High-Resolution Plasma Metabolomics and Thiamine Status in Critically Ill Adult Patients.

Background and Aim: Thiamine (Vitamin B1) is an essential micronutrient and a co-factor for metabolic functions related to energy metabolism. We determined the association between whole blood thiamine pyrophosphate (TPP) concentrations and plasma metabolites using high resolution metabolomics in critically ill patients. Methods: Cross-sectional study performed in Erciyes University Hospital, Kayseri, Turkey and Emory University, Atlanta, GA, USA. Participants were ≥ 18 years of age, with an expected length of ICU stay longer than 48 hours, receiving furosemide therapy for at least 6 months before ICU admission. Results: Blood for TPP and metabolomics was obtained on the day of ICU admission. Whole blood TPP concentrations were measured using high-performance liquid chromatography (HPLC). Liquid chromatography/mass spectrometry was used for plasma high-resolution metabolomics. Data was analyzed using regression analysis of TPP levels against all plasma metabolomic features in metabolome-wide association studies. We also compared metabolomic features from patients in the highest TPP concentration tertile to patients in the lowest TPP tertile as a secondary analysis. We enrolled 76 participants with a median age of 69 (range, 62.5-79.5) years. Specific metabolic pathways associated with whole blood TPP levels, using both regression and tertile analysis, included pentose phosphate, fructose and mannose, branched chain amino acid, arginine and proline, linoleate, and butanoate pathways. Conclusions: Plasma high-resolution metabolomics analysis showed that whole blood TPP concentrations are significantly associated with metabolites and metabolic pathways linked to the metabolism of energy, amino acids, lipids, and the gut microbiome in adult critically ill patients.

Gut barrier protein levels in serial blood samples from critically ill trauma patients during and after intensive care unit stay.

PURPOSE: In an effort to better manage critically ill patients hospitalised in the intensive care unit (ICU) after experiencing multiple traumas, the present study aimed to assess whether plasma levels of intestinal epithelial cell barrier proteins, including occludin, claudin-1, junctional adhesion molecule (JAM-1), tricellulin and zonulin, could be used as novel biomarkers. Additional potential markers such as intestinal fatty acid-binding protein (I-FABP), D-lactate, lipopolysaccharide (LPS) and citrulline were also evaluated. We also aimed to determine the possible relationships between the clinical, laboratory, and nutritional status of patients and the measured marker levels. METHODS: Plasma samples from 29 patients (first, second, fifth and tenth days in the ICU and on days 7, 30 and 60 after hospital discharge) and 23 controls were subjected to commercial enzyme-linked immunosorbent assay (ELISA) testing. RESULTS: On first day (admission) and on the second day, plasma I-FABP, D-lactate, citrulline, occludin, claudin-1, tricellulin and zonulin levels were high in trauma patients and positively correlated with lactate, C-reactive protein (CRP), number of days of ICU hospitalisation, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and daily Sequential Organ Failure Assessment (SOFA) scores (P < 0.05-P < 0.01). CONCLUSION: The results of the present study showed that occludin, claudin-1, tricellulin and zonulin proteins, as well as I-FABP, D-lactate and citrulline, may be used as promising biomarkers for the evaluation of disease severity in critically ill trauma patients, despite the complexity of the analysis of various barrier markers. However, our results should be supported by future studies.

Evaluation of whole blood thiamine pyrophosphate concentrations in critically ill patients receiving chronic diuretic therapy prior to admission to Turkish intensive care units: A pragmatic, multicenter, prospective study.

BACKGROUND/OBJECTIVES: Thiamine plays a pivotal role in energy metabolism. The aim of the study was to determine serial whole blood TPP concentrations in critically ill patients receiving chronic diuretic treatment before ICU admission and to correlate TPP levels with clinically determined serum phosphorus concentrations. SUBJECTS/METHODS: This observational study was performed in 15 medical ICUs. Serial whole blood TPP concentrations were measured by HPLC at baseline and at days 2, 5 and 10 after ICU admission. RESULTS: A total of 221 participants were included. Of these, 18% demonstrated low TPP concentrations upon admission to the ICU, while 26% of participants demonstrated low levels at some point during the 10-day study period. Hypophosphatemia was detected in 30% of participants at some point during the 10-day period of observation. TPP levels were significantly and positively correlated with serum phosphorus levels at each time point (P < 0.05 for all). CONCLUSIONS: Our results show that 18% of these critically ill patients exhibited low whole blood TPP concentrations on ICU admission and 26% had low levels during the initial 10 ICU days, respectively. The modest correlation between TPP and phosphorus concentrations suggests a possible association due to a refeeding effect in ICU patients requiring chronic diuretic therapy.

