Tatd 2015 1

Turkish Journal ofEmergency MedicineTürkiye Acil Tıp Dergisi

VOLUME 15

Citation Abbreviation: Turk J Emerg Med

NUMBER 1 YEAR 2015

ISSN 1304-7361

Case ImagesHydrofluoric Acid ExposureCaliskan Tur F, Aksay E

Visual DiagnosisThe Cause of Abdominal Pain after DialysisOzakin E, Can R, Acar N, Cevik AA, Baloglu Kaya F

ORIGINAL ARTICLESEffectiveness of the Stewart Method in the Evaluation of Blood Gas ParametersGezer M, Bulucu F, Ozturk K, Kilic S, Kaldirim U, Eyi YE

Comparison of Conventional Radiography and Digital Computerized Radiography in Patients Presenting to Emergency DepartmentOzcete E, Boydak B, Ersel M, Kiyan S, Uz I, Cevrim O

Mothers’ Knowledge Levels Related to PoisoningBilgen Sivri B, Ozpulat F

Mean Platelet Volume is Reduced in Acute AppendicitisKucuk E, Kucuk I

Systematic Analysis of Theses in the Field of Emergency Medicine in TurkeyCevik E, Karakus Yilmaz B, Acar YA, Dokur M

How was Felt Van Earthquake by a Neighbor University Hospital?Zengin Y, Icer M, Gunduz E, Dursun R, Durgun HM, Gullu MN, Orak M, Guloglu C

CASE REPORTSA Rare Case in the Emergency Department: Holmes-Adie SyndromeColak S, Erdogan MO, Senel A, Kibici O, Karaboga T, Afacan MA, Akdemir HU

Brucellar Testicular Abscess Presenting as a Testicular Mass: Can Color Doppler Sonography be used in Differentiation? Kaya F, Kocyigit A, Kaya C, Turkcuer I, Serinken M, Karabulut N

False Positive Troponin Levels due to Heterophil Antibodies in a Pregnant Woman Kaplan A, Orhan N, Ilhan E

Poisoned after Dinner: Dolma with Datura Stramonium Disel NR, Yilmaz M, Kekec Z, Karanlik M

www.trjemergmed.com

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.

@TurkJEmergMed TurkJEmergMed

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. Acıbadem University, Faculty of Medicine, Department of Emergency Medicine

Ibrahim TURKCUER, M.D.Pamukkale University, Faculty of Medicine, Department 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

Turkish Journal ofEmergency Medicine

TECHNICAL REVIEW AND METHODOLOGY EDITOR

Haldun AKOGLU, M.D.Marmara University, Faculty of Medicine, Department of Emergency Medicine

www.trjemergmed.com

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.

FORMER EDITORS

EDITORIAL CONSULTANTS (2014)

Gokhan AKSEL, M.D.Yusuf Ali ALTUNCI, M.D.Serjad Saddam AL ZAIDAWI, M.D.Serhat AKAY, M.D.Okhan AKDUR, M.D.Ersin AKSAY, M.D.Can AKTAS, M.D.Basak BAYRAM, M.D.Mehtap BULUT, M.D.Erdem CEVIK, M.D.Yunsur CEVIK, M.D.Tuba CIMILLI OZTURK, M.D.Ahmet DEMIRCAN, M.D.Murat DURUSU, M.D.Ozge DUMAN ATILLA, M.D.

Ozge ECMEL ONUR, M.D.Oktay ERAY, M.D.Bulent ERBIL, M.D.Serkan Emre EROGLU, M.D.Murat ERSEL, M.D.Yalcin GOLCUK, M.D.Betul GULALP, M.D.Tolga GUVEN, M.D.Nil HOCAOGLU AKSAY, M.D.Ahmet IMERCI, M.D.Asim KALKAN, M.D.Sule KALKAN, M.D.Funda KARBEK-AKARCA, M.D.Ozgur KARCIOGLU, M.D.Mutlu KARTAL, M.D.

Cemil KAVALCI, M.D.Isa KILICARSLAN, M.D.Ataman KOSE, M.D.Ali KOCYIGIT, M.D.Tanzer KORKMAZ, M.D.Mehmet Mahir KUNT, M.D.Ayhan OZHASENEKLER, M.D.Murat OZSARAC, M.D.Gul PAMUKCU GUNAYDIN, M.D.Mustafa SERINKEN, M.D.Umit TURAL, M.D.Murat YESILARAS, M.D.Serkan YILMAZ, M.D.Neslihan YUCEL, M.D.Aslihan YURUKTUMEN, M.D.

Emergency Medicine

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.

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

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

Murat PEKDEMIR, M.D. (2010-2013)

CORRESPONDENCE

Turkiye Acil Tip Dernegi, Cankaya Mah., Cinnah Cad., No: 51/10Cankaya, Ankara, TurkeyTel: +90 - 312 - 438 12 66 • Fax: +90 - 312 - 438 12 68e-mail: [email protected], [email protected]

PUBLISHER KARE YAYINCILIK | karepublishingSogutlucesme Cad., No: 76/103, 34730 Kadikoy, İstanbul, TurkeyTel: +90 - 216 - 550 61 11 Fax: +90 - 216 - 550 61 12

COORDINATION Ali CANGULDESIGN Edibe COMAKTEKINPRESS YILDIRIM Printing House PRESS DATE January 2015CIRCULATION 1500

ISSN 1304-7361

VOLUME 15NUMBER 1DECEMBER 2015

Published four times a year.

Printed on acid-free paper.

Periodical

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.

English correction service by makaletercume.


ISSUED BY THE EMERGENCY MEDICINE ASSOCIATION OF TURKEY

OWNER

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

KARE

@TurkJEmergMed TurkJEmergMed

Publishing with the Turk J Emerg Med Editorial Instructions for Authors

Case Images Hydrofluoric Acid ExposureCaliskan Tur F, Aksay E

Visual DiagnosisThe Cause of Abdominal Pain after DialysisOzakin E, Can R, Acar N, Cevik AA, Baloglu Kaya F

ORIGINAL ARTICLES Effectiveness of the Stewart Method in the Evaluation of Blood Gas ParametersGezer M, Bulucu F, Ozturk K, Kilic S, Kaldirim U, Eyi YE

Comparison of Conventional Radiography and Digital Computerized Radiography in Patients Presenting to Emergency DepartmentOzcete E, Boydak B, Ersel M, Kiyan S, Uz I, Cevrim O

Mothers’ Knowledge Levels Related to PoisoningBilgen Sivri B, Ozpulat F

Mean Platelet Volume is Reduced in Acute AppendicitisKucuk E, Kucuk I

Systematic Analysis of Theses in the Field of Emergency Medicine in TurkeyCevik E, Karakus Yilmaz B, Acar YA, Dokur M

How was Felt Van Earthquake by a Neighbor University Hospital?Zengin Y, Icer M, Gunduz E, Dursun R, Durgun HM, Gullu MN, Orak M, Guloglu C

CASE REPORTSA Rare Case in the Emergency Department: Holmes-Adie Syndrome Colak S, Erdogan MO, Senel A, Kibici O, Karaboga T, Afacan MA, Akdemir HU

Brucellar Testicular Abscess Presenting as a Testicular Mass: Can Color Doppler Sonography be used in Differentiation?Kaya F, Kocyigit A, Kaya C, Turkcuer I, Serinken M, Karabulut N

False Positive Troponin Levels due to Heterophil Antibodies in a Pregnant WomanKaplan A, Orhan N, Ilhan E

Poisoned after Dinner: Dolma with Datura StramoniumDisel NR, Yilmaz M, Kekec Z, Karanlik M

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Contents

Turkish Journal ofEmergency MedicineMARCH 2015Emergency 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 stud-ies, 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 emer-gency 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 manu-script deserves further evaluation or not. For submis-sions 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 origi-nal 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 au-thors 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 revi-sions. 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 method-ology editor to clarify any problems in the statistical design and evaluation of the study during the peer re-view 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 ac-ceptance 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 jour-nals.

8. Articles are listed on the content page and are pub-lished 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 cita-tion nor may it be copied in any format. Authors are responsible for all statements made in their articles.

Editors of the Turk J Emerg MedAssoc. Prof. Dr. Suleyman TUREDIAssoc. Prof. Dr. Orhan CINAR Prof. Dr. Arzu DENIZBASI


To the esteemed readers and authors of the Turkish Journal of Emergency Medicine, and our respected colleagues,

2014 was a highly successful year for our journal. Before us lies a new year, full of brand new hopes. We wish you all a very happy, healthy and successful 2015. The Turkish Journal of Emergency Medicine is Turkey’s scientific memory bank for emergency medicine. Our journal is part of the TUBITAK-ULAKBIM Turkish Medical Database and the Turkish Citation Database, the most prestigious database in the country. It also appears in the indices of such respected international databases as EBSCOhost, Index Copernicus, DOAJ, Gale/Cengage Learning, SCOPUS and EMBASE.

In order to increase our readership across the world and achieve a wider audience for our scientific publications, we took a very important decision in 2014 and have succeeded in becoming English-language only. We continued to accept submissions written in Turkish during the transition process in 2014. However, as we have already notified our esteemed readers and authors, the journal will now only accept submissions written in English.

One of the main reasons for this decision was for the journal to be capable of being scanned via prestigious indexes across the world. To that end, we completed our application to PubMed in 2014. The process is proceeding normally within that application for PubMed access. We believe that as a result it will soon be possible to access our journal through PubMed. Our next objective is to join the category of journals scanned by SCI-E or SCI.

As we have already set out, your citations of our journal are of enormous importance if we are to become scannable in these prestigious indexes. All members of the Turkish Journal of Emergency Medicine family, the editorial board, reviewers, authors and readership, have important responsibilities. In that respect, your making use of the large number of high-quality papers that appear in our journal as you prepare your own scientific papers will strengthen us enormously.

In sharing with you the first issue for 2015, we would also like to express our sincere gratitude for your great interest in our journal.

The Editors of the Turkish Journal of Emergency Medicine

Assoc. Prof. Dr. Suleyman TUREDI

Assoc. Prof. Dr. Orhan CINAR

Prof. Dr. Arzu DENIZBASI

Editorial


Instructions for Authors

SUBMITTING MANUSCRIPTSTurk J Emerg Med accepts online manuscript submission. Users should visit journal’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 REQUIREMENTSBefore 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 Typeb. Statement that the manuscript will not be published or evaluated for publication

elsewhere while under considerationc. Corresponding Author(s) Full Name, contact information including address,

phone, and e-mail addressd. 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 RCTb. 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 addresse. 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.

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

the Table.d. Tables can be included in Main text file as separate pages after References section,

or may be uploaded separately as you prefer. If you prefer a separate file, Tables

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, left-to-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 axisviii. Odds ratios should be displayed on a logarithmic scaleix. Survival curves should include number at risk below x axisx. 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 patients’ 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.

MANUSCRIPT FORMATTINGManuscript format must be in accordance with the ICMJE-Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals




(updated in August 2013). Papers that do not comply with the format of the Journal will be returned to the author for correction without further review. Therefore, to avoid loss of time and work, authors must carefully review the submission rules.

Manuscript structure should be complient with the guidelines of WAME . Please check this 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 Format1. 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 GUIDELINESIdentification 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,

experimental animal trials, or any other clinical or experimental studies. Maximum 8 authors, 4000 words (including references, tables, and figure legends), 30 references, 6 tables and/or figures. Submission of research articles should include below mentioned pages, sections and files as defined above in required filetypes section:

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 patient-centered 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

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.

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:

5. Ethics or Review Board Approval: If your manuscript involves original research, you will be asked to verify approval or exemption by an institutional review or ethics board. Turkish Journal of Emergency Medicine will be unable to further consider manuscripts without approval or formal exemption. (The only exceptions are for analyses of third party anonymized databases which already have pre-existing IRB approval or exemption.)

6. Compliance with manuscript writing guidelines: If your manuscript involves original research, you will be asked to verify compliance with guidelines for each corresponding study design. Please check Resources for Authors page for checklists and relevant documents.

Case Reports: Brief descriptions of clinical cases or the complications that are seldom encountered in emergency medicine practice and have an educational value. Consideration will be given to articles presenting clinical conditions, clinical manifestations or complications previously undocumented in the existing literature and unreported side of adverse effects of the known treatment regimens or scientific findings that may trigger further research on the topic. Abstracts of case reports should mainly include information 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 subheadings: Introduction, Case Presentations, Discussion and References. Maximum 5 authors, 1500 words (including references, tables, and figure legends), 15 references, 2 tables and/or figures. Case reports should be compatible with The CARE Guidelines: Consensus-based Clinical Case Reporting Guideline which can be found on the Resources for Authors Page.

Case Series: Brief descriptions of clinical cases or the complications that are seldom encountered in emergency medicine practice and have educational value. Abstracts 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 and/or figures. The main text of Case Series should be structured with the following subheadings: Introduction, Case Presentations, Discussion and References.

Brief Report: Original reports of preliminary data and findings or studies with small numbers demonstrating the need for further investigation. Abstracts should not exceed 250 words and structured as research articles. Limitations include: maximum 6 authors, 4000 words (including references, tables, and figure legends), 15 references, 4 tables and/or figures. Besides these constraints, all the formatting, approval, ethics and writing guidelines of research articles also applies to brief reports.

Concept: Clinical or non-clinical articles related to the field of emergency medicine and detailing improvements to emergency medicine practice. Abstracts should not exceed 250 words with free structure. Maximum 3 authors, 4000 words (including references, tables, and figure legends), 15 references, 3 tables and/or figures.

Review Article: Comprehensive articles reviewing national and international literature related to current emergency medicine practice. Generally Turkish Journal of Emergency Medicine publishes only invited review articles. Other authors should contact the editor prior to submission of review articles. Maximum 2 authors, 4000 words (including references, tables, and figure legends). There is no limit to the number of references.

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

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 DESIGNSRandomized 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 concealment3. Clear description of which outcome assessments were and were not blinded4. A figure summarizing participant flow through the trial5. Protocol deviations described, and whether analysis is intention to treat6. Outcomes each reported with size of effect and associated confidence intervals.

Chart reviewsLeast methodological elements that Turkish Journal of Emergency Medicine seek in retrospective research are as follows:

1. Trained and monitored abstractors use explicit protocols, precisely defined variables, and standardized abstraction instruments.

2. Authors clearly describe how missing, conflicting, and/or ambiguous chart elements were coded.

3. Interrater agreement assessed by having a sample of charts reviewed independently by two or more abstractors.

4. When possible, abstractors are blinded to the study hypothesis and/or study group assignment, particularly for chart elements that are not wholly objective.

Observational studiesWe prefer observational studies to be compliant with the latest STROBE guidelines.

Studies on diagnostic testsWeprefer studies on diagnostic tests to be compliant with the latest STARD guidelines.

Clinical Decision RulesWeprefer clinical decision rules performed and reported in compliance with Green: Methodologic standards for interpreting clinical decision rules in emergency medicine: 2014 update.

Meta-analysesMeta-analyses of therapeutic trials should be compliant with the PRISM-P 2015 guidelines, while meta-analyses of observational studies should be compliant with the MOOSE guidelines.

POLICY FOR THE REPORTING OF METHODOLOGY AND STATISTICSReporting Size of Effect and Its Confidence IntervalsTurkish Journal of Emergency Medicine strongly prefers that each comparative study outcome be reported with an estimated size of effect and its confidence intervals. Such reporting is advocated by the CONSORT statement, and lets readers to understand the approximate power and clinical importance of the observed magnitude of effect.

An example for the un-preferred type of reporting without size of effect:

1. A successful outcome was noticed in 98% of patients given Drug X versus 88% of patient given Drug Y.

2. In categorization of EF, the agreement (Weighted Kappa) between EPs and the cardiologist was 0.861 and 0.876, respectively.

3. For men, the average CWT on the right 5th intercostal space at the mid-axillary line was 32.7 mm and for women it was 39.3 mm (p=0.04)…

Examples for the preferred type of reporting with size of effect and confidence intervals:

1. A successful outcome was noticed in 98% of patients given Drug X versus 88% of patients given Drug Y (difference 10%, 95%CI -2%, 17%).

2. In categorization of EF, the agreement (Weighted Kappa) between EPs and the cardiologist was 0.861 (SE: 0.045, 95% CI: 0.773, 0.948) and 0.876 (SE:0.042, 95% CI: 0.793, 0.959), respectively.

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)



CASE IMAGES

Turk J Emerg Med 2015;15(1):1 doi: 10.5505/1304.7361.2015.48208

Submitted: June 10, 2014 Accepted: June 27, 2014 Published online: January 20, 2015

Correspondence: Feriyde CALISKAN TUR, MD. Gaziler Cad., No: 468,Yenisehir, Izmir, Turkey.

e-mail: [email protected]

1Department of Emergency Medicine, Tepecik Training and Research Hospital, Izmir;2Department of Emergency Medicine, Dokuz Eylül University Faculty of Medicine, Izmir, both in Turkey

Feriyde CALISKAN TUR,1 Ersin AKSAY2

Hydrofluoric Acid Exposure

A 21-year-old male was admitted to the emergency department with bleeding skin burns. He had been exposed to 70% hydrofluoric acid (HF) through his nitrile hand gloves during an etching glass procedure at work. He had painful lesions, which included bleeding skin abrasions due to second-degree burns on the first and second fingertips on the right hand, and white spots on the left first fin-ger, which covered approximately 0.1% of the surface (Figures 1a-d). Electrocardiography was per-formed and electrolyte levels were determined. After washing with water, 10% calcium gluconate was administered intravenously and 5 mL was injected around the border of the wounds for analgesia and detoxification. The pain was reduced, and six weeks later, his wounds had fully healed. Upon tis-sue penetration, hydrofluoric acid dissociates into hydrogen and fluoride ions, the latter of which is toxic.[1-3] HF burn treatment aims to neutralize the fluoride ions with calcium and magnesium ions.

1

Figure 1. (a) Hydrofluoric acid burns on the right and left hands. (b) Hydrofluoric acid did not penetrate the finger, but non-hemorrhagic white lesions were seen on the left thumb (mid metaphalangeal). (c, d) Bleeding fields due to second-degree burns by hydrofluoric acid on the first and second finger tips of the right hand.

(a)

(c)

(b)

(d)

Massive exposure to HF constitutes a life threatening situation. A 50% hy-drofluoric acid solution covering as little as 1% of the total body surface (160 cm2) area or exposure to HF of any concentration covering 5% of the total body surface area can be life threat-ening.[1] Calcium gluconate injections provide fluoride detoxification and improve pain. Intravenous calcium gluconate and locally administered subcutaneous injections are recom-mended to resolve the pain of the ex-posed skin area.

References1. Hatzifotis M, Williams A, Muller M,

Pegg S. Hydrofluoric acid burns. Burns 2004;30:156-9.

2. Dünser MW, Rieder J. Images in clini-cal medicine. Hydrofluoric acid burn. N Engl J Med 2007;356:e5.

3. Goldfrank LR, editor. Goldfrank’s toxi-cologic emergencies. 8th ed. New York, NY: McGraw Hill; 2006.

VISUAL DIAGNOSIS

Turk J Emerg Med 2015;15(1):2 [39] doi: 10.5505/1304.7361.2014.58189

Submitted: March 13, 2013 Accepted: April 29, 2014 Published online: January 25, 2015

Correspondence: Engin OZAKIN, MD. Eskisehir Osmangazi Universitesi, Tip Fakultesi,Acil Anabilim Dalı, 26000 Eskisehir, Turkey.


Department of Emergency, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey

Engin OZAKIN, Rumeysa CAN, Nurdan ACAR, Arif Alper CEVIK, Filiz BALOGLU KAYA

The Cause of Abdominal Pain after Dialysis

A 56-year-old woman presented to the emergency department with a sudden onset of nausea, vomiting, abdominal pain, and distension. Her symptoms started after dialysis and progressively worsened. Upon admission, a physical examination revealed a heart rate 96 beats/min, a blood pressure of 70/40 mmHg, left quadrant tenderness, rebound, and rigidity. Her hemoglobin level was 4.4 gr/dL and her platelet count was normal. Activated prothrombin time was high and the INR was 7.69. A computed tomographic scan without contrast was performed (Figure 1). (see page 39 for diagnosis).

2

Figure 1. Computed tomographic scan of the patient.

Turk J Emerg Med 2015;15(1):3-7 doi: 10.5505/1304.7361.2014.73604

Submitted: December 10, 2013 Accepted: April 21, 2014 Published online: January 15, 2015

Correspondence: Umit Kaldirim, MD. General Tevfik Saglam Cad., Gulhane Askeri Tip Akademisi, Acil Tip Anabilim Dali, Etlik, Kecioren, Ankara, Turkey.


ORIGINAL ARTICLE

1Department of İnternal Medicine, Mevki Military Hospital, Ankara;2Department of İnternal Medicine, Gulhane Military Medical Academy, Ankara;3Department of Gastroenterology, Gulhane Military Medical Academy, Ankara;

4Department of Public Health, Gulhane Military Medical Academy, Ankara;5Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara, all in Turkey

Mustafa Gezer,1 Fatih Bulucu,2 Kadir OzturK,3 Selim Kılıc,4 umit KaldırıM,5 Yusuf Emrah eyı5

Effectiveness of the Stewart Method in the Evaluation of Blood Gas Parameters

SUMMARYObjectivesIn 1981, Peter A. Stewart published a paper describing his concept for employing Strong Ion Difference. In this study we compared the HCO3 levels and Anion Gap (AG) calculated using the classic method and the Stewart method.MethodsFour hundred nine (409) arterial blood gases of 90 patients were collected retrospectively. Some were obtained from the same patients in different times and conditions. All blood samples were evaluated using the same device (ABL 800 Blood Gas Analyzer). HCO3 level and AG were calculated using the Stewart method via the website AcidBase.org. HCO3 levels, AG and strong ion difference (SID) were calculated using the Stewart method, incorporating the parameters of age, serum lactate, glucose, sodium, and pH, etc.ResultsAccording to classic method, the levels of HCO3 and AG were 22.4±7.2 mEq/L and 20.1±4.1 mEq/L respectively. According to Stewart method, the levels of HCO3 and AG were 22.6±7.4 and 19.9±4.5 mEq/L respectively.ConclusionsThere was strong correlation between the classic method and the Stewart method for calculating HCO3 and AG. The Stewart method may be more effective in the evaluation of complex metabolic acidosis.

Key words: Blood gases; Stewart method.

