Adaptation of Clinical Laboratories to COVID 19 Pandemic: Changes in Test Panels, Overcoming Problems and Preparation Suggestions for Future Pandemics Adaptation of Clinical Laboratories to COVID 19 Pandemic.

BACKGROUND: For Coronavirus Disease 2019 (Covid-19) infection, clinical laboratories provide essential contributions in the diagnosis of infection, stage prognostication, and evaluation of disease severity. We aimed to show laboratory problems including changes of test numbers, changes of test panels, and differences of preanalytical errors during Covid-19 pandemic and, in the current study, we also intended to give solutions for the obstacles to guide other possible pandemics. METHODS: Our study was based on data between January 10, 2020, and May 10, 2020. The first Covid-19 case of the Republic of Turkey was seen March 10, 2020, which was determined as the threshold date for comparisons. This was a single center, data mining, retrospective study. RESULTS: The number of patients admitted to hospital were 34,260 and 15,573, the number of total tests were 66,263 and 42,066 before and after pandemic, respectively, for the two-month interval. Test percentage changes were increased for D-dimer 136%, fibrinogen 3,113%, troponin 6%, and LDH 17%. Test percentage changes were decreased for CBC 37%, sedimentation 45%, aPTT 30%, PT 37%, CRP 28%, ProCT 10%, ferritin 29%, CK-MB 27%, blood gases 47%, ALT 43%, AST 42%, urea 42%, creatinine 42%, triglycerides 45%, sodium 42%, potassium 41%, chloride 21%, urine culture 58%, and blood culture 44%. When preanalytical sources of errors were investigated no differences were found. CONCLUSIONS: Laboratories must take quick action and be prepared for changes in patient services during pandemics. The most reliable ways for this are past experiences, statistical analysis, co-operation with administrations, high quality communication skills, and a risk-based management system.

Primary cardiac hydatid cyst presenting as noncompaction cardiomyopathy.

We report a case of cyst was initially labeled as left ventricular noncompaction cardiomyopathy. An accurate diagnosis is essential to establish the most effective treatment strategy. In particular, echocardiographic examination assists in identifying the correct diagnosis. In this case, two-dimensional and three-dimensional echocardiography and computed tomography were used for definitive diagnosis of cardiac hydatid cyst.

[Is there a relationship between rectal colonization and nosocomial infection of patients in intensive care unit?]. / Yogun bakim birimindeki hastalarin rektal kolonizasyonu ile hastane enfeksiyonu arasinda bir iliski var mi?

Nosocomial infections caused by multidrug-resistant (MDR) microorganisms are a major problem in intensive care units (ICUs) with high mortality and morbidity rates and the prior colonization is an important risk factor for these infections. The aim of this study was to investigate the prevalence of rectal colonization of MDR microorganisms and the association between the microorganisms that caused colonization and infection in the patients with nosocomial infections in ICUs. Rectal swabs were obtained on the day of 0, 3, 7, 14, 21 and weekly thereafter from 80 patients over 18 years of age hospitalized in ICU for more than 48 hours, and cultured for vancomycin-resistant enterococcus (VRE), methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum ß-lactamase (ESBL)- producing gram-negative bacilli (GNB) and carbapenem-resistant enteric and nonenteric bacilli. Patients whose rectal swabs were not obtained on admission (on the day of 0), were excluded even they were hospitalized more than 48 hours. Bile esculin agar containing 64 µg/mL ceftazidime and 6 µg/mL vancomycin, chromogenic MRSA agar and blood agar media, MacConkey agar containing 1 mg/L ceftazidime and ceftriaxone, and 5 mL tryptic soy broth media containing 10 µg imipenem and meropenem discs were used for identification. Identification of GNB was determined by conventional methods and ESBL production was determined by double-disc synergy test. Patients have been followed up for nosocomial infections. Bacterial identification and antibiotic susceptibility tests were performed with standard microbiological methods. In 37 (46%) of the 80 patients, at least one MDR microorganism was isolated in rectal swab cultures on the day of 0. The most common microorganisms were ESBL-positive E.coli (19%), followed by ESBL-positive K.pneumoniae (13%), carbapenem-resistant P.aeruginosa (10%), ESBL-positive K.oxytoca (3%), MRSA (1%), VRE (1%), carbapenem-resistant Acinetobacter sp. (1%) and carbapenem-resistant K.pneumoniae (1%), respectively. The number of microorganisms isolated from rectal swab cultures on the following days have increased, and on the 7th day, the rate of the patients with rectal colonization ascended to 72%. Out of 80 patients, 52 (65%) had nosocomial infections in the follow-up and the mean duration of infection development was 11.8±9.9 days in these patients. Patients with and without rectal colonization were compared in terms of subsequent nosocomial infection rates. While no statistically significant difference has been detected between two groups on the day of 0, patients with rectal colonization detected on the day of 3 and 7, had a significantly higher incidence of nosocomial infections (p=0.02, p=0.01). Among the patients with ESBL-positive GNB, carbapenem-resistant K.pneumoniae, carbapenem-resistant P.aeruginosa and VRE infections, the same microorganisms have been isolated in the rectal swab cultures taken before the development of infection. This result was statistically significant for each of these microorganisms (p=0.00-0.03). However, such a correlation was not observed for Acinetobacter infections. Since MRSA infections developed in only two patients, no istatistical analysis has been done for this microorganism. In conclusion, our data suggest that MDR microorganisms that cause nosocomial infections, initially colonize the gastrointestinal tract, and early detection of colonized patients in ICUs may help an effective infection control by preventing the spread of these resistant microorganisms.