The Clinical and Laboratory Efficacy of HA 330 Treatment Combined with Continuous Renal Replacement Therapy in Septic Shock Patients: A Case Series.

INTRODUCTION: Blood purification therapy is a method used to enable cytokine removal and to improve disturbed immune homeostasis in patients with sepsis or septic shock. This study aimed to evaluate the impact of HA 330 treatment on biochemical and hemodynamic parameters and cytokine levels in adult patients with septic shock. METHODS: Critically ill patients with septic shock who received continuous veno-venous hemodiafiltration and HA 330 treatment were included in this prospective observational study. Biochemical and hemodynamic parameters were followed throughout HA 330 treatment. Serum interleukin (IL)-1ß, IL-6, IL-8, tumor necrosis factor (TNF)-α, high-mobility group box1 (HMGB-1) protein, IL-10 levels were analyzed by ELISA method, before and after each HA 330 session. RESULTS: A total of 18 critically ill patients were included in this study. The median APACHE 2 score was 22.2 ± 7.49 and median SOFA score 9.6 ± 5.44 on intensive care unit admission. SOFA scores were significantly decreased on the 3rd day of HA 330 treatment, compared to 2nd day scores (p = 0.017). Median leukocyte value was significantly decreased (p = 0.027 and p = 0.024), while hemodynamic parameters remained unchanged throughout the HA 330 treatment. Median CRP and procalcitonin levels were significantly reduced at day 3 of HA 330 treatment compared to the baseline (p = 0.015 and p = 0.033, respectively). Serum IL-1 ß, IL-6, IL-8, TNF-a, HMGB-1, and IL-10 levels decreased insignificantly by 11.5%, 26.4%, 11.4%, 37.9%, 0.02%, and 35.5%, respectively, at the end of the hemoperfusion treatment compared to the pre-treatment. CONCLUSION: The administration of HA 330-based hemoperfusion in septic shock patients revealed improvements in SOFA scores, leukocyte count, and CRP and procalcitonin levels. However, there was no statistically significant change in concentrations of inflammatory cytokines and hemodynamic parameters during HA 330 treatment.

Enteral nutrition interruptions in critically ill patients: A prospective study on reasons, frequency and duration of interruptions of nutritional support during ICU stay.

BACKGROUND & AIMS: Enteral Nutrition (EN) may be interrupted due to various reasons in the setting of intensive care unit (ICU) care. This study aimed to investigate the reasons, frequency, and duration of EN interruptions in critically ill patients within the first 7 days of ICU stay. METHODS: A total of 122 critically ill patients (median age: 63 years, 57% were males) initiating EN within the first 72 h of ICU admission and continued EN for at least 48 h during ICU stay were included in this observational prospective study conducted at a Medical ICU. Patients were followed for hourly energy intake as well as the frequency, reason, and duration of EN interruptions, for the first seven nutrition days of ICU stay or until death/discharge from ICU. RESULTS: The median APACHE II score was 22 (IQR, 17-27). The per patient EN interruption frequency was 2.74 and the median total EN interruption duration was 960 (IQR, 105-1950) minutes. The most common reason for EN interruption was radiological procedures (91 episodes) and the longest duration of EN interruption was due to tube malfunctions (1230 min). Target energy intake were achieved on the 6th day at a maximum rate of 89.4%. Logistic regression showed that there was relationship between increased mortality and patients with ≥3 EN interruptions (OR: 6.73 (2.15-30.55), p = 0.004) after adjusting for confounding variables (age and APACHE II score). According to Kaplan Meier analysis, patients with ≥3 EN interruptions had significantly lower median survival times than patients with <3 EN interruptions (24.0 (95% CI 8.5-39.5) vs 18.0 (95% CI 13-23) days, p = 0.014). CONCLUSION: During the first week of EN support, the most common reason of EN interruptions was related to radiological procedures and the longest EN interruptions was due to feeding tube malfunctions. There was relationship between ≥3 EN interruptions and increased mortality.

Serum micronutrient levels in critically ill patients receiving continuous renal replacement therapy: A prospective, observational study.

