Beril Kose

Leech bites: massive bleeding, coagulation profile disorders, and severe anemia

Leeches have been in use for centuries, especially in plastic and reconstructive surgery wound and flap healing, in venous insufficiencies, and in the treatment of many disorders such as hemorrhoids and varicosity. With this study, we aimed to discuss coagulation disorder due to uncontrolled leech bites, consequent excessive skin hemorrhage, and anemia requiring blood transfusion. A 65-year-old male patient was referred to the emergency department because of excessive intractable bleeding that had occurred after leech bites. On physical examination, a total of 130 bites were detected on various regions of the body. In the laboratory findings of the patient, hemoglobin and hematocrit levels were extremely low, and prothrombin time, international normalized ratio, and partial thromboplastin time were markedly increased. The patient received a total of 8 units of fresh frozen plasma and 6 units of erythrocyte suspension. Bleeding stopped by decreasing after the transfusion of fresh frozen plasma. Although the complications due to leech injuries are rare, they may be an important cause of morbidity and mortality when an injury or prolonged bleeding in an internal region occurs. Prolonged skin hemorrhages rarely cause anemia, and deaths are caused by intractable hemorrhages. However, a coagulation disorder and consequent intractable hemorrhage have not been reported previously in the literature. In conclusion, it should be known that uncontrolled, blind, and excessive leech use causes severe hemorrhage and excessive blood loss, causing significant morbidity and mortality. Therefore, the awareness of either physicians or people using or recommending alternative medicine should be raised on this subject.

Protective effects of Y-27632 on acute dichlorvos poisoning in rats.

Anticholinesterase poisoning is an important health problem in developing countries, and understanding of its underlying mechanisms is essential for the effective treatment. This study is designed to examine the effects of Y-27632, a selective Rho-kinase inhibitor, on organophosphate-induced cardiac toxicity and mortality in rats. Rats were randomly divided into 4 groups: control (corn oil), dichlorvos (30 mg/kg intraperitoneally), and 1- and 10-mg/kg Y-27632 + dichlorvos groups. After 6 hours of intraperitoneal injection, venous blood and cardiac samples were obtained, biochemical or immunohistochemical analyses were performed, and the intensity of muscle fasciculation was recorded. Serum cholinesterase activities were suppressed with dichlorvos, and these reductions were inhibited with Y-27632 pretreatment. Serum creatine kinase, creatine kinase-MB activities, and myoglobin and N-terminal probrain natriuretic peptide concentrations were not markedly affected with poisoning or Y-27632. Although serum nitric oxide concentrations did not change with dichlorvos, cardiac nitric oxide levels were markedly increased with Y-27632 pretreatment. Cardiac glutathione levels also increased with 1 mg/kg Y-27632. There was no staining for apoptosis, and immunohistochemical analyses of inducible nitric oxide synthase showed no change in cardiac tissue for all of the groups. Both doses of Y-27632 abolished mortality in rats with acute dichlorvos exposure (100% survival). These results show that administration of Rho-kinase inhibitor can produce protective effects against dichlorvos intoxication in rats. These findings may provide new possibilities for the treatment of organophosphate poisoning.

Myocardial infarction, acute ischemic stroke, and hyperglycemia triggered by acute chlorine gas inhalation

Chlorine is one of the most common substances involved in toxic inhalation. Until now, several accidental exposures have been reported. The damage to the respiratory tract in the immediate phase after exposure to chlorine is well defined. Death occurs particularly due to pulmonary edema with respiratory failure and circulatory collapse. On the other hand, no association with myocardial infarction, acute stroke, severe hyperglycemia, and acute chlorine inhalation has been reported in literature. In the present study, an elderly (74-year-old) and diabetic case with myocardial infarction, acute stroke, hyperglycemia, and respiratory failure associated with acute chlorine intoxication after a diagnosis of acute chlorine poisoning and treatment in the emergency department is reported and the literature is revisited. Physicians should know that in elderly patients with a systemic disease who apply with chlorine gas inhalation, more serious complications along with damage in respiratory tract might be observed.

