Mücahit Avcil

Predictors of early death in patients with acute pulmonary embolism

AIM We aimed to determine the predictors of early death in the course of acute pulmonary embolism (APE). MATERIALS AND METHODS We included 206 patients who had been admitted to our hospital between January 2011 and April 2013 with the diagnosis of APE. We derived a new model including corrected QT interval dispersion (QTcd) and P wave dispersion (Pd), echocardiographic findings, laboratory markers, and blood cell count indices to predict early death in patients with APE. RESULTS Thirty patients (14.5%) died; 176 patients (85.5%) lived after diagnosis of APE. Logistic regression (LR) analysis found that troponin I (odds ratio [OR], 1.084 [95% confidence interval {CI}, 1.009-1.165]), creatinine (OR, 4.153 [95% CI, 1.375-12.541]), mean platelet volume (OR, 1.991 [95% CI, 1.230-3.223]), neutrophil to lymphocyte ratio (NLR) (OR, 1.079 [95% CI, 1.005-1.160]), QTcd (OR, 1.084 [95% CI, 1.043-1.127]), Pd (OR, 1.049 [95% CI, 1.004-1.096]) were associated with early death in APE. New LR model (area under the curve [AUC], 0.970) performed better than the simplified pulmonary embolism severity index (sPESI) score (AUC, 0.859) in predicting early death in APE (P=.021). The predictivity of the sPESI score significantly improved after its single combination with creatinine, QTcd, or troponin I. When the combined model was constructed together with these 6 independent variables and sPESI score, stepwise LR model automatically excluded Pd and NLR, and the AUC from the rest of the combined model was 0.976, which is significantly different from the AUC of sPESI (0.859) (P=.0031). CONCLUSIONS Creatinine, troponin I, and QTcd significantly improves sPESI score. A new model with troponin I, creatinine, mean platelet volume, NLR, QTcd, and Pd seems to have greater prognostic power than the sPESI scoring system.

Assessment of Cardiac Ultrasonography in Predicting Outcome in Adult Cardiac Arrest

OBJECTIVE: A prospective follow-up study to evaluate the ability of cardiac ultrasonography performed by emergency physicians to predict resuscitation outcome in adult cardiac arrest patients. METHODS: Ultrasonographic examination of the subxiphoid cardiac area was made immediately on presentation to the emergency department with pulseless cardiac arrest. Sonographic cardiac activity was defined as any detected motion within the heart including the atria, ventricles or valves. Successful resuscitation was defined as any of: return of spontaneous circulation for ≥ 20 min; return of breathing; palpable pulse; measurable blood pressure. RESULTS: The study enrolled 149 patients over an 18-month period. The presence of sonographic cardiac activity at the beginning of resuscitation was significantly associated with a successful outcome (19/27 [70.4%] versus 55/122 [45.1%] patients without cardiac activity at the beginning of resuscitation). CONCLUSIONS: Ultrasonographic detection of cardiac activity may be useful in determining prognosis during cardiac arrest. Further studies are needed to elucidate the predictive value of ultrasonography in cardiac arrest patients.

Evaluation of left ventricular systolic and diastolic functions in patients with coronary slow flow phenomenon