BACKGROUND: Acute kidney injury (AKI) treated with continuous renal replacement therapy (CRRT) may deplete micronutrient levels. Patients are also at risk for micronutrient depletion due to underlying illness(s), poor nutrient intake prior to intensive care unit (ICU) admission and/or increased requirements. We determined vitamin and trace element status before, during and after CRRT in critically ill patients. METHODS: This prospective observational study performed in mixed medical and surgical ICU patients. Serial serum vitamin B6 and vitamin C concentrations were measured by HPLC and folic acid by ECLIA. Serum chromium, copper, selenium, and zinc were measured using ICP-MS. Serum ceruloplasmin was measured by the Erel method. RESULTS: Fifty adult ICU patients with AKI were recruited. The median APACHE II score on ICU admission was high at 24.0 (6.0-33.0). The median days on CRRT was 2.0 (2.0-4.0) days. At baseline (within 10-15 minutes of CRRT initiation), serum vitamin C, selenium and zinc were below normal. Serum vitamin B6 levels at 72 hours on CRRT were significantly lower than at 24 hours (p = 0.011). Serum vitamin C values fell significantly at 24 and 72 hours during CRRT (p = 0.030 and p = 0.001), respectively, and remained low 24 and 48 hours after CRRT was stopped (p = 0.021). At baseline and during CRRT, 96% of participants had at least two or more micronutrient levels below the normal range. CONCLUSION: Serum vitamin C, selenium and zinc concentrations were below the normal range at baseline. CRRT was associated with a significant further decrease in levels of vitamin C, selenium and zinc.

Measurement of serial serum total and acylated ghrelin levels in critically ill patients: A prospective and observational pilot study.

BACKGROUND: Ghrelin is a hormone that regulates appetite and energy metabolism. The change of serial serum total and acylated ghrelin levels during hospital stays of critical patients are unknown. In addition, the relationship of this change with the clinical results of patients in the intensive care unit (ICU) is also unknown. The aim of this study was to determine serum total and acylated ghrelin levels serially in critically ill patients. METHODS: This prospective study was performed in the ICU. Patients who were >18 years old and stayed in ICU for >48 h were included in the study. Serum total and acylated ghrelin concentrations were measured at baseline in all participants and serially on the 2nd, 5th, and 10th day after entry into the study in those who remained in the ICU. RESULTS: A total of 60 participants were included. The mean age was 56 ± 21 years. (Baseline, 2nd, 5th, and 10th day median serum total ghrelin levels were 3551 (1651-3995), 3485.20 (1379-4071), 3359 (1167-3919), and 3355 pg/ml (2207-3843), respectively. Baseline, 2nd, 5th, and 10th day acylated ghrelin levels were 47 (0-673), 50 (0-730), 73 (0-808), and 125 pg/ml (0-689), respectively. There was no significant difference between total ghrelin/acylated ghrelin levels and mortality (P > .05). ICU mortality was 30%. CONCLUSION: Ghrelin levels were decreased slightly and acylated ghrelin levels increased substantially over time in critically ill patients. There were no differences between serum total ghrelin/acylated ghrelin levels and ICU mortality .

Serum trace elements levels in patients transferred from the intensive care unit to wards.

BACKGROUND & AIMS: Trace elements act as co-factors and/or in co-enzymes in many metabolic pathways and its deficiency contributes to metabolic and infectious complications. The aim of this study was to determine serum zinc, selenium, cobalt, chromium, copper and ceruloplasmin levels for identify the need for post intensive care unit (ICU) nutritional follow-up. METHODS: This study was prospectively conducted in medical ICU. Adult patients (≥18 years) who stayed in ICU more than 48 h and transferred to ward were included in the study. Blood samples of trace element levels were sampled at discharge. RESULTS: We enrolled 100 patients. The median age was 60 (40-70) years with Acute Physiology and Chronic Health Evaluation II (APACHE II) score 15 (11-21) . The median C-Reactive Protein (CRP) level was 53.9 (24.8-116.0) mg/L at discharge. Median serum zinc (24.4 mcg/dl:14.2-38.7) and chromium (0.22 mcg/dl:0.17-0.34) levels were below reference values, while median copper (111.9 (73.0-152.5) mcg/dl) and selenium (54.8 (36.4-95.25) mcg/L) values were within ranges. Serum concentrations of chromium, zinc, and selenium were lower than the normal values in 98, 90, and 36% of patients, respectively. The 28-day ICU mortality were correlated with low serum selenium levels (p = 0.03). CONCLUSION: Serum chromium and zinc levels were below reference values at discharge, but this finding was in context of inflammation. Low serum selenium level observed in 36% was associated to 28-day ICU mortality.

