The efficacy of hyaluronidase on flap survival: an animal model.

OBJECTIVE: It has been hypothesized that hyaluronidase may allow fluid to enter and exit the basal area of the flap more readily and thus allow waste metabolites from the distal portion of the flap to drain towards areas where the blood supply may be healthier. We aimed to test this hypothesis by seeing whether hyaluronidase enhances the survival of a flap created in an animal model. MATERIALS AND METHODS: The experiment utilized 14 male Wistar rats to test the effect of administering hyaluronidase on flap survival. The study utilized the same "flap survival method" technique reported in numerous previous studies. RESULTS: The area of necrosis in the animals of the intervention group was lower than in the control animals, and this result reached statistical significance. CONCLUSIONS: Hyaluronidase may preserve tissue flap vitality, starting at the bottom end of the dosage range. Future research should establish the minimal concentration needed to obtain benefits. The optimal mode of administration, whether by injection or topical application, is also a topic for future studies.

Autoimmune encephalitis and paraneoplastic syndromes in Turkey: a multi-centre study.

BACKGROUND: Autoimmune encephalitis (AIE) and paraneoplastic syndromes (PNS) are both rare groups of neurological diseases that are difficult to diagnose. AIM: We aimed to determine the common and distinct aspects of these two aetiologies of encephalitis as well as the characteristics of our patient group. METHODS: We respectively analysed the records of the patients including symptoms, demographic features, neurological examination, cranial-magnetic-resonance-imaging (MRI), electroencephalography (EEG) findings, cerebrospinal fluid results (CSF) findings. Autoimmune/paraneoplastic autoantibodies in blood and/or CSF were all documented. RESULTS: Forty-six patients fulfilled the diagnostic criteria. Thirty-eight of them were diagnosed with AIE, and 8 of them were diagnosed with PNS. The PNS group had higher nonconvulsive status epilepticus than the AIE (2/8 vs 0/38; p=0.027). PNS patients were diagnosed with a malignancy in their follow-ups more than those in the AIE group [4/38 vs 8/8] (p<0.001). When the symptoms of antibody-positive and negative patients were compared in the AIE group, the rates of consciousness/memory problems (13/15 vs 11/23; p=0.020) and speech impairment (8/15 vs 2/23; p=0.004) were significantly higher in patients without antibodies (n: 15) than in antibody-positive patients (n: 23). In antibody-negative groups, the rates of memory problems in neurological examination (13/15 vs 12/23 p=0.028) and temporal findings on electroencephalography were more prominent than antibody-positive groups (1/23 vs 5/15; p=0.027). The number of patients with cerebellar signs was higher in antibody-positive patients (6/23 vs 0/15; p=0.038). CONCLUSION: Although the positivity of autoantibodies is critical in the diagnosis of AIE and PNS, even minor differences in clinical and laboratory findings of patients are helpful in the diagnosis, especially in the autoantibody-negative patients. Comparing the data with other population studies has shown that several inherited and environmental factors may contribute to the pathophysiology of AIE and PNS, as well as clinical and laboratory differences.

Prevalence and risk factors for wheezing and allergic diseases in preschool children: A perspective from the Mediterranean coast of Turkey.

