Abdulkadir Gunduz

Ischemia-modified albumin levels in cerebrovascular accidents

BACKGROUND Previous studies have demonstrated that ischemia-modified albumin (IMA) is a useful marker for the diagnosis of ischemic events. It was also recently demonstrated that IMA levels increase in the acute phase of cerebrovascular diseases. Yet the data regarding IMA levels in various types of cerebrovascular events are insufficient. The aim of this study was to evaluate IMA levels in various types of cerebrovascular events such as ischemic stroke, subarachnoid hemorrhage (SAH), and intracranial hemorrhage. METHODS This case-controlled study consisted of 106 consecutive patients, 43 with brain infarction (BI), 11 with brain hemorrhage (ICH), 52 with SAH, and a 43-member control group. We investigated whether there was a statistical correlation between these 3 groups and the control group. The relations among the 3 groups were also examined. Comparisons among groups were done with analysis of variance. RESULTS Mean serum IMA levels were 0.280 +/- 0.045 absorbance units (ABSU) for BI patients, 0.259 +/- 0.053 ABSU for ICH patients, 0.243 +/- 0.061 ABSU for SAH patients, and 0.172 +/- 0.045 ABSU for the control group.There was a statistically significant difference between the mean IMA levels of BI, ICH, and SAH patients and the mean control patient IMA levels (P b .0001). CONCLUSIONS Ischemia-modified albumin levels are high in cerebrovascular diseases. Ischemia-modified albumin measurement can also be used to distinguish SAH from BI during the acute phase of cerebrovascular event in the emergency department.

Clinical review of grayanotoxin/mad honey poisoning past and present

Grayanotoxin is a naturally occurring sodium channel toxin which enters the human food supply by honey made from the pollen and nectar of the plant family Ericaceae in which rhododendron is a genus. Grayanotoxin/mad honey poisoning is a little known, but well studied, cholinergic toxidrome resulting in incapacitating and, sometimes, life-threatening bradycardia, hypotension, and altered mental status. Complete heart blocks occur in a significant fraction of patients. Asystole has been reported. Treatment with saline infusion and atropine alone is almost always successful. A pooled analysis of the dysrhythmias occurring in 69 patients from 11 different studies and reports is presented. The pathophysiology, signs, symptoms, clinical course, and treatment of grayanotoxin/mad honey poisoning are discussed. In the nineteenth century grayanotoxin/mad honey poisoning was reported in Europe and North America. Currently, documented poisoning from locally produced honey in Europe or North America would be reportable. Possible reasons for this epidemiologic change are discussed.

Ischemia-modified albumin in the diagnosis of acute mesenteric ischemia: a preliminary study

Ischemia-modified albumin (IMA) is a sensitive marker of myocardial ischemia, skeletal muscle ischemia, pulmonary embolism, and stroke. However, there are no studies showing whether IMA increases in mesenteric ischemia. The aim of this study was to determine whether IMA was elevated in acute mesenteric ischemia. This case-controlled study was performed in an emergency department of a university hospital. The measurement of IMA levels in patient plasma yielded means of 0.264 +/- 0.057 absorbance units (ABSU) in the thromboembolic occlusion of the superior mesenteric artery (SMA) group and 0.163 +/- 0.025 ABSU in the control group. When plasma IMA levels in the thromboembolic occlusion SMA group were compared with those in the control group, statistically significant increases in IMA were observed in the occlusion group (P = .003). Findings indicating that IMA may have a place in the diagnosis of acute mesenteric embolism were obtained in this preliminary study. Further prospective studies are needed to see if IMA is clinically useful in the early detection of thromboembolic occlusion of the SMA.

Time-dependent variations in ischemia-modified albumin levels in mesenteric ischemia.

OBJECTIVES The objective was to determine the value of ischemia-modified albumin (IMA) in the diagnosis of mesenteric embolism. The authors investigated whether or not plasma IMA levels rose in the acute period in a rat model of mesenteric ischemia and the related time-dependent changes. METHODS In this randomized, controlled, nonblinded trial, 36 mature female Wistar rats were divided into six groups: three control (Groups I, III, and V) and three ischemia (Groups II, IV, and VI). In the control groups, blood was sampled at 30 minutes (Group I), 2 hours (Group III), and 6 hours (Group V) following a simple laparotomy. In the ischemia groups, following laparotomy, the superior mesenteric artery (SMA) was clamped using a bulldog clamp, and blood samples were taken at 30 minutes (Group II), 2 hours (Group IV), and 6 hours (Group VI). RESULTS Plasma IMA levels in the ischemia groups were significantly higher compared to those of the control groups (p < 0.004). In addition, levels were higher in the 6-hour blood samples of the ischemia group than in the 2-hour and 30-minute samples (p < 0.001). Serum IMA was also higher in the 2-hour blood samples of the ischemia group than in the 30-minute samples (p < 0.001). CONCLUSIONS These preliminary findings suggest that serum IMA levels may represent a significant parameter in the early diagnosis of acute mesenteric ischemia and that further studies are necessary.