Seroepidemiology of hepatitis viruses, measles, mumps, rubella and varicella among healthcare workers and students: Should we screen before vaccination?

BACKGROUND: Health care workers (HCWs) and students are at increased risk for blood borne infections and vaccine preventable diseases (VPDs). The aim of this study was to determine the seroprevalence of antibodies against measles, rubella, mumps, varicella zoster virus (VZV), hepatitis A and B viruses among HCWs and students and to determine whether there are differences according to gender and age group. METHODS: Information about characteristics of the 1053 participants, history of disease and vaccination status were collected using a structured questionnaire. Serum samples were tested for antibodies by commercial immunoenzymatic assays. RESULTS: Seropositivity rates were 57.1% for measles, 74% for mumps, 96.3% for rubella, 93.7% for VZV, 33.9% for hepatitis A virus and 92.2% for hepatitis B virus. Susceptibility rates among participants 18-26, 27-38 and >38 years of age were statistically significant for measles (46%, 18.6% and 0%; p < 0.001) and mumps (27.1%, 12.9% and 21.4%; p < 0.05), respectively. CONCLUSION: Low seropositivity rates for measles, mumps and HAV are important findings. For other diseases other than VZV, it is thought that vaccination without pre-screening is more appropriate. Healthcare institutions should have policies for screening and vaccination of their staff and students.

The Effects of Initial Procalcitonin Levels on Mortality Rates in Geriatric Patients Undergoing Surgery.

Introduction The aim of the current study is to investigate the relationship between mortality rate in geriatric patients undergoing surgery with preoperative serum levels of procalcitonin, C-reactive protein, and erythrocyte sedimentation rate. Methods This was a single-center retrospective study, including three groups with 101 patients, who are older than 65 years of age. A retrospective investigation was carried out from the laboratory information system for all groups from January to December 2018. Group 1 included patients who had surgery and then mortality within 30 days after surgery. Group 2 included hospitalized patients who had surgery and no mortality within 30 days after surgery. Group 3 included outpatient patients, who had suspicion for a bacterial infection and then no surgery or no mortality within 30 days. Results When three group comparisons were made for procalcitonin, C-reactive protein, and erythrocyte sedimentation rate values, the p-value of one-way analysis of variance (ANOVA) was higher than 0.05 for procalcitonin and lower than 0.05 for C-reactive protein and erythrocyte sedimentation rate, suggesting that one or more groups were significantly different. When post-hoc multiple comparison methods were applied, there were statistically significant differences between Groups 1 and 3 for C-reactive protein and erythrocyte sedimentation rate. Conclusions Procalcitonin levels do not predict mortality following surgery. C-reactive protein and erythrocyte sedimentation rate are more useful biomarkers predicting mortality in geriatric patients undergoing surgery.