OBJECTIVES: The aim of the present study was to determine the prevalence and risk factors of allergic diseases in preschool children from one of the biggest cities in the Mediterranean Region of Turkey. METHODS: The study population included 396 preschool children attending to urban daycare centres in Mersin. In the first stage, a comprehensive standardised questionnaire modified from the International Study of Asthma and Allergies in Childhood (ISAAC) was employed. In the second stage, serum food and inhalant specific IgE, and skin tests were performed in 45 children with frequent wheezing and 28 children with no wheezing. RESULTS: The prevalence of ever wheezing, current wheezing, physician-diagnosed asthma, allergic rhinitis and eczema were 53% (210), 33.3% (132), 27.3% (108), 13.4% (53) and 8.3% (33), respectively. A family history of atopy (OR=2.5, 95% CI: 1.3-4.7, p=0.004), dampness at home (OR=2.4, 95% CI: 1.2-4.8, p=0.008), a history of intestinal parasites (OR=4.3, 95% CI: 1.7-10.9, p=0.002), previous history of pneumonia (OR=6.9, 95% CI: 1.9-25.9, p=0.004), initiation of complementary foods before the age of three months (OR=6.1, 95%CI: 1.4-26.9, p=0.02) and presence of food allergy (OR=3.1, 95% CI: 1.1-9.2, p=0.03) were found to be significant risk factors for physician-diagnosed asthma. The risk factors for frequent wheezing were maternal smoking during pregnancy (OR=5.2, 95% CI: 0.9-28.7, p=0.05) and high serum IgE levels (OR=2.9, 95% CI: 0.9-9.0, p=0.05) at borderline significance. CONCLUSION: Our study was the first epidemiological study in preschool children in the Mediterranean region of Turkey and demonstrated a high prevalence of asthma and allergic diseases, probably related to humid climatic properties in addition to other environmental and genetic factors.

A retrospective review of intensive care management of organophosphate insecticide poisoning: Single center experience.

BACKGROUND: Organophosphate (OP) compounds are used as insecticides. Given the widespread availability and use of these chemicals, OP poisoning is quite common following either accidental or intentional exposures. Immediate intensive care management can save lives in these patients. We aimed to investigate intensive care management provided to OP poisoning patients in a tertiary care hospital in Turkey. SUBJECTS AND METHODS: This was a retrospective chart review of 62 patients, admitted to the Intensive Care Unit (ICU) with OP poisoning between 2000 and 2012. RESULTS: Of the 62 patients studied, 40 (65%) were male, 45 (73%) were suicide attempts, 59 (95%) ingested the OP compounds, and three patients (5%) (two patients with suicide and 1 with accidental exposure) died in the ICU. There were statistically significant differences between survivors and nonsurvivors for Glasgow Coma Scale (GCS) on admission (P = 0.034), Acute Physiology and Chronic Health Evaluation II (APACHE II) score (P = 0.003), Sequential Organ Failure Assessment (SOFA) score (P = 0.024), time to initiation of treatment (P = 0.034) and serum lactate dehydrogenase (LDH) levels (P = 0.007). CONCLUSIONS: Organophosphate poisoning is a life-threatening condition that requires immediate diagnosis and management. GCS, APACHE II score, SOFA score, and time to admission to the emergency department and LDH levels can provide prognostic information and predict outcomes.

The effect of intra-abdominal pressure on sensory block level of single-shot spinal anesthesia for cesarean section: an observational study.

BACKGROUND: Increased intra-abdominal pressure in pregnancy is thought to affect intrathecal drug spread. However this assumption remains largely untested. The aim of this prospective study was to evaluate the association between intra-abdominal pressure and maximum sensory block level in parturients receiving spinal anesthesia for cesarean section. METHODS: Parturients having elective cesarean section with single-shot spinal anesthesia using hyperbaric bupivacaine 12.5mg were included. Intra-abdominal pressure was measured via a bladder catheter after establishing a T4 sensory block and at the end of surgery in the supine position with 10° left lateral tilt. We recorded demographic data, descriptive characteristics of pregnancy, self-reported weight gain and weight of the newborn. As secondary outcomes, we evaluated onset of sensory block, maximum sensory block, motor block, number of hypotensive episodes, fluid and ephedrine requirements, time to first analgesic request, time to one-point recovery of motor block and side effects. RESULTS: The median value of the maximum sensory block level was T2 in 117 parturients. Median [interquartile range] pre-incision and postoperative intra-abdominal pressure were 13 [11-16] and 9 [6-10]mmHg respectively. No association was observed between maximum sensory block level and pre-incision intra-abdominal pressure (P=0.83). Weight was associated with pre-incision intra-abdominal pressure with an estimated odds ratio of 1.04 per kg (99.4% CI: 1.00-1.08). There was a moderate correlation between pre-incision and postoperative intra-abdominal pressure with a Spearman correlation coefficient of 0.67 (99.5% CI: 0.5-0.79). There was no association between pre-incision intra-abdominal pressure and secondary outcomes. CONCLUSIONS: In parturients, intra-abdominal pressure was not associated with spinal block spread, block onset time, recovery or side effects.