OBJECTIVES In this study, systolic and diastolic function parameters were measured with conventional and tissue Doppler echocardiography in coronary slow flow phenomenon (CSFP) patients and compared to those of a control group. STUDY DESIGN Sixty patients (49 male; mean age 52.4±12.1) in whom CSFP was detected during coronary angiography study and 30 volunteers with normal coronary arteries (21 males; mean age 50.2±12.1) were included in this study. CSFP was determined using the TIMI frame count (TFC) method. TIMI frame count was calculated in each coronary artery using the TFC method. Left ventricular systolic and diastolic function was assessed by conventional echocardiography and tissue Doppler imaging. TFC correlation between diastolic function parameters was measured. RESULTS Baseline demographic and laboratory results did not differ significantly between the groups. TIMI frame counts were greater in the CSFP group compared to controls (p<0.001). Left ventricular ejection fraction (65.93±8.06% vs 66.63±5.96%), E/A ratio (1.11±0.36 vs 1.22±0.33), and isovolumetric relaxation time (IVRT) (85±17 cm/s vs 84±13 cm/s) measured with conventional echocardiography showed no significant difference between the two groups. Em (7.0±2.1 cm/s vs 7.4±1.7 cm/s), Am (7.4±2.0 cm/s vs 7.0±1.4 cm/s) and E/Em (10±3 vs 10±1) measured with tissue Doppler echocardiography showed no significant difference between the two groups. Corrected TIMI frame count for the left descending coronary artery (cLAD) and mean TFC were not correlated with the E/A ratio, deceleration time (DT), IVRT, or E/Em ratio. CONCLUSION Left ventricular systolic and diastolic functions were preserved in CSFP.

Blood count parameters can predict the severity of coronary artery disease

Background/Aims Because of the inflammatory nature of coronary artery disease (CAD), both platelets and white blood cells have been investigated for years. The aim of this study was to investigate the relationships between some prominently hematologic blood count parameters (mean platelet volume [MPV], neutrophil to lymphocyte ratio [NLR]) and the severity of CAD by using Gensini scores. Methods A total of 194 patients, who had undergone coronary angiography, enrolled in this study. The control group consisted of 42 patients who had normal coronary arteries. Remaining CAD patients were divided into two groups according to their Gensini scores. Results NLR and MPV were higher in the severe atherosclerosis group compared with the mild atherosclerosis group (p = 0.007, p = 0.005, respectively). The Gensini score showed significant correlations with NLR (r = 0.20, p = 0.011), MPV (r = 0.23, p = 0.004) and high density lipoprotein cholesterol (r = –0.161, p = 0.047). Using a cut-off level of 2.54, NLR predicted severe atherosclerosis with a sensitivity of 74% and specificity of 53% (area under curve [AUC], 0.627; 95% confidence interval [CI], 0.545 to 0.704; p = 0.004). MPV values above 10.4 predicted severe atherosclerosis with a sensitivity of 39% and specificity of 90% (AUC, 0.631; 95% CI, 0.549 to 0.708; p = 0.003). In the multiple logistic regression analysis, high levels of NLR (odds ratio [OR], 1.450; 95% CI, 1.080 to 1.945; p = 0.013) and MPV (OR, 1.622; 95% CI, 1.147 to 2.295; p = 0.006) were found to be independent predictors of severe atherosclerosis. Conclusions Our study suggests that both NLR and MPV are predictors of severe atherosclerosis and may be used for the prediction and identification of cardiac risks in CAD patients.

Dynamic thiol/disulfide homeostasis in children with attention deficit hyperactivity disorder and its relation with disease subtypes

BACKGROUND The aim of this study was to evaluate a novel oxidative stress marker (thiol/disulfide homeostasis) in attention deficit hyperactivity disorder (ADHD) children for the first time in literature. METHODS Ninety children with ADHD diagnosed according to DSM-V and as control group, 65 healthy children were included to the study. Native thiol, total thiol, disulfide, disulfide/native thiol, disulfide/total thiol were compared between the groups. RESULTS Total and native thiol levels were significantly higher whereas the disulfide/native thiol ratios were significantly lower in children with ADHD. ADHD combined type appeared to have higher disulfide, disulfide/native thiol and disulfide/total thiol ratios compared to other subtypes. Disulfide levels of the males with ADHD were significantly higher than those of the females with ADHD. CONCLUSION This study suggests that thiol/disulfide homeostasis is abnormal in children with ADHD. It may be used as a novel OS marker in ADHD children because it is easy, practical, fully automated and relatively inexpensive.

