Zerrin Defne Dundar

Serum Ischemia-modified Albumin Levels in an Experimental Acute Mesenteric Ischemia Model

OBJECTIVES This experimental study aimed to assess the changes in the levels of serum ischemia-modified albumin (IMA) and interleukin-6 (IL-6) by time in cases of acute mesenteric ischemia due to superior mesenteric artery occlusion. METHODS Twenty-one New Zealand rabbits were randomly divided into three groups. Blood samples were collected at hours 0, 1, 3, and 6 from animals in a control group; a sham group following a simple laparotomy; and in an ischemia group following superior mesenteric artery ligation. All blood samples were analyzed for serum IMA and IL-6 levels, and then the time-dependent changes of biomarkers were investigated. RESULTS The serum IMA levels of the ischemia group at hours 3 and 6 were significantly higher than those of the control and sham groups (hour 3, p = 0.017; hour 6, p = 0.001). The increase in serum IL-6 levels in the ischemia group at hours 1, 3, and 6 compared to the control and sham groups was also significant (hour 1, p = 0.002; hour 3, p = 0.003; hour 6, p = 0.003). CONCLUSIONS IMA may be helpful as a marker in the diagnosis of acute mesenteric ischemia; however, its diagnostic value and use as a routine biochemical test should be assessed in further studies.

Diagnostic and prognostic value of procalcitonin and phosphorus in acute mesenteric ischemia

BACKGROUND In this study, using an animal model of acute mesenteric ischemia (AMI), we investigated the possible use of procalcitonin and phosphorus in the early diagnosis of AMI. METHODS In this study, 21 New Zealand rabbits were used. Subjects were allocated into three groups as Control, Sham and Ischemia. No intervention was performed in the subjects in the Control group. In the subjects in the Sham and Ischemia groups, laparotomy was performed with midline incision. In the Ischemia group, the superior mesenteric artery was found and tied after laparotomy. Blood was drawn from the animals in all groups at 0, 1, 3 and 6 hours, and procalcitonin and phosphorus levels were studied in these samples. RESULTS In the Ischemia group, the increase in the levels of serum phosphorus and procalcitonin was found to be statistically significant compared to the Control and Sham groups (p<0.05). The levels of phosphorus and procalcitonin were detected to increase from the 1st hour after ischemia onset, and the increase continued for the following 6 hours (p<0.05). CONCLUSION Phosphorus and procalcitonin may be important parameters for use in the early diagnosis and prognosis of AMI.

Prognostic importance of neutrophil-lymphocyte ratio in critically ill patients: short- and long-term outcomes

STUDY OBJECTIVE The number of critically ill patients admitted to the emergency department increases daily. To decrease mortality, interventions and treatments should be conducted in a timely manner. It has been found that the neutrophil-lymphocyte ratio (NLR) is related to mortality in some disease groups, such as acute coronary syndrome and pulmonary emboli. The effect of the NLR on mortality is unknown in critically ill patients who are admitted to the emergency department. Our aim in this study is to evaluate the effect of the NLR on mortality in critically ill patients. METHODS This study was planned as a prospective, observational cohort study. Patients who were admitted to the emergency department because they were critically ill and required the intensive care unit were included in the study. Demographic characteristics, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sepsis-related Organ Failure Assessment, Glasgow Coma Score, and NLR values were recorded upon emergency department admission. The patients were followed up for sepsis, ventilator-associated pneumonia, multiorgan failure, in-hospital mortality, and 6-month mortality. RESULTS The median (interquartile range) age of the 373 patients was 74 (190) years, and 54.4% were men. Neutrophil-lymphocyte ratio values were divided into quartiles, as follows: less than 3.48, 3.48 to 6.73, 6.74-13.6, and more than 13.6. There was no difference among these 4 groups regarding demographic characteristics, APACHE II score, Sepsis-related Organ Failure Assessment score, Glasgow Coma Score, and length of hospital stay (P>.05). In the multivariable Cox regression model, in-hospital mortality and 6-month mortality NLR were hazard ratio (HR), 1.63 (1.110-2.415; P=.01) and HR, 1.58 (1.136-2.213; P=.007), respectively, and APACHE II scores were detected as independent indicators. CONCLUSION The NLR is a simple, cheap, rapidly available, and independent indicator of short- and long-term mortalities. We suggest that the NLR can provide direction to emergency department physicians for interventions, particularly within a few hours after admission, in the critically ill patient group.

