Serum acetylcholinesterase and prognosis of acute organophosphate poisoning

OBJECTIVE: The aim of this study is to investigate the prognostic value of serum acetylcholinesterase levels and their relationship with neurological syndromes (Type 1 syndrome, intermediate syndrome, and delayed polyneuropathy) in acute organophosphate poisoning. MATERIALS AND METHODS: Thirty-two consecutive patients with acute organophosphate poisoning admitted to the Ondokuz Mayis University Emergency Department from June 1999 to January 2001 were evaluated. Patients were assessed according to admission time, symptoms, and results of clinical exams and their serum acetylcholinesterase levels were determined on days 1, 2, 3, 7, and the last day. RESULTS: There was no significant difference between the first-day serum acetylcholinesterase of the patients with severe poisoning (n = 22, 68.75%) and of the patients with mild poisoning (n = 10, 31.25%; NS). There was no discernible difference between the serum acetylcholinesterase obtained on days 1 and 3 after poisoning from the patients with intermediate syndrome (n = 5, 15.6%; means: 0.90 +/- 0.65 vs. 0.88 +/- 0.53, 19.35 vs. 18.92%; NS, sensitivity = 80%; specificity = 87.5%). There was a significant difference between the serum acetylcholinesterase obtained on days 1 and 3 from the patients with nonintermediate syndrome (n = 24, 75%; means: 1.05 +/- 0.24 vs. 1.68 +/- 0.29, 22.58 vs. 36.12%; p < 0.001). There was no discernible significant difference in serum acetylcholinesterase between the patients with organophosphorus-induced delayed polyneuropathy (n = 7, 21.8%) and nonorganophosphorus-induced delayed polyneuropathy. In the patients who died (n = 5, 15.6%), serum acetylcholinesterase showed no discernible increase day 1-the last day (means: 0.50 +/- 0.25 vs. 0.46 +/- 0.26, 10.75 vs. 9.89%; NS). There was a significant difference between the serum acetylcholinesterase levels obtained on days 1 and the last day from the patients who survived (n = 27, 84.3%; means: 1.14 +/- 0.25 vs. 2.32 +/- 0.26, 24.51 vs. 49.89%; p < 0.001). CONCLUSION: In the acute phase of organophosphate poisoning, low serum acetylcholinesterase (> 50% of minimum normal value) supports the diagnosis of organophosphate poisoning but it does not show a significant relationship to the severity of poisoning (NS). The serum acetylcholinesterase activity may be a useful parameter in following the acute prognosis of organophosphate poisoning.     

Preemptive diclofenac reduces morphine use after remifentanil-based anaesthesia for tonsillectomy

BACKGROUND: We investigated the effect of preincisional rectal diclofenac on pain scores and postoperative morphine requirements of children undergoing tonsillectomy after remifentanil-propofol anaesthesia in a randomized clinical trial. METHODS: Induction and maintenance of anaesthesia were with remifentanil and propofol. Forty children were randomly assigned into two groups before incision. The diclofenac group (n=20) received diclofenac suppositories (approximately 1 mg x kg(-1)) and the control group (n=20) received no treatment. Following discontinuation of remifentanil, patient-controlled analgesia (PCA) with morphine (a loading dose 50 micro g x kg(-1), a background infusion 4 micro g x kg(-1) x h(-1) and a demand dose 20 micro g x kg(-1) with 5-min intervals) was started. We assessed pain score [verbal analogue scales (VAS), 0-10] and sedation level at 5-min intervals and recorded the total morphine consumption of the first hour in the PACU. Patients were discharged to the ward with a new PCA morphine programme (a demand dose 20 micro g.kg-1 with a lockout time of 30 min, for 4 h), and total morphine consumption was recorded. RESULTS: The mean VAS score of the diclofenac group was significantly lower than the control group on arrival in the PACU (2.85 +/- 0.77, 7.60 +/- 0.83, respectively, P < 0.01) and it remained significantly lower in the PACU stay of the children. The mean total morphine consumption of the diclofenac group was less than the control group in the PACU (130.33 +/- 11.26 and 169.92 +/- 9.22, respectively, P=0.012) and the ward (50.80 +/- 11.38 and 87.77 +/- 10.55, respectively, P=0.021). CONCLUSIONS: Preemptive diclofenac given rectally reduced pain intensity and morphine requirements of children anaesthetized with remifentanil for tonsillectomy.     

