Journal of Acute Disease

1–8

Authors: Adam Miklos Feher, Zoltan Bajory

Testicular torsion (TT) is a severe acute urological emergency caused by twisting of the spermatic cord. It requires prompt diagnosis and treatment. Unfortunately, its importance is still underestimated in everyday life: early-detected TT can be cured in almost every case, whereas late identification may lead to loss of the testicles. We present a comprehensive review of TT, including the aetiology, risk factors, diagnosis, treatment and outcome, based on recently published articles. The novel and the major controversial aspects of this topic are highlighted. The PubMed and ScienceDirect databases were searched with the following keywords: TT, torsion of the spermatic cord and acute scrotum, particular stress being placed on articles published in the last 5 years. The genetic aspects of TT are discussed, together with the diagnostic possibilities, such as sonography, radionuclide and fluorescent imaging techniques. The effective surgical techniques and potential drugs for reducing molecular injuries were surveyed. Finally, the major controversial aspects of TT are considered. The new concepts of TT demonstrate that certain features remain unclear. New, more accurate diagnostic tools and prompt management may contribute to a better prognosis and prevent the loss of the testicles.

16–21

Authors: Ionut Negoi, Sorin Paun, Bogdan Stoica, Ioan Tanase, Mihaela Vartic, Ruxandra Irina Negoi, Sorin Hostiuc, Mircea Beuran

Major abdominal trauma, both blunt and penetrating, is commonly seen nowadays, being particularly difficult to manage due to the frequent altered mental status of the patients and severity of associated injuries. The review article aims to make an uptodate study of the current strategies for therapeutic approach of abdominal injuries in polytrauma setting. Review of the medical literature is up to 2015, by using the PubMed/Medline, Science Direct, Cochrane Library and Web of Science databases. We have used different combinations of the keywords of “abdominal trauma”, “liver”, “spleen”, “renal”, to review the reference list of retrieved articles for further relevant studies. Nowadays, we are facing a major change in abdominal trauma therapeutic approach, due to the continuous extending indications and very high successful rate of selective nonoperative management, completed or not with minimally invasive techniques like angiography and angiographic embolization. New imaging methods offer a high-quality characterization of solid organ injuries, being a secure support for decision algorithm in polytrauma patients. After a continuous decrease in number of laparotomies for trauma, new techniques should be developed for maintaining and developing the trauma surgeons' skills. According to the current standards, for a low morbidity and mortality, the trauma patients may be approached by a multidisciplinary and experienced trauma team. Even if nonoperative management is continuously expanding, this may be applied only by a trained and skillful trauma surgeon, who is able to perform difficult surgical techniques at any moments.

29–36

Authors: Ines Anselmo da Costa, Bastian Amend, Arnulf Stenzl, Jens Bedke

Renal injury occurs in 1%–5% of all traumas, causing disability or even death. The American Association for the Surgery of Trauma (AAST) renal injury scale should be used when injuries are reported. Although there is a consensus regarding handling of lower-grade injuries conservatively, the same cannot be said for the higher-grades, for which different specialists handle either conservatively or surgically. A search of the MEDLINE database was undertaken by using the following filters: English language articles, full-text availability, last five years, humans. Pediatric studies were excluded. For most renal injuries in hemodynamically stable, patients can be safely handled conservatively. An organized assessment and treatment system can reduce the need for nephrectomy in most other cases, as has occurred in the last two decades. The AAST injury scale should be updated in light of the advancements in imaging techniques, in order to fine tune grading and treatment.

41–45

Authors: Kholoud Kahime, Samia Boussaa, Abderrahmane Laamrani-El Idrissi, Haddou Nhammi, Ali Boumezzough

Objective: To describe and compare the epidemiological features of anthroponotic cutaneous leishmaniasis (ACL) caused by Leishmania tropica, and zoonotic cutaneous leishmaniasis (ZCL) due to Leishmania major in Morocco. Methods: We performed a retrospective study of ZCL and ACL cases reported during the last ten years in Morocco (2004–2013). Epidemiological data were analyzed by using Pearson's correlation method as well as Tukey test and digital maps were produced for incidence repartition calculated by using ArcMap GIS version 10. Results: A total of 41 656 cases of cutaneous leishmaniasis were notified between 2004 and 2013 in Morocco. The mean incidence was 139 cases/100 000 population/10 years and it was significantly higher in 2010. In the spatial context, ACL form was the most common in Morocco, while ZCL was the most important in terms of the number of reported cases. For both forms, the highest incidence occurred in females and children (0– 14 years). When analyzed according to the number of cases in each province, Errachidia (8 728 cases) and Azilal (3 523 cases) were the most affected by ZCL and ACL, respectively, while the highest incidence was noted in Zagora (231 cases/100 000 population/10 years) and in Chichaoua (97 cases/100 000 population/10 years), for ZCL and ACL, respectively. Maps of incidence repartition were performed to identify the risk area of ZCL and ACL. Conclusions: ZCL and ACL are still major health problems in Morocco. We highlight the spatiotemporal change of cutaneous leishmaniasis incidence through the country during the last ten years and we underline the correlation between ZCL incidence and the percentage of rural population in Morocco.

51–58

Authors: Chiedozie Onyejiaka Ibegbulem, Paul Chidoka Chikezie, Ezeikel Chinemerem Dike

Objective: To ascertain the functional integrity of renal and hepatic tissues of Wistar rats fed with processed cocoa bean-based beverages and raw cocoa bean products-containing diets by using biochemical and histological methods. Methods: Thirty Wistar rats were designated on the basis of experimental diets which were given for 28 days. At the end of the feeding period, blood samples were drawn, and renal and hepatic tissues were excised from the experimental rat groups for functional tests and histological examinations, respectively. Results: Serum alanine aminotransferase activities of the experimental rat groups showed no significant difference (P > 0.05) and were within a relatively narrow range of (32.17 ± 4.98) IU/L to (41.00 ± 10.85) IU/L, whereas serum aspartate aminotransferase activities gave wide variation within the range of (15.67 ± 2.13) IU/L to (34.83 ± 8.31) IU/L with P < 0.05. Serum bilirubin concentrations of experimental rat groups were less than 1 mg/dL. Serum total protein and albumin concentrations varied within a relatively narrow range. Serum creatinine concentration was significantly lower (P < 0.05) than serum urea concentration. Histology showed evidence of moderate disarrangement of hepatic tissue architecture and degenerated tubules as well as glomerular turfs. Conclusions: The pattern of alanine aminotransferase activity being more active than aspartate aminotransferase one in serum appeared to correlate with the extent of disarrangement of hepatic tissue architecture. The experimental rat groups exhibited no hyperbilirubinemia. Also, diets containing processed cocoa bean and raw cocoa bean products did not substantially interfere with the capacity of the hepatocytes to biosynthesize plasma proteins and the functionality of renal tissues.

