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Correspondence / American Journal of Emergency Medicine 32 (2014) 466–485
Emre Yalcinkaya, MD Department of Cardiology, Aksaz Military Hospital 48750, Mugla, Turkey E-mail address: [email protected] Murat Celik, MD Department of Cardiology, Gulhane Military Medical Faculty 06018, Ankara, Turkey http://dx.doi.org/10.1016/j.ajem.2014.01.005
References [1] Yesilaras M, Aksay E, Atilla OD, Sever M, Kalenderer O. The accuracy of bedside ultrasonography as a diagnostic tool for the fifth metatarsal fractures. Am J Emerg Med 2013. http://dx.doi.org/10.1016/j.ajem.2013.11.009 [pii: S0735-6757(13) 00769-9. [Epub ahead of print]]. [2] Jeckel JF, Katz DL, Elmore JG, Wild DMG. Epidemiology, biostatistics and preventive medicine. 3rd ed. Philadelphia, PA: Saunders, Elsevier; 2007. [3] Rothman KJ, Greenland Sander, Lash TL. Modern epidemiology. 3rd ed. Baltimore, United States: Lippincott Williams & Wilkins; 2008. [4] Szklo M, Nieto FJ. Epidemiology beyond the basics. 2nd ed. Manhattan, NY: Jones and Bartlett Publisher; 2007. [5] Lawrence I, Kuei Lin A. Concordance correlation coefficient to evaluate reproducibility. Biometrics 1989;45:255–68.
References [1] Zarar A, Khan AA, Adil MM, Qureshi AI. Anaphylactic shock associated with intravenous thrombolytics. Am J Emerg Med 2014;32(1):113.e3-5. [2] Limsuwan T, Demoly P. Acute symptoms of drug hypersensitivity (urticaria, angioedema, anaphylaxis, anaphylactic shock). Med Clin North Am 2010;94(4): 691–710. [3] Park HJ, Kim SH. Factors associated with shock in anaphylaxis. Am J Emerg Med 2012;30(9):1674–8. [4] Yu K, Wu Y, Hu Y, et al. Neuroprotective effects of prior exposure to enriched environment on cerebral ischemia/reperfusion injury in rats: the possible molecular mechanism. Brain Res 2013;1538:93–103. [5] Koren G, Weiss AT, Ben-David Y, Hasin Y, Luria MH, Gotsman MS. Bradycardia and hypotension following reperfusion with streptokinase (Bezold-Jarisch reflex): a sign of coronary thrombolysis and myocardial salvage. Am Heart J 1986;112(3): 468–71. [6] Shah SP, Waxman S. Two cases of Bezold-Jarisch reflex induced by intra-arterial nitroglycerin in critical left main coronary artery stenosis. Tex Heart Inst J 2013;40(4): 484–6.
Bedside ultrasonography as a diagnostic tool for the fifth metatarsal fractures: methodological concern in reliability analysis☆,☆☆ To the Editor, I was interested to read the article by Yesilaras and colleagues [1] published in November 2013 issue of The American Journal of Emergency Medicine. The authors aimed to determine the reliability of ultrasonography for the diagnosis of fractures of the fifth metatarsal [1]. As the authors pointed out, the intraclass correlation coefficient (ICC) of displacement measured by x-ray and ultrasonography was K = 0.38 [1]. Why did the authors report K (K = 0.38) instead of the mentioned ICC? Regarding reliability or agreement, it is good to know that ICC should be used for quantitative variables and weighted K (not simple K because K has its own limitations too) for qualitative ones [2-5]. Moreover, statistics cannot provide a simple substitute for clinical judgment [2-5]. As the authors pointed out in their conclusion, ultrasonography is a reliable diagnostic tool for acute fifth metatarsal fractures. Considering K = 0.38, which means poor agreement, such a conclusion is simply a misinterpretation and should really be avoided by clinicians; otherwise, we will face mismanagements of the patients in our routine clinical cares. Siamak Sabour, MD, MSc, DSc, PhD, Postdoc Department of Clinical Epidemiology (COH) Safety Promotions and Injury Prevention Research Centre Shahid Beheshti University of Medical Sciences Tehran, Iran E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.01.012 ☆ Source(s) of support: None. ☆☆ Conflic of interest: None declared.