Modified Early Warning Score and VitalPac Early Warning Score in geriatric patients admitted to emergency department.

Objective The aim of this study was to evaluate the value of the Modified Early Warning Score (MEWS) and the VitalPac Early Warning Score (VIEWS) in predicting hospitalization and in-hospital mortality in geriatric emergency department (ED) patients. Patients and methods This prospective, single-centered observational study was carried out over 1 month at the ED of a university hospital in patients 65 years of age and older presenting to the ED. The vital parameters of the patients measured on admission to ED were recorded. The MEWS and VIEWS were calculated using the recorded physiological parameters of the patients. Hospitalization and in-hospital mortality were used as the primary outcomes. Results A total of 671 patients included in the study. The median age of the patients was 75 (11) years, and 375 (55.9%) were men. The MEWS is effective for discriminating patient groups that have been discharged from ED, admitted to a ward and admitted to ICU [1 (2) vs. 1 (1) vs. 3 (3), respectively, P<0.001]. The VIEWS is also effective for discriminating patient groups that have been discharged from ED, admitted to a ward, and admitted to ICU [2 (3) vs. 5 (5) vs. 8 (8), respectively, P<0.001]. The AUCs of the MEWS and VIEWS were 0.727 [95% confidence interval (CI) 0.689–0.765] and 0.756 (95% CI 0.720–0.792) in predicting hospitalization, respectively. The AUCs of the MEWS and VIEWS were 0.891 (95% CI 0.844–0.937) and 0.900 (95% CI 0.860–0.941) in predicting in-hospital mortality, respectively. Conclusion The MEWS and VIEWS are powerful scoring systems that are easy-to-use for predicting the hospitalization and in-hospital mortality of geriatric ED patients.

A new marker for myocardial injury in carbon monoxide poisoning: T peak-T end

OBJECTIVES Carbon monoxide (CO) poisoning frequently affects repolarization, resulting in abnormal electrocardiography findings. The goal of this study was to examine the effect of CO poisoning on the novel transmyocardial repolarization parameters T peak-T end (Tp-e), Tp-e dispersion, and Tp-e/QT and the relationship of these parameters to myocardial injury (MI). METHODS This prospective study included 94 patients with CO poisoning and 40 healthy controls. Participants received an electrocardiography and had their blood drawn at admission and 6 and 24 hours after admission. The QT, Tp-e, Tp-e dispersion, and the Tp-e/QT ratio were calculated. Myocardial injury was determined based on an elevation in troponin any time during the first 24 hours. The patients were divided into 2 subgroups: those with and without MI. RESULTS T peak-T end, Tp-e dispersion, and the Tp-e/QT ratio were higher at admission than after 6 and 24 hours of hospitalization and were higher than the control group (P < .001). There was a correlation between the carboxyhemoglobin level at admission and Tp-e and Tp-e dispersion (P < .001). The MI subgroup (n = 14) had a higher Tp-e at admission than did the non-MI subgroup (n = 80) (96 [11] milliseconds vs 87 [12] milliseconds, P = .03). There were no any significant differences in the Tp-e dispersion or the Tp-e/QT ratio between the 2 MI subgroups. Receiver operating characteristic analysis showed that a Tp-e cutoff value for MI of 91.5 milliseconds had a sensitivity of 72.7% and a specificity of 67.2%. CONCLUSION Transmyocardial repolarization parameters indicative of arrhythmia were prolonged in patients with CO poisoning. T peak-T end was associated with MI.

A new parameter for the diagnosis of hemorrhagic shock: jugular index.