62–70

Authors: Janet Mobolaji Olaniyan, Hadiza Lami Muhammad, Hussaini Anthony Makun, Musa Bola Busari, Abubakar Siddique Abdullah

Objective: To evaluate the acute and sub-acute toxicity of aqueous and methanol extracts of Nelsonia campestris (N. campestris) in rats. Methods: Acute oral toxicity study of aqueous and methanol extracts was carried out by administration of 10, 100, 1 000, 1 600, 2 900 and 5 000 mg/kg body weight of N. campestris extracts to rats in the respective groups. Sub-acute toxicity study was conducted by oral administration of the extracts at daily doses of 100, 300 and 600 mg/kg body weight to another group of rats for 28 days, while rats in the control group received 0.5 mL of normal saline. Results: The LD50 of the N. campestris extracts in rats was determined to be greater than 5 000 mg/kg body weight. There was no significant difference (P > 0.05) between the test groups administered with aqueous and methanol extracts in relation to the control group for serum electrolytes (Na+, K+, Cl−, HCO3−), serum albumin, total and conjugated bilirubin. Similarly, mean organ-to-body weight ratio and all haematological parameters (white blood cell, red blood cell, mean cell volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, packed cell volume) evaluated were not significantly different (P > 0.05) from the control. There was a significant increase (P < 0.05) in the activity of serum liver enzymes (aspartate aminotransferase, alkaline phosphatase), serum urea and creatinine of rats administered with 300 and 600 mg/kg body weight of the aqueous extract. Methanol and aqueous extracts at 600 mg/kg body weight resulted in a significant increase (P < 0.05) in serum urea and total protein, respectively. The activity of serum alanine aminotransferase decreased significantly (P < 0.05) when the rats received 100 and 300 mg/kg body weight of both extracts. Histopathological examination revealed mild to moderate hepatic and cortical necrosis of liver and kidney respectively on administration of both extracts at 100 and 600 mg/kg body weight. A moderate dose of 300 mg/kg body weight of the aqueous and methanol extracts caused lymphocytic infiltration and portal congestion, respectively. Conclusions: Intake of high doses of this plant extracts may exhibit mild organ toxicity.

77–78

Authors: Sora Yasri, Viroj Wiwanitkit

Quinine is a classical antimalarial drug that is used worldwide. It is also used for preexposure of malaria before visiting to the jungle in the endemic area of malaria. In this article, the authors reported a case of acute allergic reaction to oral quinine for malarial prevention.

83–85

Authors: Federico Bianchi, Quintino Giorgio D'Alessandris, Roberto Pallini, Eduardo Fernandez, Liverana Lauretti

The authors reported on a 63-year-old diabetic male who developed a strange wandering hemiparesis affecting first left side and then right side, not consistent with a right parasagittal meningioma nor with ischemic stroke. The subsequent rapid worsening of clinical picture, with occurrence of paraparesis, urinary incontinence and midthoracic sensory level, together with the evidence of leucocytosis, led to the diagnosis of a T6-T7 spondylodiscitis with spinal cord compression. The authors underlied the difficulties in diagnosing this condition in the setting of general hospital practice and the importance of clinical and neurological examination.

259-265

Authors: Remon Keriakos, Deepa Gopinath

Obstetric anal sphincter injuries can be associated with significant short and long term consequences causing devastating impacts on the quality of lives of young, otherwise healthy women. The major consequence is anal incontinence which may be short or long term and vary in severity. The other consequences include pain, infection, dyspareunia and sexual dysfunction. This may in turn result in considerable economic burden to health care providers and patients. It also has an implication on future deliveries. Although it can never be eliminated, it can be reduced by improving practice, training and provision of high quality multidisciplinary care in order to reduce long-term morbidity. Obstetric anal sphincter injuries are also a source of litigation which can be distressing to both patients and clinicians. The aim of this review article is to explore the available evidence on epidemiology, strategies for preventions, prognosis and also how to deal with governance issues.

274-276

Authors: Alaa Al Amiry

Methicillin-resistant Staphylococcus aureus (MRSA) is a serious nosocomial infection within healthcare settings, and with its community version worldwide (i.e. communityacquired-MRSA), it is safe now to classify it as an epidemic. The aim of this paper is to build the logic for the reader to understand why this drug-resistant infection can impose an occupational hazard towards emergency health services personnel in the prehospital settings. This logic started with a model, the author conceptualizes as a cross-transmission continuum, in which the author explains the role of emergency medical service personnel in possibly contributing to the transmission of MRSA back and forth the community. A solution to interrupt this continuum, particularly surveillance systems within the emergency medical service field, is suggested and discussed. This is especially important in the light of bioterrorism as surveillance can become a necessity in preparation for biological disasters whether they are intentional (i.e. bioterrorism) or natural (i.e. outbreaks).

280-286

Authors: Sibilla Focchi, Alberto Carrara, Ettore Contessini Avesani

Objective: To analyse the development of the medical and surgical treatment of acute diverticulitis to develop an appropriate decision-making algorithm. Methods: We analysed the demographic characteristics, radiological images, disease severity, treatments and surgical outcomes of all of the patients with a diagnosis of acute diverticulitis admitted to the Department of General and Emergency Surgery between 1 January 2009 and 30 June 2014. Results: During the 66-month study period, 219 patients with acute diverticulitis attended our department; 69% had simple diverticulitis (93% were treated conservatively and 7% surgically) and 31% had complicated diverticulitis (76% were treated surgically and 24% conservatively). Of the patients who were treated surgically, 62.5% underwent primary resection with anastomosis, 31.94% Hartmann's procedure, and 5.56% laparoscopic lavage and drainage. Conclusions: Our cases and a careful review of the literature allowed us to develop a decision-making algorithm for patients with acute diverticulitis.