Outcomes of percutaneous endoscopic gastrostomy in hospitalized patients at a tertiary care center in Turkey.

BACKGROUND/OBJECTIVES: The aim of this study was to perform a retrospective analysis characterizing patients receiving tube feeding following percutaneous endoscopic gastrostomy (PEG) tube placement between 2004 and 2012 at Erciyes University Hospital in Turkey. SUBJECTS/METHODS: Patients above the age of 18 years who required long-term enteral tube feeding were studied. All PEGs were performed using the pull-through technique by one experienced endoscopist. Demographic, clinical outcomes and PEG-related complication data were collected. RESULTS: Of the 128 subjects studied, 91 were men (71%) and 37 were women (29%). The mean age of this patient population was 54 ± 19 years. The most common reason for PEG tube insertion was the inability to consume oral diet due to complications of cerebrovascular disease (27%), while cerebral hypoxia, occurring after nonneurological medical disorders, was the second most common indication (23%). A total of 70 patients (55%) had chronic comorbidities, with hypertension being the most common (20%). The most common procedure-related complication was insertion-site bleeding, which occurred in 4% of patients. Long-term complications during 1 year were insertion-site cellulitis, gastric contents leakage and peristomal ulceration, which occurred in 14%, 5% and 0.5% of patients, respectively. There were no PEG insertion-related mortalities; 1-year mortality was unrelated to the indication for PEG tube insertion. CONCLUSIONS: PEG tube insertion was a safe method to provide enteral access for nutrition support in this hospitalized patient population.

The effects of subfascial wound versus epidural levo-bupivacaine infusion on postoperative pain following hysterectomy.

BACKGROUND: Local analgesia through wound catheters is used as a part of multimodal analgesia. The efficacy of continuous subfascial wound infusion compared to epidural analgesia is unknown for abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) via Pfannenstiel incision. The aim of this study was to compare the aforementioned two methods in this type of surgery for postoperative morphine consumption, acute and persistent postsurgical pain. METHODS: Fifty patients enrolled in the study were randomly allocated to receive continuous 10 mL/h levobupivacaine either via subfascial (Group S) or epidural (Group E) catheter for 48 h postoperatively. In Group S 0.25% levobupivacaine was used for the first six hours and 0.125% thereafter, whereas Group E received 0.125% levobupivacaine throughout the study period. Cumulative morphine consumption, static and dynamic pain, gastrointestinal recovery, ambulation, patient satisfaction, hospital stay, as well as pain at 2nd and 6th months were evaluated. RESULTS: Group S was superior to Group E regarding cumulative morphine consumption (16.8±7.2 mg and 28.7±10.3 mg respectively, P<0.001; mean difference -11.9 with 95% CI of the difference -17.1 to -6.7) and pain relief. Patient satisfaction was higher in Group S compared to Group E (P=0.006). Less postoperative vomiting was observed in Group S. No difference was detected in length of hospital stay and persistent postsurgical pain incidence. CONCLUSION: Wound analgesia via subfascial catheter with continuous levobupivacaine infusion decreases postoperative morphine consumption and increases patient satisfaction compared to epidural analgesia with no difference in persistent postsurgical pain following TAH-BSO via Pfannenstiel incision.

Supplemental intravenous crystalloids for the prevention of postoperative nausea and vomiting: quantitative review.