The use of high-flow nasal oxygen vs. standard oxygen therapy in hematological malignancy patients with acute respiratory failure in hematology wards

Background/aim: High flow nasal cannula (HFNC) was mostly used in intensive care units (ICUs) with few studies in other departments. We hypothesized that HFNC applied at wards is beneficial for acute respiratory failure in hematological malignancy patients. Materials and methods: The study is a single center, randomized controlled study. Inclusion criteria were hypoxemic respiratory failure and hematological malignancy. Patients were randomized to either venturi mask/nasal cannula oxygen treatment or HFNC. Results: One hundred patients were included in the study. Median age was 58.5 (18­86) years and APACHE II score was 17 (5­29). HFNC group was 51 patients and the oxygen treatment group 49 patients. P/F ratios were similar between the groups throughout the study period. Endotracheal intubation was required in 10 (20.0%) patients in oxygen group and 17 (33.0%) patients in HFNC group (p = 0.14). A total of 17 (35.0%) patients in oxygen group and 17 (33.0%) patients in HFNC group received noninvasive mechanical ventilation (p = 0.97). Median VAS comfort scores at the 2nd and 24th hours were not different between groups. The 28-day mortality rate was 36.7% (18 deaths) in the standard group and 45.0% (23 deaths) in the HFNC group (p = 0.39). Conclusion: HFNC applied in wards is not superior to standard oxygen treatment for acute respiratory failure in hematological malignancy patients.

The association between the route of nutrition and serum levels of adipokines in critical illness: a pilot study

Background/aim: Adipokines play an important role in the regulation of metabolism. In critical illness, they alter serum levels and are suspected to worsen clinical outcomes. But the effect of the route of nutrition on adipokines is not known. The purpose of this study was to evaluate the association between the route of nutrition and adipokine levels in critically ill patients. Materials and methods: This prospective study was performed in an intensive care unit (ICU). Patients admitted to the ICU for least 72 h and receiving either enteral nutrition (EN) via tube feeding or parenteral nutrition (PN) were enrolled. Serum was obtained at baseline, 24 h, and 72 h for concentrations of leptin, adiponectin, resistin, glucagon­like peptide 1 (GLP­1), insulin­like growth factors 1 (IGF­1), and ghrelin. Results: A total of 26 patients were included in the study. Thirteen patients received EN and 13 patients received PN. In the PN group, leptin level significantly increased (P = 0.037), adiponectin and ghrelin significantly decreased during follow up (P = 0.037, P = 0.008, respectively). There was no significant change between all adipokines in the EN group and resistin, IGF­1 and GLP­1 in the PN group during follow up. Resistin levels were markedly lower in the EN group at both 24 h (P = 0.015) and 72 h (P = 0.006) while GLP­1 levels were higher in the EN group at baseline, 24 h, and 72 h (P = 0.018, P = 0.005, and P = 0.003, respectively). There were no differences in leptin, adiponectin, IGF­1, and ghrelin levels over time. Conclusion: The delivery of EN in critical illness was associated with decreased resistin levels and increased GLP­1 levels. Thus, the route of nutrition may impact the clinical outcome in critical illness due to adipokines.

Value of prognostic scores in antineutrophil cytoplasmic antibody (ANCA) associated vasculitis patients in intensive care unit: a multicenter retrospective cohort study from Turkey