292-297

Authors: Mohammad-Hossein Feiz-Haddad, Hamid Kassiri, Niusha Kasiri, Assiae Panahandeh, Masoud Lotfi

Objective: To evaluate the cutaneous leishmaniasis prevalence in Shadegan County, Iran, during 2007–2009. Methods: This is a descriptive research which concentrates on the 100 patients who we referred to the Shadegan Health Center. The disease was diagnosed based on clinical exam and microscopic observation of the parasites in the lesion site. The patients' data were recorded. The statistics have examined the various epidemiological aspects of the disease by considering descriptive indices such as gender, age, occupation, month and seasonal distribution, number and site of the lesions. Information analysis was performed using SPSS software. Results: Overall, 100 cases consisting of 32 females (32%) and 68 males (68%) were examined for the presence of active ulcers. Most of the infection was in age group 11–20 years (31%) and the lowest in 31–40 years group (7%). Most of the active ulcers were on the feet (42%). The majority (47%) had one lesion. Most of the cases (42%) had occurred during 2007. All cases were observed in the rural areas. Conclusions: This study showed that the male sex and people under 20 years of age are mostly at risk. Therefore, education for groups at risk is very important.

305-308

Authors: Mustafa Karabacak, Kenan Ahmet Turkdogan, Abuzer Coskun, Orhan Akpinar, Ali Duman, Mucahit Kapci, Sevki Hakan Eren, Pınar Karabacak

Objective: To investigate neutrophil–lymphocyte ratio (NLR), which is an indicator of systemic inflammation, in patients with carbon monoxide (CO) poisoning. Methods: We included 528 patients (275 women) who presented with a diagnosis of CO poisoning between June 2009 and March 2014. Control group was composed of 54 patients (24 women). Platelet count and mean platelet volume level were significantly higher in the CO poisoning group. Results: White blood cell level (9.8 ± 3.3 vs. 8.6 ± 2.9 × 103/mL, respectively; P = 0.01), neutrophil count (6.00 ± 2.29 vs. 4.43 ± 2.04 × 103/mL, respectively; P < 0.01) and NLR (3.01 ± 2.34 vs. 2.23 ± 1.27, respectively; P = 0.02) were significantly higher in CO poisoning group. Conclusions: The increase of NLR may indicate the progression of fatal complications due to CO poisoning.

316-321

Authors: Narhari Das, Durajan Goshwami, Md. Sharif Hasan, Sheikh Zahir Raihan

Objective: To evaluate acute and subacute toxicity of methanol extract of Terminalia citrina leaves (family: Combretaceae) in Sprague Dawley rats. Methods: The acute toxicity studies were conducted where the limit test dose of 3 200 mg/kg body weight used. Observations were made and recorded systemically on 1, 2, 4, 24 and 48 h after dose administration for behavior, breathing, cutaneous effects, sensory nervous system response or gastrointestinal effects. For the subacute toxicity, four groups of 10 female rats were received; distilled water (control), 250, 500 and 1000 mg/kg of extracts respectively every 24 h orally for 28 days. Results: No significant variation in the body and organ weights between the control and the treated group was observed after 28 days of treatment. Haematological analysis and biochemical parameters revealed no toxic effects of the extract. Pathologically, neither gross abnormalities nor histopathological changes were observed. No mortality was recorded in 28 days. Conclusions: It was safer and non toxic to rats even at higher doses and therefore could be well considered for further investigation for its medicinal and therapeutic efficacy.

327-330

Authors: Naseem Munshi, Asad Abbas, Mohamed Amirali Gulamhussein, Ghulam Mehboob, Rija Aitzaz Qureshi

Objective: To assess the functional outcome of early surgical management of displaced acetabular fractures and the complications associated with the procedure. Methods: This is a case series study and data was collected using specialized performance. The study included 75 patients and the sampling technique was a non-probability purposive type. Patients presenting with close displaced acetabular fractures of more than 2 mm within 10 days of injury were included. However, elderly patients presenting after 10 days of injury, with evidence of local infection, severe osteoporotic bone and comorbid such as chronic obstructive pulmonary disease were not included in the study. New acetabular scoring system was used for assessing outcome of patients. Results: A total of 75 patients were operated on. Union was achieved in anatomical position in 66 (88%) patients and in malposition in 9 (12%) patients. Excellent results were obtained in 18 (24%) patients, good results in 41 (54.6%), fair results in 12 (16%), and poor results in 4 (5.4%) patients. Postoperative complications included infection [5 (6.7%)], heterotropic ossification [3 (4%)], sciatic nerve injury [10 (13.3%)], avascular necrosis [3 (4%)] patients. Conclusions: Patients with displaced acetabular fractures should be referred to specialised centres. Early surgical intervention and experienced management is a prime factor in achieving good results.

335-337

Authors: Dae Hee Kim, Dong Yoon Rhee, Seon Hee Woo, Woon Jeong Lee, Seung Hwan Seol, Won Jung Jeong

A report of a 62-year-old female patient with severe Mallory–Weiss syndrome after successful cardiopulmonary resuscitation (CPR) by health care providers in the emergency department is presented. The bleeding continued for five days, and the patient's total blood loss was estimated to be approximately 3000 mL. After 7 days, the patient died due to respiratory distress syndrome. Severe Mallory–Weiss syndrome after CPR may occur and should be considered as a potentially serious complication after CPR.

341-343

Authors: Josue M. Avecillas-Chasın, Jordi A. Matias-Guiu, Gustavo Gomez, Javier Saceda-Gutierrez

Spinal intradural hematoma is a rare complication of diagnostic lumbar puncture or spinal anesthesia. This complication could be overlooked with devastating neurological consequences due to a delay in diagnosis. Here, we reported a case of a patient with a lumbar spinal intradural hematoma as a result of a difficult spinal anesthesia.