PURPOSE The purpose of this study is to investigate whether there are any significant changes in the diameter and the area of the internal jugular vein (IJV) during the hemorrhagic shock. MATERIALS AND METHODS Healthy volunteers donating blood were included in the study. Arterial blood pressure, pulse rate, anteroposterior (AP) and transverse diameter, and area measurements of the IJV during inspiration and expiration were performed on the volunteers before and after 450 mL of blood donation. RESULTS A total of 35 volunteers were enrolled in the study. The IJV prehemorrhagic AP diameters during inspiration and expiration were 4.9 ± 2.2 and 7.9 ± 3.1 mm, and the posthemorrhagic values were 2.7 ± 1.6 and 6.6 ± 3.1 mm (respectively, P < .001 and P = .007). The jugular index-AP was 36% ± 15% before hemorrhage and 58% ± 17% after hemorrhage (P < .001). The IJV areas during inspiration and expiration were 0.40 ± 0.28 and 0.81 ± 0.51 cm(2) before hemorrhage and were 0.14 ± 0.15 and 0.61 ± 0.47 cm(2) after hemorrhage (for both, P < .001). The jugular index-area was found as 47% ± 18% before hemorrhage and as 73% ± 18% after hemorrhage (P < .001). CONCLUSIONS We believe that measurement of the IJV and the jugular index is a reliable indicator of class 1 hemorrhagic shock. It may be used as a part of focused abdominal sonography for trauma in clinical practice.

Intoxication due to Papaver rhoeas (Corn Poppy): Five Case Reports.

Introduction. In this paper, we aimed to present five Papaver rhoeas intoxication cases, which is very rare in the literature. Case 1. A 35-year-old female patient was admitted to our emergency room with the complaints of nausea, restlessness, and dyspnea developing 3 hours after eating Papaver rhoeas. On physical examination, her general condition was moderate; she was conscious and the vital findings were normal. The pupils were myotic. She was transferred to the toxicology intensive care unit as she experienced a generalized tonic clonic seizure lasting for three minutes. Case 2. A 41-year-old female patient was brought to our emergency room by 112 ambulance as she had contractions in her arms and legs, unconsciousness, and foam coming from her mouth two hours after Papaver rhoeas ingestion. On physical examination, she was confused, the pupils were myotic, and she was tachycardic. Arterial blood gases analysis revealed lactic acidosis. Case 3. A 38-year-old female patient was admitted to our emergency room with complaints of nausea and vomiting two hours after ingestion of Papaver rhoeas. Her physical examination and tests were normal. Case 4. A 34-year-old male patient was admitted to our emergency room with complaints of numbness and loss of power in his arms and legs one hour after Papaver rhoeas ingestion. He was hospitalized at the toxicology intensive care unit for follow-up and treatment. Dyspnea and bradycardia developed on the follow-up. The oxygen saturation without oxygen support was 90%. ECG revealed sinus bradycardia. The cardiac enzymes did not increase. Case 5. A 42-year-old female patient was brought to our emergency room by 112 ambulance with contractions in her arms and legs and unconsciousness two hours after Papaver rhoeas ingestion. On her physical examination, she was confused and the pupils were myotic. Arterial blood gases analysis revealed lactic acidosis. Conclusion. All patients were followed up for a few days and then discharged from the hospital with recovery. Unconscious consumption of Papaver rhoeas leads to a clinical condition resembling morphine intoxication, CNS depression, and epileptic seizures.

The Experiences in a Toxicology Unit: A Review of 623 Cases

Background To evaluate the etiological and demographic characteristics of adult poisoning patients followed up in a toxicology unit in Konya, Turkey. Methods Patients (≥ 15 years old) followed up with the diagnosis of poisoning in our toxicology unit in 2011 were included in this retrospective study. The patients’ medical records were investigated. Age, gender, medical history, the first medical center the patient had been admitted to, the routes and causes of poisoning, the toxins involved, the number of the pills taken, treatments, complications, the length of stay in the hospital and the outcome were recorded. Results A total of 623 patients were included in the study. The mean age of patients was 28.1 ± 15.1. Four hundred and forty-five (71.4%) of patients were female, 541 (86.9%) of them were poisoned via the oral route and 75 (12.0%) of them were poisoned by inhalation. The causes of poisoning were drugs in 408 (65.5%) patients, pesticides/insecticides in 58 (9.3%) patients and carbon monoxide in 49 (7.9%) patients. The commonly used drugs were as follows: analgesics (57.2%), antidepressants (25.4%) and gastrointestinal system drugs (15.8%). The poisonings were suicidal in 489 (78.5%) patients, accidental in 120 (19.3%) patients and overdose in 14 (2.2%) patients. The number of women was higher in the suicide group. At the end of the treatment, 604 (97.0%) of the patients were discharged and 3 (0.4%) of them died. The duration of follow-up was 39.2 ± 37.5 h. Conclusion The most common causes of poisoning are drugs, pesticides/insecticides and carbon monoxide. Health and educational policies at a national level are needed in order to prevent this medicosocial problem. Furthermore, specially equipped toxicology units should be constructed for the treatment and follow-up of the poisoned patients in order to reduce the morbidity and mortality to a significant extent.