Propofol and sevoflurane during epidural/general anesthesia: comparison of early recovery characteristics and pain relief

We investigated the early recovery characteristics and pain relief of adult patients during combined anesthesia with (epidural and general), either with propofol or sevoflurane for maintenance in major abdominal surgery. Twenty-two patients (ASA I-III) were enrolled in this randomized, prospective study. After fluid preloading, 10 ml of bupivacaine 0.5% + 5 ml of prilocaine 0.5% + 1 ml of fentanyl 50 microg mL(-1) were administered via an epidural catheter. General anesthesia was induced with fentanyl and propofol after T6 sensorial blockade. Propofol group (n = 11) received propofol (2-5 mg kg(-1) h(-1)), sevoflurane group (n = 11) received sevoflurane (1-2%) for maintenance. Anesthesia was supplemented with N2O in O2 and intravenous fentanyl. Continuous epidural infusion of 0.125% bupivacaine + 1 microg fentanyl (5-7 mL h(-1)) was started forty-five min after the epidural bolus dose and 5 ml of it was given at the start of the wound closure. All anesthetics were discontinued except epidural infusion during the last suture. After emergence time was determined, the patients were transferred to the PACU. They were observed for orientation times of person and place. The pain scores (verbal analogue scale, 0-10) were assessed with 30 min intervals. When the patient's pain score was >3, rescue analgesic protocol (diclofenac Na 75 mg im followed by meperidine HCI approximately 0.25 mg kg(-1) iv at the latter period) was applied. In the case of inadequate pain relief during the latter assessment periods, meperidine HCI approximately 0.25 mg kg(-1) was administered. Mann-Whitney U test and Fisher's exact test were used for the statistical analysis. A value of p<0.05 was considered significant. Between the groups no statistical differences were observed in the emergence time (5 vs. 6 min, median) and in the orientation time to person (6 vs. 10 min). Recovery of orientation to place was found faster in propofol group (7 vs. 12 min, p = 0.041). Pain scores of the patients between the groups were not statistically different at 0, 30, 60, 90, 120 min postoperatively (3, 2, 3, 2, 2, and 2, 4, 4, 3, 3, respectively). Rescue analgesic protocol and additional meperidine HCI were applied to 63.6% and 45.4% of patients in the propofol group, 54.5% and 36.3% of patients in the sevoflurane group, respectively. There weren't any statistical differences in regard to these, either. Except orientation time to place, the times of emergence and orientation to person, the pain scores and the analgesic requirements of the patients in both groups were similar. Propofol or sevoflurane did not offer any advantages for postoperative pain relief on behalf of either one when combined with epidural anesthesia.     

Conversion and somatization disorders; dissociative symptoms and other characteristics

OBJECTIVE: There is a difference in classification of conversion disorder in ICD-10 and DSM-IV. Conversion disorder is included in dissociative disorders in ICD-10. In view of this, we aimed to clarify this discrepancy in the classification of this diagnosis. METHODS: We assessed 87 patients with conversion disorder and 71 patients with somatization disorder for sociodemographic characteristics, suicide ideation, psychiatric symptoms and dissociative symptoms using the Patient Information Form, the Dissociative Experience Scale (DES), the Symptom Check List (SCL-90-R) and the Suicide Ideation Scale. RESULTS: The number of the high school graduates, singles and students with conversion disorders was higher than the number of patients with the same characteristics who have somatization disorder. In conversion disorder, the SCL-90-R total score and the score in paranoid ideation, psychoticism subgroups were higher than the scores in somatization disorders. There were no statistical differences in suicide ideation and the total score of dissociative symptoms between the two disorders. The number of patients whose total DES score of 30 and above was higher in conversion disorders. DISCUSSION: As a result of this present study, we concluded that to enlighten the concepts of conversion, further somatization and dissociation studies are necessary.     