169-172

Authors: Alicja Ziętek, Konrad Futyma, Łukasz Nowakowski, Marek Gogacz, Tomasz Rechberger

To provide the review of the macrophage activity products as pathophysiological markers of endometriosis by literature survey (PubMed, Cochrane). Immunoreactive cells and several of their synthesis products concentrations are elevated in the serum and peritoneal fluid in patients with endometriosis. The enhanced reactive proteins contributed to local inflammation and aggregation of endometriotic lesions. Immune response and immune surveillance of tissue play an important role in pathogenesis of endometriosis. Activated macrophages in peritoneal environment secrete immunoreactive cytokines which are responsible for inflammatory cascade of reactions. The immunoreactive cytokines should be a target not only as a disease marker but also as a part of therapeutic protocol.

178-179

Authors: Ho Ting Wong, Qian Yin, Ying Qi Guo, Kristen Murray, Dong Hau Zhou, Diana Slade

Big data is a hot topic in the academic sector, and healthcare researchers are definitely not an exception. This article aims to provide a showcase in emergency medicine research to demonstrate the advantages of conducting such research using big data. Big data is a new and cost-effective research approach, and emergency medicine researchers could benefit from using this approach and by doing so producing high-quality research at a faster pace.

186-195

Authors: Sibanarayan Rath, Rabindra N. Padhy

Objective: To record the antibiotic resistance of community acquired uropathogens over a period of 24 months (May 2011–April 2012). Methods: Urine samples from patients of outpatient department (OPD) were used for isolating urinary tract infection (UTI)-causing bacteria that were cultured on suitable selective media and identified by biochemical tests. Their antibiograms were ascertained by Kirby–Bauer's disc diffusion method, using 17 antibiotics of 5 different classes. Results: From 2137 urine samples 1332 strains of pathogenic bacteria belonging to 11 species were isolated. Two Gram-positives, Staphylococcus aureus and Enterococcus faecalis and nine Gram-negatives, Acinetobacter baumannii, Citrobacter sp., Escherichia coli, Enterobacter aerogenes, Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, Proteus vulgaris and Pseudomonas aeruginosa were isolated. Both Staphylococcus aureus and Enterococcus faecalis were vancomycin resistant, and resistant-strains of all pathogens increased in each 6-month period of study. Particularly, all Gramnegatives were resistant to nitrofurantoin and co-trimoxazole, the most preferred antibiotics of empiric therapy for UTI, but were moderately resistant to gentamicin, ampicillin, amoxyclav, ofloxacin and gatifloxacin. Most Gram-negatives produced extended spectrum b-lactamase. Conclusions: It was concluded that periodic surveillance of pathogens is an essential corollary in effective health management in any country, as empiric therapy is a common/ essential practice in effective clinical management.

202-204

Authors: Kevin Fernando Montoya, Jose Daniel Charry, Juan Sebastian Calle-Toro, Luis Ramiro Nuñez, Gustavo Poveda

Objective: To evaluate whether the shock index (SI), given by the formula SI = heart rate/systolic blood pressure (HR/SBP), is useful for predicting mortality at 24 h in trauma patients admitted to the emergency department of a university hospital in Colombia. Methods: A database of trauma patients admitted between January 2013 and December 2013 was constructed; the result according to the shock index was determined, generating a dichotomous variable with two groups: Group A (SI < 0.9) and Group B (SI > 0.9). Univariate analysis was performed. Results: A total of 666 patients were analyzed, 83.3% (555) had SI < 0.9, and 16.7% (111) SI > 0.9. The mean age for Groups A and B was 32.4 and 35.4 respectively. The average injury severity score for both groups was 9.6 and 17.6 respectively. Mortality at 24 h after injury for both groups was 3.1% (P = 0.032) and 59.5% (P = 0.027) respectively. Conclusions: An initial shock index greater than 0.9 implies a worse prognosis 24 h after injury. The shock index predicts mortality in multiple trauma patients in the emergency department, and is also a quick and applicable in all hospital.

210-213

Authors: Abubakar Hamdiya, Agbenorku Pius, Aboah Ken, Hoyte-Williams Paa Ekow

Objective: To study the trend and knowledge of first aid administration of any kind among the burns patients and also to create awareness to the general public who mostly act as first aid givers who seem ignorant about the appropriate immediate care to render to the burns victim. Methods: Pre-tested questionnaires were administered to the burns victims who had received or not some form of first aid at the scene of the burn injury. Results: The study showed varied first aid knowledge and administration outcomes as a result of different substances such as water or sand, muddy water, starch, corn dough, cow dung, egg white, calamine lotion, gentian violet, ointments, creams, lotions, tooth paste etc. applied as first aid. Conclusions: Burn injuries are common in our settings, a more reason for all to know the immediate intervention to give to victims of such accidents. The kind of first aid administered to burns victims possibly affects the burns management outcome. Thus, the earlier the right intervention implemented, the lesser the complications.

218-221

Authors: Derya Ozturk, Ertugrul Altinbilek, Murat Koyuncu, Bedriye Muge Sonmez, Cilem Caltili, Ibrahim Ikizceli, Cemil Kavalci, Gulsum Kavalci

Objective: To compare the quality and correct the deficiencies of cardiopulmonary resuscitation (CPR) procedures performed in patients who developed cardiopulmonary arrest before or after Emergency Department admission. Methods: This study was conducted on patients who were applied CPR at S ¸is ¸li Etfal Training and Research and Research Hospital, Emergency Department between 01 January 2012 and 31 December 2012. Chi-square and Mann–Whitney U test were used to compare the patients' data. The study data were analyzed in SPSS 18.0 software package. A P value less than 0.05 was considered statistically significant. Results: A total of 155 patients who were applied CPR were included in the analysis. Among the study patients, seventy eight (50.3%) were brought to Emergency Department after developing cardiopulmonary arrest while 77 (49.7%) developed cardiopulmonary arrest at Emergency Department. The mean age of the study population was (66 ± 16) years and 64% of the patients were male. The initial rhythms of the CPR-applied patients were different (P < 0.05). There were no significant differences between the groups with respect to the treatment protocols or CPR responses (P > 0.05). The CPR response time was longer in ED (P < 0.05). The survival rate was lower in the trauma patients who developed cardiopulmonary arrest at ED (P < 0.05). Conclusions: The scientific data obtained in this study suggest that an early response and therapy improves outcomes in CPR procedure.