The Importance of H-FABP in Determining the Severity of Carbon Monoxide Poisoning

Background In this study, we aimed to investigate the importance of the use of heart-type fatty acid binding protein (H-FABP) in evaluating the myocardial damage in patients admitted to the emergency department with moderate to severe carbon monoxide (CO) poisoning. Methods All patients admitted to the emergency department with severe acute CO intoxication were enrolled the study. The H-FABP and cardiac biomarker levels were assessed at 0, 6th and 24th hours. The patients were divided into groups as those with normal echocardiography findings and with wall motion abnormalities. The differences between the groups for these parameters were compared. Results The mean age of 80 patients was 32.3 ± 12.9 years old. 42 of them were male. On admission, 29 (36.3%) had elevated serum troponin I levels and 56 (70.0%) had elevated serum H-FABP levels. At 6thhour, 4 (5.0%) of 80 patients had higher serum H-FABP levels and 23 (28.8%) of them had higher serum Troponin I levels than 0 hour. The patients with wall motion abnormality had significantly higher serum H-FABP levels compared to the patients with normal echocardiography findings at 6th and 24th hours (p = 0.001 and 0.009). While the serum COHb and H-FABP levels tended to decrease continuously in time (p < 0.001), the serum troponin I levels increased at 6th hour and then decreased at 24th hour (p = 0.017). Conclusion The serum H-FABP levels are useful in identifying the myocardial damage in patients admitted to the emergency department with moderate to severe carbon monoxide poisoning at an early phase. Keywords Carbon monoxide; Poisoning; H-FABP; Myocardial injury

Antiepileptic drug poisoning: Three-year experience

Introduction Antiepileptic drugs, which are also called anticonvulsants, are used in the therapy and prophylaxis of epileptic seizures. The purpose of this paper was to investigate the relevant epidemiological data and to determine which of these drugs was the most frequent cause of intoxication. Another purpose of this study was to determine the neurological, cardiac, and biochemical problems caused by antiepileptics. Material and method This retrospective study included 95 consecutive patients under 18 years of age with antiepileptic intoxication, presenting to and being followed-up in, the Toxicology Unit between January 2010 and February 2013. The data were obtained by screening the patient files. Results Of the cases, 67 (70.5%) were self-poisoned by first generation antiepileptics (FGAEs) and 28 (29.5%) by second generation antiepileptics (SGAEs). The Glasgow Coma Scale (GCS) scores and the serum lactate levels of the patients poisoned by FGAEs and SGAEs on admission to emergency department were 15 (25th: 12; 75th: 15; 95th: 15; IQR: 3) and 1.9 (25th: 1.4; 75th: 3.1; 95th: 5.6; IQR: 1.7), and 15 (25th: 14.3; 75th: 15; 95th: 15; IQR: 0.75) and 1.07 (25th: 0.9; 75th: 1.6; 95th: 5.5; IQR: 0.71), respectively. The serum lactate levels of patients poisoned by FGAEs were significantly higher (p < 0.001). Among the cases poisoned by carbamazepine, the most frequent cause of intoxication, the GCS score was significantly lower and serum lactate level was significantly higher in the group with high serum levels of carbamazepine (p = 0.004 and p < 0.001, respectively). In cases poisoned by valproic acid (VPA), the second frequent cause of intoxication, there was neither a significant association between the serum VPA level and the GCS score, nor between the serum lactate level and the systolic blood pressure (p = 0.470, p = 0.897, and p = 0.088, respectively). However, there was a positive correlation between the serum VPA level and the serum ammonia level (kk = 0.742, p < 0.001). Conclusion First generation antiepileptics are more toxic than SGAEs. In patients with serum carbamazepine level, particularly those over 30 mg/L, serious disorders of consciousness, cardiovascular toxicity, and metabolic disorders may occur. In VPA intoxication, there is a positive correlation between the serum VPA levels and ammonia levels. On account of this finding, one should be more careful about hyperammonemic hepatic encephalopathy as the serum VPA level rises.