3

IntroductionAcid-based disorders are frequently seen problems in patients in the intensive care unit. Small changes in blood gases may cause life-threatening events. Therefore, it is essential that values such as pH, HCO3 and PCO2 are measured correctly. Al-though there are several methods currently available for the measurement of blood gas parameters, the basic bicarbonate method described by Henderson is often used.[1] However, in 1981, Peter Stewart published a new calculation method for acid-based disorders. In place of the bicarbonate-based tradi-tional approach used in the diagnosis and treatment of acid-based disorders, Stewart defined several factors that affect H+ ion concentration in biological solutions.[2] According to the Stewart method, there are three basic independent variables: the strong ion difference (SID) between the strong cation and anion total concentrations, the weak acid concentration, and the partial carbondioxide pressure (PCO2). Until the 1990s, very little interest was shown in this method described by Stewart. More recently, several researchers have used this method, giving it a place in clinical applications.[3,4]

When looking changes in pH, the Stewart method allows for a more sensitive evaluation compared to traditional methods such as Henderson and Siggard, especially in patients with complex metabolic disorders. In cases caused by multiple factors such as complex metabolic disorders, electrolytes are potentially affected and therefore more information can be obtained with the use of the Stewart. The SID value is calcu-lated with the equation, “Na+K+Ca+Mg–Cl- Lactate – other strong ions” The normal SID value is 38-42 mEq/L. A value below this interval indicates metabolic acidosis, and a value above indicates metabolic alkalosis. The Strong Ion Gap (SIG) is a parameter used in place of the Stewart Anion Gap. SIG is an indicator of abnormal ion presence in the plasma (Figure 1). Positive SIG shows the presence of metabolic acidosis. The most important weak acids in the plasma are proteins and phosphates. Of the plasma proteins, the most effective neg-ative-loaded anion is albumin. Changes in the albumin level are of great importance in the calculation of the anion gap.[5]

This study examined arterial blood samples taken from pa-tients undergoing treatment in the intensive care unit, and aimed to determine the consistency of results using the tra-ditional and Stewart methods.

Material and MethodsBlood samples were examined from patients undergoing treatment in the intensive care unit for various diseases. This retrospective, cross-sectional study was conducted at Gül-hane Military Medical Academy Intensive Care Unit between May 2010 and July 2010. The study included 409 blood gas samples, some of which were from the same patients on

different days or during different disease states. The blood gas results in the study did not define the type or severity of metabolic disorder. The arterial blood gas samples were taken from the patients with an injector, washed with hepa-rin, and transferred to the emergency biochemistry labora-tory without delay. All the blood samples were measured with the same device (ABL 800 Blood Gas Analysis Device). Measurements were taken at 37ºC. While pH and PCO2 were measured directly, the Henderson-Hasselbach method was used to calculate HCO3. The Siggard-Andersen formula was used to calculate base excess (HCO3-24.4x[2.3XHbg+7.7]x[pH -7.4 ])x(1-0.023xHgb).[6] The equation ([Na]+[K])-([Cl] +[HCO3]) was used for the calculation of the Anion Gap and [measured AG+0.25 X (normal albumin-measured albumin)] the corrected Anion Gap.[7]

The AcidBase.org website was used in the calculation of the blood gas parameters with the Stewart method. Age, gender and comorbidity status of the patient were recorded along with the pH, PCO2, CL, base excess (BE), sodium and potassi-um. The values obtained from the emergency biochemistry laboratory for albumin, glucose, urea, lactate, calcium and magnesium were recorded on the same day. After inserting the data into the website, the HCO3, anion gap, BE, chloride (corrected according to sodium), anion gap (calculated ac-cording to albumin), SID and SIG levels were calculated ac-cording to the Stewart method. The results were transferred to the computer.

In the study, the samples were also separated into 3 groups according to the sodium level (hyponatremia, hypernatre-mia and normonatremia). In each group, the chloride level was re-calculated according to the sodium level using the equation ([Cl] corrected=[Cl] measuredx([Na] normal/[Na] measured). The difference between the chloride level mea-sured with the blood gas device and the corrected chloride level was examined in each group.

Statistical Analysis

The statistical analyses were applied using SPSS (version 13) software. Descriptive statistics (mean±SD, minimum, maxi-mum) were calculated for the obtained data. Consistency between the results obtained with the blood gas device and the results with the Stewart method was evaluated using Intraclass Correlation Analysis (ICC). In addition, the direct relationship of the differences was examined with a simple regression model and Pearson correlation analysis. A value of p<0.05 was accepted as statistically significant.

Results A total of 409 arterial blood gas samples were examined from 90 patients being treated in the intensive care unit.

Turk J Emerg Med 2015;15(1):3-74

The mean age of the patients was 70.1±19.0 years and 47.3% were male (no of samples=201). Mean pH value was 7.37±0.1 and mean albumin level was 2.8mg/dl.

Using the traditional method, mean HCO3 was measured as 22.4±7.2 mEq/L and mean BE as 2.86±8 mEq/L. Mean Anion Gap was determined as 20.09±4.4 mEq/L, and mean cor-rected Anion Gap according to albumin as 24.04±4.5 mEq/L (p<0.001).

Using the Stewart method, the mean HCO3 was measured as 22.6±7.4 mEq/L and mean BE as 2.1±7.7 mEq/L. Mean An-ion Gap was determined as 19.91±4.5 mEq/L, and mean cor-rected Anion Gap according to albumin as 23.84±4.5 mEq/L (p<0.001).

In all the results a statistically significant difference was seen between the Stewart method and the Henderson method (p<0.001) (Table 1). There was a high correlation between the Stewart method and the Henderson method in all the results (p<0.001). The mean strong ion difference (SID) cal-culated with the Stewart method was 48.33±5 mEq/L. There

was a strong correlation between SID and AG and corrected AG (p<0.001 for all values).

The mean chloride of all the samples was 101.44±7.2 mEq/L. In the hyponatremia group (n=79), the mean measured chloride level was 94.49±5 mEq/L, the mean corrected chlo-ride was 100.7±4.7 mEq/L, and the mean corrected chloride level according to the absolute sodium level was 103.6±4.9 mEq/L (p<0.001).

In the hypernatremia group (n=80), the mean measured chloride level was 109.33±6 mEq/L, the mean corrected chloride level was 102.2±5 mEq/L, and the mean corrected chloride level according to the absolute sodium level was 100.9±5 mEq/L (p<0.001).

In the normonatremia group (n=250), the mean measured chloride level was 101.09±5.4 mEq/L, the mean corrected chloride level was 101.08±5 mEq/L, and the mean corrected chloride level according to the absolute sodium level was 101.75±7.4 mEq/L (p=0.174) (Table 2).

Discussion In this study, a high rate of correlation was observed between the Stewart method and the traditional method in all the results. A statistically significant difference was determined between the HCO3 results of both methods, but the differ-ence was not at the level of clinical significance. HCO3 was measured by calculating ([HCO3]=SID–(k1[Alb]+k2[Pi])=SID – [Atot]) with the Stewart method and [HCO3](pH = 6.1+log ————— ) with the Henderson method. 0.03×pCO2

In the calculation of HCO3, enzymatic direct measurement methods were also used. However, in previous studies, a high correlation was seen between the enzymatic direct measurement and the calculation method. Therefore, from a cost perspective, the use of the calculation method is rec-ommended.[8] Additionally, in a study by Story and Paustie, it was suggested that a difference between HCO3 measure-

Gezer M et al. Effectiveness of the Stewart Method in the Evaluation of Blood Gas Parameters 5

Table 1. Comparison of Stewart and traditional methods in terms of pH, HCO3, AG, BE and SID

Parameters Traditional method Stewart method P

pH 7.37±0.1 7.37±0.1 NS

HCO3 (mEq/L) 22.4±7.2 22.6±7.4 <0.001

AG (mEq/L) 20.09±4.4 19.91±4.5 <0.001

BE (mEq/L) -2.86±8 -2.1±7.7 <0.001

SID (mEq/L) 48.33±5

AG: Anyon Gap; BE: Base Excess; SID: Strong Ion Differences; NS: Non significant.

Figure 1. The Liquid-buffer system.

Na+K+Ca++Mg++

CI-

A-

HCO3-

AG ∆AG SIG

SIDeSIDa

ment methods of more than 1mEq/L is significant.[9] In the current study, the difference between the HCO3 levels of the Henderson and Stewart methods was less than 1mEq/L. Therefore, the use of either method in the calculation of HCO3 will not affect the clinical result.

The Anion Gap is used to predict the difference between strong anions and cations and organic and inorganic acids that cannot be measured in the plasma. The Anion Gap may be inaccurately low in the case of hypoalbuminemia. In hy-poalbuminemia, there is an alkalinization effect that may re-sult in anions that cannot be measured. Therefore, especially in patients with hypoalbuminemia, it is recommended that albumin correction is applied for the measurement of the Anion Gap.[6,10] In the current study, there was a clinical and statistically significant difference in the albumin-corrected Anion Gap measured by the Henderson and Stewart meth-ods. In addition, a high correlation was observed between SID and the corrected Anion Gap in the Stewart method. The use of both methods is recommended in the evaluation of metabolic disorders. However the more reliable data is ob-tained from the use of SID than from several parameters, especially in patients with complicated metabolic acidosis.

BE is used in calculations of metabolic acid-based disorders. BE below -2 is considered metabolc acidosis. In the Stew-art method of calculating the BE value, the albumin value is used.[2] In the current study, a clinical and statistically sig-nificant difference was seen between the BE measurements made with the two different methods. It has been observed in measurements made using the Van Skyle method in par-ticular, that the BE result is affected by the albumin level. This difference between the two methods is thought to be due to low albumin levels in intensive care patients. In a study by Fencl, it was determined that the BE value is misrepresenta-tive in patients with a low albumin level and correction is necessary according to albumin.[9] An experimental study by Morgan et al measured the accuracy of the Van Skyle meth-od in BE measurement. It was shown that despite no statisti-cally significant difference in the BE value in different PCO2 levels, the BE value was affected by changes in the lactate level.[11] This result demonstrated that in the evaluation of re-spiratory acid-based disorders, there is no need to measure

BE, as the BE value is not affected despite changes in PCO2. In the current study, as no differentiation was made between metabolic and respiratory disorders, the effect of PCO2 on the B value could not be determined.

Changes in plasma free fluid result from abnormal sodium concentration and cause dilutional acidosis and concentra-tional alkalosis. The change in the plasma free fluid causes change in SID. When dilution or concentration occurs in plasma free fluid, correction of the measured chloride level is necessary.[6] The corrected chloride value is used in the strong ion formula. In the current study, the patients were separated into 3 groups according to the sodium level. When intra-group comparisons were made of the chloride levels, it was necessary to correct the chloride level in those with an abnormal sodium value. However, in those with a normal sodium level, it was not necessary to apply chloride correction to calculate SID or the Anion Gap. This result was also an indicator of the accuracy of the formula applied for chloride correction.

In conclusion, the results of this study showed a high cor-relation between the Stewart method and the traditional Henderson-Hesselbach method for evaluating acid-based disorders. Both methods can be used with similar accuracy in acid-based disorders. However, in patients with complex metabolic acidosis, the Stewart method is thought to pro-vide more sensitive information. In metabolic acidosis with hypoalbuminemia, the evaluation of the Anion Gap after correction according to albumin is more accurate. In addi-tion, it has been shown that SID and AG should be calculated after correction of the chloride level in cases of abnormal se-rum sodium values.

Conflict of Interest

The authors declare that there is no potential conflicts of in-terest.

References1. Henderson LJ. The theory of neutrality regulation in the ani-

mal organism. Am J Physiol 1907;18:427-48.

2. Stewart PA. How to understand acid base balance, in A Quan-

Turk J Emerg Med 2015;15(1):3-76

Table 2. Corrected chloride levels determined according to serum sodium levels

Serum chloride level Corrected serum P (mEq/L) chloride level (mEq/L)

Hyponatremia (n=79) 94.49±5 100.7±4.7 <0.001

Normonatremia (n=250) 101.09±5.4 101.08±5 0.174

Hypernatremia (n=80) 109.33±6 102.2±5 <0.001

titative Acid-Base Primer for Biology and Medicine, edited by Stewart PA, New York, Elsevier, 1981.

3. Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic ac-id-base disturbances in critically ill patients. Am J Respir Crit Care Med 2000;162:2246-51.

4. Constable PD. Clinical assessment of acid-base status: com-parison of the Henderson-Hasselbalch and strong ion ap-proaches. Vet Clin Pathol 2000;29:115-28.

5. Rastegar A. Clinical utility of Stewart’s method in diagno-sis and management of acid-base disorders. Clin J Am Soc Nephrol 2009;4:1267-74.

6. Siggaard-Andersen O, Wimberly PD, Fogh-Andersen N, Gøth-gen IH. Measured and derived quantities with modern pH and blood gas equipment: calculation algorithms with 54 equations. Scand J Clin Lab Invest 1988;48:7-15.

7. Figge J, Jabor A, Kazda A, Fencl V. Anion gap and hypoalbu-minemia. Crit Care Med 1998;26:1807-10.

8. Memisogullari R, Ozcan ME, Celbek G, Ankaral H, Aydın Y. Cor-relation of bicarbonate values measured with direct enzy-matic method and blood gas analysis devices. Turk J Biochem 2011;36:270-2.

9. Story DA, Poustie S. Agreement between two plasma bicar-bonate assays in critically ill patients. Anaesth Intensive Care 2000;28:399-402.

10. Hatherill M, Waggie Z, Purves L, Reynolds L, Argent A. Correc-tion of the anion gap for albumin in order to detect occult tissue anions in shock. Arch Dis Child 2002;87:526-9.

11. Morgan TJ, Clark C, Endre ZH. Accuracy of base excess-an in vitro evaluation of the Van Slyke equation. Crit Care Med 2000;28:2932-6.

Gezer M et al. Effectiveness of the Stewart Method in the Evaluation of Blood Gas Parameters 7


Submitted: July 30, 2013 Accepted: July 31, 2014 Published online: January 20, 2015

Correspondence: Enver OZCETE, MD. Ege Universitesi Tip Fakultesi, Acil Tip Anabilim Dali, Izmir, Turkey.


8 ORIGINAL ARTICLE

1Department of Emergency Medicine, Ege University School of Medicine, Izmir;2Department of Internal Medicine, Ege University School of Medicine, Izmir, both in Turkey

enver Ozcete,1 Bahar BOydaK,2 Murat erSel,1 Selahattin Kıyan,1 Ilhan uz,1 Ozgur cevrıM1

Comparison of Conventional Radiography and Digital Computerized Radiography in Patients

Presenting to Emergency Department

SUMMARYObjectivesTo compare the differences between conventional radiography and digital computerized radiography (CR) in patients presenting to the emergency department.MethodsThe study enrolled consecutive patients presenting to the emergency department who needed chest radiography. Quality score of the radiogram was assessed with visual analogue score (VAS-100 mm), measured in terms of millimeters and recorded at the end of study. Examination time, interpretation time, total time, and cost of radiograms were calculated.ResultsThere were significant differences between conventional radiography and digital CR groups in terms of location unit (Care Unit, Trauma, Resuscitation), hour of presentation, diagnosis group, examination time, interpretation time, and examination quality. Examination times for conventional radiography and digital CR were 45.2 and 34.2 minutes, respectively. İnterpretation times for conventional radiography and digital CR were 25.2 and 39.7 minutes, respectively. Mean radiography quality scores for conventional radiography and digital CR were 69.1 mm and 82.0 mm. Digital CR had a 1.05 TL cheaper cost per radiogram compared to conventional radiography.ConclusionsSince interpretation of digital radiograms is performed via terminals inside the emergency department, the patient has to be left in order to interpret the digital radiograms, which prolongs interpretation times. We think that interpretation of digital radiograms with the help of a mobile device would eliminate these difficulties. Although the initial cost of setup of digital CR and PACS service is high at the emergency department, we think that Digital CR is more cost-effective than conventional radiography for emergency departments in the long-term.

Key words: Conventional radiography; digital CR; emergency department.

IntroductionDigital radiography (Digital CR) was first introduced in the 80s[1] when the first radiograms were recorded on phos-phorus-coated digital cassettes.[2] The advantages of digital radiograms include manipulation of digital data at various stages between image acquisition and final interpretation. A wide dynamic range is obtained.

There are multiple advantages of digital CR to conventional radiography. Spatial resolution is higher and images can be recorded electronically. It allows Teleradiology and Picture Archiving and Communication System (PACS) applications. It does not require image re-acquisition. It mitigates work-load by virtue of absence of stages such as dark-room and developing process.[3,4]

The aim of our study was to compare the difference be-tween conventional radiography and digital Computerized Radiography (CR) in patients presenting to the emergency department.

Materials and MethodsUniversity Faculty of Medicine is a tertiary emergency de-partment with nearly 65000 annual patient admissions. Pa-tients are examined and treated at a total of 3 sites of care (emergency care unit, resuscitation, and trauma). Our study was conducted between January 2010 and June 2010.

All consecutive patients who presented to the emergency department and had a chest radiogram for any reason were included in this study, following permission from the Univer-sity Faculty of Medicine Local Committee of Ethics. Hemody-namically unstable patients, those undergoing emergency operations, and those in need of a necessary intervention (ex. tension pneumothorax, evisceration, traumatic cardiac arrest outside the hospital) were excluded from the study. Only patients who consented were included in the study. To form a more homogeneous group, only chest radiograms were included. Chest radiograms were only obtained in pa-tients who demonstrated need for the imaging by virtue of indication, diagnosis, comparison, and higher frequency of use.[5] Three research assistants were involved in the study, each with 2 years experience. Research assistants were in-structed in filling of the patient enrollment forms prior to study onset, but had no instruction on evaluating the qual-ity of radiographs. VAS scores were determined based on personal perceptions of overall quality of the radiograms. The emergency department had a conventional radiogra-phy device before installing the Digital CR device. The con-ventional chest radiography group was therefore formed first, followed by digital CR. Digital CR was performed using the Kodak CR 975 digital radiography device. Emergency

service assistants evaluated the radiographs at terminals in the emergency department (emergency care unit, resusci-tation, and trauma), and filled the appropriate scores. Ege University Faculty of Medicine Department of Emergency Medicine performs a mean of 175 radiographic examina-tions each day. A total of 621 chest radiographies, 301 con-ventional and 320 digital CR, were included in the study.

The quality score of the radiography was measured using vi-sual analog scale (VAS-100 mm) in millimeters and recorded at the end of the study. The examination time was calculated by subtracting the radiographic examination time from the examination request time and recorded in minutes, and the interpretation time was calculated by subtracting radio-graphic examination time from the radiographic interpreta-tion time and recorded in minutes.

All data from this cross-sectional study were transferred to digital medium and analyzed by SPSS 11.0 statistical software.

As a basic statistical analytical method, descriptive statistics, mean, standard deviation, and frequency tables were used. Continuous variables were presented as mean±standard de-viation; categorical variables were presented as frequency and percentage. Advanced statistical analyses included Chi Square analysis to test the significance of the difference be-tween the paired groups and Student’s t-test to test the sig-nificance of the difference between the means.

ResultsThe mean age was 55.9±19.9 for conventional radiography and 57.3±18.6 for digital CR. No significant difference in age was detected between both groups (T:1.092, p=0.375).

Gender of the study population was distributed evenly, with 342 (53.3%) male patients and 279 (46.7%) female pa-tients. The conventional radiography group was composed of 159 (25.6%) males and 142 (22.8%) females, whereas the Digital CR group consisted of 183 (29.4%) males and 137 (22.0%) females. Gender distribution was not different in both groups.

There was a significant difference between conventional ra-diography and Digital CR groups in terms of units (Care Unit, Trauma, Resuscitation) at which they were cared (Table 1).

There was a significant difference between conventional ra-diography and Digital CR groups in terms of the distribution of the hour of presentation (Chi Square: 25,068, p≤0,0001) (Figure 1).

Mean examination time and Interpretation time for conven-tional radiography and digital CR show a statistically signifi-cant difference.

Ozcete E et al. Comparison of Conventional Radiography and Digital CR in Patients Presenting to ED 9

Total times for conventional radiography and Digital CR dif-ference were statistical insignificant (Table 2).

The mean radiography perceived quality scores were 69.1±15.9 mm and 82.0±8.4 mm for conventional radiogra-phy and digital CR, respectively. This difference was statisti-cally significant (t:-12.757, p≤0.0001).

Digital CR has advantages to conventional radiography. The patient’s was blocked loss of data. Old and new X-ray radio-graphs can be compared. In addition, the radiographs do not need additional space for archiving.

Cost

Mean cost of a conventional radiogram is $0.70, which equals 1.05 TL according to the exchange rate on 8 April 2011.

Mean cost of a 35x43 cm Digital cassette is $1000, and nearly

30000 examinations can be performed per cassette. A single radiography costs a mean of $0.033, which equals to 0.0495 TL. As a result, 1.005 TL is saved per a single radiogram by us-ing digital CR. A mean of 175 radiograms are taken each day at emergency departments, bringing a savings of 175.08 TL.

Kodak directview CR 975 system, PACS system, and Kodak directview CR PQ cassettes (24x30 cm, 35x43 cm) cost ap-proximately 100.000 TL. The device would pay off itself after approximately 571 days.

DiscussionMany studies have been performed so far to compare digital CR and conventional method. In these studies, parameters such as examination time for digital radiography, manipula-tion of data at the post-examination period, graphic quality, and number of hourly examinations were investigated.[6-9]

Trauma and resuscitation patients were more commonly in the conventional radiography group, and care unit patients were more commonly in the digital CR group. A greater number of care unit patients in digital CR group may have prolonged the interpretation time, since patient crowding in care unit is greater than resuscitation and trauma units at our emergency department. Interpretation time is influenced by patient crowding. While conventional radiographies are in-terpreted at bedside, Digital CR radiograms are interpreted via the terminals at the care unit, which delays interpretation in conjunction with patient crowd. In addition, radiographic interpretation time may have been affected during the run-ning-in-period following the onset of Digital CR use at the emergency department.

Most common presentations in conventional radiography and Digital CR groups occur between 08:00-16:00 and 16:00-24:00, respectively. The mean patient density between 16:00-24:00 is greater than that between 08:00-16:00 at our emergency department. Crowded hours are characterized by delayed interpretation process.

Table 1. Patient distribution in terms of type of radiographic examination

Patient care unit Type of radiographic examination

Conventional Digital CR Total

Number % Number % Number %

Care Unit 232 37.4 275 44.2 507 81.6

Trauma 36 5.8 24 3.9 60 9.7

Resuscitation 33 5.3 21 3.4 54 8.7

Total 301 48.5 320 51.5 621 100

Chi Square: 8.140, p=0.017.

00:00-04:00

100

ConventionalDigital CR

90

80

70

60

50

40

30

20

10

0

04:00-08:00

08:00-12:00

12:00-16:00

16:00-20:00

20:00-24:00

Figure 1. Distribution in terms of type of radiography and presen-tation hour groups of the patients.

Turk J Emerg Med 2015;15(1):8-1210

Ozcete E et al. Comparison of Conventional Radiography and Digital CR in Patients Presenting to ED 11

In conventional radiography group, additional time is re-quired after the examination for dark-room, development, and image printing. In addition, a radiology technician is needed at the emergency department to perform the devel-opment process. In the case of digital CR, a radiology techni-cian automatically sends patient radiogram directly from the digital cassette with the software of Picture Archiving and Communication System (PACS) to the provider. Therefore, conventional radiography examination time is prolonged.