226-229

Authors: Evis Bendo, Margarita Resuli, Spiros Metaxas

Objective: To investigate the early detection of the damage of cochlear activity by using distortion product otoacoustic emissions (DPOAE) (DP-gram) comparing to the results of the impedance audiometry. Methods: We examined 53 patients including 43 hemodialyzed patients, and 10 controls. First it was applied a tympanometry, and then in normal results we applied impedance audiometry and DPOAE (DP-gram). Results: We found sensorineural hearing loss in 67% of audiometric results of the hemodialyzed patients and there was a decrease of the DPOAE amplitude in 77% of hemodialyzed patients. In the control group there was one patient (10%) with neurosensorial in high frequencies hearing loss in both measurements with audiometry and DPOAE. Conclusions: There is a sensorineural hearing loss observed in most of the patients with chronic renal failure. DPOAE audiogram shows lower amplitudes than impedance audiometry and it can be used for the early detection of cochlear damage.

236-248

Authors: Abhijit Dey, Anuradha Mukherjee

Bryophytes, taxonomically placed between the algae and the pteridophytes, are divided into three classes such as Liverworts, Hornworts and Mosses. Indigenous use involves this small group of plants to treat various diseases. Bryophytes have been investigated pharmacologically for active biomolecules. Several constituents with therapeutic potential have been isolated, characterized and investigated for antibacterial, antifungal, antiviral, antioxidative, antiinflamatory and anticancerous efficacy. The present review deals with the literature covering the anticancerous potential of bryophytes. Apart from the examples of the compounds and the containing bryophyte genera, the authors have tried to include the examples of cancer cell lines on which the efficacy have been tested and the mode of action of certain cytotoxic agents. Crude extracts and isolated compounds from bryophytes were found to possess potent cytotoxic properties. Different types of terpenoids and bibenzyls have been reported among the most potent cytotoxic compounds. Most of these compounds were found to induce apoptosis by activating a number of genes and enzymes. Biochemical markers such as DNA fragmentation, nuclear condensation, proteolysis of poly (ADP-ribose) polymerase, activation of caspases, inhibition of antiapoptotic nuclear transcriptional factor-kappaB, activation of p38 mitogen-activated protein kinase etc. have been found to be associated with apoptotic and necrotic response. This review summarizes recent scientific findings and suggests further investigations to evaluate the cytotoxic efficacy of bryophytes.

250-251

Authors: Emmanouil Petrou, Vasiliki Karali, Vasiliki Vartela

Transfusion-related acute lung injury is the most common cause of serious morbidity and mortality associated with the transfusion of plasma-containing blood components. The syndrome can be confused with other causes of acute respiratory failure. Herein, we describe a 71-year-old man who was transfused with fresh frozen plasma due to prolonged INR, and died of what was considered as transfusion-related acute lung injury, despite treatment.

255-258

Authors: Zihni Sulaj, Gentian Vyshka, Amarda Gashi

We performed a retrospective study of 176 patients in the University Hospital Center of Tirana (Albania), during the period 2001–2011, admitted with the diagnosis of a suspected spider bite. Three fatalities were registered during this decade covered from our study, with a clinical picture of marked hypertension, tachycardia and acute cardiac failure leading to death within a minimum of 25 h and a maximum of 42 h from the occurrence. Out of the total of 176 patients, we had 59% (104 cases) females, and 41% males. The overwhelming majority of the patients lived in rural areas (155 of the cases); extremities were mostly affected from the bites. A summary of clinical signs and a brief review of the available literature are made in the results and discussion section of this paper. Authors advocate that special precautions should be taken especially in severe forms of interesting autonomous nerve system, with aggressive fluid resuscitation, supportive therapy and close monitoring of vital signs.

85-90

Authors: Sherif Emara

Burn trauma is in need for prognostic indicators or admission scores. This aims for realistic documentation of the burn injury, expectation of the prognosis, and to facilitate a patient stratification to evaluate therapeutic strategies. A computer search through different medical websites was performed looking for articles correlating prognosis with different burn indices. These were carefully summarized and analyzed for this review. Variable studies were found related to that issue; the reliable indicators found had been classified as general or specific. All of them had certain clinical importance, but limitations are a common feature. All the listed indices are useful to serve in the only special clinical situations. We couldn’t claim that they are actual prognostic indicator in burn victims. We believe that we still lack the proper prognostic indicator in burn patients. Researchers are invited for more effort to organize a more reliable prognostic indicator and scoring system for burn patients.

97-100

Authors: Ioannis Stefanidis, George Galyfos, Stavros Kerasidis, Ioannis Stamatatos, Georgios Geropapas, Sotirios Giannakakis, Georgios Kastrisios, Gerasimos Papacharalampous, Chrisostomos Maltezos

Anticoagulant therapy using heparins or per os vitamin K antagonists has been the treatment of choice in patients with venous thromboembolic disease for decades. However, the introduction of inferior vena cava (IVC) filters recently has provided new therapeutic choices appropriate for specific groups of patients with venous thromboembolic disease. This review aims to present all current evidence on the indications and precautions for the proper IVC filters utilization. There is still a great challenge in identifying the proper populations that would benefit from an IVC filter implantation or extraction. New randomized trials are needed to produce safe and clear guidelines of proper use.

107-111

Authors: Hamid Karimi, Mahnoush Momeni, Mahtab Vasigh

Objective: To evaluate the outcome of electrical burn on a patient’s life performance and the disability induced by this type of injury. Methods: This study is a prospective 6 years descriptive study. The injured patients admitted to our center between 2006 and 2008 were followed for 6 years to estimate the ability of their life and job performance after the injury. Results: In the patients, 96.8% were male. The mean age of patients was 27.9 years. 73.9% of those injuries were occupational injuries. 86.5% were pure electrical injuries. 81% of patients went back to their previous job within a 5-6 year period. Only 5% had the ability to perform their usual daily activities-these patients needed financial support from family, insurance companies and government. Unfortunately 6.3% were totally disabled and needed complete help even for their minor natural needs. These patients are young and probably have a long-term life expectancy and would have a huge financial impact on the government and society. The mean length of hospital stay was 17.7 d. The mean total body surface area burned was 13.3%±11.5%. We could see an association between high voltage burns and falling down (P=0.005). High voltage burns needed longer periods away from work (197 d) in comparison with low voltage injuries (145.8 d) (P=0.003). Conclusions: High voltage electrical burns are severe, needing more flap repairs and/or amputations and cause longer periods away from work.