Background/aim: There is a need for a scoring system for predicting ICU prognosis of patients with ANCA-associated vasculitis (AAV), but there are limited data on it in the literature. Therefore, we aimed to determine the scores that can estimate the prognosis of patients with AAV during intensive care follow up. Materials and methods: All adult patients admitted to the medical ICUs of 4 reference university hospitals in Turkey due to AAV activation and/or disease/treatment complications in the last 10 years were included in this study. Demographic data, treatments before ICU, the Birmingham Vasculitis Activity Score (BVAS) score at the time of vasculitis diagnosis, and BVAS, APACHE II, SOFA, and SAPS II scores at the ICU admission, treatments, procedures, and complications during ICU stay were recorded for all AAV patients. Results: Thirty-four patients were included in the study. The median age of the patients was 60 (42­70) years, and 64.7% were male. Twenty-five patients were diagnosed with Granulomatosis with polyangiitis, and 9 were diagnosed with Microscopic polyangiitis. The most common ICU admission causes were hemorrhage (85.3%) and sepsis/septic shock (67.6%). Twenty patients (58.8%) died in the ICU follow up. There were significant differences in APACHE II (P = 0.004) and SAPS II (P = 0.044) scores between survivors and nonsurvivors, while there were no significant differences in BVAS (during diagnosis P = 0.089 and ICU admission P = 0.539) and SOFA (P = 0.097) scores. APACHE II score was found to be an independent risk factor for ICU mortality (OR = 1.231, CI 95% = 1.011­1.498, P = 0.038) according to logistic regression analysis. An APACHE II score of greater than 20.5 predicted ICU mortality with 80% sensitivity and 70% specificity (AUC = 0.8, P = 0.004, Likelihood ratio = 2.6) according to the ROC curve analysis. Conclusion: APACHE II score can be used for the prediction of ICU mortality in AAV patients.

Effects of oral/enteral nutrition alone versus plus pantoprazole on gastrointestinal bleeding in critically ill patients with low risk factor: a multicenter, randomized controlled trial

Background/aim: Critically ill patients are at risk of developing gastrointestinal (GI) bleeding due to stress causing mucosal damage. Aim of the study was to determine the effect of oral/enteral nutrition with or without concomitant pantoprazole on upper GI bleeding in low risk critically ill patients. Materials and methods: This was a prospective, randomized, open-label, multicenter study conducted with intensive care unit (ICU) patients receiving oral/enteral nutritional support. Patients were randomly assigned into two groups including intervention group (received oral/EN plus pantoprazole) and control group (received only oral/EN). Results: A total of 300 patients (intervention group: 152, control group: 148) participated in the study. Overall, 226 (75%) patients were fed by orally and 74 (25%) patients fed by enteral tube feeding. Median duration of nutritional support 4 (range: 2­33) days. Overt upper GI bleeding was noted only in one patient (0.65%) who was in the intervention group. The overall length of ICU stay of 4 (2­105) days, while ICU stay was significantly longer in the intervention group than in the control group (P = 0.006). Conclusions: Our findings seems to indicate that in patients who are at low risk for GI bleeding and under oral/enteral nutritional support, the use of PPIs may not reduce the risk of bleeding, however these results are imprecise because of low event (GI bleeding) rate and limited power.

Thiamin Status in Adults Receiving Chronic Diuretic Therapy Prior to Admission to a Medical Intensive Care Unit: A Pilot Study.

BACKGROUND: The aim of the study was to determine serum thiamin concentrations in critically ill medical patients who required chronic diuretic drug treatment before admission to a medical intensive care unit (ICU). METHODS: This prospective study was performed in a medical ICU. Subjects who received diuretic drug therapy for at least 6 months prior to ICU admission constituted the diuretic group. The control group was clinically matched adults admitted to the same ICU but without a history of diuretic therapy. RESULTS: A total of 50 subjects were included (25 subjects in each of the diuretic and control groups). In the diuretic group, daily dose of furosemide prior to admission was 40 mg/d (range of 20-160 mg/d). In all subjects, the ICU admission baseline blood thiamin concentrations were 31.2 ± 27.1 ng/mL. In the diuretic group, the baseline whole blood thiamin level was significantly lower compared with levels in the control group (15.5 ± 10.7 vs 46.8 ± 29.5 ng/mL; P < 0.001). On day 2 after entry, thiamin levels remained low (23.2 ± 15.4 ng/mL in the diuretic group vs 49 ± 38 ng/mL in the control group; P = 0.003). Low thiamin levels were found in 96% of patients at baseline and in 72% of patients on the second day in the diuretic group. CONCLUSION: Adults receiving chronic diuretic therapy and then requiring medical ICU care commonly exhibit thiamin depletion on admission to the ICU and during the initial days of ICU care.

Current Statement of Intensive Care Units in Turkey: Data obtained from 67 Centers.