One study has reported that Digital radiography increased mean number of examinations by 12% compared to con-ventional radiography. The same study has found that the time for the radiogram to get ready for interpretation short-ened by 77% in Digital CR compared to conventional CR.[10]

A shorter interpretation time in conventional radiography is an unexpected finding in our study. The emergency depart-ment; including emergency care unit 2, resuscitation and trauma unit 2 are total number of 4 staff. Patient relatives cannot enter the emergency service. This phenomenon may be explained as follows: in conventional radiography group, personnel brought the printed radiogram to the physician or patient bed after the examination. Thus, bed-side radio-graphic interpretation could be made. In case of Digital CR group, radiogram was transmitted to the terminals found at the emergency department, where the radiograms were interpreted. Presentation of the patients in the Digital CR group took place between 16:00-24:00 when the emergency department was most crowded and majority of the patients in the digital CR group consisted of care unit patients. There-fore, we think that radiography interpretation times were prolonged in the digital CR group. We also think that difficul-ties in usage due to newly implemented digital CR technol-ogy contributed to prolongation of interpretation time.

We think that the reason why we could not detect any sig-nificant difference between conventional radiography and digital CR groups in terms of the mean total time stems from the differences in mean examination times and mean inter-pretation times.

We expected to find a higher radiographic quality score in dig-ital CR group owing to the ability of the manipulation of the digital data, acquisition of a wide dynamic range, and a higher spatial resolution compared to conventional radiography.[11,12] Two studies reported that Digital CR (phosphorus cassette) radiograms assess mediastinal structures and peripheral lung fields with a higher score compared with conventional radio-grams.[5,13] Van Soldt et al. reported a better image quality with Digital CR compared to conventional radiography.[14]

The mean cost of conventional radiography and Digital CR has been calculated. According to this calculation, Digital CR is 1.005 TL cheaper per radiogram. Digital CR has a lower cost and it is more profitable for an emergency department in the long term compared to conventional radiography. The device would pay off itself after approximately 571 days.

One study has reported that the cost of the setup of Digital CR is higher than conventional radiography, whereas cost per radiogram is lower with the former.[15]

Limitations

It took time to be accustomed to an evaluation system via radiography terminals since patient admission began short-ly after the digital CR system setup was completed at the emergency department. This may be the reason for a pro-longed digital CR interpretation time in our study. Difference between enrolled patients in terms of care units and initial diagnoses may have altered study findings. Interpretation time of the radiograms may have been affected by many reasons such as ED crowding and severity of the patient symptoms and status.

Conclusions and Recommendations

Radiography examination and interpretation times may vary based on crowding and the care unit the patient presents. We think that interpretation of digital radiograms with the help of a mobile device would eliminate these difficulties.

Digital CR provides better image quality by conventional ra-diography. The patient’s was blocked loss of data. The Digital

Table 2. Distribution of the examination times of both radiographic examination types

Variable Examination type Mean±SD (Min) t p

Examination time Conventional 45.2±41.1 3.333 0.001*

Digital CR 34.2±41.3

Interpretation time Conventional 25.2±21.2 -6.545 <0.0001*


Total time Conventional 70.5±49.4 -0.849 0.396


CR does not need additional space for archiving.

Although the initial cost of setup of digital CR and PACS service is high at the emergency department, we think that Digital CR is more cost-effective than conventional radiogra-phy for emergency departments long-term.



References1. Ovitt TW, Christenson PC, Fisher HD 3rd, Frost MM, Nudelman

S, Roehrig H, et al. Intravenous angiography using digital vid-eo subtraction: x-ray imaging system. AJR Am J Roentgenol 1980;135:1141-4.

2. Moore R. Computed radiography. Med Electron 1980;11:78-9.3. Advent of digital radiography: Part 1 BS Verma, IK Indrajit In-

dian J Radiol Imaging /May 2008/Vol 18/Issue 2.4. Schaefer-Prokop CM, Prokop M. Storage phosphor radiogra-

phy. Eur Radiol 1997;7 Suppl 3:58-65.5. Busch HP, Lehmann KJ, Drescher P, Georgi M. New chest im-

aging techniques: a comparison of five analogue and digital methods. Eur Radiol 1992;2:335-41.

6. Andriole KP, Luth DM, Gould RG. Workflow assessment of dig-ital versus computed radiography and screen-film in the out-patient environment. J Digit Imaging 2002;15 Suppl 1:124-6.

7. Reiner BI, Siegel EL. Technologists’ productivity when using PACS: comparison of film-based versus filmless radiography. AJR Am J Roentgenol 2002;179:33-7.

8. Dalla Palma L, Grisi G, Cuttin R, Rimondini A. Digital vs con-ventional radiography: cost and revenue analysis. Eur Radiol 1999;9:1682-92.

9. Pathi R, Langlois S. Evaluation of the effectiveness of digi-tal radiography in emergency situations. Australas Radiol 2002;46:167-9.

10. Andriole KP. Productivity and cost assessment of computed radiography, digital radiography, and screen-film for out-patient chest examinations. Journal of Digital Imaging 2002;15:161-9.

11. Commission of the European Communities a – Radiation Pro-tection Programme. CEC Quality Criteria for Diagnostic Ra-diographic Images and Patient Exposure Trial. CAATS-INSERM EUR 12952. (1989).

12. Busch HP. Digital radiography for clinical applications. Eur Ra-diol 1997;7 Suppl 3:66-72.

13. Ramli K, Abdullah BJ, Ng KH, Mahmud R, Hussain AF. Comput-ed and conventional chest radiography: a comparison of im-age quality and radiation dose. Australas Radiol 2005;49:460-6.

14. van Soldt RT, Zweers D, van den Berg L, Geleijns J, Jansen JT, Zoetelief J. Survey of posteroanterior chest radiography in The Netherlands: patient dose and image quality. Br J Radiol 2003;76:398-405.

15. Dalla Palma L, Grisi G, Cuttin R, Rimondini A. Digital vs con-ventional radiography: cost and revenue analysis. Eur Radiol 1999;9:1682-92.

Turk J Emerg Med 2015;15(1):8-1212


Submitted: December 13, 2013 Accepted: January 30, 2014 Published online: February 14, 2014

Correspondence: Birsen BILGEN SIVRI. Mevlana Universitesi Saglik Hizmetleri Yuksekokulu, Konya, Turkey.


ORIGINAL ARTICLE

1Department of Health Services, Mevlana Universty, Nursing, Konya, Turkey;2Department of Nursing, Selcuk University, Aksehir Kadir Yallagoz School of Health, Konya, Turkey

Birsen BılGen Sıvrı,1 Funda Ozpulat2

Mothers’ Knowledge Levels Related to Poisoning

SUMMARYObjectivesThis study was done to evaluate mothers’ level of knowledge regarding poisoning, to plan training for issues with an identified lack of knowledge, to collect required data regarding protection and approach issues on poisoning cases which may occur in children for various reasons.

MethodsThis descriptive study was performed after obtaining permission from the County Health Department and involved mothers who applied to Family Health Centers No. 1-7 between April 1st and May 31st 2012, and who agreed to participate in the study (n=290). The questionnaire was composed of three parts: “Personal Information Form,” “House Poisoning Evaluation Form” and “Home Poisoning Prevention Knowledge Level Form.”

ResultsParticipant ages were between 16 and 50 years and the mean age was 33.09±7.10 years. The number of children ranged from 1 to 6, and 203 people had seven children under the age of six. 37.6% of the mothers were primary school graduates, while 74.5% were housewives. There was a significant relationship between the knowledge score of the mothers on poisoning and education, career, neighborhood, and social security (p<0.05).

ConclusionsChildhood poisoning is the most common cause of admission to the hospital. Protective precautions such as family education, storage of medication out of reach of children and use of secure lids are thought to be important.

Key words: First aid; level of knowledge; mother-child; nurses; poisoning.

13

IntroductionPoisoning is an emergent condition that presents with signs and symptoms specific to the causative substance. It is caused by intake of a toxic substance in an amount harmful to the body through different ways. Poisonings are types of emergency pediatric diseases with preventable causes that lead to significant morbidity and mortality.[1,2] In developed countries, accidents and poisonings represent the most significant causes of death among the 1-14 year age group.[2,3] In developed countries 2% of child deaths are caused by poisoning, with this number being more than 5% in devel-oping countries.[3]

According to the American Association of Poison Control Centers Toxic Exposure Surveillance System records, 65.8% of the 2.3 million reported poisoning cases are constituted of children under the age of 19 years.[4] Poisoning is common in 1-5 year old children. Because of curiosity and willingness to learn, investigation of children’s surrounding is frequently seen in this age group, and the substances found can be taken by mouth by children which may lead to poisoning.[5] Since children have a lesser ability to control themselves than individuals of other ages, yet cannot distinguish pos-sible harmful substances and hazardous situations, they are particularly vulnerable to accidents and poisonings.

Turk J Emerg Med 2015;15(1):13-2214

Table 1. Socio-demographic characteristics and knowledge score distribution

N % X² SD P*

Age of mother

16-24 years 31 10.7 0.270 3 0.966

25-33 127 43.8

34-42 years 90 31.0

43 years and older 42 14.5

Mother education level N % X² SD P*

Illiterate 8 2.8 46.773 5 0.000

Literate 4 1.4

Primary school graduate 109 37.6

Secondary school graduate 43 14.8

High school graduate 63 21.7

University graduate and higher 63 21.7

Mother profession N % X² SD P*

Housewife 216 74.5 35.865 4 0.000

Civil servant 56 19.3

Employee 13 4.5

Self employed 3 1.0

Farmer 2 0.7

Family type N % X² SD P*

Core family 253 87.2 4.142 2 0.126

Large family 29 10.0

Separated family 8 2.8

Number of children N % X² SD P*

1 child 84 29.0 6.769 3 0.080

2 children 111 38.3

3 children 77 26.5

4 children and more 18 6.2

Social Insurance N % Mann-Whitney U Z P**

Have 281 96.9 947.500 -1.288 0.198

Do not have 9 3.1

Total 290 100.0

*Kruskal-Wallis H test was used; **Mann-Whitney U test was used.

[6,7] Much of the child’s life up until the age of 7 is spent in a home environment; it is thus important for caregivers to understand protective precautions such as the storage of medication out of reach of children and the use of secure lids.[8] At this point, it is clear that nurses, who today have many tasks in terms of patient care, have great responsibility in family education regarding the prevention and reduction of poisoning (which is a significant cause of mortality and morbidity in childhood).[9]

Factors that led to poisoning may vary according to region, civic society’s traditions and customs, the level of education and the season.[10] Therefore, precautions should be taken by identifying characteristics associated with poisoning of each country and even of each region.[11] In our country numer-ous studies related to childhood poisonings are performed; however, all of them contain regional characteristics.[5-8,10-37] Epidemiological data of each region are required be deter-mined and updated for the development of appropriate pro-tection and treatment methods, for health personnel educa-tion and raising society awareness.[29] Therefore, this study was aimed to evaluate mothers’ knowledge level regard-ing poisoning, organize training about the topics in which inadequacies were detected and collect the required data about the approach and protection of poisoning events in children.

Materials and MethodsThis descriptive study was applied to mothers who applied for examination and treatment to Family Health Centers No. 1-7 between April 1st and May 31st 2012 (1008 applied, 15-49 year old women), who have one or more children under the age of fourteen (496 people) and who agreed to partici-pate in the study (n=290) after obtaining permission from the County Health Department. Because in the literature, rates of poisoning of children under of age seven years and younger are rapidly increasing, in this study the “Measuring information score about poisoning of mothers with children under the age of seven years and younger” was designed. However, due to difficulties in each sample group, we tried to reach mothers who had children aged fourteen and younger. Only 203 of mothers in the study were found to have children age seven and younger.

Collection of Data

The study data were collected through questionnaires com-pleted by face to face interviews of mother and the research-ers. Questions about poisoning were prepared by research-ers by investigating literature data on the subject.[1,2,3-41] Pre-treatment of the survey was performed on 10 mothers who applied for treatment to the State Hospital, and had children under the age of seven (due to poisonings being

more common in this age group). After making the neces-sary adjustments on the questionnaire we switched to the original application, mothers who participated in the pre-treatment group were not included in study again. Collec-tion of research data occurred via a questionnaire that que-ried mothers regarding their knowledge of poisoning. The questionnaire consisted of three sections. The first section was termed the “Personal Information Form” and consisted of 15 questions including the sociodemographic character-istics of the mother, while the second section was the “Home poisoning Evaluation Form” which was made up of 12 ques-tions including where they obtain their information about poisoning, whether they encountered poisoning, and poi-soning type house features and the third section included the “House Poisoning Prevention Knowledge Level Form”

Bilgen Sivri B E et al. Mothers’ knowledge levels related to poisoning 15

Table 2. Mothers’ features related to poisoning stories

Poisoning information source N* %

TV / internet 146 50.5

Newspaper, magazine, book 61 21.1

Family elders 31 10.7

Health care staff 27 9.4

Other 24 8.3

Total 289 100.0

Home poisoning cases during last one year N** %

Stove / heater poisoning 12 34.3

Chemicals 9 25.7

Medication poisoning 6 17.1

Fungus 3 8.6

Corrosive substance 2 5.7

Food 2 5.7

Other 1 2.9

Time of home poisoning N** %

Noon 17 48.6

Morning 12 34.3

Night 3 8.5

Evening 2 5.7

Afternoon 1 2.9

Place of home poisoning N** %

Hall 12 34.3

Kitchen 9 25.7

Bedroom 5 14.3

Living room 4 11.4

Bathroom 4 11.4

Balcony 1 2.9

Total 35 100.0

*More than one answer was given; ** Number of poisoning occurred in the last year was considered.

which consisted of 20 questions identifying the symptoms observed in various poisoning cases and what should/should not be done as an intervention.

Analysis and Evaluation of Data

In this study, knowledge scores were calculated by evaluat-ing each of the 20 questions, determining the level of knowl-edge of mothers, with each question scoring a maximum of 5 points. The lowest and the highest possible survey scores were “0” and “100”.

Appropriate statistical tests were used depending on whether dependent or independent variables were being assessed. SPSS 17 statistical software package was used for the analysis of data. The “Kolmogorov-Smirnov” and “the Shapiro-Wilk” tests did not display a normal distribution of poisoning knowledge scores. According to test assump-tions, for comparison of more than two groups measure-ments, Kruskal-Wallis H test, for comparison of two different groups of measurements, Mann-Whitney U test and for de-

termination of level and direction of the relationship, Pear-son Product Moment Correlation Coefficient Analysis were used; the significance level was determined as 0.05.

ResultsParticipants were between 16 and 50 years old and the mean age was 33.09±7.10 years. The number of children was between 1 and 6 persons, and 203 individuals had children under age of 7 years (Table 1).

37.6% of mothers were primary school graduate, 74.5% of them were housewives and 19.3% were civil servants. In-comes of 39.9% of the participants were found to be be-tween 1,000 and 1,999 TL (Table 1).

Based on the correlation analysis results of “Age-Poisoning Knowledge Score” and “Number of Children-Poisoning Knowledge Score” of mothers participating in the study; the relationship between poisoning knowledge scores and the age of the mothers was not statistically significant (r=-0.023,

Turk J Emerg Med 2015;15(1):13-2216

Table 3. Conditions of mothers’ intervention during poisoning cases of the past year

First aid / Intervention performed N** % Mann-Whitney U Z P*

Yes 22 75.9 72.500 -.231 0.823

No 7 24.1

Total 29 100.0

The person who performed first intervention N*** % X² SD P*

Father 14 48.0 5.401 5 0.369

Mother 11 38.0

Older brother 1 3.5

Aunt 1 3.5

Caregivers 1 3.5

Grandmother 1 3.5

Total 29 100.0

Status of applying to hospital after being poisoned N** % Mann-Whitney U Z P*

Yes 12 40.0 92.000 -.683 0.495

No 18 60.0

Total 30 100.0

Condition of taking precautions after poisoning N** % Mann-Whitney U Z P*

Yes 27 93.1 25.500 -0.130 0.896

No 2 6.9

Total 29 100.0

The result of poisoning N** %

Full recovery 30 96.8

Death 1 3.2

Total 31 100.0

*Mann-Whitney U test was used; **Incomplete answer was given; ***More than one answer was given.

p=0.698). According to the number of children, a relation-ship in a negative direction was significant at the 0.05 error level (p<0.05) (r=-0.125, p=0.035).

50.5% of the mothers reported that they had received infor-mation on intoxication via television or internet. 34.3% of 35 individuals who indicated childhood poisoning had oc-curred during the last year stated that the event occurred by stove/heater, 25.7% by chemicals, 17.1% by medication; based on time 48.6% occurred in the morning, 34.3% in the afternoon; based on place, 34.3% occurred in the hall and 25.7% in the kitchen (Table 2).

As shown in Table 3, it was determined that in 7 out of 35 house poisonings no type of intervention was performed and in 22 cases an intervention was performed; 6 people did not answer this question. It was found than in 48% and in 38% of poisonings at home, first intervention was performed by the father and mother, respectively. It was defined that 40% of poisonings were brought to the hospital and that in 93.1% of poisonings, precautions after the accidents were taken. 96.8% of poisonings resulted with full recovery, with a death of one child (Table 3).

64% of mothers have water heaters in the bathroom, and 85.2% and 89% have sufficient bathroom ventilation and lighting, respectively. It was found that 61.1% of mothers had to clean the building chimney every year. 89.8% of mothers reported that they do not put materials such as pesticides or detergents into food containers, and 67.9% do not keep chemical substances such as pesticides and bleach. The per-centages of mothers who keep drugs in their own contain-ers, in the refrigerator and in the bathroom are 89.8%, 5.6% and 46% respectively (Table 4).

The poisoning knowledge score of the participants ranged from 5 to 65 points and the mean knowledge score was 43.34±14.84. It was found that 83.1% of the mothers gave correct answers to first aid during drug poisoning questions, 80% to non-poisoning symptom questions and 71.7% to general poisoning symptom questions. It was detected that at most, first aid to gas poisoning question (87.6%), and ac-tions that should not be done during water heater poison-ing question (84.1%) were answered wrong; in addition, the poison control center number was not known by mothers (12.1%) (Table 5)

Discussion Advancement of technology and improvement of socio-economic status has led to more industrial and petroleum products, drugs and bleaches in homes. The negligence of families and those who are involved in child care, ignorance about poisoning, packaging of produced drugs in attractive

colors, launch of pesticides for cheapest price to the mar-ket, uninformed use of drugs, nonprescription sale of some drugs and leaving them within reach of children lead to in-crease in poisonings.[27]

Our study is one of the few studies measuring the level of knowledge about the poisoning of mothers living in a town. In our study, 37.6% of the mothers were primary school graduates and an increase of poisoning knowledge scores during increase of mothers’ education level was observed (p<0.05). In the study of Coşkun et al about first aid knowl-edge level of mothers who have children aged 0-14 years, in a similar manner first aid knowledge level increases with mothers’ education level.[15] Uskun and colleagues, in a study performed on 180 women in Aksaray, reported an increase of first aid knowledge with increased level of education. In-creasing knowledge of first aid in the community and for eliminating need of training on this issue may benefit more from formal education institutions.[23]

In our study, when we examine the socio-demographic characteristics, 74.5% of the mothers were housewives and 19.3% were civil servants. Mothers who are civil servants and who have a higher income level have greater knowledge scores; in addition, it was determined that poisoning knowl-edge scores changed according to the mother’s profession status (p=0.000, <0.05). Similar to our study, Uskun and his friends reported that women with good economic status and a higher education level have higher level of knowledge about first aid.[23]

In our study, a negative correlation between number of chil-dren and poisoning knowledge scores occurred (r=-0.125, p=0.035) and this correlation appeared to be significant (p<0.05). Coşkun and his friends in their work in Eldivan found that in a similar way average knowledge decreased with increase in children number.[15] It was considered that a decrease in knowledge scores may be due to a possible de-crease of child care caused by increased number of children.

In our study, 48.6% of the 35 people indicating intoxication indicated morning and 34.3% indicated afternoon poison-ings. This may be due to housewives being busy with house-hold chores and are unable to deal with children in the morn-ing. Akçay and friends in their study in Denizli reported that poisonings mostly occurred in the afternoon (48.5%) and in the evening (28.4%); Yılmaz et al toxicity study conducted in the Çukurova region reported that poisoning cases occur between 09:00 and 12:00 hours (24.9%).[10,30]

In the home environment there are many factors (bleach, drain openers, stove, drugs, etc.), that can easily cause poi-soning in children. These substances are sold exposed and unbranded, which can be stored in water or other beverage


Turk J Emerg Med 2015;15(1):13-2218

Table 4. Features related to the precautions taken by mothers against poisoning

Presence of water heater in the bathroom N* % Yes 181 64.0 No 102 36.0 Total 283 100.0Sufficiency of the bathroom ventilation N* % Yes 241 85.2 No 42 14.8 Total 283 100.0Sufficiency of bathroom enlightenment N* % Yes 252 89.0 No 31 11.0 Total 283 100.0Building chimney cleanliness condition N* % Yes 173 61.1 No 110 38.9 Total 283 100.0Presence of automatic switches of the stove N* % Yes 143 50.5 No 140 49.5 Total 283 100.0Switching off tube/gas appliances from the gas valve after usage N* % Yes 189 66.8 No 94 33.2 Total 283 100.0Placing materials such as pesticide and the detergent in food containers N* % Yes 29 10.2 No 254 89.8 Total 283 100.0Keeping chemicals such as bleach, pesticides in the kitchen N* % Yes 90 32.1 No 190 67.9 Total 280 100.0Placing drugs into other containers than their own containers N* % Yes 29 10.2 No 254 89.8 Total 283 100.0Drugs storage places N* % Refrigerator 152 52.6 Bathroom 133 46.0 Over the loom 3 1.0 Beneath the loom 1 0.4 Total 289 100.0Place of buying mushrooms N* % Bazaar 144 50.2 Shop 143 49.8 Total 287 100.0

*Incomplete answer was given.


Table 5. Poisoning knowledge questions (n=290)*

Questions False Correct Do not know

n % n % n %

When you notice that your child taken medicinewhich of the following applications would you apply? 241 83.1 40 13.8 9 3.1

In which of the following situations you would 232 80.0 47 16.7 11 3.8not think that your child is poisoned?

