Bilgin Comert

Evaluation of mid-regional pro-atrial natriuretic peptide, procalcitonin, and mid-regional pro-adrenomedullin for the diagnosis and risk stratification of dyspneic ED patients☆☆☆★★★

OBJECTIVEnThe aim of this study was to evaluate the diagnostic and the prognostic value of a laboratory panel consisting of mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) for patients presenting to the emergency department (ED) with acute dyspnea.nnnMETHODSnWe prospectively enrolled ED patients who presented with a chief complaint of dyspnea and who had an uncertain diagnosis after physician evaluation. Final primary diagnosis of the cause of shortness of breath was confirmed through additional testing per physician discretion. We recorded inpatient admission and 30-day mortality rates.nnnRESULTSnOne hundred fifty-four patients were enrolled in the study. Congestive heart failure exacerbation was the final primary diagnosis in 42.2% of patients, while infectious etiology was diagnosed in 33.1% of patients. For the diagnosis of congestive heart failure exacerbation, MR-proANP had a sensitivity of 92.7% and specificity of 36.8%, with a negative likelihood ratio (LR-) of 0.16 and a positive likelihood ratio (LR+) of 1.44 (cut-off value: 120 pmol/L). For the diagnosis of an infectious etiology, PCT had a 96.5% specificity and 48.8% sensitivity (LR-: 0.58, LR+: 13.8, cutoff value: 0.25 ng/mL). As a prognostic indicator, MR-proADM demonstrated similar values: odds ratio for 30-day mortality was 8.5 (95% CI, 2.5-28.5, cutoff value: 1.5 nmol/L) and the area under the receiver operating characteristic curve in predicting mortality was 0.81 (95% CI, 0.71-0.91).nnnCONCLUSIONnThe good negative LR- of MR-proANP and the good positive LR+ of PCT may suggest a role for these markers in the early diagnosis of ED patients with dyspnea. Furthermore, MR-proADM may assist in risk stratification and prognosis in these patients..

Comparison of GlideScope video laryngoscope and intubating laryngeal mask airway with direct laryngoscopy for endotracheal intubation.

The aim of this study was to determine whether GlideScope video laryngoscope (GVL) and intubating laryngeal mask airway (i-LMA) improve the intubation success rate and could be easily learned and performed by paramedic students when compared with the direct laryngoscopic (DL) method. The study was designed as a prospective randomized crossover trial that included 121 paramedic students. All participants were asked to intubate each Ambu Airway Management Trainer manikins after the lecture and demonstration. Successful intubation was defined as the passage of the tube through the vocal cord within 60 s. At the end of the study, a questionnaire survey was given to all participants about their preferences, and they were requested to define each method on an easy–difficult scale. Successful intubation was achieved by 95 students (78.5%) with DL, 112 students (92.6%) with i-LMA, and 111 students (91.7%) with GVL. Mean time of intubation was 25.06±14 s for DL, 22.32±12 s for i-LMA, and 22.63±10 s for GVL. Success rates of i-LMA and GVL were significantly higher compared with DL (P=0.005 and P=0.006, respectively). No significant difference was determined between i-LMA and GVL in terms of successful intubation (P>0.05). This study showed that GVL and i-LMA provided better intubation success rates and were easier for paramedic students when compared with the classic DL method.

Is there any relation between insulin resistance and cognitive function in the elderly