Effects of a selective Rho-kinase inhibitor Y-27632 on oxidative stress parameters in acute dichlorvos poisoning in rats

This study examined the effects of Y‐27632, a selective Rho‐kinase inhibitor, on organophosphate‐induced acute toxicity in rats. Rats were randomly divided into four groups as control (corn oil), dichlorvos (30 mg kg−1 i.p.), 1 and 10 mg kg−1 Y‐27632 + dichlorvos groups. Cholinergic signs (fatigue, tremor, cyanosis, hyper‐secretion, fasciculations) were observed in all the rats in the dichlorvos group and the mortality rate was 50%. No cholinergic findings and deaths were observed in the control and Y‐27632 groups. Plasma cholinesterase activities were suppressed with dichlorvos and these reductions were attenuated with Y‐27632 pretreatment. There was a marked increase in plasma malondialdehyde level in the dichlorvos group, but Y‐27632 pretreatment abolished this elevation. Dichlorvos markedly depressed cardiac paraoxonase activity, but these changes were not markedly modified with Y‐27632. Total antioxidant capacities, total oxidant status, oxidative stress index, total free sulfhydryl groups and catalase activities in plasma and cardiac tissues were not markedly different between the groups. No significant changes were observed with cardiac myeloperoxidase activities or plasma arylesterase and ceruloplasmin activities. In conclusion, our results suggest that Rho‐kinase pathway is involved in organophosphate intoxication, and a decrease in cardiac paraoxonase activities may play a role in the pathogenesis of acute organophosphate poisoning in rats. Copyright

Admission appropriateness and profile of the patients attended to a state hospital emergency department

The aim of this study was to determine the profile and appropriateness of the patients’ indications admitted to the emergency department in a state hospital. Adult and pediatric trauma patients admitted to the emergency department of Van State Hospital between March 01 and March 31, 2010, in the course of one month period, were retrospectively analyzed. Data of the 32800 patients admitted to the emergency department during this period were evaluated. Male and female ratio of these patients was 54.8% and 45.2%, respectively, and the most intense group with 77% was the age group of 17-65. The majority of the applications with 60.5% occurred between 8 a.m. and 17 p.m. An examination was asked for 50% of the patients. It was determined that emergency examinations and therapies were applied to 9.9% of the patients, consultation rates were 4.5%, and the highest consultations were taken from orthopedic clinics (16.1%). It was established that 1.4% of the patients were hospitalized, with the highest admission to the general surgery clinic (13.8%). In hospitalized patients, the most common diagnoses were abdominal pain (9.6%), and 88.4% of the patients were discharged from the emergency department. It was observed that the majority of patients admitted to the emergency department need not have been in emergency, and should have applied to primary health care services and policlinics. The results of this study showed that non-emergency patients highly increase the workload of emergency departments, therefore, patients should be trained and awareness of patients should be increased; primary health care services should be made available; accurate, effective and enforceable policies for emergency medical services in the country must be established.

Response to Dr. Unal's Letter

To the Editor, We read the letter written by Unal et al., and we realized the point that they mentioned. During our research we were aware of this stuation. But, since we did not have enough equipment and support, we could not evaluate serum levels of cardiac troponin-I (CTI). Therefore, we could not make any comment on whether serum levels of CTI was interfere with myocardial damage related to carbon monoxide poisoning (COP) or not. As for the cardiac troponin-T (CTT), higher levels of serum CTT related to myocardial damage in patients with COP were reported by Zhu et al. (2006). While their patients were postmortem, our patients did not die, and our many patients also discharged from the hospital at between 24 and 48 h. In the other study by Aslan et al., serum levels of CTT were slightly elevated in only 1 patient among 40 patients (Aslan et al., 2005). For this reason, we think that the serum levels of CTT could not be elevated from myocardial damage related to COP. In the case of a patient with ST depresion on electrocardiograph (ECG) and decreased left ventricular systolic function (EF < 40%) the situation can be explained as follows: In the detection of myocardial damage, since the specificity of the serum levels of CTT was not 100% (Jaffe et al., 2000), the serum levels of CTT in the mentioned patient might have not been elevated. As a result, although we completely agree with the reader’s opinion that serum levels of CTI must be measured in the evaluation of myocardial damage in COP, we would like to emphasize that the specificity of the serum levels of CTT in the detection of myocardial damage was not 100%.