Lymphocytic Colitis Associated with Lansoprazole Treatment

Introduction: There have been several reported cases of lansoprazole-associated collagenous colitis (CC) reported in the literature but only 1 reported case of lansoprazole-associated lymphocytic colitis (LC) in the literature. Both CC and LC are considered inflammatory bowel diseases, but they are distinctly classified based on the condition of the colon, which is typically confirmed through biopsy.Case summaries: A 52-year-old white male (Patient 1), with a height of 178 cm and weight of 75 kg, presented to Gazi University Hospital, Ankara, Turkey, with a 3-month history of abdominal pain and nonbloody, watery diarrhea. The patient reported receiving PO lansoprazole 30 mg/d to treat heartburn ~1 week prior to the onset of diarrhea. The patient's medical history revealed that he did not have any preexisting conditions, other than gastroesophageal reflux disease (GERD) for which lansoprazole was prescribed. The medical history report also revealed that the patient was not receiving any concomitant medications or treatments at the time. A colon biopsy confirmed LC. Additionally, a 43-year-old white female (Patient 2), with a height of 168 cm and weight of 61 kg, presented to the same facility with a 6-month history of nonbloody, watery diarrhea and mild lower abdominal cramping. The patient reported that initial onset began ~2 months after receiving a 10-day Helicobacter pylori eradication combination treatment regimen that included lansoprazole, amoxicillin, and clarithromycin, followed by lansoprazole monotherapy to treat GERD. The patient's medical history revealed no other concomitant medications were being adminstered at the time. A colon biopsy confirmed LC.Discussion: A search of the literature using the MEDLINE database and all relevant English-language articles with key words lansoprazole and lymphocytic colitis, found that there were several cases of lansoprazole-associated CC reported and 1 reported case of lansoprazole-associated LC. Histologic findings from laboratory tests and colon biopsies confirmed diagnoses of LC in both patients in this case report. Patient 1 presented with diarrhea and cramping, which the patient reported had been ongoing for ~3 months, following lansoprazole administration. However, after lansoprazole was discontinued, the symptoms completely resolved within 7 days. Patient 2 presented with diarrhea and cramping, which had been occurring for ~6 months. That patient reported that initial onset commenced ~2 months after a 10-day H pylori eradication combination treatment regimen that included lansoprazole, amoxicillin, and clarithromycin, followed by lansoprazole monotherapy to treat GERD. However, after sulfasalazine (3 g/d) was prescribed for 2 months immediately upon diagnosis of LC, there was little improvement in the effort to control the diarrhea in this patient. After omeprazole 20 mg/d was substituted for lansoprazole, the patient's diarrhea ceased. Follow-up sigmoidoscopy 2 months later revealed normal mucosa and complete normalization of histologic findings. The patient remains diarrhea-free while on omeprazole. A causality assessment using the Naranjo adverse reaction algorithm produced scores of 6 for both patients, suggesting that LC was probably associated with lansoprazole treatment.Conclusions: Here we report 2 cases of LC in patients probably associated with the administration of lansoprazole treatment. Complete remission occurred after lansoprazole was discontinued.     

Diagnostic value of procalcitonin levels as an early indicator of sepsis

Researchers and clinicians have been investigating and implementing various methods of early diagnosis for sepsis before documentation of infection. The aim of this study was to outline the efficiency of procalcitonin (PCT), C-reactive protein (CRP), and white blood cell count (WBC) in determining the early diagnosis of sepsis in the emergency department. Between January 1999 and September 2000, 34 patients with signs of systemic inflammatory response syndrome (SIRS) were enrolled in the study. The patients were divided into 2 groups according to non-suspected sepsis and suspected sepsis clinically. Admission PCT was significantly higher in suspected sepsis group (median 68.7 microg/L; lower [L] = 15.24 microg/L, upper [U] = 120.54 microg/L) compared with the unsuspected sepsis group (.23 microg/L; L =.10 microg/L, U =.44 microg/L). PCT values were compared with WBC and CRP levels. Predictive accuracy for sepsis expressed as area under the receiver operating characteristic (ROC) curve was.88 for PCT,.44 for WBC, and.34 for CRP. PCT can probably be used as a predictive marker in bacterial infections in emergency departments.