Which of the following is not a symptomof the common symptoms of poisoning? 208 71.7 75 25.9 7 2.4

In which of the following situations certainly childshould not be induced to vomiting? 204 70.3 74 25.6 12 4.1

Which is the wrong first aid application for unknownreasoned digestive tract poisoning? 197 67.9 80 27.6 13 4.5

What should be the first attempt to apply toa child who had drunken petroleum products? 193 66.6 84 28.9 13 4.5

What is the phone number of national poison control center? 187 64.5 68 23.4 35 12.1

What should be the first attempt to applyto a child who had taken pesticides? 185 63.8 97 33.4 8 2.8

What should be the first attempt to applyto a child who had drunken bleach? 184 63.4 102 35.2 4 1.4

Performing of which of the followings is falsefor poisoning through skin? 180 62.1 99 34.1 11 3.8

Imagine that you entered environment poisoned with gaswhich you would use to protect yourself while intervention? 179 61.7 95 32.8 16 5.5

What symptoms you would not wait to be observed primarilyin a child who is conscious and know that he had eaten rotten food? 178 61.4 101 34.8 11 3.8

Which of the following information is wrong aboutprevention of water heater poisoning? 174 60.0 108 37.2 8 2.8

Which of the following is the correct information aboutthe mushroom consumption? 172 59.3 92 31.7 26 9.0

In which of the following poisoning routes feeding yogurtto the child is sufficient for the first aid? 161 55.5 118 40.7 11 3.8

Which of the following provided informationis the correct about mushrooms? 130 44.8 138 47.6 22 7.6

In poisoning occurred by inhalation in what positionpatient should be kept? 128 44.1 147 50.7 15 5.2

Which of the following are symptoms for stove poisoning? 64 22.1 214 73.8 12 4.1

Which of the following should not be performedin water heater poisoning? 29 10.0 244 84.1 17 5.9

Which of the following first aid applications shouldbe performed to respiratory poisonings caused by gas? 27 9.3 254 87.6 9 3.1

* Line percentage was taken.

bottles in the kitchen are within easy reach of children.[5-7]

In a study conducted in the past year, it was found that in 35 poisoned children, 34.3% were due to stove/heater, 25.7% were from chemicals and 17.1% were poisoned by a drug. Of poisoning cases admitted to the Child Emergency Depart-ment of İzmir Training and Research Hospital mostly medical drugs (50.6%), effective corrosive ingestion (20%) and car-bon monoxide poisonings (16.6%) were found.[31] Polat et al (2005) in his study that examined the causes of poisonings observed that food poisonings (50%) occurred most fre-quently, followed by drugs (33.4%) and chemical poisonings (16.6%).[17] In a study investigating poisoning cases admitted to Trakya University Medical Faculty it was identified that in 221 cases, toxic substances were taken orally, four cases oc-curred by inhalation and two cases through the skin; based on complications, there were four cases with liver failure, four cases with disseminated intravascular coagulation com-plication (DIC), two cases with status epilepticus and two cases with renal failure (0.9%).[11] Epidemiological studies conducted in different regions of our country and at differ-ent time intervals support our research findings.[5-8,10,15,31-33]

While mortality rates in poisoning cases vary according to re-gion; these rates had decreased compared to previous years. In our country, the mortality rate was reported as 0.5% by Çıtak and colleagues (2002), as 0.6% by Akbay-Öntürk and Uçar and as 5.5% by Ertekin et al (2001).[6,40,41] In our study, number of children died as a result of poisonings occurred during past year is one. The rate of mortality we obtained in our study is lower than in other regions of our country, which is pleasing. However, significant improvement is made in the treatment of poisonings, taking preventive measures is more valid method for solving this problem.

Family education about poisonings, production of child-proof box and covers, sticking warning labels and increasing the number of educated individuals, will significantly de-crease the number of poisoning. This will lead to a significant decrease of morbidity and mortality rates.

50.5% of the mothers get information about poisoning via TV/internet. Coşkun et al (2008), in his study stated that mothers mostly get knowledge on first aid from television (37.6%) and books, newspapers, magazines (18.2%).[15] In a study performed by Örsal et al (2011), it was reported that the main resources of information on first aid used by women in home accidents was television and internet (40.4%).[34] This result lead us to think that the number of television programs giving basic information about first aid during encountered home accidents and poisonings should be increased.

In poisoning cases, getting help form “poison information center” or by calling “112” for application of early and appro-

priate interventions is an important factor in reducing risks of mortality and morbidity. In a study of Coşkun et al (2008), it was found that 47.5% of the mothers know the Hızır Emer-gency phone number.[15] A study by Örsal et al (2011) deter-mined that almost all the women (98.8%) knew the phone number of the emergency ambulance service as “112”.[34] In our study, only 64.5% of mothers knew the number of the poison control center; this may be due to educational level of mothers who participated in the study.

Poisoning is an important public health problem which makes a significant part of the emergency department, re-quires a serious approach and when early intervention is per-formed, it responds well to a treatment.[18] Due to frequent accidents among children, it is important for the child’s health that caregivers know what to do in cases of poison-ing. In our study, poisoning knowledge score of the mothers ranged from 5 to 65 points and the mean knowledge score was 43.34±14.84. In a study conducted in Ankara - Gölbasi, mothers were found to have insufficient knowledge of first aid to children during possible home poisoning.[35] In a study of Örsal et al (2011) in Eskisehir, women received scores re-garding first aid in home accidents that ranged from 10 to 36, with an average score of 24.4±3.6.[34] In research by Turan et al (2010) performed in Denizli within the scope of “0-6 years Prevention Group of Children Home Accidents” proj-ect, as the result of studies performed on home accidents and first aid, providing training leads to an increase in the level of knowledge of housewives and results showed a pos-itive behavior change.[36] As a result of our study, it has been suggested that healthcare institutions and organizations in their own region should perform protective measures and training on topics such as possible home poisonings, poi-sonings requiring immediate intervention, and accidents. We should remember that the future of our children is close-ly related to unintentional injuries during childhood.

Limitations

Limitations of this study included not being a multicenter study, including only mothers who applied to the Fam-ily Health Centers, and the collection of information based solely on the statement of mothers. Also, trying to reach to mothers with children under age of seven years during per-mitted dates, led to difficulties in reaching a sufficient sam-ple group. In order to take the epidemiological generaliza-tion of mothers’ level of knowledge about poisoning further, studies with a larger sample group should be performed.

Conclusion In conclusion, our study determined that mothers’ knowl-edge regarding poisoning is insufficient. Informative courses about poisoning for mothers should be planned and in the

Turk J Emerg Med 2015;15(1):13-2220

future, more correct use of visual media should be shown. Nurses who have a significant role in the development and protection of a child’s health should educate families about the proper storage of substances that can cause poisoning and about applications which should be performed during material ingestion.



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Turk J Emerg Med 2015;15(1):13-2222


Submitted: June 14, 2014 Accepted: November 20, 2014 Published online: January 20, 2015

Correspondence: Egemen KUCUK, MD. Sakarya Universitesi Egitim ve Arastirma Hastanesi Acil Servisi, 54000 Sakarya, Turkey.


ORIGINAL ARTICLE

1Department of Emergency Medicine, Sakarya University Training and Research Hospital, Sakarya;2Department of Gastroenterology, Diyarbakir Military Hospital, Diyarbakir, both in Turkey

egemen KucuK,1 ırfan KucuK2

Mean Platelet Volume is Reduced in Acute Appendicitis

SUMMARYObjectivesAcute appendicitis (AA) is the most common indication for emergency abdominal surgery, although it remains difficult to diagnose. In this study, we investigated the the clinical utility of mean platelet volume in the diagnosis of acute appendicitis.

MethodsThe medical records of 241 patients who had undergone appendectomy between June 2013 and March 2014 were investigated retrospectively. Sixty patients who had undergone at least one complete blood count during preoperative hospital admission and who had no other active inflammatory conditions at the time the sample was taken were included in the study. Mean platelet volume and leukocyte count values were determined in each patient at hospital admission and during active acute appendicitis. Age, sex, mean platelet volume and leukocyte counts were recorded for each patient.

ResultsThe mean age of patients was 33.15±10.94 years and the male to female ratio was 1.5:1. The mean leukocyte count prior to acute appendicitis was 7.42±2.12×103/mm3. Mean leukocyte count was significantly higher (13.14±2.99×103/mm3) in acute appendicitis. The optimal leukocyte count cutoff point for the diagnosis of acute appendicitis was 10.10×103/mm3, with sensitivity of 94% and a specificity of 75%. The mean platelet volume prior to acute appendicitis was 7.58±1.11 fL. Mean platelet volume was significantly lower (7.03±0.8 fL) in acute appendicitis. The optimal mean platelet volume cutoff point for the diagnosis of AA was 6.10 fL, with a sensitivity of 83% and a specificity of 42%. Area under the curve for leukocyte count diagnosis was 0.67 and 0.69 for the diagnosis of AA by mean platelet volume.

ConclusionsMean platelet volume was significantly decreased in acute appendicitis. Mean platelet volume can be used as a supportive diagnostic parameter in the diagnosis of acute appendicitis.

Key words: Acute appendicitis; diagnosis; mean platelet volume.

23

IntroductionAcute appendicitis (AA), remains the most common indica-tion for emergency abdominal surgery with a lifetime inci-dence of 7%.[1] Although AA can occur at any age, onset of infection is most common between the ages of 10 and 20 years . AA is more common in males, with a reported male to female ratio of 1.4:1. The cause of AA is unknown and is likely to be multi-factorial; luminal obstruction, dietary, and familial factors have all been proposed as potential contribu-tors to AA.[2] The diagnosis of AA can be difficult due to the the absence of a pathognomonic signs or symptoms and the poor predictive value of associated laboratory testing.[3] In-flammation plays an important role in the pathology of AA.[4] Laboratory indicators that have been associated with AA in-clude leukocytosis, left shift, and elevated markers of inflam-mation such as C-reactive protein and erythrocyte sedimen-tation rate.[5] Mean platelet volume (MPV) is a measure of platelet size generated by full blood count analyzers as part of the routine complete blood count test.[6] Although MPV is not generally taken into consideration by clinicians, it may be a marker of platelet activation. Large platelets are more re-active, produce more pro-thrombotic factors, and aggregate more easily.[7] Mean platelet volume is one of the most widely used surrogate markers of platelet function and has been shown to reflect inflammatory burden and disease activity in several diseases including pre-eclampsia, acute pancreatitis, unstable angina, myocardial infarction, and systemic inflam-mation such as ulcerative colitis and Crohn’s disease.[8]

The aim of this study is to investigate the supporting role of MPV in the diagnosis of AA. In the present study each pa-tient’s previous MPV and leukocyte count (LC) values, col-lected under non-inflammatory conditions, were compared with laboratory values from samples taken at the time of AA.

Material and MethodsThis study was designed and conducted at Sakarya University Education and Research Hospital. We retrospectively reviewed the medical records of 241 patients who had undergone ap-pendectomy in the General Surgery Unit between June 2013 and March 2014. The primary analysis in this study was the comparison of the patient MPV and LC values that at the time

of AA to data collected prior to the operation. In this study, laboratory and clinical data were obtained from the digital medical records database of the hospital. All patients included in the study had confirmed AA noted in the surgical report.

The medical records of 241 patients who underwent appen-dectomy for AA were investigated. Exclusion criteria and the number of excluded patients are listed in Table 1.

A total of 103 patients were excluded from study. Records for the remaining 138 patients were examined retrospec-tively using the computerized medical records database of the hospital. This evaluation included all records dated withing the previous 6 years. In 78 patients no blood sample data prior to the onset of AA were available. Twenty three patients had a diagnosis of tonsillitis, 18 patients had gastro-enteritis, 11 patients had pneumonia, 10 patients had soft tissue infection, 9 patients had renal colic, 5 patients had bone fracture and 2 patients had a diagnosis of acute chole-cystitis. As a result, these patients were excluded from study. According to the medical records 60 patients had provided least one blood sample was taken during a previous non-in-flammatory state. These patients were included in the study. The clinic where each patient was admitted prior to onset of AA, the diagnosis at this clinic, gender, and the number of patients are shown in the Table 2.

Previous MPV and LC values corresponding to the non-in-flammatory state were determined in all 60 patients (Group 1). Mean platelet volume and LC values of the same patients at the time of AA were also determined (Group 2). These val-ues were obtained from the first blood samples collected af-ter onset of AA. Age, sex, MPV and LC values were recorded.

The LC and MPV analyses were performed using a commer-cially available analyzer (CELL-DYN 3700, Abbott Diagnostics, Abbott Park, IL, USA) in the laboratory. The upper limits of the reference interval for LC was 4600-10200/μL. The expected MPV values in our laboratory ranged between 7.0 and 12 fL.

Statistical Analysis

Statistical analyses were performed using SPSS software (SPSS: An IBM Company, version 16.0, IBM Corporation,

Turk J Emerg Med 2015;15(1):23-2724

Table 1. Exclusion criteria and number of excluded patients

Exclusion criteria Number of excluded patients

Patients under the age of 18 2

Pregnant women 9

A history of additional diseases and chronic drug use 19

Patients that had no any hospital admission before operation 73

and Armonk, New York, USA). All data are expressed as the mean±standard deviation. The Student’s t-test was used to compare continuous variables between the control and the patient groups. The Pearson correlation analysis was carried out to examine the linear relationships among the variables. The cut-off values for discrimination of the groups were determined using Receiver Operating Characteristic (ROC) curve analysis. The areas under the ROC curves (AUC) were calculated and the specificity, sensitivity and accuracy of the LC and MPV for predicting AA were calculated for various cut-off points.

ResultsA total of 60 patients were included in the final study group The mean age of the patients was 33.15±10.94 years (range: 19 to 70 years); 36 patients were male and 24 patients were female. The male to female ratio was 1.5:1.

The mean LC was 7.42±2.12×103/mm3 in group 1 and 13.14±2.99×103/mm3 in group 2. There was a significant difference between group 1 and group 2 with respect to LC (p=0.02). Receiver operating characteristic curve analysis in-dicated that the best cutoff point for LC in the diagnosis of AA was 10.10×103/mm3, which had a sensitivity of 94% and a specificity of 75%. Area under curve for LC was 0.67 (Figure 1).

The mean MPV 7.58±1.11 fL in group 1 and 7.03±0.8 fL in group 2. Mean platelet volume was significantly lower in the group 2 relative to group 1 (p=0.01). Receiver operating characteristic curve analysis suggested that the optimal cut-off point for MPV in the diagnosis of AA was 6.10 fL, which had a sensitivity of 83% and a specificity of 42%. Area under curve for MPV was 0.69 (Figure 2).

DiscussionAcute appendicitis is one of the most common indications for emergency surgery.[9] Appendicitis occurs in patients of all ages, although it is more common among patients 10 to 30 years old.[10] AA is more common in men, with a male to female ratio of 1.4:1.[2] In our study group the mean age of the patients was 33.15±10.94 years (range: 19 to 70 years), and the male to female ratio was 1.5:1, findings that are con-sistent with the current literature.

Several reports have suggested that elevated LC is typically the first laboratory measure to indicate inflammation of the appendix, and most patients with AA present with leukocyto-sis.[11,12] In several published studies, the sensitivity and speci-ficity of LC in the diagnosis of AA has been reported as 67%-97.8% and 31.9%-80%, respectively.[13,14] The present study found that LC was significantly higher in AA, and the sensitiv-ity and specificity of LC were 94% and 75%, respectively.

Elevated MPV has been associated with chronic inflammatory disease. Elevated MPV has been correlated with coronary ar-tery disease severity[15,16] as well as acute pancreatitis remis-sion,[17] chronic sinusitis,[18] arterial erectile dysfunction,[19] vari-cocele,[20] and chronic hepatitis B infection.[21] Elevated MPV reflects augmented production of platelets and an increased number of large, hyperaggregable platelets.[22] Reduced MPV has been associated with acute inflammatory disorders. Re-duced MPV has been recently demonstrated in rotavirus gas-troenteritis,[23] as well as exacerbation of chronic obstructive pulmonary disease,[24] active pulmonary tuberculosis,[25] and acute pancreatitis.[8] Similar to these these studies, we found significantly lower MPV in patients with AA. A number of previous studies have reported varying results regarding the

Kucuk E et al. Mean Platelet Volume is Reduced in Acute Appendicitis 25

Table 2. Referenced clinics, diagnoses, gender and number of patients that previous blood samples were taken during an non-inflammatory state

Referenced clinic Diagnosis Gender

Cardiology Nonspecific chest pain Male: 8; Female: 10

Blood bank Blood donation Male: 9

Internal medicine Dyspepsia, constipation Male: 6; Female: 5

PTR Myalgia Male: 2; Female: 2

Psychiatry Depression and anxiety Male: 1; Female: 3

Neurology Benign positional vertigo Male: 3; Female: 1

Chest diseases Dyspnea Male: 2; Female: 1

Urology Infertility and BPH Male: 2

Otorhinolaryngology Tinnutus and NSD Male: 2

Obstetrics Infertility Female: 1

İnfectious diseases Tick bite Male: 1; Female: 1

PTR: Physical Therapy and Rehabilitation; BPH: Benign Prostatic Hypertrophy; NSD: Nasal Septum Deviation.

association between MPV and AA. Uyanik et al.[26] found no significant decrease in MPV in AA patients, but Narci and col-leagues reported significantly higher MPV in AA patients.[27] Similar to the present study, Albayrak,[28] Tanrikulu,[29] Bilici[30] and their coworkers reported a significant decrease in MPV in AA patients relative to healthy control subjects. In all of these studies the control group was composed of distinct patients with no symptoms, including patients admitted to outpatient centers for routine exams. Inter-individual platelet respon-siveness to a variety of agonists is highly variable.[31] This may introduce bias into certain study designs. Our study is there-fore more meaningful because control and AA groups data were obtained from the same patients and there was no intra-individual differences between patients in terms of MPV. The present study thereofore has excellent clinical applicability.

Albayrak et al. reported sensitivity of 73%, and specificity of 84% using an MPV cut-off of 7.6 fL in the diagnosis of AA.[28] Tanrikulu et al. Reported sensitivity of 45% and specificity of 89% using an MPV cutoff point of ≤7.3 fL in the diagnosis of AA.[29] Additionally, Bilici et al. Reported specificity of 54% and sensitivity of 87% using an MPV cut-off of <7.4 fL to di-agnose AA.[30] Comparable to these studies, we found speci-ficity of 42% and sensitivity of 83% using an MPV cut-off of 6.10 fL in the diagnosis of AA. Sensitivity and specificity of LC were higher than the MPV. This may be attributable to physi-cian preference for LC over MPV in the diagnosis of AA. In the present study, the area under curve for MPV was 0.69 and 0.67 for LC. Bilici et al. reported AUC of 0.80 for MPV and 0.94

for LC.[30] Tanrikulu et al. reported AUC of 0.71 for MPV and 0.87 for LC.[29] According to these results, LC has greater diag-nostic accuracy for AA than MPV. However, MPV is a useful-supportive parameter in the diagnosis of acute appendicitis.

Limitations

It was impossible to exclude the presence of undocumented inflammatory conditions in patients at the time when the baseline blood sample was collected. This was the most im-portant limitation of this study. The relatively small number of patients included in the study may also represent a limitation.

ConclusionAcute appendicitis is the most common indication for emer-gent abdominal surgery and remains difficult to diagnose. The current study indicates that mean platelet volume is decreased in acute appendicitis. Mean platelet volume has lower diagnostic accuracy than leukocyte count in acute ap-pendicitis, although it can be used as a supportive param-eter in the diagnosis of acute appendicitis.



Ethics Committee Approval

Due to the retrospective nature of this study ethics commit-tee approval was waived.

Turk J Emerg Med 2015;15(1):23-2726

Figure 1. Receiver operating characteristic curve of leukocyte count.Figure 2. Receiver operating characteristic curve of mean platelet volume.

Sens

itivi

ty

1.0

0.8

0.6

0.4

0.2

0.01.00.80.60.40.20.0

ROC Curve

1 - SpecificityDiagonal segments are produced by ties

Sens

itivi

ty

1.0

0.8

0.6

0.4

0.2

0.01.00.80.60.40.20.0

ROC Curve

1 - Specificity

Informed Consent

Due to the retrospective nature of this study informed con-sent was waived.

Financial Disclosure

The authors declared that this study has received no finan-cial support.

References1. Omari AH, Khammash MR, Qasaimeh GR, Shammari AK, Yas-

een MK, Hammori SK. Acute appendicitis in the elderly: risk factors for perforation. World J Emerg Surg 2014;9:6.

2. Humes DJ, Simpson J. Acute appendicitis. BMJ 2006;333:530-4.3. Pinto F, Pinto A, Russo A, Coppolino F, Bracale R, Fonio P, et

al. Accuracy of ultrasonography in the diagnosis of acute ap-pendicitis in adult patients: review of the literature. Crit Ultra-sound J 2013;5 Suppl 1:S2.

4. Bhasin SK, Khan AB, Kumar V, Sharma S, Saraf R. Vermiform appendix and acute appendicitis. JK Science 2007;9:167-70.

5. Wray CJ, Kao LS, Millas SG, Tsao K, Ko TC. Acute appendicitis: controversies in diagnosis and management. Curr Probl Surg 2013;50:54-86.

6. Sandhaus LM, Meyer P. How useful are CBC and reticulocyte reports to clinicians? Am J Clin Pathol 2002;118:787-93.

7. Martin JF, Bath PMW. Platelets andmegakaryocytes in vascu-lar disease in antithrombotics. In: Herman AG, editor. Patho-physiological rationale for pharmacological inventions. Bos-ton, Mass, USA: Kluwer Academic Publisher; 1991. pp. 49-62.

8. Beyazit Y, Sayilir A, Torun S, Suvak B, Yesil Y, Purnak T, et al. Mean platelet volume as an indicator of disease severity in patients with acute pancreatitis. Clin Res Hepatol Gastroen-terol 2012;36:162-8.

9. Ishikawa H. Diagnosis and treatment of acute appendicitis. JMAJ 2003;46:217-21.

10. Spirt MJ. Complicated intra-abdominal infections: a focus on appendicitis and diverticulitis. Postgrad Med 2010;122:39-51.

11. Andersson RE. Meta-analysis of the clinical and laboratory di-agnosis of appendicitis. Br J Surg 2004;91:28-37.

12. Birchley D. Patients with clinical acute appendicitis should have pre-operative full blood count and C-reactive protein assays. Ann R Coll Surg Engl 2006;88:27-32.

13. Al-Gaithy ZK. Clinical value of total white blood cells and neu-trophil counts in patients with suspected appendicitis: retro-spective study. World J Emerg Surg 2012;7:32.

14. Kamran H, Naveed D, Nazir A, Hameed M, Ahmed M, Khan U. Role of total leukocyte count in diagnosis of acute appendici-tis. J Ayub Med Coll Abbottabad 2008;20:70-.

15. Abalı G, Akpınar O, Söylemez N. Correlation of the coronary severity scores and mean platelet volume in diabetes melli-tus. Adv Ther 2014;31:140-8.

16. Ekici B, Erkan AF, Alhan A, Sayın I, Aylı M, Töre HF. Is mean platelet volume associated with the angiographic severity of coronary artery disease? Kardiol Pol 2013;71:832-8.

17. Mimidis K, Papadopoulos V, Kotsianidis J, Filippou D, Spanou-dakis E, Bourikas G, et al. Alterations of platelet function, number and indexes during acute pancreatitis. Pancreatol-ogy 2004;4:22-7.

18. Koc S, Eyibilen A, Erdogan AS. Mean platelet volume as an inflammatory marker in chronic sinusitis. Eur J Gen Med 2011;8:314-7.