Comparison of different methods for measurement of electrolytes in patients admitted to the intensive care unit

Objectives: To investigate whether electrolyte levels measured by using blood gas analyzers (ABG) and auto-analyzers (AA) are equivalent and can be used interchangeably. Methods: This observational prospective study was conducted in 100 patients admitted to the Intensive Care Unit, Adnan Menderes University School of Medicine, Aydin, Turkey, between March and August 2014. Samples for both AA and ABG analyzers were collected simultaneously from invasive arterial catheters of patients. The electrolyte levels were measured by using 2 methods. Results: The mean sodium level measured by ABG was 136.1±6.3 mmol/L and 137.8±5.4 mmol/L for AA (p=0.001). The Pearson’s correlation coefficient was 0.561 (p<0.001). The Bland-Altman 95% limits of agreement were -9.4 to 12.6 mmol/L. The mean potassium levels measured by ABG was 3.4±0.7 mmol/L and AA was 3.8±0.7 mmol/L (p=0.001). The Bland-Altman comparison limits were -0.58 to 1.24 and the associated Pearson’s correlation coefficient was 0.812 (p<0.001). Conclusion: The results of the 2 analyzing methods, in terms of sodium, were not equivalent and could not be used interchangeably. However, according to the statistical analyses results, by including, but not blindly trusting these findings, urgent and vital decisions could be made by the potassium levels obtained from the BGA, but a simultaneous follow-up sample had to be sent to the central laboratory for confirmation.

A rare complication of scorpion venom: atrial fibrillation

Although the clinical findings of scorpion stings are often mild, they may lead to multiorgan failure and even cardiogenic shock. The toxin has both local and systemic effects. Local effects include edema, bruising(ecchymosis), and burning pain,whereas systemic effects include nausea,vomiting, hypotension or hypertension, cardiovascular toxicity, renal failure,and hemorrhage at different areas. The toxins have been implicated in a number of cardiac arrhythmias, including torsade de pointes, long QT syndrome, and atrial fibrillation. Here, we present a 90-year-old woman with no history of drug use or complaints due to dysrhythmias who developed atrial fibrillation after being stung by a scorpion.

Providing full recovery with single-dose intravenous reteplase in a patient presented to emergency department with acute ischemic stroke

Administration of intravenous reteplase might be a choice of treatment of acute ischemic stroke.

Exchange Transfusion for Severe Imported Falciparum Malaria with Hyperparasitaemia: Case Report

Severe falciparum malaria is a potentially fatal infection despite optimal antimalarial treatment. Exchange transfusion is successfully used in severe falciparum malaria with hyperparasitaemia. In this paper, we describe a case of severe Plasmodium falciparum infection in a 23-yearold man. The patient was referred to our emergency department with high fever after returning from Equatorial Guinea. The thin and thick blood smears revealed the presence of P. falciparum ring forms with a parasite density of 30%. P. falciparum infection was confirmed by Polymerase Chain Reaction (PCR). The patient was successfully treated by exchange transfusion in addition to antimalarial chemotherapy. Despite limited evidence of its efficacy in improving survival, exchange transfusion can be used as an-supportive treatment in selected cases where rapid reduction in the parasite load appears necessary.

Simultaneous Use of Intravenous Lipid Emulsion and Plasma Exchange Therapies in Multiple Drug Toxicity.

Objective: The aim of this study was to highlight the use of combined intravenous lipid emulsion (ILE) and plasma exchange (PE) therapies in multidrug toxicity. Clinical Presentation and Intervention: A 45-year-old woman who attempted suicide by ingesting large quantities of amisulpride (28 g), diazepam (250 mg), valsartan (2,240 mg), aripiprazole (45 mg) and paliperidone (21 mg) was taken to the hospital of Adnan Menderes University School of Medicine. Upon arrival, she exhibited signs of cardiotoxicity and severe depression of the central nervous and respiratory systems. She was treated successfully with ILE for 4 h and PE therapy for 36 h, consecutively. She was discharged on the fourth day of hospitalization having fully recovered. Conclusion: The patient was successfully treated with the combination of ILE and PE.