BACKGROUNDnVascular risk factors are blamed as being involved in the pathogenesis of cognitive dysfunction in the elderly. Alzheimers disease or vascular-type dementia could be part of a metabolic syndrome. The aim of this study was to evaluate whether there is any relation between insulin resistance and cognitive status of the elderly regarding normal, mild cognitive impairment (MCI), Alzheimers disease (AD), vascular dementia (VaD) and mixed dementia.nnnMETHODSn267 elderly patients admitted to an outpatient geriatrics clinic were evaluated medically and cognitively in this study. The patients were diagnosed using ARDRA and DSM-IV criteria for AD; NINDS-AIREN and DSM-IV criteria for VaD; and Petersen criteria for MCI. Insulin resistance was calculated using both the homeostasis model assessment (HOMA) and quantitative insulin sensitivity check index (QUICKI) formulas.nnnRESULTSnThe mean values of HOMA and QUICKI scores were 2.79 (SD+/-3.56) and 0.346 (SD+/-0.036) for the normal group, 2.81 (SD+/-3.06) and 0.354 (SD+/-0.047) for AD group, 2.20 (SD+/-1.82) and 0.360 (SD+/-0.048) for VaD group, 2.87 (SD+/-1.81) and 0.339 (SD+/-0.038) for mixed dementia group, 2.79 (SD+/-2.81) and 0,349 (SD+/-0.042) for MCI group, respectively. There were no statistically significant differences between HOMA and QUICKI scores of all the groups.nnnCONCLUSIONnThis is the first study of the possible relation between insulin resistance and cognitive function in people categorized according to five forms of cognitive status. Unfortunately the results do not allow generalizations. Further prospective cohort studies that follow a normal cognitive group and MCI patients with and without insulin resistance are necessary.

Hyperbaric oxygen-induced changes in bacterial translocation and acinar ultrastructure in rat acute necrotizing pancreatitis

BackgroundWe aimed to investigate the effects of hyperbaric oxygen therapy on bacterial translocation and acinar cell ultrastructure in a rat model of acute necrotizing pancreatitis.MethodsForty-eight male Sprague-Dawley rats were randomly divided into three groups. Acute pancreatitis was induced in groups II and III. Groups I and II did not receive any treatment, and group III was treated with hyperbaric oxygen. All surviving animals were killed 48u2009h after the induction of pancreatitis. Bacterial translocation and histological and ultrastructural changes were determined.ResultsThe incidence of bacterial translocation in group III was significantly lower in comparison with group II (P < 0.001). Histopathological and ultrastructural injury scores were also significantly lower in group III (P < 0.001 and P < 0.04, respectively).ConclusionsHyperbaric oxygen therapy displayed beneficial effects on pancreatic superinfection and or histopathological and ultrastructural changes in experimental necrotizing pancreatitis.

Paraoxonase 1 Activity and Survival in Sepsis Patients

BACKGROUNDnSepsis is a state of augmented oxidative stress and diminished antioxidant capacity. High density lipoprotein (HDL) particles were shown to possess antioxidant and anti-inflammatory properties, as well as Paraoxonase 1 (PON1), which is an enzyme that is also protective against HDL oxidation. Previous studies suggested a possible role of decreased PON1 activity or HDL levels in sepsis patients.nnnAIMSnThe present study was designed to test a hypothesis that higher PON1 activity and HDL-cholesterol levels could predict a better survival in sepsis patients.nnnSTUDY DESIGNnObservational study.nnnMETHODSnVenous blood samples were collected from sepsis patients for HDL-cholesterol levels, PON1 activity and cytokine assays (TNF-α and IL-6) and Acute Physiologic and Chronic Health Evaluation II (APACHE II) scores were calculated in order to weight patients disease severity on the day of sepsis diagnosis. Patients were followed-up until the 28(th) day for any cause intra-hospital mortality. Data were statistically analyzed for effects of study parameters on patients survival.nnnRESULTSnIn total, 85 patients with sepsis were included in the study. The mean age was 65.2±17.9 years and 48 were male; at the end of the 28-day follow-up period, 46 survived. TNF-α (86.9±10.5 vs 118.6±16.4) and IL-6 levels (906.7±82.7 vs 1323.1±54.3) were significantly higher in non-survivors, while PON1 activity (140.7±42.3 vs 66.7±46.6) and HDL-cholesterol levels (43.6±8.1 vs 34.5±8.9) were significantly higher in survivors (p<0.001 for all). TNF-α (r=-0.763) and IL-6 levels (r=-0.947) showed strong negative correlations, PON1 activity (r=0.644) and HDL-cholesterol levels (r=0.477) showed positive correlations with patient survival (p<0.001 for all). Survival estimates significantly favored TNF-α (Log Rank 59.5, p<0.001) and IL-6 levels (Log Rank 53.2, p<0.001) according to PON1 activity (Log Rank 5.4, p<0.03) and HDL-cholesterol levels (Log Rank 8.3, p<0.005). Regression analyses for relative contributions of parameters to survival showed that higher IL-6 levels (t: -16.489, p<0.001) were the most significant negative factor for survival, and TNF-α levels (t: -4.417, p<0.001), whereas PON1 activity had a positive effect (t:3.210, p<0.003).nnnCONCLUSIONnThe present study showed that although low PON1 activity and HDL-cholesterol levels were related to mortality, higher levels were not found to be as predictive as cytokine levels for survival.