Mad honey poisoning-related asystole

Mad honey poisoning is well known in the eastern Black Sea region of Turkey. The cause of the poisoning is the toxin grayanotoxin, found in honey obtained from the nectar of Rhododendron species on the mountains in the region. A 60-year-old man was brought to the emergency department with dizziness and syncope after eating a few spoonfuls of honey. While the patient was being treated, bradycardia and asystole developed. The patient was given 0.5 mg of atropine, and asystole began and ended. The patient was transferred to the catheter laboratory and a temporary pacemaker was implanted. Mad honey poisoning related asystole has not been previously reported, and the rapid response to atropine is significant.

Investigation of the possibility of using ischemia-modified albumin as a novel and early prognostic marker in cardiac arrest patients after cardiopulmonary resuscitation.

BACKGROUND Early and accurate prediction of survival to hospital discharge following resuscitation after cardiac arrest (CA) is a major challenge. Our aim was to investigate the levels of ischemia-modified albumin (IMA) and malondialdehyde (MDA) in CA patients and whether IMA levels are valuable early marker of post-cardiopulmonary resuscitation prognosis in CA patients. METHODS We enrolled 52 in- or out-of-hospital CA patients, with 47 healthy volunteers as the control group (CG). Blood samples were taken for IMA and MDA measurement at the beginning or within 5 min of commencement of CPR. The patients were classified according to the Glasgow Outcome Score (GOS) into a poor outcome group (POG) and a good outcome group (GOG). RESULTS Mean IMA levels were higher in POG (0.25+/-0.07 ABSU) than in GOG (0.19+/-0.07 ABSU, p=0.002) and also than CG (0.16+/-0.04 ABSU, p=0.0001). The IMA levels were not significantly higher in GOG than in CG (p=0.32). The mean MDA levels in POG (0.77+/-0.27 nmol/ml) were comparable to the levels in GOG (0.75+/-0.18 nmol/ml, p>0.05), but were significantly higher than in CG (0.60+/-0.15 nmol/ml, p=0.001). MDA levels were not significantly higher in GOG than in CG (p=0.06). The optimum cut-off point for IMA maximizing sensitivity and specificity was 0.235 ABSU, with sensitivity of 65.8% and specificity of 78.6%. The corresponding +PV and -PV were 85.3% and 45.8%, respectively. CONCLUSION In conclusion, though the result may not be applied clinically in every patient, the ischemia-modified albumin may be a valuable prognostic marker in cardiac arrest patients following CPR.

Ischemia-modified albumin in the diagnosis of pulmonary embolism: an experimental study

STUDY OBJECTIVE We designed this experimental study to determine the value of ischemia-modified albumin in the diagnosis of pulmonary embolism. METHODS Twenty-four mature female New Zealand rabbits were divided into 4 groups, each consisting of 6 animals. These were classified into group 1 ,the control group; group 2, the deep venous thrombosis group; group 3, the deep venous thrombosis with pulmonary embolism group; and group 4, the pulmonary embolism-alone group. Deep venous thrombosis was produced by ligation of the iliac vein. To establish pulmonary embolism, 2 clots were administered from the iliac vein. Blood samples were taken from all the groups at hours 0, 1, 3, and 6 for ischemia-modified albumin measurement. RESULTS Pulmonary embolism was established in all the rabbits in groups 3 and 4, and this was confirmed by tomographic and histologic findings. Measurement of mean ischemia-modified albumin levels for all rabbits at hours 0, 1, 3, and 6 revealed that mean ischemia-modified albumin levels in groups 3 and 4 were statistically significantly higher than those in groups 1 and 2. There was no difference between the mean ischemia-modified albumin levels in groups 1 and 2 nor between groups 3 and 4. The alteration in ischemia-modified albumin levels over time was statistically significant. CONCLUSIONS The results of our experimental study demonstrate that ischemia-modified albumin levels may be useful in the diagnosis of pulmonary embolism.