Hypovolaemia after overnight fasting is believed to exacerbate postoperative nausea and vomiting (PONV). However, data on the efficacy of supplemental i.v. crystalloids for PONV prophylaxis are conflicting. We performed a literature search using CENTRAL, MEDLINE, EMBASE, CINAHL, and Web of Science. We included prospective randomized controlled trials that reported PONV event rates in patients receiving supplemental i.v. crystalloids or a conservative fluid regimen after elective surgery under general anaesthesia. Studies were evaluated with regard to random sequence generation, allocation concealment, blinding of participants, personnel, and outcome assessment, incomplete outcome data, and selective reporting. We identified 15 trials (n=787 crystalloids; n=783 conservative fluids). Compared with conservative fluids, i.v. crystalloids reduced the risk of early postoperative nausea (PON) (relative risk 0.73, 95% confidence interval 0.59-0.89; P=0.003), late PON (0.41, 0.22-0.76; P=0.004), and overall PON (0.66, 0.46-0.95; P=0.02). I.V. crystalloids did not reduce the risk of early postoperative vomiting (POV) (0.66, 0.37-1.16; P=0.16) or late POV (0.52, 0.25-1.11; P=0.09), but did reduce overall POV (0.48, 0.29-0.79; P=0.004). I.V. crystalloids did not reduce the risk of early PONV (0.74, 0.49-1.12; P=0.16), but did reduce the risk of late PONV (0.27, 0.13-0.54; P<0.001) and overall PONV (0.59, 0.42-0.84; P=0.003). I.V. crystalloids reduced the need for antiemetic rescue treatment (0.56, 0.45-0.68; P<0.001). In summary, supplemental i.v. crystalloids were associated with a lower incidence of several PONV outcomes. However, a number of PONV outcomes failed to reach statistical significance, perhaps due to the lack of power. Thus, studies sufficiently powered for the less frequent outcomes (e.g. POV) are required.

Economic burden of ventilator-associated pneumonia in a developing country.

Ventilator-associated pneumonia (VAP) developed in 96 (60%) of 159 patients with 37.2 cases per 1000 ventilation-days in a medical intensive care unit (MICU). Median time for VAP development was 5.5 days (range: 2-25). The most significant risk factors for VAP were stay in hospital before MICU and length of stay in MICU. The mean length of stay in MICU for VAP patients was 23.8 ± 19.8 days, which was four-fold higher than for non-VAP patients. The daily cost for VAP patients was half that for non-VAP patients. The total costs for VAP patients were about three-fold higher than for non-VAP patients.

Evaluation of the therapeutic use of antibiotics in Aegean Region hospitals of Turkey: a multicentric study.

PURPOSE: The antibiotic restriction policy has been validated nationwide since February 2003 by the Ministry of Health because the excessive consumption of antimicrobials causes a high cost. The aim of this study was to evaluate the therapeutic use of antibiotics in Aegean Region hospitals and to assess the impact of this nationwide antibiotic restriction policy. This new policy is based on justification that the infectious disease (ID) physicians should be primarily responsible for the prescription of antimicrobials. MATERIALS AND METHODS: Eight university and government hospitals were included in the study. The criteria of the Council for Appropriate and Rational Antibiotic Therapy (CARAT) were considered. Both patient-based and antibiotic-based analyses were performed. For the analysis of inappropriate use, logistic regression was modeled. RESULTS: Therapeutic use was determined in 540 patients by a total of 29 ID physicians.In the study, 30.2% of the patients were given antimicrobials and empirically started antibiotics accounted for 79% cases of therapeutic antibiotic use, and 60% of those were inappropriate (P = 0.001). The appropriate use of ID level antibiotics (P = 0.000) were very compatible with other antimicrobial groups. CONCLUSION: The study shows that the Turkish government's new intervention policy on antimicrobial prescribing has been effective.

Effect of nasal cannula oxygen administration on oxygen concentration at facial and adjacent landmarks.

An oxygen-enriched atmosphere enhances the potential for operating-room fires. We thus determined oxygen concentrations at various facial landmarks during oxygen administration via nasal cannulae. Thirteen supine volunteers were draped similarly to patients undergoing a cervical-node biopsy. Oxygen was delivered in random order through nasal cannulae at rates of 2, 4, and 6 l x min(-1). Oxygen concentration was measured at pre-determined facial landmarks and also distal to the drape at non-facial sites. At a flow of 2 l x min(-1), oxygen concentrations exceeded 23% only within a few centimetres of the nasal cannula. Concentration increased as a function of flow, but rarely exceeded 26%. At all flow rates, concentrations distal to the drape were < 24%. To reduce combustion risk, ignition sources should be kept at least 10 cm from the oxygen outlet when using nasal cannula at a flow rate > or = 4 l x min(-1).

