Table of Content

15 September 2016, Volume 7 Issue 3

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Review Article

Neutrophil-to-lymphocyte ratio in occlusive vascular diseases: the literature review of the past 10 years

Egemen Küçük, İbrahim Kocayiğit, Candan Günel, Hasan Düzenli

2016, 7(3):  165-172.  doi:10.5847/wjem.j.1920-8642.2016.03.001

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BACKGROUND: This study aims to evaluate the results of studies investigating neutrophil-to-lymphocyte ratio (NLR) and to identify the prognostic and diagnostic value of NLR in occlusive vascular diseases.
METHODS: With the aim of identifying the studies related to NLR, a search was performed on http://www.ncbi.nlm.nih.gov/pubmed by using the key words "neutrophil lymphocyte ratio" between January 2005 and December 2014. All of the original articles were evaluated according to date of publications, countries, clinics and topics. Studies about occlusive vascular diseases were evaluated according to their qualifications, review methods and results. SPSS for Windows 16.0 was used in data analysis and data were expressed as mean, standard deviation and percentage.
RESULTS: A total of 735 original research articles were investigated. The number of publications have shown a regular logarithmic increase over the years. Thirty-two percent of all publications were performed by clinics in Turkey and 56.4% were performed by general-oncological surgery and cardiology clinics. A total of 107 publications were identified to be about occlusive vascular diseases, 80.3% of these publications were found to be prognostic and 19.6% to be diagnostic, 82.2% of them were found to be planned as retrospective and 17.7% as prospective. In 95.3% of prognostic publications, there was a positive correlation between high NLR values at admission and poor prognosis. In 95.3% of diagnostic publications high NLR values at admission were identified to be significant diagnostically.
CONCLUSION: Elevated neutrophil-to-lymphocyte ratio at admission, could be used as a diagnostic and/or prognostic parameter in occlusive vascular diseases.

Original Article

Prospective evaluation of point-of-care ultrasound for pre-procedure identification of landmarks versus traditional palpation for lumbar puncture

Shadi Lahham, Priel Schmalbach, Sean P. Wilson, Lori Ludeman, Mohammad Subeh, Jocelyn Chao, Nadeem Albadawi, Niki Mohammadi, John C. Fox

2016, 7(3):  173-177.  doi:10.5847/wjem.j.1920-8642.2016.03.002

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BACKGROUND: The objective of this study is to determine if point-of-care ultrasound (POCUS) pre-procedure identification of landmarks can decrease failure rate, reduce procedural time, and decrease the number of needle redirections and reinsertions when performing a lumbar puncture (LP).
METHODS: This was a prospective, randomized controlled trial comparing POCUS pre-procedure identification of landmarks versus traditional palpation for LP in a cohort of patients in the emergency department and intensive care unit.
RESULTS: A total of 158 patients were enrolled. No significant difference was found in time to completion, needle re-direction, or needle re-insertion when using POCUS when compared to the traditional method of palpation.
CONCLUSION: Consistent with findings of previous studies, our data indicate that there was no observed benefit of using POCUS to identify pre-procedure landmarks when performing an LP.

Point-of-care ultrasound versus radiology department pelvic ultrasound on emergency department length of stay

Sean P. Wilson, Kiah Connolly, Shadi Lahham, Mohammad Subeh, Chanel Fischetti, Alan Chiem, Ariel Aspen, Craig Anderson, John C. Fox

2016, 7(3):  178-182.  doi:10.5847/wjem.j.1920-8642.2016.03.003

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BACKGROUND: The study aimed to compare the time to overall length of stay (LOS) for patients who underwent point-of-care ultrasound (POCUS) versus radiology department ultrasound (RDUS).
METHODS: This was a prospective study on a convenience sample of patients who required pelvic ultrasound imaging as part of their emergency department (ED) assessment.
RESULTS: We enrolled a total of 194 patients who were on average 32 years-old. Ninety-eight (51%) patients were pregnant (<20 weeks). Time to completion of RDUS was 66 minutes longer than POCUS (95%CI 60-73, P<0.01). Patients randomized to the RDUS arm experienced a 120 minute longer ED length of stay (LOS) (95%CI 66-173, P<0.01)
CONCLUSION: In patients who require pelvic ultrasound as part of their diagnostic evaluation, POCUS resulted in a significant decrease in time to ultrasound and ED LOS.