OBJECTIVES: We aimed to obtain information about the characteristics of the ICUs in our country via a point prevalence study. MATERIAL AND METHODS: This cross-sectional study was planned by the Respiratory Failure and Intensive Care Assembly of Turkish Thoracic Society. A questionnaire was prepared and invitations were sent from the association's communication channels to reach the whole country. Data were collected through all participating intensivists between the October 26, 2016 at 08:00 and October 27, 2016 at 08:00. RESULTS: Data were collected from the 67 centers. Overall, 76.1% of the ICUs were managed with a closed system. In total, 35.8% (n=24) of ICUs were levels of care (LOC) 2 and 64.2% (n=43) were LOC 3. The median total numbers of ICU beds, LOC 2, and LOC 3 beds were 12 (8-23), 14 (10-25), and 12 (8-20), respectively. The median number of ventilators was 12 (7-21) and that of ventilators with non-invasive ventilation mode was 11 (6-20). The median numbers of patients per physician during day and night were 3.9 (2.3-8) and 13 (9-23), respectively. The median number of patients per nurse was 2.5 (2-3.1); 88.1% of the nurses were certified by national certification corporation. CONCLUSION: In terms of the number of staff, there is a need for specialist physicians, especially during the night and nurses in our country. It was thought that the number of ICU-certified nurses was comparatively sufficient, yet the target was supposed to be 100% for this rate.

Evaluation of chromosomal DNA damage, cytotoxicity, cytostasis, oxidative DNA damage and their relationship with endocrine hormones in patients with acute organophosphate poisoning.

Pesticides are commonly used compounds in agriculture. Especially, organophosphates (OPs) are among the extensively used pesticides. Therefore, OPs poisoning is common, especially in underdeveloped and developing countries. Primary aim of this study was to research the effects of acute OPs poisoning on genome instability in the individuals' lymphocytes with acute OPs poisoning both by using the cytokinesis-block micronucleus cytome (CBMN-cyt) assay to examine chromosome/genome damage, cell proliferation index and cell death rate and by using the plasma 8-hydroxy-2'-deoxyguanosine (8-OHdG) levels to determine oxidative DNA damage. Secondary aim of this study was also to assess whether a relation exists between endocrine hormones and the genome damage in acute OPs poisoning. In the study, blood samples were analysed of 13 patients before and after treatment admitted to the Department of Intensive Care Unit with acute OPs poisoning and of 13 healthy subjects of similar age and sex. The present study demonstrates that genome damage (micronucleus; MN and nucleoplasmic bridges; NPBs frequencies), apoptotic and necrotic cell frequencies increased in lymphocytes of patients with acute OPs poisoning before treatment and decreased after treatment. The present study also show that CBMN cyt assay parameters and 8-OHdG levels could be affected by some endocrine hormones such as E2, fT3, fT4, GH, IGF-1, FSH, LH, TSH, PRL, but not be related to ACTH and tT levels in acute OPs poisoning. In conclusion, it is believed that this is the first study to evaluate the chromosomal/oxidative DNA damage, cell proliferation, cell death and their associations with endocrine hormones in acute OPs poisoning. These preliminary findings need to be supported by further studies with larger sample sizes.

Increased DNA damage and increased apoptosis and necrosis in patients with severe sepsis and septic shock.

PURPOSE: Reactive oxygen species (ROS) has a key role in the pathogenesis of sepsis. We wanted to evaluate ROS-associated lymphocyte necrosis and apoptosis. MATERIALS AND METHODS: A total of 51 patients were included in the study, 29 in the patient group and 22 in the control group. Blood samples were taken from patients in the patient group during severe sepsis or septic shock, then again once they had recovered. Oxidative DNA damage was evaluated by 8-hydroxy-2'-deoxyguanosine (8-OHdG) levels. Peripheral blood lymphocytes from patients were evaluated with a microscope immediately. The rate of apoptosis and necrosis of lymphocytes were evaluated according to the number of cells in the peripheral. RESULTS: The level of 8-OHdG increased with severe sepsis or septic shock. There were significant differences between the pre- and post-treatment values for apoptotic cell frequency (4.21±3.15 vs. 3.82±3.07, P<0.05) and necrotic cell frequency (4.75±3.61 vs. 4.09±3.37, P<0.05). Apoptosis and necrosis was increased during severe sepsis and septic shock, and apoptosis increase also continued after recovery, but necrosis decreased following disease recovery. CONCLUSiONS: In patients with severe sepsis or septic shock, apoptosis and necrosis were increased along with increased 8-OHdG level.

Comparison of total, salivary and calculated free cortisol levels in patients with severe sepsis.