117-119

Authors: Babur M. Shakirov

Objective: To study the different surgical treatments in 154 elderly patients with acute deep burns of lower extremities admitted in Burn Department of RSCUMA. Methods: Skin grafts in extensive burns were performed in 32 patients for the purpose of achieving early closure of the burn area. In 116 patients with burn surface area of 6-25 %, skin grafting was performed on the granulating wound when the wound was ready for accepting skin graft. In these 19 cases, a stamp graft procedure was used in 12 patients and Mowlen-Jackson method of skin grafting in 7 cases. Results: Analysis of the nearest results showed that 28 out of 154 patients came back to the hospital for new surgery due to loss of ability of normal movement of their extremities. Conclusions: Careful patient selection and timing of surgery will help to avoid any adverse effect on patient outcome.

129-134

Authors: Chilaka K.C, Ifediba E.C, Ogamba J.O

Objective: To evaluate the effects of Citrus sinensis seed oil on blood glucose, lipid profile and some liver enzymes activities in alloxan induced diabetic rats. Methods: About 120 mg/kg body weight alloxan monohydrate was injected intraperitoneally into 18 adult male albino rats weighing 180-200 g, which has been acclimatized in our laboratory for two weeks. Approximately 72 h after the alloxan injection, the rat became hyperglycaemic with blood glucose above 200 mg/dL. The diabetic rats were randomly assigned into three diabetic and one control groups of six rats each: normal control, diabetic treated with 1 000 mg/kg body weight of emulsified seed oil; diabetic control, diabetic treated with 150 mg/kg body weight of metformin hydrochloride. Both controls received weight-checked solution of 4.8% v/v Tween-80 in distilled water. All injections in all groups were done intraperitoneally once daily for 28 d. The blood glucose estimation was done every week, with one touch glucometer as well as the weight checked with animal weighing balance. Lipid profiles and some liver enzymes activities (AST, ALT and ALP) were analysed using test kits and spectrophotometer. Data obtained were analyzed using One way ANOVA and post hoc test done using graph pad prism-version 6. Results: The results of this study indicated that Citrus sinensis seed oil was able to reduce blood glucose significantly (P<0.001) in the early weeks of the study when compared with both the diabetic control group and the metformin-treated group. The seed oil significantly lowered serum triglyceride, the serum LDL-cholesterol, total cholesterol and VLDL-cholesterol; the activities of all the liver enzymes assayed (P<0.05) but significantly increased the HDL-cholesterol in the diabetic oil-treated rats as compared to diabetic control (P<0.05). Conclusions: However, further studies need to be carried out to show its mechanism of action and to isolate the active ingredient in the Citrus sinensis seed oil that is responsible for these actions.

141-146

Authors: Behrooz Sadeghi Kalani, Abazar Pournajaf, Mansour Sedighi, Abbas Bahador, Gholamreza Irajian, Firuzeh Valian

Objective: To evaluate antimicrobial resistance, invasion index and genetic profile in Listeria monocytogenes isolated from clinical samples. Methods: At all, 170 clinical samples were collected from patients with spontaneous abortions hospitalized in Shariati hospital in Tehran during June 2010 to August 2013. Invasion index was determined using HeLa cells. The multiplelocus variable-number tandem-repeats analysis (MLVA) was used for evaluation of genetic relatedness. Results: Out of 14 L. monocytogenes isolates, 4 (28.57%), 2 (14.28%), 0 (0%), 5 (35.71%) and 3 (21.42%) were isolated from placental tissue, urine, blood, vaginal and rectal swabs, respectively. High resistance to penicillin and multidrug resistant were found amongst isolates. The invasion index was in the range of 0.001-0.007. Seven different types were obtained by MLVA assay and type 2 and 3 with 4 strains were the most frequent type. Strains isolated from the vagina and the placenta of the same type were also more resistant to penicillin. Conclusions: Since MLVA is a high-throughput screening method that is fairly inexpensive, easy to accomplish, rapid, and trustworthy, it is well suited to interlaboratory comparisons during epidemiological investigations. Also further studies of larger samples from a variety of sources such as food and animal specimens recommended comparing by MLVA method.

152-154

Authors: Louay Al-Mouazzen, Emeka Oragui, Karthig Rajakulendran, Nurul Ahad

Injury to the Lisfranc joint is usually as a result of a direct blow or indirect axial loading of the foot. Lisfranc injuries are associated with significant morbidity and early recognition and treatment is imperative. To date, there has been no description of this injury arising from electrocution. We describ the unusual presentation of a Lisfranc injury in a diabetic patient caused by electrocution of the midfoot. We discuss the surgical management of this case and review the anatomical and pathomechanical considerations of the Lisfranc injury.

158-161

Authors: Hung Yi Chen

Aortic dissection is a critical condition requiring immediate assessment and management. Clinical presentation is commonly associated with severe chest pain and high blood pressure. However, misdiagnosis is frequent because of various features. We presented a case of 51- year-old woman who complained of dyspnea for 3 d after she experienced back pain for one week. She was presented with severe respiration distress with impending respiration failure on arrival to our hospital. Her chest X-ray showed cardiomegaly with acute pulmonary edema. The laboratory data revealed elevated cardiac enzyme and electrocardiography demonstrated sinus tachycardia. She was hospitalized under the initial diagnosis of acute coronary syndrome. The patient remained hemodynamically stable, and experienced one episode of chest discomfort. After electrocardiography, she was found with bigeminy ventricular premature beats without ST-T change. Follow-up cardiac enzyme demonstrated progressive declined. Cardiac catheterization was performed on the third day of admission, and coronary angiography revealed large intimal flap on aortic root with bilateral coronary artery involvement. Surgical management was arranged after immediate chest computed tomography study.