19. La Vignera S, Condorelli RA, Burgio G, Vicari E, Favilla V, Russo GI, et al. Functional characterization of platelets in patients with arterial erectile dysfunction. Andrology 2014;2:709-15.

20. Mahdavi-Zafarghandi R, Shakiba B, Keramati MR, Tavakkoli M. Platelet volume indices in patients with varicocele. Clin Exp Reprod Med 2014;41:92-5.

21. Qi XT, Wan F, Lou Y, Ye B, Wu D. The mean platelet volume is a potential biomarker for cirrhosis in chronic hepatitis B virus infected patients. Hepatogastroenterology 2014;61:456-9.

22. Park Y, Schoene N, Harris W. Mean platelet volume as an indi-cator of platelet activation: methodological issues. Platelets 2002;13:301-6.

23. Mete E, Akelma AZ, Cizmeci MN, Bozkaya D, Kanburoglu MK. Decreased mean platelet volume in children with acute rota-virus gastroenteritis. Platelets 2014;25:51-4.

24. Wang RT, Li JY, Cao ZG, Li Y. Mean platelet volume is de-creased during an acute exacerbation of chronic obstructive pulmonary disease. Respirology 2013;18:1244-8.

25. Gunluoglu G, Yazar EE, Veske NS, Seyhan EC, Altin S. Mean platelet volume as an inflammation marker in active pulmo-nary tuberculosis. Multidiscip Respir Med 2014;9:11.

26. Uyanik B, Kavalci C, Arslan ED, Yilmaz F, Aslan O, Dede S, et al. Role of mean platelet volume in diagnosis of childhood acute appendicitis. Emerg Med Int 2012;2012:823095.

27. Narci H, Turk E, Karagulle E, Togan T, Karabulut K. The role of mean platelet volume in the diagnosis of acute appendicitis: a retrospective case-controlled study. Iran Red Crescent Med J 2013;15:11934.

28. Albayrak Y, Albayrak A, Albayrak F, Yildirim R, Aylu B, Uyanik A, et al. Mean platelet volume: a new predictor in confirm-ing acute appendicitis diagnosis. Clin Appl Thromb Hemost 2011;17:362-6.

29. Tanrikulu CS, Tanrikulu Y, Sabuncuoglu MZ, Karamercan MA, Akkapulu N, Coskun F. Mean platelet volume and red cell dis-tribution width as a diagnostic marker in acute appendicitis. Iran Red Crescent Med J 2014;16:10211.

30. Bilici S, Sekmenli T, Goksu M, Melek M, Avci V. Mean platelet volume in diagnosis of acute appendicitis in children. Afr Health Sci 2011;11:427-32.

31. Kunicki TJ, Nugent DJ. The genetics of normal platelet reactiv-ity. Blood 2010;116:2627-34.

Kucuk E et al. Mean Platelet Volume is Reduced in Acute Appendicitis 27


Submitted: February 26, 2014 Accepted: April 08, 2014 Published online: January 20, 2015

Correspondence: Erdem CEVIK, MD. Van Asker Hastanesi, Van, Turkey.


28 ORIGINAL ARTICLE

1Van Military Hospital, Van;2Department of Emergency Medicine, Bagcilar Training and Research Hospital, Istanbul;

3Etimesgut Military Hospital; Ankara;4Zirve University EBN Medical Faculty, Gaziantep, all in Turkey

erdem cevıK,1 Banu KaraKuS yılMaz,2 Yahya Ayhan acar,3 Mehmet dOKur4

Systematic Analysis of Theses in the Field of Emergency Medicine in Turkey

SUMMARY

ObjectivesThe aim of this study is to systematically evaluate the theses in the field of emergency medicine in Turkey and to determine whether they were published as a scientific paper.

Methods

This is a retrospective observational study. Theses in the field of emergency medicine between 1998 and 2013 were browsed from the internet database of National Thesis Center (Council of Higher Education). Study type, both if it was in the field of emergency, or if it was published and the journal’s scope of published studies were assessed and recorded in the study chart.

Results

579 theses were included in the study. 27.1% of them were published and 14.9% of them were published in SCI/SCI-E journals. Advisors of theses were emergency medicine specialists in 67.6% of theses and 493 (85.1%) of them were in the field of emergency medicine. 77.4% of theses were observational and 20.9% were experimental study. Most of the experimental studies (72.7%, n=88) were animal studies.

ConclusionsIt was concluded that very few theses in the field of emergency medicine were published in journals that were indexed in SCI/SCI-E.

Key words: Emergency medicine; systematic analysis; theses.

IntroductionIn Turkey, the first Emergency Medicine (EM) residency was founded in Turkey by Department of Emergency Medicine of Dokuz Eylul University in 1994, and thenceforward many other departments started EM residency programs.[1,2] EM residency programs were firstly established in Educational and Training Hospitals in 2006 and residents were enrolled to a program by a nationwide examination. Currently, 70 centers (43 University hospitals, 27 Education and Training Hospitals) have been providing EM residency programs.[3]

In Turkey, residents must complete a thesis about their spe-cialty before graduating according to applicable legislations.[1] Studies on EM have been increasing gradually and many studies reported evaluating these studies by the means of qualification and quantity.[4] The aim of a thesis is to learn all phases of conducting a scientific study but, to our knowl-edge, there is not any study evaluating the theses in the field of EM. Similar studies to ours have been reported in the field of Family Medicine.[5,6,7]

The aim of this study is to evaluate systematically all the the-ses in the field of EM that were conducted from the begin-ning of EM residency programs in Turkey, and determine the publication status of these theses.

Materials and MethodsIn this retrospective observational study, EM theses between 1998 and 2013 were reanalyzed.

Data were collected via browsing internet database of the National Thesis Center (Council of Higher Education) (https://tez.yok.gov.tr/UlusalTezMerkezi/tarama.jsp). While searching, “Emergency Medicine” was selected in the “De-partment” tab. Information on author, supervisor, institution, objectives, materials and methods, results, and conclusion were analyzed and recorded to the study chart for all theses.

Additionally, year, study design, whether the supervisor was an emergency medicine physician, whether the subject of the thesis was associated with EM topics, whether the power analysis was performed, financial support status, whether the thesis was reported as a publication, if yes, journal’s in-dex status and the year of publication were analyzed. While classifying the studies, a standard algorithm was used (Fig-ure 1). For randomized controlled studies (RCT), the registra-tion status was assessed by browsing the internet addresses of clinicaltrials.gov, clinicaltrialsregister.eu, isrctn.org.

The publication status of theses were assessed by entry of author’s name, title of the thesis and keywords to the search engines of PubMed, Google scholar and Google search. If the study was published, it was assessed if the journal was

indexed in SCI (Science citation Index) or SCI-E (Science Cita-tion Index Expanded) by searching the lists of Thomson Re-uters. The indexing status of the journal at the time that the thesis was published could not be analyzed.

Whether the subject of the thesis was associated with EM topics was determined by assessing the objectives, meth-ods, results, and conclusion sections. For the final decision, two of three researchers’ decision was accepted.

There are 1021 emergency physicians (EP) in Turkey as of January 2014. 17 of them are professors, 88 of them are as-sociate professors, 88 of them are assistant professors, 20 of them are instructors and 808 of them are attending physi-cians. EM residency programs were established in Education and Training Hospitals in 2011 and 282 EP received their de-grees from these institutions but in National Thesis Center database we could not find the theses of them. While assess-ing the publication status, the last two years were excluded because of time constraints for publication.

Frequency and percentage were given for categorical vari-ables in descriptive statistics. Statistical analysis was per-formed by SPSS 15.0 (SPSS Inc. Chicago, IL).

ResultsA total of 579 theses were included in the study. Three theses were excluded because they lacked an abstract of full text, and one thesis was excluded because of an irrelevant text upload. 579 (56.7%) theses were reached from the target population of the study (theses of 1021 EPs). Demograph-ics are shown in table 1. All of the theses were conducted in university hospitals and according to that, we reached only 78.4% of the target population of study (784 EPs graduated from university hospitals). A great majority of supervisors were EPs (n=390, 67.6%) and this proportion was increased significantly over time. 493 (58.1%) of the theses were clas-

Cevik E et al. Systematic Analysis of Theses in the Field of Emergency Medicine in Turkey 29

Figure 1. Algorithm for categorizing the studies.

Design of study

Qualitative(579, 100%)

Descriptive(233, 40.3%)

Analytic(215, 37.1%)

Clinical(33, 5.7%)

Animal study(88, 15.2%)

Experimental(121, 20.9%)

Methodological(10, 1.7%)

Quantitative(0)

Observational(448, 77.4%)

sified as having a subject associated with EM topics and this proportion also showed a gradual increase over time. 157 (27.1%) of the theses were published and 68 (14.9%) of them were published in the journals indexed in SCI/SCI-E (Figure 2). The distribution of the journals according to their index

status are given in table 2.

448 (77.4%) of the theses were observational, and 121 (20.9%) of the theses were experimental. Descriptive and analytic studies among observational studies showed close percent-ages (52.1% and 47.9%, respectively). A great majority of the experimental studies were animal studies (n=88, 72.7%).

53 (43.8%) of the experimental studies were randomized and 11 (9.1%) of them were blinded. 75 (62%) of experimen-tal studies had a control group. 38 (31.4%) of these studies were randomized-controlled, and 11 (9.1%) of them were controlled and blinded. Only one study among experimen-tal studies was submitted in a clinical trial registry platform (clinicaltrials.org). Financial disclosure was stated in only one article. Power analysis was assessed in two theses.

DiscussionWe reached only the theses from university hospitals in our study that was conducted to evaluate the theses on EM. We found that the number of the theses have been increasing over time in direct proportion to number of EPs, most of these theses were observational studies, and 27.1% of them were published. To our knowledge, this is the first study eval-uating the theses in the field of EM.

There are several studies evaluating the background of the publication in the era of EM in Turkey.[4,8,9] Çınar et al. reported that publication numbers have been increasing over time, and 514 articles were published from Turkish emergency departments between 1995 and 2010 according to data acquired from PubMed search engine.[4] They have reported that, 40 (7.8%) of these articles were animal stud-ies, and 75 (14.6%) of them were designed as a retrospective study.[4] The international EM literature showed that 57% of the studies were original articles, and the maximal contri-bution to literature was from US and England.[10,11] We also

Turk J Emerg Med 2015;15(1):28-3230

Table 1. Demographics of the theses

Determinants n %

Observational 448 77.4%

Descriptive 233 52.1%

Analytic 215 47.9%

Experimental 121 20.9%

Animal 88 72.7%

Clinical study 33 27.3%

Methodological 10 1.7%

Supervisor*

Emergency physician 390 67.6%

Non-emergency physician 187 32.4%

Data acquisition†

Prospective 273 53.7%

Retrospective 108 21.3%

Cross-sectional 127 25.0%

Published theses 157 27.1%

Journals published

National 93 59.2%

International 64 40.8%

Indexing of the journal

SCI / SCI-E 86 54.8%

Non SCI / SCI-E 71 45.2%

*Supervisor was not recorded in two theses and the total number was given as 577; †A total number was given as 508 because 71 of theses could not be differentiated.

Table 2. The distribution of the published studies’ design according to the indexing of the journals

Study design Non- SCI/ SCI-E SCI / SCI-E Total

n % n % nObservational

Descriptive 26 16.6% 18 11.5% 44

Analytic 36 22.1% 29 18.5% 65

Experimental

Animal study 7 4.5% 24 15.3% 31

Clinical study 18 0.6% 11 7.0% 12

Methodological 1 0.6% 4 2.5% 5

found that the number of theses increased over time and concluded that this increase was associated with an increase in the number of educational institutions.

In a study evaluating the theses in the field of Family Medicine, Yaman et al. showed that 67.1% of them were observational, 7.9% of them were experimental, and 25% of them were ret-rospective.[5] It was reported in the same study, that 59.3% of observational studies were descriptive, and 70% of them were cross-sectional.[5] Our result showed that most of the theses on EM were also observational studies and that was compati-ble with Yaman et al. But the proportion of experimental stud-ies were higher from the results of Yaman et al. and Çınar et al. According to another study evaluating the studies of aca-demic members of EM on the subject of trauma in Turkey, it was demonstrated that the number of articles increased over time, 74.3% of the studies were original articles, 74.3% of the studies were original articles, and most of experimental stud-ies (88.8%) were conducted on human subjects. But accord-ing to our results minority of the experimental studies (27.2%, 33/121) were conducted on human subjects.[4,12] We conclud-ed that this difference may result from a disparity between the target population of studies and family medicine topics that were mainly directed to primary health care.

Doğan et al. reported that academic members of EM in Tur-key published 94.4% of their studies on trauma in the jour-nals indexed in SCI/SCI-E.[12] This number was 2.1% for the theses on family medicine.[5] Our results showed that 27.1% of the theses on EM were published, and 14.9% of the pub-lished articles were in journals indexed in SCI/SCI-E. Most of the SCI/SCI-E articles were observational analytical studies and animal studies.

While evaluating the contribution of Turkish EM to inter-national literature, Çınar et al. reported that 31 (6%) of the studies were RCTs, presenting a high level of evidence.[4] Our results showed that 49 (8.5%) of theses were designed as RCT and that was compatible with the results of Çınar et al..[4]

Clinical studies (especially the RCTs) must be submitted to accepted platforms in order to maintain the transparency of the study, and to prevent the methodological changes. In 2005, the Committee of Medical Journal Editors made a decision not to publish the studies made a decision to al-low submission of clinical trials only after registration to an accepted platform.[13] However, in our study, only one thesis was submitted to these platforms.

Power analysis can be used to calculate the minimum re-quired sample size prior to study. According to our results, power analysis was assessed in only two theses. The power analysis may be omitted to state in the text.

Financial disclosure was not mentioned in any study. In the specific assessment of animal studies and experimen-tal studies that used drugs or kits, we determined that the power analysis was calculated and financial support was received but neither of them were mentioned adequately in the abstracts/ full texts of the theses. From this we con-cluded that negative perceptions may be caused by not pro-viding this information, as the theses in the field of EM have limited financial support or power analysis.

LimitationsWe reached just the theses from university hospitals because

Figure 2. Number of theses and publication rates in years.

120

100

80

60

40

20

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

3 36 6

33

20

31

49

38

51

4147

99

87

53

12

ThesesPublications

Cevik E et al. Systematic Analysis of Theses in the Field of Emergency Medicine in Turkey 31

of the theses from Education and Research Hospitals were not uploaded to national thesis database. Theses conducted in the last two years were excluded because of limited time to publish. So, 56.7% of the theses of 1021 EPs could have been included in the study. In some theses, evaluation was based on the abstract rather than full text because of unau-thorized access. These determinants make it impossible to comment for all theses on EM.

ConclusionWe concluded that only minority of theses on EM are pub-lished in journals indexed in SCI/SCI-E. It was assessed that clinical, experimental and analytical observational studies were regarded as insufficient. Original subjects that can con-tribute to the literature may be important for the evolution of EM. If all theses were uploaded (including the theses from Education and Training Hospitals) to the national thesis da-tabase, it would facilitate further studies based on theses.



References1. Cevik AA, Rodoplu U, Holliman CJ. Update on the develop-

ment of emergency medicine as a specialty in Turkey. Eur J Emerg Med 2001;8:123-9.

2. Tipta ve Dishekimligi’nde uzmanlık egitimi yonetmeligi. http://www.tuk. saglik.gov.tr/pdfdosyalar/mevzuat/TUEY.pdf Avalilable at February 01, 2014.

3. Dogan NO, Pamukcu G, Cevik Y, Otal Y, Levent S, Cikrikci G. Turkiye’deki acil tip asistanlarinin bilgi duzeylerinin bir teorik

sinav araciligiyla degerlendirilmesi. JAEM 2013;12:30-24. Cinar O, Dokur M, Tezel O, Arziman I, Acar YA. Contribution

of Turkish Emergency Medicine to the international litera-ture: evaluation of 15 years. Ulus Travma Acil Cerrahi Derg 2011;17:248-52.

5. Yaman H, Kara IH, Baltaci D, Altug M, Akdeniz M, Kavukcu E. Turkiye’de aile hekimligi alaninda yapilan tezlerin kalitatif de-gerlendirilmesi. Konuralp Tip Dergisi 2011;3:1-6.

6. Mendis K, Solangaarachchi I. PubMed perspective of fam-ily medicine research: where does it stand? Fam Pract 2005;22:570-5.

7. Sparks BL, Gupta SK. Research in family medicine in develop-ing countries. Ann Fam Med 2004;2 Suppl 2:S55-9.

8. Yanturali S, Yuruktumen A, Aksay E, Cevik AA. International publications from Turkish Emergency Medicine Depart-ments: analysis of first ten years. [Article in Turkish] Turk J Emerg Med 2004;4:170-3.

9. Ersel M, Yuruktumen A, Ozsarac M, Kiyan S, Aksay E. Interna-tional publications of Academic Emergency Medicine De-partments in Turkey: 15th year analysis. [Article in Turkish] Turk J Emerg Med 2010;10:55-60.

10. Birkhahn RH, Van Deusen SK, Okpara OI, Datillo PA, Briggs WM, Gaeta TJ. Funding and publishing trends of original re-search by emergency medicine investigators over the past decade. Acad Emerg Med 2006;13:95-101.

11. Wilson MP, Itagaki MW. Characteristics and trends of pub-lished emergency medicine research. Acad Emerg Med 2007;14:635-40.

12. Dogan NO. Evaluation of international scientific publications and citations on trauma authored by professors and associ-ate professors of emergency medicine in Turkey. [Article in Turkish] Turk J Emerg Med 2013;13:64-8.

13. De Angelis CD, Drazen JM, Frizelle FA, Haug C, Hoey J, Horton R, et al. Is this clinical trial fully registered?-A statement from the International Committee of Medical Journal Editors. N Engl J Med 2005;352:2436-8.

Turk J Emerg Med 2015;15(1):28-3232


Submitted: November 24, 2014 Accepted: December 09, 2014 Published online: January 20, 2015

Correspondence: Dr. Yilmaz Zengin. Dicle Universitesi, Tip Fakultesi, Acil Tip Anabilim Dali, 21280 Diyarbakir, Turkey.


ORIGINAL ARTICLE

1Department of Emergency Medicine, Dicle University, Diyarbakır;2Department of Internal Medicine, Hacettepe University, Ankara, both in Turkey

yilmaz zenGın,1 Mustafa ıcer,1 ercan Gunduz,1 recep durSun,1 Hasan Mansur durGun,1 Mehmet Nezir Gullu,2 Murat OraK,1 Cahfer GulOGlu1

How was Felt Van Earthquake by a Neighbor University Hospital?

SUMMARYObjectivesNatural disasters, which are defined as events causing great damage or loss of life, are events of natural origin unpreventable by human beings that occur in a short period of time and lead to loss of life and property. The aim of the study is to analyze which patient groups and problems at a university hospital after the earthquakes in Van.

MethodsFor the purposes of this study, 169 patients who presented to our emergency room following the earthquakes that occurred on the 23rd of October, 2011 and the 9th of November, 2011 in Van and were treated as an outpatient or inpatient were enrolled. Patients were divided into two groups. Patient data including the clinical and demographic characteristics were analyzed.

ResultsAmong the 169 patients included in our study, 97 (57.4%) were male and 72 (42.6%) were female. The mean age was 26.95±16.44 years in Group 1 and 39.80±23.08 years in Group 2. In our study, the majority of the patients in Group 1 had orthopedic injuries, while internal problems were more common in Group 2. The need for intensive care was greater among the patients in Group 1 compared to Group 2 (p<0.05). The leading cause of death in Group 1 was multi-systemic trauma in 7 out of the 10 patients (70%) and internal problems in Group 2 with 5 out of 12 patients (41.5%).

ConclusionsOur country is in a geographical location where earthquakes are responsible for great losses of life and property. An efficient disaster relief plan may help to minimize the possible damage of earthquakes.

Key words: Disaster; university hospital; Van earthquake.

33

IntroductionNatural disasters, which are defined as events causing great damage or loss of life, are events of natural origin unpre-ventable by human beings that occur in a short period of time and lead to loss of life and property.[1] Earthquakes are among the leading natural disasters that cause the greatest number of mortalities and disabilities both in our country and around the world.[2,3] The earthquakes that occurred in Van on the 23rd of October, 2011 and the 9th of November, 2011 measuring 7.2 and 5.6 on the Richter scale, respective-ly, caused a total of 644 fatalities and destroyed or severely damaged nearly 30,000 buildings in Van, Ercis and the sur-rounding provinces and townships.[4] Although earthquakes occur frequently in our country due to its location in an earthquake-prone zone, unplanned urbanization and struc-turally weak buildings as well as inadequate earthquake education and preparation still contribute to high rates of earthquake-related fatalities and disabilities.[5,6] Therefore, earthquake-associated data should be gathered, meticu-lously analyzed and published in order for the necessary measures against future earthquakes to be taken.

This study presents a retrospective analysis of the patients who presented to our emergency department after the earthquakes in Van. The aim of the study is to analyze which patient groups and problems can be expected at a univer-sity hospital after a natural disaster such as an earthquake.

Material and MethodFor the purposes of this study, 169 patients who presented to our emergency department following the earthquakes that occurred on the previously mentioned dates in Van and were treated in an outpatient or inpatient status were en-rolled. The type of study was a retrospective cross-sectional study. Patients were divided into two groups as patients who presented after the first earthquake on the 23rd of Oc-tober, 2011 (Group 1, n=41) and those who presented after the second large earthquake on the 9th of November, 2011 (Group 2, n=128). Patient data including age, gender, reason for referral, diagnoses, subsequent clinical condition, need for blood transfusion, compartment syndrome, amputa-tions, crush syndrome, surgeries, need for dialysis, need for intensive care, laboratory results, length of hospital stay, and the outcome were retrieved from the hospital data base and analyzed. Patients whose data in the file could not be verified or was inadequate were excluded from the study. Differences between Group 1 and Group 2 in terms of the assessed parameters were investigated. This study was ap-proved by the local ethical committee (2013/180).

The statistical analysis was performed using the SPSS version 15.0 (SPSS Inc., Chicago, IL, USA) software. The normality of

the data was tested using the Kolmogorov–Smirnov test. The results were expressed as mean±SD or number of pa-tients. Categorical data were analyzed using the chi-square test. For the normally distributed continuous variables, the student’s t test was used for statistical comparisons. Statisti-cal significance was based on a p-value of <0.05.