BACKGROUND: The purposes of the study were to compare serum total cortisol (STC), salivary cortisol (SaC) and calculated free cortisol (cFC) levels at baseline and after the adrenocorticotrophic hormone (ACTH) stimulation test in patients with severe sepsis (SS) and determine the suitability of use of SaC and cFC levels instead of STC for the diagnosis of adrenal insufficiency (AI) in patients with SS. And secondary aims of this study were to compare these parameters in patients with SS with healthy controls and check their effects on survival status of the patients. METHODS: Thirty patients with SS (15 men and 15 women) were compared with 16 healthy controls. Low-dose (1 µg) ACTH stimulation test was performed to the patients on the first, seventh and 28th days of diagnosis of SS, but in control group, 1 µg ACTH stimulation test was performed only once. STC, SaC and cFC levels were measured during ACTH stimulation test. RESULTS: Patients were categorized as having low or high baseline STC according to a cut-off level of 10 µg/dL. In high STC group, baseline and peak SaC levels were found to be 2.3 (0.2-9.0) and 3.4 (0.5-17.8) µg/dL on D1 and 1.1 (0.8-4.6) and 2.6 (1.3-2.9) µg/dL on D7, respectively. In the control group, baseline and peak SaC levels were 0.4 (0.1-1.4) and 1.1 (0.4-2.5) µg/dL, respectively. Baseline and peak SaC levels after ACTH stimulation were found to be higher in high STC group than in controls, but they were found to be similar in low STC and control groups. In high STC group, cFC levels were 0.3 (0.1-0.3) and 0.4 (0.3-0.7) µg/dL on D1 and 0.2 (0.1-0.3) and 0.4 (0.1-0.7) µg/dL on D7, respectively. In the control group, baseline and peak cFC levels were 1.7 (0.4-1.9) and 1.8 (1.0-6.6) µg/dL, respectively. cFC levels were found to be lower in patients with SS subgroups than in the control group. Baseline and stimulated STC, SaC and cFC levels did not differ according to the survival status. SaC, cFC and STC levels were found to be correlated with each other. CONCLUSIONS: SS is associated with increased SaC, but decreased cFC levels when baseline STC is assumed to be sufficient. When STC level is assumed to be insufficient, SaC levels remain unchanged, but cFC levels are decreased. Lower STC levels is not associated with increased mortality in patients with SS. More data are needed in order to suggest the use of SaC and cFC instead of STC. TRIAL REGISTRATION: ClinicalTrials.gov No: NCT02589431.

Refeeding hypophosphatemia: a potentially fatal danger in the intensive care unit.

AIM: To determine the overall and comparative incidence of refeeding hypophosphatemia (RH) between enteral and parenteral nutrition in general adult intensive care unit (ICU) patients. MATERIALS AND METHODS: This study was performed as a retrospective analysis. A total of 117 patients who received enteral and parenteral nutrition were included in the study. Demographic characteristics, type of nutrition, daily energy intake, and serum phosphorus levels before and after the initiation of the nutrition were recorded for 7 days. RESULTS: The mean age of the patients was 65.8 ± 16.7 years. RH was found in 61 patients (52.14%). There was no significant difference in RH with regard to nutrition type (P = 0.756). The duration of the ICU stay was longer in the patients with RH compared with the patients without RH [median: 12 (3-68) and 8.5 (3-41) days, respectively; P = 0.025]. The mortality rate was higher in patients with RH compared with patients without RH (P = 0.037). CONCLUSION: The incidence of RH was quite high in our medical ICU. The mortality rate and the duration of ICU stay were higher in the patients with RH than those without RH.

Effects of endosulfan intoxication on pituitary functions.

CONTEXT: We investigated the effects of endosulfan intoxication on pituitary functions in three patients. METHODS: This is an observational case series including three patients with endosulfan intoxication. Patients were evaluated 3 months after the acute event. RESULTS: Based on the baseline hormonal values and dynamic endocrine tests, one patient had hypothalamo-pituitary-adrenal axis impairment and was diagnosed as ACTH deficiency (peak cortisol level was found 13.12 µg/dl after low dose ACTH stimulation test), and another one had GH-IGF-I axis impairment and was diagnosed as GH deficiency (peak GH level was found 1.06 µg/L after glucagon stimulation test). CONCLUSIONS: Endosulfan intoxication might cause pituitary hormone deficiencies after the acute phase. Therefore, patients with endosulfan toxicity should be followed for possible pituitary gland dysfunction.