Emergency department use among patients from residential aged care facilities under a Hospital in the Nursing Home scheme in public hospitals in Queensland Australia

Bill Lukin, Li-jun Fan, Jing-zhou Zhao, Jian-dong Sun, Kaeleen Dingle, Rhonda Purtill, Sam Tapp, Xiang-yu Hou

2016, 7(3):  183-190.  doi:10.5847/wjem.j.1920-8642.2016.03.004

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BACKGROUND: Hospital emergency department (ED) use by patients from residential aged care facilities (RACFs) is not always appropriate, and this calls for interventions to avoid some unnecessary uses. This study aims to compare patterns of ED use by RACF patients with and without a Hospital in the Nursing Home (HiNH) program.
METHODS: RACF patients presenting to EDs of a hospital with and a hospital without this program during pre- and post-intervention periods were included. Data on patient demographics and ED presentation characteristics were obtained from the Emergency Department Information System database, and were analysed by descriptive and comparative statistics.
RESULTS: In both hospitals, most RACF residents presenting to EDs were aged between 75-94 years, female, triaged at scale 3 to 5, and transferred on weekdays and during working hours. Almost half of them were subsequently admitted to hospitals. In accordance with the ICD-10-AM diagnostic coding system, diagnoses that consistently ranked among the top three reasons for visiting the two hospitals before and after intervention included Chapter XIX: injury and poisoning and Chapter X: respiratory diseases. Associated with the intervention, significant decreases in the numbers of presentations per 1 000 RACF beds were identified among patients diagnosed with Chapter XI: digestive diseases [rate ratio (95%CI): 0.09 (0.04, 0.22); P<0.0001] and Chapter XXI: factors influencing health status and contact with health services [rate ratio (95%CI): 0.22 (0.07, 0.66); P=0.007].
CONCLUSION: The HiNH program may reduce the incidence of RACF residents visiting EDs for diagnoses of Chapter XI and Chapter XXI.

Acute care needs in an Indian emergency department: A retrospective analysis

Elizabeth G. Clark, Jessica Watson, Allison Leemann, Alan H. Breaud, Frank G. Feeley III, James Wolff, Tamorish Kole, Gabrielle A. Jacquet

2016, 7(3):  191-195.  doi:10.5847/wjem.j.1920-8642.2016.03.005

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BACKGROUND: Emergencies such as road traffic accidents (RTAs), acute myocardial infarction (AMI) and cerebrovascular accident (CVA) are the most common causes of death and disability in India. Robust emergency medicine (EM) services and proper education on acute care are necessary. In order to inform curriculum design for training programs, and to improve the quality of EM care in India, a better understanding of patient epidemiology and case burden presenting to the emergency department (ED) is needed.
METHODS: This study is a retrospective chart review of cases presenting to the ED at Kerala Institute of Medical Sciences (KIMS), a private hospital in Trivandrum, Kerala, India, from November 1, 2011 to April 21, 2012 and from July 1, 2013 to December 21, 2013. De-identified charts were systematically sampled and reviewed.
RESULTS: A total of 1 196 ED patient charts were analyzed. Of these patients, 55.35% (n=662) were male and 44.7% (n=534) were female. The majority (67.14%, n=803) were adults, while only 3.85% (n=46) were infants. The most common chief complaints were fever (21.5%, n=257), renal colic (7.3%, n=87), and dyspnea (6.9%, n=82). The most common ED diagnoses were gastrointestinal (15.5%, n=185), pulmonary (12.3%, n=147), tropical (11.1%, n=133), infectious disease and sepsis (9.9%, n=118), and trauma (8.4%, n=101).
CONCLUSION: The patient demographics, diagnoses, and distribution of resources identified by this study can help guide and shape Indian EM training programs and faculty development to more accurately reflect the burden of acute disease in India.

Emergency medicine as a growing career in Iran: an Internet-based survey

Shervin Farahmand, Ehsan Karimialavijeh, Hojjat Sheikh Mottahar Vahedi, Amirhossein Jahanshir

2016, 7(3):  196-202.  doi:10.5847/wjem.j.1920-8642.2016.03.006

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BACKGROUND: In Iran, few studies have evaluated emergency medicine as a career option. In the present study, we aimed to find out how Iranian emergency-medicine specialists view their specialty as a career.
METHODS: Following a qualitative study, a Likert-scale questionnaire was developed. Iranian emergency physician specialists who had at least two years' job experience were contacted via email. A uniform link to a Web-based survey and a cover letter that explained the survey were sent to the recipients. We used the Kruskal-Wallis test and post hoc analysis to determine the differences between demographic subgroups.
RESULTS: A total of 109 eligible responses were received, a response rate of 72.63%. Of the responders, 57.8% were 30-40 years of age, 86.2% were male, 86.2% were single, 84.4% were faculty members and 90.8% had fewer than 10 years' job experience. The main problems occurring during the career of Iranian emergency physicians were: insufficient income, inadequate recognition of the specialty by the community, inadequate union support, insecurity in the emergency wards, overcrowding, job stresses and night shifts. Despite insufficiency of income, Iranian emergency physicians (EPs) did not care about the financial benefits of patient care. Academic activity had positive effects on the perspectives of Iranian emergency physicians regarding their careers.
CONCLUSION: Iranian emergency physicians and leaders in emergency medicine should struggle to improve the present situation, aiming at an ideal state.

