Intensive care management of organophosphate insecticide poisoning

INTRODUCTION: Organophosphate (OP) insecticides inhibit both cholinesterase and pseudo-cholinesterase activities. The inhibition of acetylcholinesterase causes accumulation of acetylcholine at synapses, and overstimulation of neurotransmission occurs as a result of this accumulation. The mortality rate of OP poisoning is high. Early diagnosis and appropriate treatment is often life saving. Treatment of OP poisoning consists of intravenous atropine and oximes. The clinical course of OP poisoning may be quite severe and may need intensive care management. We report our experience with the intensive care management of serious OP insecticide poisonings. METHODS: A retrospective study was performed on the patients with OP poisoning followed at our medical intensive care unit. Forty-seven patients were included. Diagnosis was performed from the history taken either from the patient or from the patient's relatives about the agent involved in the exposure. Diagnosis could not be confirmed with serum and red blood cell anticholinesterase levels because these are not performed at our institution. Intravenous atropine and pralidoxime was administered as soon as possible. Pralidoxime could not be given to 16 patients: 2 patients did not receive pralidoxime because they were late admissions and 14 did not receive pralidoxime because the Ministry of Health office was out of stock. Other measures for the treatment were gastric lavage and administration of activated charcoal via nasogastric tube, and cleansing the patient's body with soap and water. The patients were intubated and mechanically ventilated if the patients had respiratory failure, a depressed level of consciousness, which causes an inability to protect the airway, and hemodynamic instability. Mechanical ventilation was performed as synchronized intermittent mandatory ventilation + pressure support mode, either as volume or pressure control. Positive end expiratory pressure was titrated to keep SaO(2) above 94% with 40% FIO(2). Weaning was performed using either T-tube trials or pressure support weaning. The chi-square test was used for statistical analysis. Data are presented as mean ± standard deviation. RESULTS: There were 25 female and 22 male patients. Thirty-two (68%) were suicide attempts and 15 (32%) were accidental exposure. The gastrointestinal route was the main route in 44 (93.6%) patients. The mortality rates for the patients who did and did not receive pralidoxime were 32 and 18.7%, respectively, and were not statistically different. The most frequent signs were meiosis, change in mental status, hypersalivation and fasciculations. Ten patients (21.2%) required mechanical ventilation. The mortality rate for the patients who required mechanical ventilation was 50%, but the rate was 21.6% for the patients who were not mechanically ventilated. Intermediate syndrome was observed in 9 (19.1%) patients. Complications were observed in 35 (74.4%) patients. These complications were respiratory failure (14 patients), aspiration pneumonia (10 patients), urinary system infection (6 patients), convulsion (4 patients) and septic shock (1 patient). The duration of the intensive care stay was 5.2 ± 3.0 days. DISCUSSION: Ingestion of OP compounds for suicidal purposes is a major problem, especially in developing countries. Thirty-two (68%) of our patients used the OP insecticide for suicide. Two patients did not receive pralidoxime because of delayed admission and they were successfully treated with atropine alone. Three of the patients who did not receive pralidoxime because of unavailability died. The mortality rate was no different between the patients treated with pralidoxime or those without pralidoxime. De Silva and coworkers have also reported that the mortality rate was not different between each group. Three patients with intermediate syndrome died due to delay for endotracheal intubation. The average respiratory rate of these patients increased from 22 to 38 breaths/min, which is an important sign of respiratory distress. The nurse to patient ratio was increased after these events. Early recognition of respiratory failure resulting in intubation and mechanical ventilation is a life-saving intervention for patients with OP poisoning. Respiratory failure is the most troublesome complication, which was observed in 35 (74.4%) patients. Patients with OP poisoning may have respiratory failure for many reasons, including aspiration of the gastric content, excessive secretions, pneumonia and septicemia complicating acute respiratory distress syndrome. CONCLUSIONS: OP insecticide poisoning is a serious condition that needs rapid diagnosis and treatment. Since respiratory failure is the major reason for mortality, careful monitoring, appropriate management and early recognition of this complication may decrease the mortality rate among these patients