A fatal case of severe serotonin syndrome accompanied by moclobemide and paroxetine overdose

Aim: To present a fatal case of serotonin syndrome accompanied by moclobemide and paroxetine overdose. Case presentation: A 34-year-old married woman was presented following intentional ingestion of 3.5 g moclobemide and 2.6 g paroxetine. She was drowsy, agitated, and having rigor. In 1 h she developed myoclonus and diffuse muscle rigidity prominent in lower extremities. All laboratory tests were unremarkable except hyperglycemia (160 mg/dl), sinus tachycardia (103/min), and metabolic acidosis (7.051 pH, 52 mmHg pO2, 74.7 mmHg pCO2, 15% HCO3, 77% SaO2). Despite oxygen supplementation, her respiratory acidosis got worse and the SaO2 concentration decreased to 72%. Endotracheal intubation and paralysis were decided to control muscle hyperactivity followed by hyperthermia (max. 42.3oC) unresponsive to benzodiazepine. Even aggressive supportive treatment (mechanical ventilation, buffer replacement, cyproheptadine, and dantrolene) were applied, the patient could not recover and suffered cardiopulmonary arrest 20 h after presentation. Conclusion: Physicians working in the emergency departments and intensive care units, managing patients presenting with acute ingestion of selective serotonin reuptake inhibitors combined with monoamine oxidase inhibitors, should be aware of recognizing and treating serotonin stndrome. This is because many of these patients may require intensive care monitoring as well as tracheal intubation and ventilatory support.

A New Combination Therapy in Severe Acute Pancreatitis—hyperbaric Oxygen Plus 3-aminobenzamide: An Experimental Study

Objectives This study was designed to evaluate effects of hyperbaric oxygen (HBO) plus 3-aminobenzamide (3-AB) cotreatment on tissue oxidative stress parameters (TOSp), tissue histopathology scores (THSc), and bacterial translocations (Bact-Trans) in an experimental model of severe acute pancreatitis (AP). Methods Seventy-five Sprague-Dawley rats were randomized into 5 groups. Group 1 received sham. Severe AP was induced by intraductal taurocholate infusion and then group 2 received saline, group 3 received 3-AB, group 4 received 3-AB plus HBO, and group 5 received HBO. 3-Aminobenzamide (10 mg/kg per day, once daily, intraperitoneal) and saline (1 mL/kg) were started right after the induction, whereas HBO (2,8 atm pressure, BID, 90 minutes each) was started at the sixth hour. The rats were euthanized at the 54th hour, and TOSp, THSc, and Bact-Trans were studied. Results In treatment groups 3 and 5, Bact-Trans (P < 0.05, P < 0.05), TOSp (P < 0.05, P < 0.05), and THSc (P < 0.001, P < 0.001) were significantly lower than controls. In addition to these findings, group 4 (cotreatment) showed the most significant effect on Bact-Trans and THSc (P < 0.001, P < 0.001) and also better in TOSp (P < 0.02). Conclusions Poly(ADP-ribose) polymerase inhibition by 3-AB and HBO treatment alone was effective in the course of severe AP, and favorable with cotreatment because of the improved cascades of inflammatory process by different aspects.