ResultsAmong the 169 patients included in our study, 97 (57.4%) were male and 72 (42.6%) were female. The mean age was 26.95±16.44 years in Group 1 and 39.80±23.08 years in Group 2. The clinical and demographic characteristics of the patients are presented in Table 1. Among the 131 patients ad-mitted to the hospital, 42 (32.1%) were in internal medicine, 18 (13.7%) were in orthopedics and traumatology, 16 (7.7%) were in the pediatrics and pediatric surgery departments, 11 (5.3%) were in neurosurgery, and 44 (33.5%) were in the oth-er services. The length of the hospital stay was 10.85±9.85 days in Group 1 and 8.68±12.71 days in Group 2. Three out of the 5 patients (60%) who underwent fasciotomies had to re-ceive hemodialysis due to acute renal failure. The mean age of the mortalities in Group 1 was 24±16.9, while the mean age among the mortalities in Group 2 was 26.6±29.7 years. The leading cause of death in Group 1 was multi-systemic trauma in 7 out of the 10 patients (70%) and internal prob-lems in Group 2 with 5 out of 12 patients (41.5%).

DiscussionWithin the last 25 years, natural disasters have caused over 3 million deaths and disabilities and affected the living standards of approximately 800 million people around the world.[7] Earthquakes are the most destructive kind of natu-ral disasters in terms of loss of life and property.[8] Due to our country’s high-risk location in an earthquake-prone zone, 100,000 people have lost their lives between the years 1908 and 1995. Furthermore, the Marmara earthquake on the 17th of August, 1999 caused 17,127 mortalities and 604 peo-ple were lost in the earthquake in Van in 2011.[6,9,10] The great number of structurally weak buildings and the inadequate disaster response and recovery framework lead to higher mortality rates after these earthquakes. The relatively lower number of fatalities in the earthquake in Van was due to the advantageous timing of the earthquake during daytime at a weekend when only few people were inside buildings.

In a study where the patients who had presented to the Uludag University hospital after the Marmara earthquake, 147 out of 330 of the wounded patients were admitted to the Orthopedics and Traumatology clinic, while the other patients were followed up by the general surgery, plastic surgery, and cardiothoracic surgery departments.[11] In an-

Turk J Emerg Med 2015;15(1):33-3834

other study on the Marmara earthquake, the majority of the patients who had presented to hospitals were reported to be admitted to the Orthopedics and Traumatology clinic and 96 out of the 160 operations were orthopedic surgeries.[12] In India, the majority of the injuries after the earthquake in Gujarat were orthopedic conditions.[13] Also in the study by Dursun et al, the majority of patients who presented af-ter the Van earthquake were reported to be orthopedic pa-

tients with 28%.[14] In our study, the majority of the patients in Group 1 had orthopedic injuries, while internal problems were more common in Group 2. We are of the opinion that this was caused by the fact that a greater number of the lo-cals had abandoned the damaged buildings after the first earthquake and moved into tents.

One of the most important problems observed after earth-quakes is crush syndrome or traumatic rhabdomyolysis that

Zengin Y et al. How was Felt Van Earthquake by a Neighbor University Hospital? 35

Table 1. The clinical and demographic characteristics of the patients

Group 1 Group 2 P*

n (%) n (%)

Gender

Female 15 (36.6) 57 (44.5)

Male 26 (63.4) 71 (55.5) 0.46

Extremity injury

Upper 3 (7.3) 0 (0) 0.01

Lower 8 (19.5) 3 (2.3) 0.01

Pelvis 4 (9.8) 0 (0) 0.03

Vertebra 3 (7.3) 0 (0) 0.01

Lung injury

Hemothorax 3 (7.3) 1 (0.8) 0.04

Pneumothorax 2 (4.9) 0 (0) 0.06

Rib fractures 4 (9.8) 1 (0.8) 0.01

Head injury

Subarachnoid hemorrhage 1 (2.4) 2 (1.6) 0.56

Epidural hemorrhage 1 (2.4) 1 (0.8) 0.42

Parenchymal hemorrhage 1 (2.4) 1 (0.8) 0.42

Pregnancy 1 (2.4) 6 (4.7) 1

Ocular injury 1 (2.4) 3 (2.3) 1

Abdominal injury 1 (2.4) 12 (9.4) 0.19

Liver injury 2 (4.9) 0 (0) 0.06

Splenic injury 2 (4.9) 0 (0) 0.06

Pneumonia 1 (2.4) 8 (6.3) 0.69

Acute coronary syndrome 0 (0) 5 (3.9) 0.33

Diabetes mellitus 0 (0) 3 (2.3) 1

Blood transfusion 14 (34.1) 7 (5.5) <0.001

Compartment syndrome 5 (12.2) 0 (0) <0.001

Amputation 1 (2.4) 0 (0) 0.24

Crush syndrome 16 (39.6) 0 (0) <0.001

Performed operations 20 (48.8) 16 (12.5) <0.001

Chronic renal failure 0 (0) 58 (45.3) <0.001

Dialysis 8 (19.5) 57 (44.5) 0.01

Need for intensive care 15 (36.6) 22 (17.2) 0.01

Death 10 (24.4) 12 (9.4) 0.03

* Chi-squared test.

occurs due to the exposure of the muscle tissue to pressure over longer periods.[15] Crush injuries were reported in 600 patients after the earthquake in Armenia in 1988, 372 pa-tients after the Hanshin-Awaji earthquake in 1995, 110 pa-tients who presented to the Uludag University hospital af-ter the Marmara earthquake in 1999, 202 patients after the Wenchuan earthquake in China in 2008 and in 46 patients after the earthquake in Van.[11,16-20] In our study, 16 (39.6%) of the patients in Group 1 had crush injuries, while no crush injuries were observed in any of the patients in Group 2. This result may be associated with the fact that the majority of locals had left their houses after the first earthquake, as well as the relatively lower magnitude of the second earthquake.

Following crush injuries, the increased pressure on the skel-etal muscles in the extremities and the reduction in the capil-lary perfusion leads to compartment syndrome that is char-acterized by ischemia, dysfunction and tissue necrosis.[21,22] Although compartment syndrome frequently occurs in the forearms and legs, it may also be observed in the hands, feet arms, shoulders and thighs.[9] Starting an effective treatment at an early stage may reduce the mortality and morbidity asso-ciated with compartment syndrome.[23] During the early stage (the first 6-12 hours) a fasciotomy with the surgically appropri-ate and accurate indication and wound debridement should be performed and antibiotic therapy should be initiated.[20] In the literature, amputation rates after fasciotomies performed due to crush injury are given as 4- 21%.[23,24] After the Marmara earthquake, 92 out of the 146 patients with crush injuries ad-mitted to the Gulhane Haydarpasa Training Military Hospital underwent fasciotomies and 5 patients (5.4%) had subse-quent amputations. After the Wenchuan earthquake, 15 out of 32 patients were given fasciotomies and 5 (15.6%) out of these had to undergo amputations. After the earthquake that occurred in Van in 2011, 21 out of the 46 patients admitted to the Van Regional Training and Research Hospital with crush injuries had received fasciotomies and 7 (15%) out of these later required amputations.[20,25,26] In our study, 1 patient (20%) out of the 5 patients who had undergone fasciotomies due to compartment syndrome in Group 1 had to receive an ampu-tation. The higher rate of amputation in our study may result from the low number of patients in our study.

Another problem faced due to crush injuries is the need for hemodialysis.[9] According to a study conducted on the 1988 Armenian earthquake, 80 (67%) out of the 120 patients with crush injuries required hemodialysis; while 156 patients had to receive hemodialysis after the Iranian earthquake in 1990; 491 out of the 704 patients with crush injuries underwent dialysis after the Marmara earthquake in 1999, and 9 out of 21 patients with crush injuries were treated through hemo-dialysis after the 2011 Van earthquake.[20,27-29] In our study, 8 out of the 16 patients with crush injuries and serum creati-

nine concentrations over 5 mg/dl in Group 1 received hemo-dialysis due to acute renal failure.

Management of the chronic renal failure patients under-going dialysis is one of the greatest problems following earthquakes. After the Marmara earthquake, 266 of the 531 dialysis patients in the region had to receive treatment in the neighboring provinces.[29] In our study, 57 of the chronic dialysis patients in Group 2 were observed to present to our hospital since the dialysis centers at which they normally re-ceived treatment were destroyed or severely damaged.

Another problem faced after earthquakes is the need for intensive care.[30] According to a study conducted on the Marmara earthquake, 10 (10.5%) out of the 95 patients who presented to the hospital required intensive care, while 39 (13%) out of the 301 hospitalized patients after the earth-quake in Van had to be admitted to intensive care.[14,30] In our study, the need for intensive care was greater among the patients in Group 1 compared to Group 2. This may be explained by the greater magnitude of the first earthquake and the higher number of the severe injuries.

When the earthquake mortalities were evaluated based on age groups, approximately half of the deaths are observed to occur between the ages of 20 and 40.[14] A previous study reported an earthquake mortality risk in the age group above 65 years to be 2.9 times higher.[31] Accordingly, the majority of the fatalities after the Sultandagi earthquake were observed in the age group <65 years.[32] In the study by Dursun et al. on the earthquake in Van, the majority of the fatalities were found to be between 20-40 years of age.[7] Also in our study, the majority of the deaths were among the younger generation in both groups. This result may be asso-ciated with the younger population of the city and the con-centration of the damage on the buildings at the city center.

Although the causes of mortality vary after earthquakes, deaths at the site mainly occur due to respiratory failure due to entrapment under debris, while hospital deaths are usual-ly associated with multi-systemic trauma.[33] A previous study pointed out the three top causes of death in the Hanshin-Awaji earthquake as abdominal trauma, head trauma and thoracic trauma.[34] Also in the Marmara earthquake of 1999, the causes of death among the patients followed up at dif-ferent hospitals comprised multi-systemic traumas including abdominal, head and chest trauma.[11,12] In our study, the high prevalence of multi-systemic traumas as the leading cause of death in Group 1 in comparison to Group 2 may be explained with the reduced risk of trauma in the second earthquake af-ter the locals had left their buildings to stay in tents. On the other hand, the prevalence of internal problems in Group 2 may be explained by the high number of the healthcare cen-ters rendered dysfunctional after the two earthquakes.

Turk J Emerg Med 2015;15(1):33-3836

ConclusionOur country is in a geographical location where earthquakes are responsible for great loss of life and property. For this rea-son, all the data about earthquakes from our country should be gathered, the necessary measures taken, adequate edu-cation given, disaster relief plans prepared and regular drills should be performed. An efficient disaster relief plan may help to minimize the possible damage of earthquakes.



References1. Gulkan P, Sucuoglu H. Course on disaster preparedness and

management. Dogal Afetlerin Tipleri ve Etkileri: T.C. Bay-indirlik ve Iskan Bakanligi, Ankara: s. 9-25.

2. Taviloglu K. Felaketlerde yaralilara yaklasim ve hekimlik hizmetleri. In: Depremlerde uzmanlık hizmetleri. Istanbul Tabip Odası Yayinlari, Istanbul: Ekspres Ofset; 2000. s. 1-36.

3. Cakmakci M. Felakette saglik duzeni. Bilim Teknik Dergisi 1999;31:11-7.

4. Yagmurlu F, Senturk M, Dumlupinar İ. 23 Ekim 2011 ve 9 Kasım 2011 tarihlerinde meydana gelen Van depremlerinin jeolojik degerlendirmesi. SDU Geo 2011;2:3-10.

5. Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med 1996;334:438-44.

6. Taviloğlu K. 17 Ağustos 1999 Marmara depreminin ardından: Felaket organizasyonunda neredeyiz? Ulusal Cerrahi Derg 1999;15:333-42.

7. Peek-Asa C, Kraus JF, Bourque LB, Vimalachandra D, Yu J, Abrams J. Fatal and hospitalized injuries resulting from the 1994 Northridge earthquake. Int J Epidemiol 1998;27:459-65.

8. Building Seismic Safety Council. Seismic considerations: Health care facilities. Washington DC: Federal Emergency Management Agency Publication, FEMA 150;1990.

9. Yıldız Ş, Yıldız DŞ, Özkan DS, Dündar DK, Ay DH, Kıralp DZM, et al. Hyperbarıc Oxygen Therapy In Crush Injurıes After 17th Of August Earthquake In Marmara. Gulhane Med J 2004;46:194-9.

10. Atasoy S, Ziyalar N, Alsancak B. Earthquake epidemiology in Turkey: 1900-1995. (Poster) American Academy of Forensic Sci-ences 51. Annual Meeting. Orlando, Florida, USA 1999:15-20.

11. Bulut M, Turanoğlu G, Armağan E, Akköse S, Ozgüç H, Tokyay R. The analysis of traumatized patients who were admitted to the Uludag University Medical School Hospital after the Marmara earthquake. [Article in Turkey] Ulus Travma Derg 2001;7:262-6.

12. Kurt N, Küçük HF, Celik G, Demirhan R, Gül O, Altaca G. Evalu-ation of patients wounded in the 17 August 1999 Marmara earthquake. [Article in Turkish] Ulus Travma Derg 2001;7:49-51.

13. Phalkey R, Reinhardt JD, Marx M. Injury epidemiology after the 2001 Gujarat earthquake in India: a retrospective analysis

of injuries treated at a rural hospital in the Kutch district im-mediately after the disaster. Glob Health Action 2011;4:7196.

14. Dursun R, Görmeli CA, Görmeli G. Evaluation of the patients in Van Training and Research Hospital following the 2011 Van earthquake in Turkey. [Article in Turkish] Ulus Travma Acil Cerrahi Derg 2012;18:260-4.

15. Better OS, Abassi Z, Rubinstein I, Marom S, Winaver Y, Silber-man M. The mechanism of muscle injury in the crush syn-drome: ischemic versus pressure-stretch myopathy. Miner Electrolyte Metab 1990;16:181-4.

16. Oda J, Tanaka H, Yoshioka T, Iwai A, Yamamura H, Ishikawa K, et al. Analysis of 372 patients with Crush syndrome caused by the Hanshin-Awaji earthquake. J Trauma 1997;42:470-6.

17. Shimazu T, Yoshioka T, Nakata Y, Ishikawa K, Mizushima Y, Morimoto F, et al. Fluid resuscitation and systemic complica-tions in crush syndrome: 14 Hanshin-Awaji earthquake pa-tients. J Trauma 1997;42:641-6.

18. Oda Y, Shindoh M, Yukioka H, Nishi S, Fujimori M, Asada A. Crush syndrome sustained in the 1995 Kobe, Japan, earthquake; treatment and outcome. Ann Emerg Med 1997;30:507-12.

19. Quan Y, Pan X, Deng S, Lu S, Tao S, Zhou J, et al. Features of crush injury in Wenchuan earthquake and the corresponding operational methods. [Article in Chinese] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2009;23:549-51. [Abstract]

20. Görmeli G, Görmeli CA, Güner S, Ceylan MF, Dursun R. A clini-cal analysis of patients undergoing fasciotomy who experi-enced the 2011 Van earthquake. [Article in Turkish] Eklem Hastalik Cerrahisi 2012;23:156-60.

21. Coget JM. The compartment syndrome. [Article in French] Phlebologie 1989;42:259-69.

22. von Schroeder HP, Botte MJ. Crush syndrome of the upper ex-tremity. Hand Clin 1998;14:451-6.

23. Rollins DL, Bernhard VM, Towne JB. Fasciotomy: an appraisal of controversial issues. Arch Surg. 1981;116:1474-81.

24. Duman H, Kulahci Y, Sengezer M. Fasciotomy in crush injury resulting from prolonged pressure in an earthquake in Tur-key. Emerg Med J 2003;20:251-2.

25. Us HM, Rodop O, Özkan S, Civelek A, Elbüken E, İnan K. Our Experıences In Treatment Of Compartment Syndrome After 17 August Earthquake. [Article in Turkish] Turkish J Thorac and Cardiovasc Surg 2000;8:805-7.

26. Li W, Qian J, Liu X, Zhang Q, Wang L, Chen D, et al. Manage-ment of severe crush injury in a front-line tent ICU after 2008 Wenchuan earthquake in China: an experience with 32 cases. Crit Care 2009;13:R178.

27. Richards NT, Tattersall J, McCann M, Samson A, Mathias T, Johnson A. Dialysis for acute renal failure due to crush injuries after the Armenian earthquake. BMJ 1989;298:443-5.

28. Nadjafi I, Atef MR, Broumand B, Rastegar A. Suggested guide-lines for treatment of acute renal failure in earthquake vic-tims. Ren Fail 1997;19:655-64.

29. Erek E, Sever MŞ. Marmara Earthquake and Turkish Ne-phrology. Türk Nefroloji Diyaliz ve Transplantasyon Dergisi 1999;4:158-62.

30. Akpek AE, Dönmez A, Kızılkan A, Arslan G. Role Of A Back-Up Anaesthesia Department After Massive Disaster:Our Ex-

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perience During The Marmara Earthquake. T Klin J Med Sci 2002;22:502-4.

31. Peek-Asa C, Ramirez M, Seligson H, Shoaf K. Seismic, structur-al, and individual factors associated with earthquake related injury. Inj Prev 2003;9:62-6.

32. Akbulut G, Yilmaz S, Polat C, Sözen M, Leblebicioğlu M, Dilek ON. Afyon sultandagi earthquake. [Article in Turkish] Ulus

Travma Acil Cerrahi Derg 2003;9:189-93.33. Cakir Z, Saritas A, Aslan S, Uzkeser M, Sarıkaya S. Erzurum -

Askale Earthquake and Its Results. EAJM 2006;38:81-4.34. Tanaka H, Oda J, Iwai A, Kuwagata Y, Matsuoka T, Takaoka

M, et al. Morbidity and mortality of hospitalized patients after the 1995 Hanshin-Awaji earthquake. Am J Emerg Med 1999;17:186-91.

Turk J Emerg Med 2015;15(1):33-3838

VISUAL DIAGNOSIS

Turk J Emerg Med 2015;15(1):2 [39] doi: 10.5505/1304.7361.2014.58189

DIAGNOSIS: Psoas Hematoma

Computed tomographic scan without contrast revealed a psoas muscle hematoma at the widest point of 9 cm (Figure 1). Spontaneous hematomas of the iliac psoas muscle are rare lesions seen in patients receiving anticoagulant agent. Several reports have suggested that most traumatic psoas hematomas are caused by blunt trauma or rupture.[1,2] However, a considerable amount of patients suffered a spontaneous hemorrhage even though they were on anti-coagulant therapy, specifically heparin.[3,4] Hemodialysis catheter patency is regularly maintained by a high-concentration heparin filling, according to manufacturer’s recommendation. Surprisingly, there are only a few reports of serious bleeding complications.

References1. Maffulli N, So WS, Ahuja A, Chan KM. Iliopsoas haematoma in an adolescent Taekwondo player. Knee Surg

Sports Traumatol Arthrosc 1996;3:230-3.2. Margulies DR, Teng FW. Psoas muscle hematoma from blunt trauma: an unusual cause of severe abdominal

pain. J Trauma 1998;45:155-6.3. Guivarc’h M. Hematoma of the iliac psoas muscle. 29 cases. [Article in French] J Chir (Paris) 1997;134:382-9.

[Abstract]4. Niakan E, Carbone JE, Adams M, Schroeder FM. Anticoagulants, iliopsoas hematoma and femoral nerve com-

pression. Am Fam Physician 1991;44:2100-2.

39

[see page 2]

Figure 1. Psoas hematoma (red arrow) 1. Aorta; 2. Inferior vena cava; 3. Psoas muscle; 4. Vertebra; 5. Vertebra (spinous process); 6. Erector spinae muscle; 7. Colon; 8. External oblique muscle; 9. Internal oblique muscle; 10. Tranversus ab-dominis muscle; 11. Rectus abdominis muscle.

A Rare Case in the Emergency Department:Holmes-Adie Syndrome

CASE REPORT40

Department of Emergency Medicine, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey

Sahin COLAK, Mehmet Ozgur ERDOGAN, Ahmet SENEL, Ozge KIBICI,Turker KARABOGA, Mustafa Ahmet AFACAN, Hizir Ufuk AKDEMIR

SUMMARY

Holmes-Adie syndrome (HAS) is a rare syndrome characterized by tonic pupil and the absence of deep tendon reflexes. HAS was first described in 1931 and is usually idiopathic, with inci-dences reported to be 4-7 per 100,000. Although tonic pupil is usually unilateral, it can also be bilateral. Enlarged and irregular pupil is usually noticed by the patient. Light reflex is weak or un-responsive. Another characteristic of HAS is the absence of deep tendon reflexes, and unilateral involvement is more common. This case report emphasizes that HAS should be considered in the differential diagnosis of patients presenting to the emergency department with anisocoria, and the dilute pilocarpine test can be used in diagnosis.

Key words: Emergency department; Holmes-Adie syndrome; pilocarpine.

IntroductionHolmes-Adie syndrome (HAS) is characterized by tonic pupil and the absence of deep tendon reflexes. The incidence is reported to be 4-7 per 100,000.[1-4] Tonic pupil seen in HAS is usually unilateral, but it can rarely be seen in both eyes. The involvement of deep tendon reflexes is a characteristic of HAS. The Achilles tendon reflex is most commonly affected. This case report emphasises that HAS should be considered in the differential diagnosis of patients presenting to the emergency department with anisocoria.

Case ReportA 31-year-old female patient presented to the emergency department upon noticing in the mirror at home that her left pupil was bigger than the right. There was no disease, chronic medication use, or trauma story in the case history. The case reported no decrease in her vision except for diffi-culty when reading. The examination revealed that she had anisocoria, and her left pupil was dilated and irregular. The left pupil was unresponsive to direct and indirect light sti-muli (Figure 1a). Eye movements were normal. Miosis was


Submitted: February 20, 2014 Accepted: April 21, 2014 Published online: January 20, 2015

Correspondence: Dr. Şahin Çolak. Haydarpaşa Numune Eğitim ve Araştırma Hastanesi,Acil Tıp Kliniği, İstanbul, Turkey.


present in both eyes at near vision. Motor and sensory exa-mination was normal; however, bilateral Achilles reflex was absent. Other system examinations, vital signs, and labo-ratory values were normal. Visual field and macula of the case were evaluated as normal in consultation with the eye department. No pathology was detected in the cranial com-puted tomography (CT) and magnetic resonance imaging (MRI). The Neurology Department was consulted about the case. In order to confirm the diagnosis of suspected HAS, di-lute pilocarpine 0.5% (Pilomin®) was instilled into both eyes. In the examination performed about 30 minutes later, aniso-coria was now not observed (Figure 1b). Light reflexes were present in both eyes. The case was discharged after neces-sary information was provided.

DiscussionAnisocoria is defined as a difference of more than 0.1 mm in the diameter of the pupils. Many causes, from physiological anisocoria to HAS, can be included in the etiology of aniso-coria.[5-7]

Holmes-Adie Syndrome (HAS) is characterized by tonic pu-pil and the absence of deep tendon reflexes. It is usually idiopathic and more common in young women in the third decade of life.[1-3] Our case was a 31-year-old woman. There was no known disease or chronic medication use in the case history. Cranial computed tomography (CT) and magnetic resonance imaging (MRI) was normal.