Naiv hepatit C enfeksiyonlu hastaların on-altı yıllık prognozu

Objectives: In this study, we aimed to evaluate the clinical course of treatment-naive patients infected with hepatitis C virus (HCV) who were followed up in various centers in Turkey. Materials and Methods: This was a retrospective study performed with the participation of 15 centers. Patients aged 18 years and older with HCV infection were included. Results: A total of 391 treatment-naive patients infected with HCV were included in this study. During the follow-up period, the final values of alanine aminotransferase, aspartate transaminase, and total protein were significantly decreased when compared to the initial values (p<0.001, p<0.001, and p=0.005, respectively). In the study group, 19.2% of the patients underwent liver biopsy and 4.1% underwent transient elastography (FibroScan). An increased histological activity index (HAI) score and fibrosis in the second biopsy were observed in one patient, only increased HAI in two patients and increased fibrosis in one patient, as shown on the FibroScan. In the 16 years of the study period, cirrhosis was radiologically detected in only one patient. Conclusion: Even if rapid progression is not observed, close monitoring of the clinical findings related to liver failure and fibrosis with invasive or non-invasive methods may be useful.Amaç: Bu çalışmada ülkemizin çeşitli merkezlerinde takip edilen naiv hepatit C virüs (HCV) ile enfekte hastaların klinik seyrini değerlendirmeyi amaçladık. Gereç ve Yöntemler: Bu çalışma retrospektif olarak 15 merkezin katılımıyla gerçekleştirilmiştir. Çalışmaya 18 yaş üstü, HCV enfeksiyonu olan hastalar dahil edilmiştir. Bulgular: Çalışmada 391 tedavi-naiv HCV enfeksiyonlu hasta yer almıştır. Hastaların takip süresinde son alanine aminotransferase, aspartate transaminase ve total protein değerleri ilk düzeyine göre önemli düzeyde azalmıştır (sırasıyla p<0,001, p<0,001, p=0,005). Çalışma grubunda hastaların %19,2’sine karaciğer biyopsisi, %4,1’ine elastografi (FibroScan) uygulanmıştır. Takip esnasında bir hastada ikinci biyopside histolojik aktivite indeksi (HAI) ve fibroziste artma, iki hastada sadece HAI’da artma, birinde FibroScan ile fibrozis değerinde artma olduğu gözlenmiştir. Bir hastada 16 yıl içinde radyolojik olarak siroz saptanmıştır. Sonuç: Hızlı progresyon gözlenmemekle birlikte hastaların izleminde karaciğer yetmezliği ile ilgili klinik bulguların ve invaziv veya noninvaziv yöntemlerle fibrozisin yakın takibi yararlı olabilir

First-line treatment of patients with HER2-positive metastatic gastric and gastroesophageal junction cancer

Fluoropyrimidine+cisplatin/oxaliplatin+trastuzumab therapy is recommended for the first-line treatment of HER2-positive metastatic gastric adenocarcinoma. However, there is no comprehensive study on which platinum-based treatment should be preferred. This study aimed to compare the treatment response and survival characteristics of patients with HER2-positive metastatic gastric or gastroesophageal junction (GEJ) cancer who received fluorouracil, oxaliplatin, and leucovorin (mFOLFOX)+trastuzumab or cisplatin and fluorouracil (CF)+trastuzumab as first-line therapy. It was a multicenter, retrospective study of the Turkish Oncology Group, which included 243 patients from 21 oncology centers. There were 113 patients in the mFOLFOX+trastuzumab arm and 130 patients in the CF+trastuzumab arm. The median age was 62 years in the mFOLFOX+trastuzumab arm and 61 years in the CF+trastuzumab arm (P = 0.495). 81.4% of patients in the mFOLFOX+trastuzumab arm and 83.1% in the CF+trastuzumab arm had gastric tumor localization (P = 0.735). The median progression-free survival (PFS) was significantly higher in the mFOLFOX+trastuzumab arm (9.4 months vs. 7.3 months, P = 0.024). The median overall survival (OS) was similar in both groups (18.4 months vs. 15.1 months, P = 0.640). Maintenance trastuzumab was continued after chemotherapy in 101 patients. In this subgroup, the median OS was 23.3 months and the median PFS was 13.3 months. In conclusion, mFOLFOX+trastuzumab is similar to CF+trastuzumab in terms of the median OS, but it is more effective in terms of the median PFS in the first-line treatment of HER2-positive metastatic gastric and GEJ cancer. The choice of treatment should be made by considering the prominent toxicity findings of the chemotherapy regimens

Lung carbon dioxide elimination corralates with physiologic dead space volume during mechanical ventilatory support