Clinical Decision Instruments for CT Scan in Minor Head Trauma

Previous studies have presented conflicting results regarding the predictive value of various clinical symptoms and signs for performing computed tomography (CT) scan in minor head injury. Moreover, despite the presence in the literature of several similar publications regarding whether or not CT should be employed at the time of presentation of minor head injured patients, data regarding delayed CT are limited. The objective of this study was to determine whether high-risk criteria represent a significant indication for initial CT scan in patients with minor head trauma, and whether or not analysis using delayed CT scan is necessary in patients with high-risk criteria before being discharged. Patients presenting to the Emergency Department with minor head trauma between September 1, 2003 and September 1, 2004 were evaluated prospectively. After being divided into two main groups, low- and high-risk, four separate sub-groups based on age were established. Initial spiral CT examination was done within 3 h of trauma on all patients in addition to a delayed control CT scan in those with high-risk criteria between 16 and 24 h after trauma. The difference between the high- and low-risk groups in terms of abnormal CT findings was statistically significant (p < 0.0005). Among high-risk patients there was a significant difference between patients with a Glasgow Coma Scale (GCS) score of 13 or 14 and those with a GCS score of 15 (p < 0.0005). The relationship between vomiting and abnormal CT scan was significant (odds ratio 4.61, 95% confidence interval 2.20-9.64, p = 0.0001), and the relationship between abnormal CT scan and suspected skull fracture was also significant (odds ratio 3.46, 95% confidence interval 1.52-7.91, p = 0.0032). No significant correlations between other high-risk criteria and abnormal CT scan were determined. The difference between initial and delayed CT scans in patients with high-risk criteria was not significant (p = 0.161). Low-risk patients with a GCS score of 15 may be discharged without initial CT scan being performed. Initial CT scan absolutely must be performed, however, on patients with GCS < or = 15 in the event of vomiting or suspected skull fracture, even if isolated. Even though the difference between initial and delayed CT scans in patients with high-risk criteria is not significant, it is our opinion that it is still prudent for delayed CT scan to be performed, particularly on patients whose GCS score does not rise to 15, or decreases.

Effect of deep vein thrombosis on ischaemia-modified albumin levels

Background: An increasing number of studies have shown that ischaemia-modified albumin (IMA) levels rise in a number of acute ischaemic conditions such as cerebral infarct, myocardial infarct, pulmonary infarct and mesenteric infarct, suggesting that IMA may be useful as a diagnostic marker. A study was undertaken to investigate the effect on IMA levels of deep vein thrombosis (DVT), frequently encountered at the outset or during the course of diseases such as pulmonary embolism and cerebral infarct. Methods: A case-control study was performed in the emergency department of Karadeniz Technical University Hospital, Turkey. 41 patients presenting to the emergency and vascular surgery departments and definitively diagnosed with DVT using Doppler ultrasonography were enrolled in the study. A control group of 66 age-matched healthy volunteers served as a reference for biochemical parameters. Results: Mean (SD) plasma IMA levels were 0.259 (0.066) absorbance units (ABSU) in the DVT group and 0.171 (0.045) ABSU in the control group (p<0.005). The area under the curve for IMA was 0.850 (95% CI 0.768 to 0.933). The IMA value with acceptable sensitivity and specificity capable of being raised was 0.195 ABSU (sensitivity 80.5%, specificity 71.2%). Conclusions: DVT is associated with raised serum IMA levels but IMA levels are not suitable as a diagnostic marker for DVT.

Serum ischaemia-modified albumin increases in critical lower limb ischaemia

Background: Ischaemia is a common phenomenon in the pathogenesis of a wide range of medical and surgical conditions, including myocardial infarction, mesenteric vascular occlusion and compartment syndrome. Ischaemia modified albumin has been suggested as an aid to clinical decision making in various clinical settings. This study examines the usefulness of IMA in the diagnosis of limb ischaemia (LI). Methods: This case-controlled study was performed in the emergency department of Karadeniz Technical University Hospital, Turkey. 22 patients presenting to the emergency departments and definitively diagnosed with LI were enrolled in the study. A control group of 22 healthy volunteers served as a reference for biochemical parameters. Results: The mean serum IMA level for LI patients was 0.295 (SD 0.062) ABSU. The mean serum IMA level for control patients was 0.174 (SD 0.061) ABSU. There was a statistically significant difference between the mean LI patient and mean control patient IMA levels (p<0.0005). A ROC curve analysis reveals the relationship between sensitivity and specificity for IMA in limb ischaemia. Conclusion: There is a significant increase in serum IMA in limb ischaemia. Furthermore, using a cutoff of 0.22 ABSU, ROC curve analysis shows that IMA is 81.8% sensitive and 81.8% specific 81.8% in patients with clinically severe lower limb ischaemia. Future studies would be needed to determine if IMA would be clinically useful in the diagnosis of subtle limb ischaemia.