Remifentanil for general anaesthesia: a systematic review.

We performed a quantitative systematic review of randomised, controlled trials that compared remifentanil to short-acting opioids (fentanyl, alfentanil, or sufentanil) for general anaesthesia. Eighty-five trials were identified and these included a total of 13 057 patients. Intra-operatively, remifentanil was associated with clinical signs of deeper analgesia and anaesthesia, such as fewer responses to noxious stimuli (relative risk 0.65, 95% CI 0.48-0.87), more frequent episodes of bradycardia (1.46, 1.04-2.05), more hypotension (1.68, 1.36-2.07) and less hypertension (0.60, 0.46-0.78). Postoperatively, remifentanil was associated with faster recovery (difference in extubation time of -2.03, 9.5% CI, -2.92 to -1.14 min), more frequent postoperative analgesic requirements (1.36, 1.21-1.53) and fewer respiratory events requiring naloxone (0.25, 0.14-0.47). Remifentanil had no overall impact on postoperative nausea (1.03, 0.97-1.09) or vomiting (1.06, 0.96-1.17), but was associated with twice as much shivering (2.15, 1.73-2.69). Remifentanil does not seem to offer any advantage for lengthy, major interventions, but may be useful for selected patients, e.g. when postoperative respiratory depression is a concern.

Ondansetron does not reduce the shivering threshold in healthy volunteers.

BACKGROUND: Ondansetron, a serotonin-3 receptor antagonist, reduces postoperative shivering. Drugs that reduce shivering usually impair central thermoregulatory control, and may thus be useful for preventing shivering during induction of therapeutic hypothermia. We determined, therefore, whether ondansetron reduces the major autonomic thermoregulatory response thresholds (triggering core temperatures) in humans. METHODS: Control (placebo) and ondansetron infusions at the target plasma concentration of 250 ng ml(-1) were studied in healthy volunteers on two different days. Each day, skin and core temperatures were increased to provoke sweating; then reduced to elicit peripheral vasoconstriction and shivering. We determined the core-temperature sweating, vasoconstriction and shivering thresholds after compensating for changes in mean-skin temperature. Data were analysed using t-tests and presented as means (sds); P<0.05 was taken as significant. RESULTS: Ondensetron plasma concentrations were 278 (57), 234 (55) and 243 (58) ng ml(-1) at the sweating, vasoconstriction and shivering thresholds, respectively; these corresponded to approximately 50 mg of ondansetron which is approximately 10 times the dose used for postoperative nausea and vomiting. Ondansetron did not change the sweating (control 37.4 (0.4) degrees C, ondansetron 37.6 (0.3) degrees C, P=0.16), vasoconstriction (37.0 (0.5) degrees C vs 37.1 (0.3) degrees C; P=0.70), or shivering threshold (36.3 (0.5) degrees C vs 36.3 (0.6) degrees C; P=0.76). No sedation was observed on either study day. CONCLUSIONS: /b>. Ondansetron appears to have little potential for facilitating induction of therapeutic hypothermia.

BIS guided sedation with propofol during spinal anaesthesia: influence of anaesthetic level on sedation requirement.