Cerebrospinal fluid/blood glucose should be used as a good diagnostic tool and mortality indicator in bacterial meningitis To the Editor, We have read with interest the recently published article titled “Cerebrospinal fluid (CSF)/blood glucose ratio as an Indicator for Bacterial Meningitis” by Tamune et al [1]. Cerebrospinal fluid/blood glucose ratio with high sensitivity and specificity has been found as a good marker in predicting bacterial meningitis. Although these results are classic information, it may be important to test the information about significance of CSF/blood glucose ratio by current study. We think that data about 1 patient would be incorrect (original article, Table 2) in this study. This case is of a 26-year-old man diagnosed with bacterial meningitis. There is no history of prior antibiotic use. Gram staining is negative. Other parameters are CSF total cell count 125 uL, CSF polymorphonuclear total cell ratio 1.8%, CSF protein 63 mg/dL, and CSF glucose 54 mg/dL. Moreover, CSF culture result was coagulase-negative staphylococci. These bacteria, which are frequently yielded by blood cultures are generally contaminant [2]. Therefore, we suppose that the case was not bacterial meningitis, but this condition would not change the major result in the study. In addition, recently, Erdem et al [3] reported a study including 308 cases of culture positive of pneumococcal meningitis from Turkey as a multicenter study. Some easily available parameters in emergency departments for patients with pneumococcal meningitis who died and those who survived were compared. Most importantly, mortality indicator for patients with pneumococcal meningitis was found: CSF/ blood glucose ratio (P = b.001). Futhermore, other indicators for mortality were found: thrombocytopenia (P = .009), CSF protein (P = .013), and CSF glucose (P = .029). As a result, we think CSF/blood glucose can be used as a diagnostic tool and an important mortality indicator in bacterial meningitis. Mustafa Hatipoglu, MD Asim Ulcay Deniz Eray Gokce Vedat Turhan Department of Infectious Diseases and Clinical Microbiology GATA Haydarpasa Training Hospital Istanbul, Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.01.014 References [1] Tamune H, Takeya H, Suzuki W, Tagashira Y, Kuki T, Honda H, et al. Cerebrospinal fluid (CSF)/blood glucose ratio as an indicator for bacterial meningitis. Am J Emerg Med 2013. http://dx.doi.org/10.1016/j.ajem.2013.11.030. [2] Elzi L, Babouee B, Vogeli N, Laffer R, Dangel M, Frei R, et al. How to discriminate contamination from bloodstream infection due to coagulase-negative staphylococci: a prospective study with 654 patients. Clin Microbiol Infect 2012;18:E355–61. [3] Erdem H, Elaldi N, Oztoprak N, Sengoz G, Ak O, Kaya S, et al. Mortality indicators in pneumococcal meningitis: therapeutic implications. Int J Infect Dis 2013. http://dx.doi.org/10.1016/j.ijid.2013.09.012.
Correspondence / American Journal of Emergency Medicine 32 (2014) 466–485
Emre Yalcinkaya, MD Department of Cardiology, Aksaz Military Hospital 48750, Mugla, Turkey E-mail address: [email protected] Murat Celik, MD Department of Cardiology, Gulhane Military Medical Faculty 06018, Ankara, Turkey http://dx.doi.org/10.1016/j.ajem.2014.01.005
References [1] Yesilaras M, Aksay E, Atilla OD, Sever M, Kalenderer O. The accuracy of bedside ultrasonography as a diagnostic tool for the fifth metatarsal fractures. Am J Emerg Med 2013. http://dx.doi.org/10.1016/j.ajem.2013.11.009 [pii: S0735-6757(13) 00769-9. [Epub ahead of print]]. [2] Jeckel JF, Katz DL, Elmore JG, Wild DMG. Epidemiology, biostatistics and preventive medicine. 3rd ed. Philadelphia, PA: Saunders, Elsevier; 2007. [3] Rothman KJ, Greenland Sander, Lash TL. Modern epidemiology. 3rd ed. Baltimore, United States: Lippincott Williams & Wilkins; 2008. [4] Szklo M, Nieto FJ. Epidemiology beyond the basics. 2nd ed. Manhattan, NY: Jones and Bartlett Publisher; 2007. [5] Lawrence I, Kuei Lin A. Concordance correlation coefficient to evaluate reproducibility. Biometrics 1989;45:255–68.
References [1] Zarar A, Khan AA, Adil MM, Qureshi AI. Anaphylactic shock associated with intravenous thrombolytics. Am J Emerg Med 2014;32(1):113.e3-5. [2] Limsuwan T, Demoly P. Acute symptoms of drug hypersensitivity (urticaria, angioedema, anaphylaxis, anaphylactic shock). Med Clin North Am 2010;94(4): 691–710. [3] Park HJ, Kim SH. Factors associated with shock in anaphylaxis. Am J Emerg Med 2012;30(9):1674–8. [4] Yu K, Wu Y, Hu Y, et al. Neuroprotective effects of prior exposure to enriched environment on cerebral ischemia/reperfusion injury in rats: the possible molecular mechanism. Brain Res 2013;1538:93–103. [5] Koren G, Weiss AT, Ben-David Y, Hasin Y, Luria MH, Gotsman MS. Bradycardia and hypotension following reperfusion with streptokinase (Bezold-Jarisch reflex): a sign of coronary thrombolysis and myocardial salvage. Am Heart J 1986;112(3): 468–71. [6] Shah SP, Waxman S. Two cases of Bezold-Jarisch reflex induced by intra-arterial nitroglycerin in critical left main coronary artery stenosis. Tex Heart Inst J 2013;40(4): 484–6.