Increased mean airway pressure (Paw) predisposes to increased alveolar dead space volume and, hence, physiologic dead space volume (VDphys). This is the result of overdistending alveoli, converting Zone 2 and Zone 3 units to Zone 1 units. Lung carbon dioxide elimination (LCO2) is a reflection of pulmonary capillary blood flow. It is hypothesized that as Zone 1 units form or VDphys increases, LCO2 decreases proportionately and eventually PaCO2 increases, The purpose of this study is to determine if LCO2 correlates with VDphys during mechanical ventilation. Six sheep (66.3 ± 6.5 kg), anesthetized with sodium thiopental and paralyzed using pancronium, had pulmonary artery and arterial catheters inserted, and were intubated and ventilated [Fraction of inspired oxygen of 1.0, controlled mechanical ventilation]. Acute lung injury was induced by tracheal instillation of hydrochloric acid (pH 2.5, 0,25 mL/kg). Continuous positive airway pressure (CPAP) levels of 5, 10 and 20 cm H2O were randomly applied. Cardiac output was maintained nearly constant at all CPAP levels. Data from flow/pressure and infrared capnometer sensors, positioned between the endotracheal tube and the "Y" piece of the breathing circuit, were directed to a commercially available respiratory monitor (Novametrix), which provided real time display of Paw and LCO2 (area under the exhaled volume and CO2 curve integrated over 1 min). VDphys and the physiologic dead space volume to tidal volume ratio (VD/VT), calculated using the single breath CO2 elimination technique, were also displayed on the monitor. Data were analyzed using regression analysis; alpha was set at 0.05 for statistical significance. Conclusion: CPAP increases Paw, which correlated positively with VDphys. LCO2 correlated negatively and PaCO2 correlated positively with VD/VT. At VD/VT of approximately 0.5. LCO2 began decreasing and PaCO2 increasing, LCO2 is simple to measure, and real time data provides useful clinical information, i,e., a noninvasive inference of changes in VDphys and PaCO2 following application of positive pressure

The role of green energy investments in energy supply security

Renewable energy sources provide the management and control of energy production. The increase in the share of renewable energy sources in the energy portfolio ensures that the renewable energy obtained from local sources is controlled nationally. Since energy is obtained by using local resources, control can be achieved completely. Ensuring the control of energy resources constitutes a priority step towards ensuring supply security. An important element of energy supply security is to ensure continuity of access to energy while meeting energy needs. If the continuity of access to energy is affected by any political, political, or economic factor and dragged into a negative direction, it is a risk factor for energy supply security. Reducing or eliminating the current risk will be possible by focusing on renewable energy sources. Investments in renewable energy resources will reduce foreign dependency as it will ensure energy supply stability through energy management and control. The fragility of access to energy will decrease. Energy supply security will be ensured by reducing the vulnerability of energy access. In this context, renewable energy investments are a factor that needs to be increased to ensure energy supply security

The contribution of sustainable energy policies to the economic improvements of the countries

Sustainable energy policies are important for the adoption and integration of sustainable energy into our lives. The adoption of sustainable energy not only improves our quality of life, but also ensures that we leave a habitable world for future generations. These policies can play a role in the changing of variables that affect all aspects of society, from national security to economic growth. Such important sustainable energy policies must be properly directed with the right policies. If not properly channeled, it is an undisputed fact that they can cause serious problems. Sustainable energy policies should be used effectively within the framework of existing goals. While national circumstances or special positions may sometimes change policies, changes are usually observed in the forms of implementation rather than policies. Just as different prescriptions can be written for individuals with the same diagnosis in the treatment of a disease, the same is true for sustainable energy policies. Policies must be carefully and meticulously created. Market structures, social order, and current habits should not be overlooked within the scope of policies. The successful development of policies can be achieved through everyone taking responsibility. Sustainable energy policies are strategically important for countries and individuals

The effect of NaCl concentration on the interaction energy between feldspar minerale

The impact of the usage of monovalent ion concentration on the selective flotation of feldspar minerals has been receiving more attention in recent years. Although many experimental studies have been reported to justify its contribution to their flotation recovery, the effect of particle-particle interaction with theoretical calculations has rarely been studied. The objective of this study was, therefore, to explain the effect of monovalent ion concentration (in particular NaCl) on interactions between albite and microcline particles with a theoretical model based on the classical DLVO. The theoretical modeling results suggested that controlling the monovalent ion concentration not only adjusts the energy barrier between particles but also can be used to determine the critical salt concentration for further tests