BACKGROUND: In this prospective, clinical study we tested the hypothesis whether two different doses of spinal administered bupivacaine and accordingly, two different levels of spinal anaesthesia can affect the dose requirement of propofol during BIS guided sedation. METHODS: Fifty women undergoing vaginal hysterectomy (high spinal group, HS) or transvaginal tape (TVT) procedure for urinary incontinence (low spinal group, LS) under spinal anaesthesia were enrolled to the study. In group HS, 17.5 mg and in group LS, 7.5 mg of hyperbaric bupivacaine were given intrathecally. After 15 min to obtain the appropriate level of spinal anaesthesia, propofol infusion was started at a rate of 100 microg kg(-1) min(-1) to reach a BIS level of less than 75 (onset time), and titrated to maintain the BIS value between 65 and 75. Propofol infusion was stopped 45 min after placing the spinal to measure the time to reach a BIS level of 90 (recovery time). RESULTS: Median anaesthetic level was T3 (T1-4) in the HS group and T10 (T9-11) in the LS group. In both the HS and the LS groups, onset time was 226 (47) vs 273 (48) s (P=0.001), recovery time was 234 (47) vs 202 (56) s (P=0.03), total dose of propofol was 2.17 (0.43) vs 3.14 (0.56) mg kg(-1) (P<0.001), respectively. CONCLUSION: A high spinal block obtained with hyperbaric bupivacaine 17.5 mg was associated with a faster onset, delayed recovery and lower doses of propofol sedation compared with a low spinal block with 7.5 mg of the same drug.

Effects of three different dose regimens of magnesium on propofol requirements, haemodynamic variables and postoperative pain relief in gynaecological surgery.

BACKGROUND: In this double-blind, randomized, placebo-controlled study we compared the effects of three different dose regimens of magnesium on intraoperative propofol and atracurium requirements, and postoperative morphine consumption in patients undergoing gynaecological surgery. METHODS: Eighty women were allocated to four equal groups. The control group received normal saline; magnesium groups received 40 mg kg(-1) of magnesium before induction of anaesthesia, followed by i.v. infusion of normal saline, magnesium 10 mg kg(-1) h(-1) or magnesium 20 mg kg(-1) h(-1) for the next 4 h. Propofol infusion was targeted to keep bispectral index values between 45 and 55. Postoperative analgesia was achieved using PCA with morphine. RESULTS: Magnesium groups required significantly less propofol [mean (sd) 121.5 (13.3), 102.2 (8.0) and 101.3 (9.7) microg kg(-1) min(-1) respectively] than the control group (140.7 (16.5) microg kg(-1) min(-1)). Atracurium use was significantly higher in the control group than magnesium groups [0.4 (0.06) vs 0.34 (0.06), 0.35 (0.04), 0.34 (0.06) mg kg(-1) h(-1) respectively]. Morphine consumption was significantly higher in control group than magnesium groups on the first postoperative day [0.88 (0.14) vs 0.73 (0.17), 0.59 (0.23), 0.53 (0.21) mg kg(-1) respectively]. The heart rate was lower in magnesium groups and 20 mg kg(-1) h(-1) infusion group demonstrated the lowest values. CONCLUSION: Magnesium 40 mg kg(-1) bolus followed by 10 mg kg(-1) h(-1) infusion leads to significant reductions in intraoperative propofol, atracurium and postoperative morphine consumption. Increasing magnesium dosage did not offer any advantages, but induced haemodynamic consequences.

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 SaO2 above 94% with 40% FIO2. 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.

The effect of passive smoking on pulmonary function during childhood.

Passive smoking, especially of maternal origin, is known to influence adversely the development of children's pulmonary function. In this study, the effect of parental smoking on the pulmonary function of 360 primary school children aged 9-13 (mean 10.8 +/- 0.7) years was investigated. Information on parental smoking history was collected using a questionnaire, and spirometric measurements were performed on the children. All spirometric indices were lower in children who had been passively exposed to parental tobacco smoke than those not exposed. The percentage of households in which at least one parent smoked was 81.5%. This figure was significantly lower for mothers (27.5%) than for fathers (79%). Paternal smoking was associated with reduced levels of forced expiratory flow between 25-75% of vital capacity, peak expiratory flow, and flow rates after 50% and 75% of vital capacity expired (p < 0.05). Maternal smoking did not have statistically significant adverse effects on children's pulmonary function. This result might be due to the low occurrence of either pre- or post-natal smoking among mothers and confirms that, in our population, the main target group for antitobacco campaigns should be fathers.