Bedside ultrasonography as a diagnostic tool for the fifth metatarsal fractures: methodological concern in reliability analysis☆,☆☆ To the Editor, I was interested to read the article by Yesilaras and colleagues [1] published in November 2013 issue of The American Journal of Emergency Medicine. The authors aimed to determine the reliability of ultrasonography for the diagnosis of fractures of the fifth metatarsal [1]. As the authors pointed out, the intraclass correlation coefficient (ICC) of displacement measured by x-ray and ultrasonography was K = 0.38 [1]. Why did the authors report K (K = 0.38) instead of the mentioned ICC? Regarding reliability or agreement, it is good to know that ICC should be used for quantitative variables and weighted K (not simple K because K has its own limitations too) for qualitative ones [2-5]. Moreover, statistics cannot provide a simple substitute for clinical judgment [2-5]. As the authors pointed out in their conclusion, ultrasonography is a reliable diagnostic tool for acute fifth metatarsal fractures. Considering K = 0.38, which means poor agreement, such a conclusion is simply a misinterpretation and should really be avoided by clinicians; otherwise, we will face mismanagements of the patients in our routine clinical cares. Siamak Sabour, MD, MSc, DSc, PhD, Postdoc Department of Clinical Epidemiology (COH) Safety Promotions and Injury Prevention Research Centre Shahid Beheshti University of Medical Sciences Tehran, Iran E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.01.012 ☆ Source(s) of support: None. ☆☆ Conflic of interest: None declared.
Cerebrospinal fluid/blood glucose should be used as a good diagnostic tool and mortality indicator in bacterial meningitis To the Editor, We have read with interest the recently published article titled “Cerebrospinal fluid (CSF)/blood glucose ratio as an Indicator for Bacterial Meningitis” by Tamune et al [1]. Cerebrospinal fluid/blood glucose ratio with high sensitivity and specificity has been found as a good marker in predicting bacterial meningitis. Although these results are classic information, it may be important to test the information about significance of CSF/blood glucose ratio by current study. We think that data about 1 patient would be incorrect (original article, Table 2) in this study. This case is of a 26-year-old man diagnosed with bacterial meningitis. There is no history of prior antibiotic use. Gram staining is negative. Other parameters are CSF total cell count 125 uL, CSF polymorphonuclear total cell ratio 1.8%, CSF protein 63 mg/dL, and CSF glucose 54 mg/dL. Moreover, CSF culture result was coagulase-negative staphylococci. These bacteria, which are frequently yielded by blood cultures are generally contaminant [2]. Therefore, we suppose that the case was not bacterial meningitis, but this condition would not change the major result in the study. In addition, recently, Erdem et al [3] reported a study including 308 cases of culture positive of pneumococcal meningitis from Turkey as a multicenter study. Some easily available parameters in emergency departments for patients with pneumococcal meningitis who died and those who survived were compared. Most importantly, mortality indicator for patients with pneumococcal meningitis was found: CSF/ blood glucose ratio (P = b.001). Futhermore, other indicators for mortality were found: thrombocytopenia (P = .009), CSF protein (P = .013), and CSF glucose (P = .029). As a result, we think CSF/blood glucose can be used as a diagnostic tool and an important mortality indicator in bacterial meningitis. Mustafa Hatipoglu, MD Asim Ulcay Deniz Eray Gokce Vedat Turhan Department of Infectious Diseases and Clinical Microbiology GATA Haydarpasa Training Hospital Istanbul, Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.01.014 References [1] Tamune H, Takeya H, Suzuki W, Tagashira Y, Kuki T, Honda H, et al. Cerebrospinal fluid (CSF)/blood glucose ratio as an indicator for bacterial meningitis. Am J Emerg Med 2013. http://dx.doi.org/10.1016/j.ajem.2013.11.030. [2] Elzi L, Babouee B, Vogeli N, Laffer R, Dangel M, Frei R, et al. How to discriminate contamination from bloodstream infection due to coagulase-negative staphylococci: a prospective study with 654 patients. Clin Microbiol Infect 2012;18:E355–61. [3] Erdem H, Elaldi N, Oztoprak N, Sengoz G, Ak O, Kaya S, et al. Mortality indicators in pneumococcal meningitis: therapeutic implications. Int J Infect Dis 2013. http://dx.doi.org/10.1016/j.ijid.2013.09.012.