Galantamine is safe as well as metoprolol on cardiac electrophysiology of patients with Alzheimer's disease

Background: Cholinesterase inhibitors may have vagotonic effects which may cause bradycardia and/or heart block with or without a history of cardiac disease. Therefore, to evaluate the effect of the galantamine, a cholinesterase inhibitor, on the cardiac electrophysiology, this study was designed. Methods: Thirty two consecutive elderly patients with newly diagnosed Late Onset Alzheimer Disease (LOAD) treated with a flexible 4-weekly galantamine dose titration regimen up to 24 mg/day and 41 elderly patients with hypertension, treated with metoprolol (50 mg/day) as a control group, were evaluated. Electrocardiogram (ECG) records were received at the each dose of galantamine therapy (8mg, 16 mg, and 24 mg respectively) and after the baseline. And also, ECG records were received at the baseline and one week after the metoprolol therapy. Results: When compared to the baseline values of galantamine treated patients, there were minimal changes at the each dose of galantamine in the ECG parameters including; heart rate, QRS duration, intervals of PR and corrected QT, but this isn’t significant (for each comparison p>0.05). In addition, these changes were less than changes at the 50 mg/ day dose of metoprolol. Conclusions: In this study, it was demonstrated that each dose of galantamine did not effect the ECG parameters compared with the baseline, significantly, and this effect is similar to metoprolol. In conclusion, otherwise the current data related to the cholinesterase inhibitors, galantamine seems like a reliable drug for the cardiac electrophysiology.

P4-375: Can insulin resistance in Alzheimer's disease be localized in the brain?

increased level of tests performance in Group III by CUR therapy (p 0.01). Similar to test performance of the whole rat, it was also demonstrated that IGF level decreasing (1.78 0.34) by STZ was increased (3.46 0.41) by CUR therapy (p 0.001). Moreover, mild beneficial effect was also demonstrated, histopathologically. Conclusions: Therefore, efficacy of CUR therapy was demonstrated in this model. In addition, it was firstly demonstrated that neuroprotection related to CUR might be proved by increasing the IGF-I level. In further studies, it should be needed to randomized controlled human study for CUR efficacy in Alzheimer’s disease.

Clinical and laboratory characteristics in the patients with pulmonary embolism

Pulmonary embolism is a common disorder that is accompanied by significant morbidity and mortality. This study attempts to determine the clinical and laboratory characteristics of established acute pulmonary embolism in the medical intensive care unit. n nBetween 1 January 2002 and 1 November 2003, 33 consecutive patients admitted to the Medical ICU had a diagnosis of acute pulmonary embolism proved by angiography. There were 21 men (63%) and 12 women (37%), with a mean age of 63.7 ± 12.6 years (range, 23–90 years). Whereas only eight of these 33 patients had associated deep vein thrombosis, 11 patients had heart failure, nine had diabetes mellitus, eight had associated malignancy, and seven patients had hypertension. n nSudden onset dyspnea (69%), palpitations (21%), cough (18%), and pleuritic chest pain (12%) were the most common comlaints. Tachycardia (33%), tachypnea (27%), and crackles (15%) were the most common findings on physical examination. n nFourteen of 33 patients had normal effusion, nine had pleural effusion and five had hilar effusion, and seven had atelectasia findings on chest X-ray. ECG findings were normal in eight patients (24%), inverted precordial T waves in nine patients (27%), atrial fibrillation in seven patients (21%), and nonspecific ST segment abnormalities in four patients (12%). Echocardiografic examination of patients revealed that 18 of 33 patients had normal findings (54%), 10 patients had pulmonary hypertension (30%) and five of them had right atrial enlargement (16%). Biochemical analysis results were within normal range in nine patients (27%), whereas LDH elevation in 17 (51%) and AST elevation in 13 patients (40%) were detected. Arterial blood gas analysis results gave that CO2 and O2 levels were below the reference values in 27 of 33 patients (81%). Mean APACHE II scores were 13.03 ± 4.01 points (range 5–17). The average ICU length of stay was 11.7 ± 3.3 days, and 24 of 33 patients (72%) were discharged home after that period. Nine of 10 patients diagnosed with massive embolism and complicated conditions (e.g. diabetes, heart failure) died before day 3 (28%). n nThis studys results showed, similar to the literature, that pulmonary embolism has challenges with a considerably high mortality rate. Future research should be planned on more accurate and specific diagnostic tests, which probably will improve mortality rates.