prospektif olarak değerlendirilerek 3 gruba ayrılmıştır: 88 kortikal infarkt hastası, 55 laküner infarkt hastası ve 39 geçici iskemik ataklı hasta. Çalışma populasyonu aynı zamanda 60 kişilik kontrol grubunu da içermektedir. İstatistiksel önemlilik için t-testi, tek yönlü ANOVA analizi ve korelasyon analizi uygulanmıştır ve p<0.05 değeri istatistiksel olarak anlamlı olarak kabul edilmiştir. Kontrol grubuyla karşılaştırıldığında, kortikal infarkt hastaları ve geçici iskemik atak hastalarının MPV sonuçları daha yüksek olarak bulunmuştur (p<0.001 ve p=0.002, ANOVA). Aynı zamanda hastaneye yatan hastalarda, acilden taburcu olan hastalara göre MPV düzeyleri istatistiksel olarak anlamlı ölçüde yüksektir (p=0.036, ANOVA). Hastaların NIHSS skorları ile MPV düzeyleri arasında zayıf pozitif korelasyon bulunmuştur (r=0.207, p=0.001). MPV düzeyleriyle geçirilmiş inme öyküsü arasında da ilişki tespit edilmiştir (p=0.005, t-testi). MPV düzeylerinin ölçümü, geçici iskemik atak ve iskemik inme hastalarıyla ilgilenen acil hekimleri için tanısal ve prognostik bilgi verebilir. Şüpheli nörolojik iskemik semptomları olan hastalarda tanıda MPV düzeyleri göz önünde bulundurulmalıdır

Following Accidental Low Dose Sodium Azide Ingestion - Case Report

Sodyum azid bazı laboratuarlarda koruyucu madde olarak kullanılmaktadır. Fakat sodyum azid zehirlenmesinin tedavisiyle ilgili deneyim son derece sınırlıdır. En küçük ölümcül doz olan 10 mg/kg ve üstü dozlarda; nöbet, koma, solunum depresyonu, metabolik asidoz, aritmi ve asistol gibi ciddi etkilerin izlendiğini gösteren yayınlar mevcuttur. Yirmibeş yaşında diş hekimi olan bir bayan hasta, yaklaşık 10 mg sodyum azid içeren 5 ml’lik seyreltilmiş çözeltiden yanlışlıkla içmişti. Alımdan 5 dakika kadar sonra uykuya eğilimi arttı ve 2 dakika kadar süren ve postiktal dönemin eşlik ettiği jeneralize tonik - klonik nöbet geçirdi. Sodyum azidin düşük dozlarında da ciddi zehirlenme semptomları gelişebilir. Özellikle bilinç durumu değişiklikleri, tremor, taşikardi, temporal görme kaybı ve nefes darlığıyla birlikte olan açıklanamayan nöbetlerde sodyum azid maruziyeti düşünülmelidir. (JAEM 2011; 10: 41-2)Sodium azide is used as a preservative in many laboratory settings. Clinical experience with treatment of sodium azide intoxication is very limited. Some publications reported severe side eff ects such as seizure, coma, respiratory depression, metabolic acidosis, arrhythmia and asystole. Major side eff ects were observed following doses of 10 mg/kg or over, the minimal lethal dosage. A 25 years old female dentist accidentally ingested approximately 5 ml of a diluted solution of (10 mg) sodium azide. Five minutes after ingestion, she became drowsy and had a generalized tonic-clonic seizure which continued for two minutes and was followed by a postictal period. Critical toxicity symptoms may develop with exposure to low doses of sodium azide. the risk of exposure to sodium azide should be considered especially when there are mental status changes, tremor, tachycardia, temporary vision loss and shortness of breath in the presence of unexplained seizures. (JAEM 2011; 10: 41-2

Comparison of diagnostic and prognostic utility of lactate and procalcitonin for sepsis in adult cancer patients presenting to emergency department with systemic inflammatory response syndrome

Objectives: Differentiating sepsis from other noninfectious causes of systemic inflammatory response syndrome (SIRS) in cancer patients is often challenging. Although lactate and procalcitonin have been studied extensively regarding sepsis management, little is known about their utility in cancer patients.This study aimed to compare the diagnostic and prognostic utility of lactate and procalcitonin for sepsis in cancer patients. Material and methods: This prospective case-control study was conducted with adult cancer patients presenting to emergency department (ED) with at least two SIRS criteria. The infection status of each patient was determined retrospectively.Main diagnostic variables were calculated for diagnostic and prognostic utilities of lactate and procalcitonin. Results: Among 86 patients, mean age was 61. Twenty-two (25.6%) were determined in the sepsis group.In the ROC analysis, a lactate value of 1 mmol/L predicted sepsis with 86.36% (95%CI: 65.1%–97.1%) sensitivity and 28.12% (95%CI: 17.6%–40.76%) specificity. A procalcitonin value of 0.8 ng/mL yielded a sensitivity of 63.64% (95%CI: 40.7%–82.8%) and 76.56% (95%CI: 63.4%–86.2%) specificity for differential diagnosis of sepsis in cancer patients.Lactate and procalcitonin showed similar abilities in differentiating sepsis from non-infective SIRS in cancer patients [AUROCs of 0.638 (95%CI:0.527–0.739) vs 0.637 (95%CI:0.527–0.738), respectively. p=0.994].They were also similar in predicting poor clinical outcome with AUROCs of 0.629 (95%CI:0.518–0.731) and 0.584 (95%CI: 0.473–0.69), respectively (p=0.577). Conclusions: The results of this study indicated that, none of the lactate and procalcitonin can be recommended alone to differentiate sepsis from non-infectious SIRS and to predict the poor clinical outcomes in adult cancer patients with SIRS in the ED. Keywords: Cancer, Sepsis, Lactate, Procalcitoni

Evaluation of the Diagnostic Role of Bedside Lung Ultrasonography in Patients with Suspected Pulmonary Embolism in the Emergency Department

Background: Despite the existence of detailed consensus guidelines, challenges remain regarding efficient, appropriate, and safe imaging methods for the diagnosis of suspected pulmonary embolism. Aims: To investigate the role of the wedge sign, B-lines, and pleural effusion seen on bedside lung ultrasound in the diagnosis of pulmonary embolism. Study Design: Diagnostic accuracy study. Methods: During the first evaluation of patients with suspected pulmonary embolism, bedside lung ultrasound was performed, and the B-lines, wedge sign, and pleural effusion were investigated. Computed tomography angiography was used as a confirmatory test and was compared with the lung ultrasound findings. Results: Pulmonary embolism was detected in 38 (38%) patients. In the comparison of bedside lung ultrasound results, statistically significant differences were found between the groups in terms of the B-lines and wedge sign (p=0.005 and p<0.001, respectively). There were no significant differences in terms of effusion (p=0.234). Comparison of these findings with computed tomography angiography of the chest showed weak negative correlations between the groups in terms of B-lines (r=-0297) and a moderately positive correlation in terms of the wedge sign (r=0.523). The sensitivity, specificity, and positive and negative predictive values of lung ultrasound findings alone were low. In the logistic regression analysis, the wedge sign (p<0.01, OR=69.45, 95% CI=6.94-695.17) and B-line (p=0.033, OR=1.96, 95% CI=0.41-8.40) were found to be effective in the diagnosis of pulmonary embolism. Conclusion: Although the role of lung ultrasound has been increasing in the management of critically ill patients, its value is limited and cannot replace the gold standard tests in the diagnosis of pulmonary embolis