Tonic pupil as seen in HAS is usually unilateral, but can rarely be seen in both eyes. It occurs due to the injury of postgang-lionic parasympathetic nerve fibers. Diagnosis of unilateral involvement cases with no disease history is easier than those with bilateral involvement. The onset of tonic pupil is quite slow and usually noticed by the patient. The involved pupil is dilated and irregular compared to the other. Light reflex is weak or unresponsive. The near reaction in cases

with weak or unresponsive light reflex is defined as the light-near dissociation, which is generally present in HAS cases. Accommodation is also impaired.[1,4,5] Our patient noticed that her pupils were unequal and presented to the emer-gency department. Her left pupil was affected and dilated and irregular compared to the other. Light reflex was unres-ponsive; however, contraction was present in both eyes at near vision. After the pilocarpine drop, light reflex and sig-nificant contraction was observed in the affected eye. There was no decrease in her vision, but she had difficulty in rea-ding because of visual accommodation disturbances. These symptoms observed in our case corresponded to tonic pupil findings seen in HAS.

The involvement of deep tendon reflexes is a characteristic of HAS. The Achilles tendon reflex is most commonly affec-ted. In general, unilateral involvement is common, but bila-teral involvement has been also reported. The loss of tendon reflexes is permanent. Studies have proven that the number of nerve cells decreases in the thoracic and lumbar ganglia, and the myelin sheath is reduced by grey and white matter involvement in the posterior root and the medial region of the spinal cord. It is thus is estimated that impaired spinal monosynaptic connections have a role in areflexia pathoph-ysiology.[1] Bilateral Achilles tendon reflexes were absent in the patient’s neurological examination. Motor and sensory examination was normal. Our case was diagnosed with HAS based on normal neuroimaging, tonic pupil, and the absen-ce of bilateral Achilles tendon reflex. Autonomic dysfunction may occur with HAS. It has been reported that HAS is accom-panied by sweating, cardiovascular dysfunction, diarrhea, cough, and orthostatic hypotension.[2,8-10] In our case, auto-nomic dysfunction was not observed.

Conclusion

HAS is one of the rare causes of anisocoria in the emergency department. In these cases, the pupil should be examined in detail. In case of tonic pupil and areflexia, emergency physi-cians should consider HAS in the differential diagnosis, and the diagnosis should be confirmed by pilocarpine test.



References1. Martinelli P. Holmes-Adie syndrome. Lancet 2000;18:356.

2. Guaraldi P, Mathias CJ. Progression of cardiovascular auto-nomic dysfunction in Holmes-Adie syndrome. J Neurol Neu-rosurg Psychiatry 2011;82:1046-9.

3. Bremner FD, Smith SE. Bilateral tonic pupils: Holmes Adie

Colak S et al. Holmes-Adie Syndrome 41

Figure 1. (a) The left pupil was unresponsive to direct and indirect light stimuli. (b) Pilocarpine was instilled into both eyes, 30 minutes later, anisocoria was now not observed.

(a)

(b)

Turk J Emerg Med 2015;15(1):40-42

syndrome or generalised neuropathy? Br J Ophthalmol 2007;91:1620-3.

4. Bakbak B, Donmez H. Adie’s tonic pupil. [Article in Turkish] Turk Norol Derg 2009;15:153-4.

5. Turk A, Gunay M, Erdol H. The role of pupillometric measure-ments at different light amplitudes in diagnosis of Adie’s ton-ic pupil. [Article in Turkish] Genel Tıp Derg 2011;21:4.

6. Wilhelm H, Wilhelm B. Diagnosis of pupillary disorders. In: Schiefer U, Wilhelm H, Hart W. Clinical neuro-ophthalmology 2007;55-69.

7. Bakbak B, Gedik S. Anisocoria. TJO 2012;42:68-72.

8. Johnson RH, McLellan DL, Love DR. Orthostatic hypotension and the Holmes-Adie syndrome. A study of two patients with afferent baroreceptor block. J Neurol Neurosurg Psychiatry 1971;34:562-70.

9. Kimber J, Mitchell D, Mathias CJ. Chronic cough in the Holmes-Adie syndrome: association in five cases with autonomic dys-function. J Neurol Neurosurg Psychiatry 1998;65:583-6.

10. Sogut O, Erdogan MO, Yigit M, Albayrak L. Anisocoria due to datura inoxia. Emergency Med 2013;3:162.

42

Brucellar Testicular Abscess Presenting as a Testicular Mass: Can Color Doppler Sonography

be used in Differentiation?

CASE REPORT


Submitted: January 23, 2014 Accepted: February 16, 2014 Published online: June 02, 2014

Correspondence: Ali KOCYIGIT, MD. Pamukkale Universitesi Tip Fakultesi,Radyoloji Anabilim Dali, Denizli, Turkey.


43

1Department of Radiology, Pamukkale University Faculty of Medicine, Denizli;2Department of Emergency Medicine, Pamukkale University Faculty of Medicine, Denizli, both in Turkey

Furkan KAYA,1 Ali KOCYIGIT,1 Cihan KAYA,1 Ibrahim TURKCUER,2 Mustafa SERINKEN,2 Nevzat KARABULUT1

IntroductionBrucellosis is an endemic, zoonotic disease in some regions of the world and affects several organs and tissues in hu-mans. Direct contact with infected animals or ingestion of contaminated animal products are routes of transmission to humans.[1,2] Brucellar orchi-epididymitis is a complication of systemic brucellosis in humans and can be seen in 5.7% of affected patients.[1] Brucellar testicular abscess can be mis-diagnosed as a necrotic testicular mass leading to unneces-sary orchiectomy.[3-8] Thus, the diagnosis of an abscess is of critical importance to avoid testicular loss in these patients. We present the case of a 23-year-old man with a brucellar

testicular abscess that was diagnosed with color Doppler so-nographic findings, and treated with drainage and adminis-tration of combined antibiotic therapy.

Case ReportA 23-year-old male patient was admitted to the Emergency Department for right testicular swelling for 2 months. The pa-tient declared that he was prescribed gentamycin 1x100 mg in 7 days by a family physician one month before his admis-sion, but his complaints continued. The patient had no his-tory of direct contact with infected animals but had a history of relatively recent ingestion of unpasteurized cheese. Physi-

SUMMARY

Brucellosis is an endemic disease in various regions of the world. Testicular abscess is a very rare complication of brucellosis which can be misdiagnosed as a testicular mass and may lead to un-necessary orchiectomy. To our knowledge there are only eight reported cases in the literature of a brucellar testicular abscess. We present a case of testicular abscess due to brucellosis diagnosed with serologic tests and color Doppler sonography, and treated with antibiotics and fine needle aspiration.

Key words: Abscess; brucellosis; color Doppler sonography; testicular; ultrasonography.

Turk J Emerg Med 2015;15(1):43-4644

cal examination revealed a body temperature of 36.5 °C and blood pressure of 110/70 mmHg. There was right testicular swelling and tenderness. There was no color change on the scrotum. His laboratory findings included: leukocytes 8470/mm3, hemoglobin 13.4 g/dl, thrombocytes 467.000/mm3, ALT (alanine aminotransferase) 24.7 IU/L (normal range, 7-40), AST (aspartate aminotransferase) 27.1 IU/L (normal range, 8-41), ESR (erythrocyte sedimentation rate) 19 mm/h, CRP (C-reactive protein) 0.335 mg/dl (normal value, 5 mg/dl), and the Brucella agglutinin titer was positive at 1/1280. The blood cultures of the patient were negative. Sonographic evalua-tion was performed with a Nemio ultrasound scanner using a 9-12 MHz linear transducer (Toshiba, Tokyo, Japan). Real time scrotal sonography revealed an anechoic cystic lesion with irregular borders and a thick wall measuring 31x41x74 mm, and containing low level echoes with few septa, which almost replaced the entire right testis (Figure 1a). The periph-eral border of the lesion and the septa were hypervascular on color Doppler sonography suggestive of an abscess (Figure 1b). The right epididymis and entire right testis tissue were also hypervascularized on Doppler sonography consistent with orchi-epididymitis. The left testis was normal on scrotal gray-scale and Doppler sonography. The patient was diag-nosed with brucellar orchi-epididymitis with right testicular abscess based on the constellation of laboratory and sono-graphic findings. Antibiotic therapy with doxycycline (100 mg twice daily) and streptomycin (1 gram daily) was initi-ated for 7 days. However, the diameter of the abscess did not change at the end of 7 days, and we decided to drain the ab-scess using fine needle aspiration to reduce the size of lesion and increase the efficacy of medication. The patient received a 6-week course of oral doxycycline (100 mg twice daily) and rifampicin (600 mg once daily), and follow-up scrotal sonog-raphy after two months showed complete resolution of the lesion leaving a residual small area of heterogeneity in the right testis (Figure 1c).

DiscussionBrucellosis, caused primarily by B. melitensis, remains the most common zoonotic disease all over the world, and it is endemic particularly in Mediterranean countries.[1,2,7] Brucel-losis is a multisystem infectious disease which may cause suppurative complications most frequently at the bones and joints.[2] Most common clinical findings of brucellosis are fever, osteoarticular involvement, and sweating. The genitourinary system is the second most common site of focal brucellosis which can appear as orchi-epididymitis or nephritis. Orchi-epididymitis can be seen in 5.7% of affected patients.[1] Brucellar abscess occurs when the necrosis oc-curs in the region of granulomatous infection induced by the persistence of the bacteria in macrophages.[9] Testicular abscesses associated with brucellosis in the process of orchi-

epididymitis are very rare, and only eight cases have been reported in the literature to our knowledge.[3-8,10,11] The char-acteristics of the reported cases are summarized in Table 1.

Figure 1. (a) Gray-scale sonography image demonstrates a large an-echogenic cystic mass with a thick septum (arrow) and pressed tes-ticular parenchyma (asterisk). (b) Color Doppler sonography image demonstrates the hypervascularity in the thick septum (arrow head), pressed testicular parenchyma (short arrow) and epididymis (long arrow) resembling orchi-epididymitis. (c) Gray-scale sonography im-age demonstrates heterogeneous hypoechogenic area (arrows) at the right testis on follow up sonography after 2 months.

(a)

(b)

(c)

Kaya F et al. Brucellar Testicular Abscess Case Presenting As A Testicular Mass 45

In the acute phase of brucellosis, blood cultures are positive in only 10-30% of patients and clinical findings are generally nonspecific. Incidence of blood culture positivity decreases during the course of the infection. The main diagnostic cri-teria for brucellosis are high agglutination titers (>1/160) for anti-Brucella antibodies using the standard tube agglutina-tion (STA) test, and the presence of the clinical signs and symptoms of brucellosis.[1] In chronic brucellosis the STA test can reveal negative or very low agglutination titers (<1/160). In some cases of brucellosis, anemia (35-55%) or leukopenia (21%) can be observed.[12] In our case, the leukocytes and he-moglobin values were within normal range and there were no abnormal results in other blood tests either. The diag-nosis of brucellar testicular abscess was established by the positive serologic test results, history of ingestion of unpas-teurized dairy product, and the visualization of dense cystic lesion with thick walls on gray-scale sonography, revealing hypervascularization in the region of epididymis and around the abscess on Doppler sonography.

The main differential diagnosis of testicular brucellar ab-scess is a necrotic tumor. Failure to diagnose the abscess ap-propriately can lead to unnecessary orchiectomy in patients with delayed diagnosis due to large suspicious lesions which

cause partial or total destruction of the testis.[10] Six patients underwent orchiectomy with combined antibiotic treatment among the reported eight cases in the literature.[3-8] A con-servative treatment with antibiotics or combined antibiotic therapy and drainage is usually adequate in the treatment of brucellar testicular abscess. Two patients[10,11] underwent conservative treatment with antibiotics and drainage as in our patient. In the report of Yemisen et al,[11] orchiectomy was offered to the patient at one month follow up because of no change in gray-scale sonographic findings, but the pa-tient did not accept the surgery. In the report of Koc et al,[10] the testicular abscess was diagnosed based on color Dop-pler sonography and the drainage and the administration of combined antibiotic therapy were applied. In our case, the initial clinical diagnosis was also testicular abscess upon clin-ical, laboratory and color Doppler sonographic findings. We believe that color Doppler sonography plays an important role in the diagnosis of an abscess as it shows hypervascular-ization at the region of orchi-epididymitis. Therefore, brucel-lar testicular abscess can be accurately diagnosed by color Doppler sonography on the basis of hypervascularization in the region of epididymis and testis (i.e. orchi-epididymitis) in a patient with consistent clinical and laboratory findings. Color Doppler sonography was performed in two reported

Table 1. Charesteristics of patients with testicular brucellar abscess

Study Age Imaging findings Biopsy Serologic Culture Treatment (years) (US and CDUS) Test

Fernandez et al. ND Increased testicular size Abscess Positive Negative Orchiectomy,

double drugx

Castillo Soria et al. ND Complete destruction of testis Abscess Positive Negative Orchiectomy,

double drugx

Bayram et al. ND Hypoechoic tumor-like lesion NGO STA Positive B.melitensis Orchiectomy,

D+R

Gonzalez Sanchez et al. ND Hypoechoic tumor-like lesion NGO Positive ND Orchiectomy,

double drugx

Kocak et al. 32 Hypoechoic tumor-like mass CGI STA Positive Negative Orchiectomy,

C+D

Akinci et al. ND Hypervascularity NGO STA Positive B.melitensis Orchiectomy,

D+R

Koc et al. 42 Hypervascular, thick-walled lesion CGI STA Positive B.melitensis Drainage, D+R

Yemisen et al. 43 Hypoechoic, No biopsy STA Positive Negative D+R

heterogeneous, cystic lesion

Case in this study 42 Anechoic cystic lesion with Abscess STA Positive Negative Drainage,

hypervascularization in D+R+S

thetestis and epididimis

C+D: Ciprofloxacin+doxycycline; CDUS: Color Doppler sonography; CGI: Choronic granulamatous inflammation; D+R: Doxycycline+rifampicin; D+R+S: Doxycycline+rifampicin+streptomycine; ND: Not defined; NGO; Necrotizing granulomatous orchitis; S+D: Streptomycine + doxycycline; STA: Standard tube agglutination; US: Ultrasonography. x: Possibly doxycycline and rifampicin.

Turk J Emerg Med 2015;15(1):43-4646

cases[8,10] and hypervascularization in the testicular and epi-didymal region was the main finding in both examinations.

In conclusion, testicular abscess is a very rare complication of brucellosis which can be under or misdiagnosed. The initial diagnosis of brucellar testicular abscess can be considered in patients with a history of unpasteurized dairy product consumption, clinical findings and serologic test results, and suggestive color Doppler sonographic findings for orchi-ep-ididymitis. Color Doppler sonography is instrumental in the clinical diagnosis when the gray-scale sonographic findings resemble a necrotic testicular tumor.



References1. Pappas G, Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N

Engl J Med 2005;352:2325-36.2. Gür A, Geyik MF, Dikici B, Nas K, Cevik R, Sarac J, et al. Com-

plications of brucellosis in different age groups: a study of 283 cases in southeastern Anatolia of Turkey. Yonsei Med J 2003;44:33-44.

3. Kocak I, Dündar M, Culhaci N, Unsal A. Relapse of brucellosis simulating testis tumor. Int J Urol 2004;11:683-5.

4. Fernández Fernández A, Jiménez Cidre M, Cruces F, Guil M, Bethencurt R, Dehaini A, et al. Brucellar orchitis with abscess. [Article in Spanish] Actas Urol Esp 1990;14:387-9. [Abstract]

5. Castillo Soria JL, Bravo de Rueda Accinelli C. Genital brucello-sis. A rare cause of testicular abscess. [Article in Spanish] Arch Esp Urol 1994;47:533-6. [Abstract]

6. Bayram MM, Kervancioğlu R. Scrotal gray-scale and color Doppler sonographic findings in genitourinary brucellosis. J Clin Ultrasound 1997;25:443-7.

7. González Sánchez FJ, Encinas Gaspar MB, Napal Lecumberri S, Rajab R. Brucellar orchiepididymitis with abscess. [Article in Spanish] Arch Esp Urol 1997;50:289-92. [Abstract]

8. Akinci E, Bodur H, Cevik MA, Erbay A, Eren SS, Ziraman I, et al. A complication of brucellosis: epididymoorchitis. Int J Infect Dis 2006;10:171-7.

9. Cosme A, Barrio J, Ojeda E, Ortega J, Tejada A. Sonograph-ic findings in brucellar hepatic abscess. J Clin Ultrasound 2001;29:109-11.

10. Koc Z, Turunc T, Boga C. Gonadal brucellar abscess: imaging and clinical findings in 3 cases and review of the literature. J Clin Ultrasound 2007;35:395-400.

11. Yemisen M, Karakas E, Ozdemir I, Karakas O. Brucellar testicu-lar abscess: a rare cause of testicular mass. J Infect Chemother 2012;18:760-3.

12. Akdeniz H, Irmak H, Seçkinli T, Buzgan T, Demiröz AP. Hema-tological manifestations in brucellosis cases in Turkey. Acta Med Okayama 1998;52:63-5.

False Positive Troponin Levels due to HeterophilAntibodies in a Pregnant Woman

CASE REPORT

1Department of Cardiology, Van Ercis State Hospital, Van;2Department of Biochemistry, Van Ercis State Hospital, Van, both in Turkey

Abdullah KAPLAN,1 Nuri ORHAN,2 Erkan İLHAN1

SUMMARYPositive troponin test results in peripheral blood can be detected either during myocardial injury or from falsely positive test results. In this report, we present the positive results of a troponin test in a 24-year-old pregnant woman referred to the emergency department with atypical chest pain, and the clinical algorithm that we used to make the correct diagnosis. This patient present-ed with the same complaint of chest pain at different times while positive troponin levels were detected. In the absence of signs of myocardial injury, we suspected that heterophil antibodies were playing a major role. Further examinations revealed heterophil antibodies that could cross react with the troponin tests in peripheral blood.

Key words: False positive troponin; heterophil antibodies.

IntroductionAs a result of myocardial infarction, enzymes such as myo-globin, cardiac troponins, creatine kinase, and lactate dehy-drogenase rise in the blood. Among these, cardiac troponins play a special role by virtue of their characteristics of being released only from cardiac muscle; increased levels even in minor myocardial injury retain the ability to make a diagno-sis with high sensitivity and accuracy. As a result, European and American societies of cardiology have recommended the use of troponin I or T as a diagnostic laboratory criterion of myocardial infarction since 2000.[1] Elevated level of tro-ponin indicates myocardial injury in spite of no information about the cause of the injury.

Apart from myocardial infarction, positive troponin level may also be detected due to myocardial injury or false posi-tive test results.[2,3] In this report, we aimed to present a case with troponin positivity due to heterophil antibodies.

Case ReportA 24-year-old housewife referred to the emergency depart-ment with left submammarian chest pain that was con-fined to a point and increased with leaning forward or deep breathing (November 14th). Due to a positive troponin level she was transferred to the cardiology polyclinic (troponin-I level: 0.20 ng/mL, reference level: 0-0.04 ng/ml) (Table 1).


Submitted: January 27, 2014 Accepted: March 23, 2014 Published online: January 20, 2015

Correspondence: Abdullah KAPLAN, MD. UKAMER Kalp Merkezi, Sanliurfa, Turkey.


47

Turk J Emerg Med 2015;15(1):47-50

Her medical history was remarkable for being 20 weeks pregnant. She had no history of heart disease, medication use, cigarette smoking, alcohol, or drug abuse. Function-ally, she was in a good status. Her physical examination was unremarkable. Both electrocardiography and echocardiog-raphy were negative with respect to perimyocarditis, myo-cardial ischemia, or myocardial infarction. Other blood tests were normal for creatine kinase (CK), creatine kinase MB isoenzyme (CK-MB), and alkaline phosphatase or rheuma-toid factor (Table 2) with false positive potential in result of troponin level. As she revealed she had similar complaints before pregnancy with positive troponin levels (Table 1). In the absence of typical myocardial ischemia, which was not confirmed by electrocardiography, echocardiography or normal range result of the CK and the CK-MB despite troponin-I elevatıon, we concluded the possibility of labora-tory error that resulted in a false positive troponin elevation. For increased accuracy of the test result we surveyed the

result in two different laboratories simultaneously (Novem-ber 15th). The obtained laboratory results showed positive troponin-I levels in our center with normal troponin-T levels in another center. When the same sample was studied using the interference test at our laboratory, the troponin-I level was found within the normal range. The false positivity was attributed to interference of heterophil antibodies and her blood sample was sent to a tertiary center to search for het-erophil antibodies.

DiscussionCardiac troponins are sensitive and specific laboratory mark-ers for myocardial injury and thus replaced CK-MB, the con-ventional diagnostic marker. Troponins are currently consid-ered the gold standard for the diagnosis of acute myocardial infarction.[1,4] Depending on the cellular damage, cardiac tro-ponins begin to emerge in plasma 4-6 hours after the onset

48

Table 1. Patient’s troponin levels during eight months

Date-Hour Troponin-I CK CK-MB Troponin-T Studying (reference) (reference) (reference) (reference) laboratory

April 4th 0.20 (0-0.04 ng/ml) Our laboratory

01:59 p.m.(*)

April 4th 0.21 (0-0.04 ng/ml) Our laboratory

04:42 p.m.

April 4th <0.01µg/L (<0.01µg/L) 1st outside center

10:12 p.m.

November 14th 0.20 (0-0.04 ng/ml) 11 (0-25 u/l) Our laboratory

08:11 p.m.(#)

November 15th 0.20 (0-0.04 ng/ml) Our laboratory

00:56 a.m.(#)

November 15th 0.24 (0-0.04 ng/ml) 46 (0-145 u/l) 10 (0-25 u/l) Our laboratory

09:56 a.m.

November 15th <0.01µg/L (<0.01µg/L) 2nd outside center

12:23 p.m.

November 20th 0.20 (0-0.04 ng/ml) 53 (0-145 u/l) 11 (0-25 u/l) Our laboratory

03:28 p.m.(#)

(*): Blood results before pregnancy. (#): Blood results during pregnancy.

Table 2. Other blood results from the patient

Date WBC RBC HGB HTC PLT CRP ALP AST RF (reference) (reference) (reference) (reference) (reference) (reference) (reference) (reference) (reference)

November 7.4 x109 L 4.05 x1012 L 12.1 g/dL 35.9% 230 x109 L 4 mg/dl 52.39 U/L 19 u/I 4 IU/L

20th (4-12x109 L) (3. 5-5.2 x1012 L) (12-16 g/dL) (35-49%) (130-450x109 L) (0-5 mg/dl) (30-120 U/L) (0-31 u/I) (0-18 IU/L)

WBC: White Blood Count; RBC: Red Blood Cells; HGB: Hemoglobin; HTC: Hematocrit; PLT: Platelet; CRP: C-reactive protein; ALP: Alkaline Phosphatase; AST: Aspartate Trans-aminase; RF: Rheumatoid Factor.

of ischemic symptoms and continue to be elevated for 10 days to 2 weeks.[5]

Despite the advantages of troponins, clinicians should keep in mind other processes that elevate troponin levels apart from myocardial infarction.[2,3,6-11] While some of the events with troponin elevation other than myocardial infarction are associated with myocardial injury, some of them occur as a result of troponin tests giving false positive results.