165-167

Authors: Yu-Jang Su

Urticaria is a systemic allergic reaction leading to wheal formation with skin itching. Occasionally we come across some intractable cases, in which we may administrate epinephrine infusion besides steroid and anti-histamine. A 19 year-old man suffered from intractable urticaria for 2 days, although anti-histamine and steroids were used. Titration of adrenaline was considered in the treatment of intractable urticaria. He was administrated 1 mg epinephrine intravenous bolus due to mis-dilution by the nurse. Transient atrial fibrillation with cardiac ischemia occurred. After 12.5 mg labetalol i.v., and 11-hour observation in the emergency room, he gradually recovered to normal sinus rhythm without ST-T change. In the past, ventricular tachycardia, hypertension, chest pain, pulmonary edema, the need to intubate, renal failure requiring renal transplant, coronary artery spasm, myocardial ischemia/infarction and hypokalemia have been reported after mis-diluted or excessive doses of epinephrine in treating anaphylaxis. To our knowledge, our case is the first worldwide to describe transient atrial fibrillation after epinephrine overdose, and the patient was successfully resuscitated by 12.5 mg labetalol. It is important to know how to rescue accidental epinephrine intravenous injection patients.

1-6

Authors: Gentian Vyshka, Altin Kuqo, Serla Grabova, Eris Ranxha, Liro Buda, Jera Kruja

Acute flaccid paraplegia is a clinical occurrence with extreme importance, due to the dramatic presentation, the severity of the underlying disorder, and the generally poor prognosis that follows such a condition. Among etiological factors, the traumatic events are of particular interest, with the clinical treating dealing with a severely ill patient, following fall from height, motor vehicle collisions, and direct shocks applied over the vertebral column. The non-traumatic list is more numerous; however the severity of the acute paraplegia is not necessarily of a lesser degree. Viral infections, autoimmune disorders, and ischemic events involving feeding spinal arteries have been imputed. However, chemical and medications injected during procedures or accidentally intrathecal administration can produce acute flaccid paraplegia. A careful neurological assessment and complete electrophysiological and imaging studies must follow. In spite of the poor prognosis, different therapeutic options have been proposed and applied. Neurosurgical and orthopedic interventions are often necessary when trauma is present, with high dose glucocorticoids treatment preceding the intervention, in a hope to decrease edema-related compression over the spinal cord. Immunoglobulins and plasmapheresis are logical and helpful options when a polyradiculoneuritis produces such a clinical picture. The role of decompression, as neurosurgical exclusivity, has been considered as well.

12-17

Authors: Sivaprabha J, Dharani B, Padma PR, Sumathi S

Objective: To evaluate DNA damage inducing effect of the methanolic extract of both the leaves and the rhizomes of Curcuma amada (C. amada) against breast cancer cell lines MCF-7 and MDA MB 231 and analyze the active components present in the methanolic extract of the leaves and the rhizomes. Methods: The DNA damage induced in yeast was assessed using diphenylamine method. The DNA damage induced by the extracts in cell lines was assessed using single cell gel electrophoresis (Comet assay). Various phytochemicals present in the leaves and the rhizomes were analysed using various chromatographic and spectral studies. A normal non-cancer cell line HBL-100 and an eukaryotic model organism yeast was also used for comparison. Results: The results indicated that the methanolic extract of both the leaves and the rhizomes of C. amada induced cell death in the breast cancer cell lines MCF-7 and MDA MB 231. The extracts showed less DNA damage in yeast and HBL-100 cells. The phytochemical investigation revealed the presence of more amounts of terpenoids and steroids in both the leaves and rhizomes. Conclusions: The results indicated that the methanolic extract of leaves of rhizomes of C. amada possess genotoxic and cytotoxic activity against the breast cancer cell lines.

23-27

Authors: Akuodor Godwin Christian, Ajoku Gloria Ahunna, Ezeunala Mercy Nwakaego, Chilaka Kingsley Chimsorom, Asika Ebere Chile

Objective: To establish the efficacy of Pseudocedrala kotschyi (P. kotschyi) for the treatment of acute malaria attack used in Nigeria. Methods: The ethanolic leaf extract was investigated fo r antimalarial activity against Plasmodium berghei berghei (P. berghei berghei) in mice. Fourday suppressive, curative effect against established infection and prophylactic models of antiplasmodial studies were used. Results: The leaf extract of P. kotschyi (100-400 mg/kg b.w. p.o.) exhibited significant dose dependent activity against the parasite in the suppressive and curative, and also had repository activity. The antimalarial effect of P. kotschyi is comparable to that of chloroquine. The ethanolic leaf extract also prolonged the survival time of the infected mice. The LD 50 of the plant extract was established to be ≥5 000 mg/kg b.w. p.o. in mice. Conclusion: The results showed that the leaf extract has potential antiplasmodial activity, which can be exploited in malaria therapy.

32-36

Authors: Jason Imperato, Louisa Canham, Tyler Mehegan, John D. Patrick, Gary S. Setnik, Leon D. Sanchez

Objective: To determine the effect of a clinical triggers program in the Emergency Department (ED) setting that utilized predetermined abnormal vital signs to activate a rapid assessment by an emergency physician led multidisciplinary team. Methods: A retrospective, separate sample, pre-post intervention study following implementation of an ED triggers program. Abnormal vital sign criteria that warranted a trigger response included: heart rate <40 or >130 beats/ min, respiratory rate <8 or >30 respirations/min, systolic blood pressure <90 mm Hg, or oxygen saturation <90% on room air. The primary outcome investigated was time to physician evaluation with secondary outcomes being the time to disposition decision and time to first critical therapeutic intervention. Results: The median time to physician evaluation was reduced by 25% fr om 28 min to 21 min (P<0.05). The median time to disposition decision was decreased by 12% fr om 154 minutes to 135 minutes (P<0.05). The median time to first intervention was 46 min and 43 min (P=0.33) in the before and after groups, which did not represent a statistically significant difference.Conclusions: In our model, the implementation of an ED triggers program resulted in a modest decreased time to physician evaluation and disposition decision but not time to intervention.