Evaluation of factors affecting psychological morbidity in emergency medicine practitioners

Mehdi Momeni, Farshid Fahim, Elnaz Vahidi, Amir Nejati, Morteza Saeedi

2016, 7(3):  203-207.  doi:10.5847/wjem.j.1920-8642.2016.03.007

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BACKGROUND: Assessing and evaluating mental health status can provide educational planners valuable information to predict the quality of physicians' performance at work. These data can help physicians to practice in the most desired way. The study aimed to evaluate factors affecting psychological morbidity in Iranian emergency medicine practitioners at educational hospitals of Tehran.
METHODS: In this cross sectional study 204 participants (emergency medicine residents and specialists) from educational hospitals of Tehran were recruited and their psychological morbidity was assessed by using a 28-question Goldberg General Health Questionnaire (GHQ-28). Somatization, anxiety and sleep disorders, social dysfunction and depression were evaluated among practitioners and compared to demographic and job related variables.
RESULTS: Two hundreds and four participants consisting of 146 (71.6%) males and 58 (28.4%) females were evaluated. Of all participants, 55 (27%) were single and 149 (73%) were married. Most of our participants (40.2%) were between 30-35 years old. By using GHQ-28, 129 (63.2%) were recognized as normal and 75 (36.8%) suffered some mental health disorders. There was a significant gender difference between normal practitioners and practitioners with disorder (P=0.02) while marital status had no significant difference (P=0.2). Only 19 (9.3%) declared having some major mental health issue in the previous month.
CONCLUSION: Females encountered more mental health disorders than male (P=0.02) and the most common disorder observed was somatization (P=0.006).

Code Blue evaluation in children's hospital

Kubra Evren Sahin, Oktay Zeki Ozdinc, Suna Yoldas, Aylin Goktay, Selda Dorak

2016, 7(3):  208-212.  doi:10.5847/wjem.j.1920-8642.2016.03.008

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BACKGROUND: True alarm rate of the Code Blue cases is at a low level in the Dr. Behçet Uz Children's Hospital in İzmir. This study aims to analyse the use of the Code Blue alarm cases in the children's hospital.
METHODS: This retrospective clinical study evaluated the age and the gender of the cases, the arriving time of the Code Blue team, the date and time of the Code Blue Call, the reasons of the Code Blue Call, and the verification which were all obtained from the Code Blue forms of the hospital dated between January 2014 and January 2015. The data of 139 Code Blue cases' forms were investigated and was divided into two groups: before and after the education containing 88 and 51 cases, respectively.
RESULTS: Conversive disorder (26% to 13%, P<0.01), syncope (21.5% to 19.6%, P<0.01), convulsion (17% to 13.7%, P<0.01), hypoglycemia (4.5% to 3.9%, P<0.01), anxiety (4.5% to 1.9%, P<0.01), head trauma due to syncope (4.5% to 0%), cardiac arrest (1.1% to 0%), respiratory difficulties (2.2% to 1.9%, P<0.01), suspicion of myocardial infarction (2.2% to 1.9%, P<0.01), fall from stairs (2.2% to 0%) and agitation cases (1.1% to 0%) were reduced, however, the hypertension cases were dramatically increased (3.4% to 29.4%, P<0.01) owing to the hospital staff's education. The Pearson's correlation coefficient before and after education was 0.837. About 97.8% of the Code Blue cases were false calls with female greater than male (P<0.01).
CONCLUSION: The results of this study show that more education is required for the hospital's staff and a new color code that is to say pre-diagnosis team should be formed.

Geospatial and clinical analyses on pediatric related road traffic injury in Malaysia

Nik Hisamuddin Rahman, Ruslan Rainis, Syed Hatim Noor, Sharifah Mastura Syed Mohamad

2016, 7(3):  213-220.  doi:10.5847/wjem.j.1920-8642.2016.03.009

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BACKGROUND: The main aim of this study is to utilize the geographical information system (GIS) software and perform the spatial analysis in relation to clinical data for road traffic injury (RTI) pediatric cases attending the emergency department.
METHODS: The study sample included pediatric patients (age less than 18 years) with road-related injuries within a district in Malaysia who attended emergency departments of two tertiary hospitals within the district. In addition to injury, pre-hospital care and outcome data, the coordinate of the locations were obtained by the ambulance paramedics by using portable handheld GPS unit brand Garmin^® model GPS 72 H. The data was transferred into the excel format which in turn underwent GIS analysis by using ARCGIS^® (by ESRI) software version 10.1 licensed to the study institution.
RESULTS: A total of 102 (24.8%) of all motor vehicle crash (MVC) victims involved the pediatric age group (age 18 years and below). The mean (SD) age of the pediatric victims was 14.30 years (SD 3.830). Male comprised of 68 (66.7%) of the cases. Motorcyclists [88 (88.0%)] were the most common type of victims involved. Interestingly, the majority of the severely injured victims [75 (73%)] sustained the RTI on roads with maximum speed limit of 60 km/hour. The mean (SD) length of hospital stay was 7.83 days (5.59).
CONCLUSION: The pediatric related road traffic injury in Malaysia causes significant health and social burden in the country. This study showed both important clinical and geographical factors that need to be taken into consideration for future preventive action.