Troponin positivity as a result of myocardial injury may occur with the following: congestive heart failure, coronary vaso-spasm, cardiac trauma, myocarditis/perimyocarditis, pulmo-nary embolism, post-cardiac surgery and cardiac ablation, cardioversion and cardiopulmonary resuscitation, sepsis, critically ill patients, end-stage renal disease, arrhythmias, stroke, and epileptic seizures.

False positive troponin testing may result from: heterophile antibodies, Rheumatoid factor, or macroenzymes. Several additional examples of interfering substances are found in the literature;[3,10,11] among which are circulating antibodies from immunotherapies, vaccinations or blood transfusions, fibrin clots, immunocomplexes, and malfunction of the ana-lyzers.

We did not determine any clinical event that might have been associated with elevated troponin levels. Thus, we fo-cused on the conditions with potential false positive tropo-nin results. We ordered another test the same day at an out-side center. The troponin-T result of the outside center was normal. Hence, we took a sample from the troponin positive blood sample and sent it to a tertiary center for testing for heterophil antibodies. The latter testing was positive for het-erophil antibodies.

It has been reported that heterophil antibodies lead to a false positive result in one of 2000 patients assessed by modern immunoassay methods.[12] This condition may lead to misdiagnoses and unnecessary invasive interventions. Therefore, the clinicians should be vigilant about this in-terference. In the event of any doubt, the suspicious blood sample should be studied with other devices using at least 2 different methods.[12] Alternatively, this sample may be re-evaluated by adding heterophil blocking reagents.[13]

Heterophil antibodies are formed in human serum against animal immunoglobulins. However, they usually do not lead to any clinical disease state, although they may interact with immunoassays.[14] The effects of heterophil antibodies on the immunoassays have been well documented.[15-17] Het-erophil antibodies may arise accidentally or due to occupa-tional exposure to foreign proteins. The chance of hetero-phil antibody formation increases in people with frequent

contact with animals such as veterinarians, farmers, or pet owners. They may also be formed as a result of administra-tion of animal antibodies in cancer therapy or radiological tumor imaging.

Our patient was a woman living in a rural area where close contact with animals is prevalent. That may have led to de-velopment of the heterophil antibodies in this patient.

Conclusion

As in our case, patients with an elevated troponin level but without clinical, electrocardiographic, or echocardiographic findings consistent with myocardial infarction or other con-ditions that may have elevated troponin levels should be evaluated for the presence of heterophil antibodies before further invasive therapies are commenced. If heterophil an-tibody positivity is suspected, troponin levels should be re-evaluated with another device or method.



References1. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial in-

farction redefined-a consensus document of The Joint Euro-pean Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000;36:959-69.

2. Korff S, Katus HA, Giannitsis E. Differential diagnosis of elevat-ed troponins. Heart 2006;92:987-93.

3. Makaryus AN, Makaryus MN, Hassid B. Falsely elevated car-diac troponin I levels. Clin Cardiol 2007;30:92-4.

4. Jaffe AS, Ravkilde J, Roberts R, Naslund U, Apple FS, Galvani M, et al. It’s time for a change to a troponin standard. Circula-tion 2000;102:1216-20.

5. Topol EJ. Acute coronary syndromes. 2nd ed., Chap. 13:329-65.

6. Panteghini M. Role and importance of biochemical markers in clinical cardiology. Eur Heart J 2004;25:1187-96.

7. Dixit S, Castle M, Velu RP, Swisher L, Hodge C, Jaffe AS. Car-diac involvement in patients with acute neurologic dis-ease: confirmation with cardiac troponin I. Arch Intern Med 2000;160:3153-8.

8. Salah AK, Gharad SM, Bodiwala K, Booth DC. You can assay that again! Am J Med 2007;120:671-2.

9. Banerjee S, Linder MW, Singer I. False-positive troponin I in a patient with acute cholecystitis and positive rheumatoid fac-tor assay. Cardiology 2001;95:170-1.

10. Galambos C, Brink DS, Ritter D, Chung HD, Creer MH. False-positive plasma troponin I with the AxSYM analyzer. Clin Chem 2000;46:1014-5.

11. Plebani M, Mion M, Altinier S, Girotto MA, Baldo G, Zaninotto

Kaplan A et al. False Positive Troponin Levels due to Heterophil Antibodies in a Pregnant Woman 49

Turk J Emerg Med 2015;15(1):47-50

M. False-positive troponin I attributed to a macrocomplex. Clin Chem 2002;48:677-9.

12. Levinson SS, Miller JJ. Towards a better understanding of het-erophile (and the like) antibody interference with modern immunoassays. Clin Chim Acta 2002;325:1-15.

13. Preissner CM, Dodge LA, O’Kane DJ, Singh RJ, Grebe SK. Preva-lence of heterophilic antibody interference in eight automat-ed tumor marker immunoassays. Clin Chem 2005;51:208-10.

14. Després N, Grant AM. Antibody interference in thyroid as-

says: a potential for clinical misinformation. Clin Chem 1998;44:440-54.

15. Boscato LM, Stuart MC. Heterophilic antibodies: a problem for all immunoassays. Clin Chem 1988;34:27-33.

16. Levinson SS. Antibody multispecificity in immunoassay inter-ference. Clin Biochem 1992;25:77-87.

17. Ward G, McKinnon L, Badrick T, Hickman PE. Heterophilic an-tibodies remain a problem for the immunoassay laboratory. Am J Clin Pathol 1997;108:417-21.

50

Poisoned after Dinner: Dolma with Datura Stramonium

CASE REPORT 51

1Department of Emergency Medicine, Cukurova University, Faculty of Medicine, Adana;2Department of Emergency Clinic, Necip Fazil City Hospital, Kahranmaras;

3Department of Emergency Clinic, Kilis Government Hospital, Gaziantep, all in Turkey

Nezihat Rana DISEL,1 Mustafa YILMAZ,2 Zeynep KEKEC,1 Meryem KARANLIK3

SUMMARYDatura stramonium, which is also known as Thorn Apple or Jimson Weed, is an alkaloid containing plant that is entirely toxic. The active toxic constituents of the plant are atropine, scopolamine and hyoscyamine. It has been abused worldwide for hundreds of years because of its hallucinogenic properties. Previous reports have shown that herbal medication overdose and accidental food contamination are ways it can cause poisoning. Herein we present a family that had three of its members poisoned after eating a traditional meal “dolma” made of datura flowers. None had fatal complications and all were discharged healthy. Datura stromonium may be used accidentally as a food ingredient. Since its poisonous effects are not known, people should be informed and warned about the effects of this plant.

Key words: Anticholinergic effects; Datura stramonium; plant poisoning; rhabdomyolysis.

IntroductionDatura stramonium is an annual, leafy herbaceous plant that is a powerful hallucinogen that causes delirium. Because of this, it is often used in “love potions and witches’ brews.” Since all parts of the plant are toxic, poisoning may occur after consuming any part of the plant.[1-5] Datura causes an-ticholinergic toxicity since it contains atropine, scopolamine and hyoscyamine. The classical symptoms of poisoning are tachycardia, hyperthermia, dryness of skin and mucous membranes, reddening of skin, visual defect, speech disor-der, a decrease in intestinal sounds, urinary retention, agita-tion, disorientation and hallucination. The symptoms gener-ally occur 1-4 hours after ingestion and may continue 24-48 hours depending on gastric depletion.[6]

Dolma is a traditional Turkish meal that is made by mixing rice and small chopped vegetables with the leaves of vari-

ous green plants (generally grapevine, cabbage, pumpkin flower, etc.).

Herein we present a series of Datura stromonium poison-ing that occurred after eating dolma prepared with Datura flowers. Three patients in the same family were affected and cured successfully.

Case ReportA family was admitted to our university hospital-based Emer-gency Department (ED) with similar complaints after eating the same meal. The father had eaten nine pieces of dolma made with Datura flowers, while the mother and daughter had eaten one each. All three had anticholinergic symptoms and were managed as having anticholinergic poisoning due to herbal origination. All were discharged healthy.


Submitted: January 22, 2013 Accepted: June 02, 2014 Published online: January 25, 2015

Correspondence: Nezihat Rana DISEL, MD. Cukurova Universitesi Tip Fakultesi, Acil Tıp Anabilim Dalı, 01330 Adana, Turkey.


Presented as a poster 6th European Congress of Emergency Medicine, 12th Annual Meeting of SWESEM (October 11-14, 2010, Stockholm, Sweden).

Turk J Emerg Med 2015;15(1):51-5552

Case 1 (Mother) — A 58-year-old woman was brought to the ED with complaints of changes in consciousness, visual impairment and hallucinations. Her accompanying relatives indicated that she ate one piece of dolma made with the Datura stramonium flower six hours before the initiation of her complaints. Her past medical history revealed nothing pathologic, she did not take any ongoing medication, and she did not have allergies or substance addiction. In the first examination, her vitals were as follows: blood pressure, 110/60 mmHg; pulse rate, 124/minutes; respiration rate, 24/minute; and axillary temperature, 36.8oC. She had a Glasgow

Coma Scale (GCS) score of 12 (E4V2M6), her pupils were myd-riatic, she had tachycardia and tachypnea, her mucous mem-branes and skin were dry and red, and her bowel sounds were decreased. There were no other pathologic physical findings. Sinus tachycardia with PR interval of 0.16 seconds, a QRS duration of 0.08 seconds, and a corrected QT interval of 0.46 seconds were seen in her electrocardiogram (ECG). The patient’s laboratory results are summarized in Table 1.

The patient was assessed and diagnosed as having anticho-linergic poisoning, and therefore, proper management with airway control, oxygenation, hydration and observation

Table 1. Initial laboratory results of the patients

Normal Case 1 Case 2 Case 3 values (Mother) (Father) (Daughter)

WBC (uL) 4-10 6.2 7.0 12.6

Hgb (g/dL) 11-18 12.3 14.8 13.1

Hct (%) 37-54 33.5 41.6 37.2

Plt (uL) 150-500 176 214 263

Glucose (mg/dL) 70-105 157 143 91

AST (U/L) 0-31 33 43 17

ALT (U/L) <31 28 22 15

Amylase (U/L) 28-100 83 56 48

BUN (mg/dL) 8-25 9.5 16.9 12

Creatinine (mg/dL) 0.8-1.2 0.5 0.9 0.5

CPK (U/L) <170 160 233 157

CK-MB (ng/mL) 0.97-4.97 3.43 2.41 1.56

Troponin T (ng/mL) <0.1 <0.01 <0.01 <0.01

PTZ (sec) 11-15 12 12.8 12.7

INR 0.85-1.25 1.0 1.08 1.07

aPTT (sec) 25.3-34.6 21.7 24.7 23.5

pH 7.35-7.45 7.34 7.40 7.40

PaCO2 (mm/Hg) 35-45 43.8 34.1 38.4

PaO2 (mm/Hg) 98-100 95 98 98

HCO3- (mEq/L) 22-24 23.6 20.07 23.4

Table 2. CPK and cardiac biomarker levels of the Case 2

Day CPK (U/L) CK-MB (ng/mL) Troponine T (ng/mL)

1 233 2.41 <0.012 221 9.97 0.0013 1252 30.83 0.094 2666 34.84 0.205 1769 7.50 0.296 852 3.75 0.34

were performed. Sodium bicarbonate was started, and she had serial ECG and vitals evaluations. She was alert, her GCS score was 15, and all abnormal physical findings were re-solved on the 24th hour of hospitalization. She was observed for a total of 48 hours and discharged with full recovery.

Case 2 (Father) — A 60-year-old man was admitted to the ED with complaints of changes in consciousness, visual im-pairment and hallucinating approximately an hour after eating nine pieces of dolma that was made with the Datura stramonium flower. His medical history indicated that he had hypertension and coronary artery disease, he was on antihypertensive and salicylate medication, and he had no allergies or addiction. The patient’s vital findings were as fol-lows: blood pressure, 160/100 mmHg; pulse rate, 129/min-utes; respiration rate, 24/minutes; and axillary temperature, 38.1oC. His GCS score was 12 (E4V2M6). His physical exami-nation revealed that his pupils were mydriatic and that his mucous membranes and skin were dry and red. He had de-creased bowel sounds. In his ECG, there was a left bundle branch block and sinus tachycardia. His corrected QT inter-val was 0.48 seconds. He had rhabdomyolysis with normal urinary excretion and increased creatinephosphokinase (CPK) levels. His renal functions were normal. He was started on clindamycin due to aspiration pneumonia on the second day of hospitalization. The patient’s laboratory findings are summarized in Table 1, and his cardiac enzyme and CPK lev-els are summarized in Table 2.

This patient was assessed and diagnosed with anticholiner-gic poisoning, and therefore, proper management with air-way control, oxygenation, hydration and observation were performed. Sodium bicarbonate was started with serial ECG and evaluation of vitals. He was monitored closely because his cardiac markers were elevated. He was hospitalized for a total of 6 days and discharged with full recovery.

Case 3 (Daughter) — A 33-year-old female was transferred to the ED from an urban hospital because of visual defect and hallucinations after eating one piece of dolma that was made with the Datura stramonium flower. She was trans-ferred to our clinic since her problems did not resolve in the first hospital, where she was observed for 19 hours.

Her medical history indicated that she did not have any ill-nesses and that she was not using any medication on a continuous basis. Her vital findings were as follows: blood pressure, 140/80 mmHg; pulse rate, 110/minutes; respira-tion rate, 23/minutes; and axillary temperature, 37.5oC. Her GCS score was 15, her pupils were mydriatic, and she had tachycardia. Her skin was not red and dry, her mucous mem-branes were normal and she was not experiencing confu-sion. There was sinus tachycardia in her ECG. Her PR interval was 0.20 seconds, her QRS duration was 0.08 seconds, and

her corrected QT was 0.40 seconds. The laboratory results for this patient are summarized in Table 1.

The patient was started on hydration with normal saline and observed for 12 hours. Her physical findings returned to nor-mal and she was discharged the next day.

DiscussionDatura is one of the oldest and most frequently abused psy-choactive plant species.[7] All Datura plants contain tropane alkaloids such as scopolamine, hyoscyamine, and atropine,[6] which has led to their use in some cultures as a poison and as a hallucinogen for centuries.[8] It is widely used, especially by teenagers, for its mind altering properties, and the pre-ferred way to consume it is by smoking its leaves.[9]

A given plant’s toxicity depends on its age, its location, and the local weather conditions. Scopolamine levels are much higher in young plants. There are 24 kinds of Datura related to the Solanaceae family. Datura stramonium is also known as Thorn Apple or Jimson Weed (Şeytan Elması, Boru Otu, Tatula, Mengilik are common Turkish names for the plant). It is an alkaloid-containing plant that is entirely toxic. The plant itself is dried and used as a decorative substance in many houses in Turkey. Many people use Datura as an herbal med-ication for the flu, common cold, asthma and diarrhea, since the anticholinergic activities of the constituents can lead to symptomatic healing. The seeds of Datura stramonium appear similar to tomato seeds. They are flat, disk shaped, brown, and nearly 3 millimeters in diameter. One hundred units of seeds contain approximately 6 mg atropine, which may be fatal.[8] Half a teaspoon of Datura seeds contains ap-proximately 0.1 mg atropine, on average. Although atropine is present in all parts of the plant, the highest concentration is in the seed and the root. To our knowledge, there are no data relevant to the frequency of Datura stramonium poi-soning in our country. According to our clinical practice, Da-tura seeds or leaves are commonly consumed accidentally by children in Turkey. However, it is commonly used to treat illnesses such as the flu, common cold, asthma, diarrhea, ab-dominal or rectal pain and nocturia due to the popularity of botanical treatment.[6,10,11] Accidental poisonings due to the use of street drugs adulterated with scopolamine have been reported reported.[12]

In our cases, poisoning occurred as a result of using the Datura stramonium plant’s leaves to prepare dolma, a tra-ditional Turkish meal. Dolma is made with cabbage, grape, beet leaves or pumpkin flowers. The similar appearance of the Datura flowers and pumpkin flowers may have led to the accidental poisoning. Both are trumpet shaped, easy to fill with rice, and easy to find in nature. The patients were un-aware of the toxicity and potential fatality of the plant.

Disel NR et al. Dolma with Datura Stramonium 53

The tropane alkaloids in Datura stramonium cause anticho-linergic toxicity. Clinical features of this toxicity are both cen-tral and peripheral.[13] Red, hot and dry skin, dilated pupils and tachycardia are the most frequent clinical findings. Ir-ritability, disorientation, agitation, hallucinations, and jerks in the limbs are central features, while urinary retention, de-creased peristalsis in bowels, and hyperthermia due to de-creases in sweating are caused by a peripheral muscarinic blockade. Hyperthermia may lead to failure in all organ sys-tems, cause rhabdomyolysis, and result in liver, kidney and brain damage. Seizures, hyperthermia, wide-complex dys-rhythmias, and cardiovascular collapse are serious effects of poisoning that may cause death.[13] The blockage of sodium and potassium channels can cause dysrhythmias, and treat-ment modalities target this mechanism. Similar to treatment for other overdoses, management of this condition includes maintaining airway patency and circulation, monitoring of vitals and urinary output, observation, and supportive care as a whole. Within the first hour of ingestion, gastric lavage and activated charcoal administration are suggested, as mul-tidose activated charcoal is said to be effective in patients with dysmotility. Benzodiazepines are used to control agi-tation and can decrease hyperthermia, rhabdomyolysis and traumatic injuries. Arrhythmias are controlled with sodium bicarbonate boluses and infusions. Physostigmine, a cho-linesterase inhibitor, is suggested by some authors for cases with severe delirium.[13] None of our patients had intractable agitation or delirium, and we did not need any cholinergic agents for their treatment. Sodium bicarbonate was started in cases 1 and 2 (the mother and father).

There are many cases of Datura poisoning in the literature. J. Russel et al reported that six members of the same fam-ily who ate homemade stew that included Datura devel-oped anticholinergic toxidrome. Two of these patients had increased CPK levels.[14] In addition, Ertekin et al reported that fulminant hepatitis and rhabdomyolysis occurred in an 8-year-old child who ate Datura leaves. The patient’s hepatic enzyme levels also increased, but they returned to normal ten days later.[15] In 2007, Diker et al. reported that rhabdomy-olysis occurred in two cases after drinking tea that was made with Datura Stromonium, and the CPK levels of one of the patients reached 6694 U/L. This patient underwent fatal met-abolic acidosis.[16] In a 2008 study published by Wiebe et al, delirium developed in four patients due to Datura stramoni-um poisoning, and rhabdomyolysis occurred in one of those patients whose CPK level was 1338 U/L.[17] In our second case (father), the increase in CPK indicated rhabdomyolysis. The patient’s hepatic and renal functions were normal. The pres-ence of sinus tachycardia, left bundle block, aspiration pneu-monia and rhabdomyolysis prolonged his duration of hospi-talization, and his symptoms of Datura poisoning were more distinctive. However, he recovered with suitable treatment.

In conclusion, Datura Stromonium may be accidentally used as a food ingredient. Since its poisonous effects are not known to the public, they should be informed and warned. Ingestion of this plant can cause not only anticholinergic toxicity, but also the deterioration of cerebral functions, serious liver tox-icity, cardiac conduction problems and decline in renal func-tions due to rhabdomyolysis. Public awareness is needed to prevent severe poisoning, morbidity and mortality.



References1. Dugan GM, Gumbmann MR, Friedman M. Toxicological evalu-

ation of jimson weed (Datura stramonium) seed. Food Chem Toxicol 1989;27:501-10.

2. Greene GS, Patterson SG, Warner E. Ingestion of angel’s trum-pet: an increasingly common source of toxicity. South Med J 1996;89:365-9.

3. Ramirez M, Rivera E, Ereu C. Fifteen cases of atropine poison-ing after honey ingestion. Vet Hum Toxicol 1999;41:19-20.

4. Pereira CA, Nishioka Sde D. Poisoning by the use of Datura leaves in a homemade toothpaste. J Toxicol Clin Toxicol 1994;32:329-31.

5. Chang SS, Wu ML, Deng JF, Lee CC, Chin TF, Liao SJ. Poison-ing by Datura leaves used as edible wild vegetables. Vet Hum Toxicol 1999;41:242-5.

6. Vanderhoff BT, Mosser KH. Jimson weed toxicity: manage-ment of anticholinergic plant ingestion. Am Fam Physician 1992;46:526-30.

7. Baker JR, Lee A, Ballent C. The Encyclopedia of physchoactive plants. Park Street Press 2005 ISBN 978-0-89281-978-2, trans-lation of Rätsch C. Enzyklopedia der Psychoactiven Pflanzen. AT Verlag Aarau/Switzerland 1998.

8. Boumba VA, Mitselou A, Vougiouklakis T. Fatal poisoning from ingestion of Datura stramonium seeds. Vet Hum Toxicol 2004;46(2):81-2.

9. Guharoy SR, Barajas M. Atropine intoxication from the inges-tion and smoking of jimson weed (Datura stramonium). Vet Hum Toxicol 1991;33:588-9.

10. Bildik F, Kahveci O, Aygencel G, Keleş A, Demircan A, Aksel G, et al. Two Herbal Poisoning Cases From Turkey; Datura For Haemorrhoidal Pain Relief, Mandragora For Aphrodisiac Ef-fect. AKATOS 2011;2:18-21.

11. Işıkay S. Datura Stramonium Intoxication: A Case Report. AKA-TOS 2011;2:26-8.

12. Hamilton RJ, Perrone J, Hoffman R, Henretig FM, Karkevan-dian EH, Marcus S, et al. A descriptive study of an epidemic of poisoning caused by heroin adulterated with scopolamine. J Toxicol Clin Toxicol 2000;38:597-608.

13. Wax PM, Young AC. Anticholinergics. In: Tintinalli JE, Stapc-zynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, editors. Tintinalli’s emergency medicine: a comprehensive study

Turk J Emerg Med 2015;15(1):51-5554

guide. 7th ed. New York, NY: McGraw-Hill; 2011. p. 1305-8.14. Centers for Disease Control and Prevention (CDC). Jimson-

weed poisoning associated with a homemade stew - Mary-land, 2008. MMWR Morb Mortal Wkly Rep 2010;59:102-4.

15. Ertekin V, Selimoğlu MA, Altinkaynak S. A combination of un-usual presentations of Datura stramonium intoxication in a child: rhabdomyolysis and fulminant hepatitius. J Emerg Med

2005;28:227-8.16. Diker D, Markovitz D, Rothman M, Sendovski U. Coma as a

presenting sign of Datura stramonium seed tea poisoning. Eur J Intern Med 2007;18:336-8.

17. Wiebe TH, Sigurdson ES, Katz LY. Angel’s Trumpet (Datura stra-monium) poisoning and delirium in adolescents in Winnipeg, Manitoba: Summer 2006. Paediatr Child Health 2008;13:193-6.

Disel NR et al. Dolma with Datura Stramonium 55

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