44-47

Authors: Ashok Kumar, Anoop Kumar, Kelash Rai, Shaista Ghazal, Nadeem Rizvi, Sunil Kumar, Sadhna Notani

Objective: To determine frequency of factors leading to poor outcome of non-invasive positive pressure ventilation in acute exacerbation of chronic obstructive pulmonary disease. Methods:This cross sectional study was conducted at our center between May 2012 and November 2012. A total of 195 diagnosed patients of acute exacerbation of chronic obstructive pulmonary disease meeting the inclusion criteria were selected from the ER department. At the time of admission age was inquired BP, respiratory rate and oxygen saturation will be noted and pedal edema was assessed and investigations were sent for pH assessment. Noninvasive positive pressure ventilation (NIPPV) using BiPAP was applied in spontaneous mode by the help of oronasal mask. Presence of respiratory rate (less than 12/min), systolic blood pressure <90 mmHg, GCS <13 and PaO 2 ≤65, pH <7.2 and heart rate >140 bpm was taken as poor outcome. Results: The average age of the cases was 61.9±9.3 years with male to female ratio being 1.5:1. NIPPV was successful in 151 (77.4%) cases and 44 (22.6%) cases were underwent endotracheal intubation. About 38 (44.7%) of patients with oxygen saturation (82%-86%) had poor prognosis. A total of 40 (55.6%) of patients with pH range 7.20-7.26, required endotracheal intubation, 43 (66.2%) with pedal edema underwent endotracheal intubation. While 29 (24.16%) patients of age >60 years needed endotracheal intubation. Conclusions:In this study, NIPPV was successful in 77.4% cases and 22.6% cases were underwent endotracheal intubation. Pedal edema was the most common factor leading to poor outcomes while age >60 years was the least common factor, 66.2% and 24.2% respectively.

51-53

Authors: Evis Bendo, Margarita Resuli, Spiros Metaxas

Objective: To evaluate hearing threshold and the severity of hearing loss at different frequencies in patients with chronic renal failure (CRF), and to analyze the role of duration of disease on hearing threshold in patients of CRF by measuring pure-tone audiometry (PTA) and distortionproduct otoacoustic emission (DPOAE). Methods: There were analysed 61 subjects (122 ears) from which 12 were patients starting hemodialise (A), 24 subjects were patients undergoing hemodialise over a year (B), 15 subjects were patients undergoing conservative treatment (C) and 10 controls (D). We did hearing evaluation by testing them using tympanometry, PTA and DPOAEs. Other parameters (blood pressure, body weight, blood chemistries) were also evaluated. Results: It was found a severe high-frequency hearing loss among patients with CRF comparing to the control group. Duration on haemodialysis treatment does not seem to have a significant impact on the incidence of hearing loss, although the method of treatment may influence the impact of the disease on hearing. Hearing loss among patients with CRF seemed to deteriorate fu rther a year after the first evaluation. Conclusions: DPOAE raised the percentages of detection of SNHL indicating that it is a better technique than the conventional PTA for evaluation of hearing acuity.

59-62

Authors: Yu-Jang Su, Chia-Jung Liao

Objective: To study the epidemiology, etiologies and prognostic factors of hypoglycemia. Methods: A retrospective chart review of hypoglycemic cases from December, 2009 to February, 2012 was conducted to gather the following patient data: age, gender, vital signs at triage, white blood cell count, serum glucose, C-reactive protein, glutamic oxaloacetic transaminase, creatinine, sodium, potassium, past history of liver cirrhosis, uremia, concomitant infection, concomitant cancer/malignancy, length of stay, lack of recent meal, status of acute renal failure and concomitant stroke. A total of 186 cases were enrolled in our study. We analyzed the data using commercial statistics software (SPSS for Windows, version 11.0, SPSS Inc., Chicago, IL). We used the Student's t-test and χ2 test for the statistical analyses, and significance was set at a P value less than 0.05. Results: Hypoglycemia is related to several co-morbidities. In total, 10.2% of the patients had liver cirrhosis and 7.0% had uremia. More than half (55.4%) were bacterial infection during hospitalization. Acute renal failure accounted for 26.3% of the hypoglycemic episodes. In addition to the etiology of infection, the lack of a recent meal accounted for 44.6% hypoglycemic episodes. A total of 2.2% of the cases resulted from an acute cerebrovascular accident. Approximately 8.6% were concomitant with malignancy. Conclusions: When hypoglycemic patients present in the emergency department, physicians should pay attention to the presence of infection, malignancy, liver diseases (liver cirrhosis and biliary tract infection), and acute renal failure.

68-72

Authors: Rejeb I., Chakroun O., Chtara K., Boujelbene M., Ksibi H., Chaari A., Bahloul M., Rekik N.

Objective: To determine predictive factors of early mortality among severe traumatic brain injury in emergency department. Methods: This study is based on a retrospective analysis of 198 admitted in emergency depatment with severe head injury (Glasgow coma scale score ≤8) of an university hospital (Sfax, Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during emergency department stay. Results: Forty two patients were died. Univariate analysis showed that the presence of shock, cardiac arrest, bilateral mydriasis, high value of injury severity score and low value of Glasgow coma scale were associated with mortality. Moreover, meningeal hemorrhage, cerebral and subdural haematoma were associated with poorer outcome. Multivariate analysis showed that factors associated with a poor prognosis were cardiac arrest cerebral and the presence of cerebral haematoma. Conclusions: Improving pre-hospital care and ovoid futile resuscitation to given priority in resource allocation and urgent CT scan of the head to look for operable mass lesions as early detection should improve the prognosis of severe head injury at emergency department.

78-82

Authors: Gabriele Falzarano, Antonio Medici, Giuseppe Pica, Predrag Grubor, Milan Grubor, Francesco Vitaliano Muziì, Mirza Biscevic, Arianna Falzarano, Luigi Meccariello

The "ideal" timing and modality of fracture fixation for unstable thoracolumbar spine fractures in multiply injured patients remains controversial. The concept of "damage control orthopedics" is expressed. We presented a case report of a 27 years' old male who sustained a multilevel spine fr actures associated a floating knee (Fraser’s Type A), ulna fracture and carpal scaphoid fracture in July 2014 after car accident (very high energy trauma). All these fractures were treated in early total care. We reported a case control to discuss about the early spinal total care associated at orthopedic total care in patients with multiple trauma.