Outcome of application of primary versus secondary Illizarov's fixator in open tibial shaft fractures

Anil Joshi, Saurabh Singh, Sudeep Jain, Narender Rohilla, Vivek Trikha, Chandra Yadav

2016, 7(3):  221-226.  doi:10.5847/wjem.j.1920-8642.2016.03.010

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BACKGROUND: The present study aimed to compare outcome of primary and secondary Illizarov's fixator application as a treatment method for type III open tibial fractures in terms of non-union and wound infection.
METHODS: This prospective study was done in a tertiary care center. Forty-eight type III tibial fractures were treated with Illizarov's apparatus between 2008 and 2011. The patients were divided into two groups depending on the treatment protocol, timing of wound closure and Illizarov's application, primary (n=28) and secondary (n=20).
RESULTS: In the primary group, healing was achieved in all 28 patients. The median time to recovery was 24 weeks, and the median number of operations was 3. There were 6 patients with a bone defect. In the secondary group, complete recovery was achieved in 18 out of 20 patients. The median time to recovery was 30 weeks, and the median number of operations 5. There were 9 patients with a bone defect. The median time to recovery and the number of operations were significantly smaller in patients undergoing primary operation. Union was 100% in the primary group and more than 95% in the secondary group. Chronic osteomyelitis persisted in one patient and below amputation was done in one patient in the secondary group.
CONCLUSION: Primary wound closure and Illizarov's fixation required a smaller number of operations and shorter time to recovery than secondary wound closure and Illizarov's fixation, mostly due to a significantly less number of patients with a bone defect in the primary group.

Urgent tracheostomy: four-year experience in a tertiary hospital

Liliana Costa, Ricardo Matos, Sara Júlio, Fernando Vales, Margarida Santos

2016, 7(3):  227-230.  doi:10.5847/wjem.j.1920-8642.2016.03.011

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BACKGROUND: Urgent airway management is one of the most important responsibilities of otolaryngologists, often requiring a multidisciplinary approach. Urgent surgical airway intervention is indicated when an acute airway obstruction occurs or there are intubation difficulties. In these situations, surgical tracheostomy becomes extremely important.
METHODS: We retrospectively studied the patients who underwent surgical tracheostomy from 2011 to 2014 by an otolaryngologist team at the operating theater of the emergency department of a tertiary hospital. Indications, complications and clinical evolution of the patients were reviewed.
RESULTS: The study included 56 patients (44 men and 12 women) with a median age of 55 years. The procedure was performed under local anesthesia in 21.4% of the patients. Two (3.6%) patients were subjected to conversion from cricothyrostomy to tracheostomy. Head and neck neoplasm was indicated in 44.6% of the patients, deep neck infection in 19.6%, and bilateral vocal fold paralysis in 10.7%. Stridor was the most frequent signal (51.8%). Of the 56 patients, 15 were transferred to another hospital. Among the other 41 patients, 21 were decannulated (average time: 4 months), and none of them were cancer patients. Complications occurred in 5 (12.2%) patients: hemorrhage in 3, surgical wound infection in 1, and cervico-thoracic subcutaneous emphysema in 1. No death was related to the procedure.
CONCLUSION: Urgent tracheostomy is a life-saving procedure for patients with acute airway obstruction or with difficult intubation. It is a safe and effective procedure, with a low complication rate, and should be performed before the patient's clinical status turns into a surgical emergency situation.

Clinical Images

Infective endocarditis as a rare cause for acute limb ischemia

George Galyfos, Sotirios Giannakakis, Stavros Kerasidis, Georgios Geropapas, Georgios Kastrisios, Gerasimos Papacharalampous, Chrisostomos Maltezos

2016, 7(3):  231-233.  doi:10.5847/wjem.j.1920-8642.2016.03.012

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Cerebral venous thrombosis presenting with headache only and misdiagnosed as subarachnoid hemorrhage

Aslihan Yuruktumen Unal, Ali Unal, Erkan Goksu, Savas Arslan

2016, 7(3):  234-236.  doi:10.5847/wjem.j.1920-8642.2016.03.013

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