Epidemiological characteristics, clinical and laboratory findings supporting preliminary diagnosis of Crimean-Congo hemorrhagic fever in an endemic region in Turkey.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne disease that has various symptoms. Since rapid diagnosis is crucial for survival, understanding the characteristics of patients is important for clinicians while waiting for results. This study aimed to evaluate findings that support the preliminary diagnosis of suspected CCHF in patients and take a look at the management of CCHF in Turkey. METHODS: Demographics, presenting symptoms and laboratory findings of the patients admitted with a suspicion of CCHF, were recorded from the patient files and database of Ministry of Health. A diagnosis of CCHF was based on detection of immunoglobulin M (IgM) antibodies and/or viral RNA. The patients with and without CCHF were compared in terms of differences in epidemiological, clinical and laboratory findings. RESULTS: Out of 87 patients, 61 (70.1%) were CCHF and 26 (29.9%) were non-CCHF cases. Working with agriculture/livestock, tick exposure, contact with body fluids of animals, travel to rural areas within 2 weeks, fever, headache, leucopenia, anemia, international normalized ratio (INR) elevation were significantly more common in CCHF cases. According to multivariate analysis, tick exposure (odds ratio, OR 9.03, 95% confidence interval, CI 1.96-41.47, p = 0.005), contact with body fluids of animals (OR 14.9, 95% CI 2.23-99.94, p = 0.005), leucopenia (OR 13.65, 95% CI 2.55-72.91, p = 0.02) and anemia (OR 8.41, 95% CI 1.06-66.42, p = 0.04) were independently indicative for CCHF. CONCLUSION: As it takes a considerable time for a definitive diagnosis, determining epidemiological features and risk factors is an important step for preliminary diagnosis of CCHF as well as early implementation of precautions against nosocomial transmission of the virus.

Are physicians aware of current HIV / AIDS diagnostic practices? A study from a tertiary centre in Turkey.

INTRODUCTION: Early diagnosis of HIV infection is essential for the reduction of morbidity/mortality rates, health expenditures and the prevention of infection spread. In this study we aimed to test the knowledge of physicians regarding HIV risk groups, AIDS indicator diseases and their current practices about screening. METHODOLOGY: A questionnaire was used to collect data from physicians working in a multidisciplinary 170-bed tertiary university hospital in Istanbul, Turkey. The questionnaire measured physician knowledge of the above-mentioned points. RESULTS: Ninety-six physicians replied to the questionnaire. "Preoperative screening" was found to be the most common (65.6%) indication for HIV testing. A large portion of physicians (72.9%) felt comfortable with an HIV test and 71.9% of the physicians had no impeding condition for HIV testing. Physicians were mostly (67.7%) unaware of the current guidelines for HIV testing. CONCLUSIONS: Teaching programs are essential to increase knowledge of HIV screening for physicians as this is an essential part of early diagnosis and therefore important for decreasing morbidity and mortality.

Acute hepatitis due to Epstein-Barr virus with cross-reacting antibodies to cytomegalovirus.

Epstein-Barr virus (EBV) is the cause of systemic infection known as infectious mononucleosis with classic presentation of fever, oropharyngitis and lymphadenitis. EBV rarely causes acute hepatitis. In this report, we present a 19-year-old patient presented with nausea, fatigue and jaundice. Her physical examination and laboratory tests revealed the diagnosis as acute hepatitis due to EBV with cross-reacting antibodies to cytomegalovirus.

Haemophagocytosis in a patient with Crimean Congo haemorrhagic fever.

Crimean-Congo haemorrhagic fever (CCHF) is a severe disease with a case fatality of 2.8 to 80 %. A patient dwelling in an endemic region for CCHF was admitted with fever preceding bleeding diathesis and pancytopenia. Despite no history of tick exposure, CCHF was highly suspected. With an oral ribavirin therapy, clinical and laboratory improvements were obtained. The diagnosis was confirmed by detection of IgM antibody to CCHF virus and positive RT-PCR. Although the main pathogenesis of CCHF infection is not elucidated yet, haemophagocytosis, a symptom rarely reported in viral haemorrhagic fevers, was observed in this case. Haemophagocytosis is suggested to have a role in the development of pancytopenia in CCHF, the mechanism of which still needs to be investigated, probably with cytokine studies. Together with clinical symptoms and patient history, haemophagocytosis may be an indicator for CCHF.

Acute Acalculous Cholecystitis: A Rare Presentation of Primary Epstein-Barr Virus Infection in Adults-Case Report and Review of the Literature.

Primary Epstein-Barr virus (EBV) infection is almost always a self-limited disease characterized by sore throat, fever, and lymphadenopathy. Hepatic involvement is usually characterized by mild elevations of aminotransferases and resolves spontaneously. Although isolated gallbladder wall thickness has been reported in these patients, acute acalculous cholecystitis is an atypical presentation of primary EBV infection. We presented a young women admitted with a 10-day history of fever, nausea, malaise who had jaundice and right upper quadrant tenderness on the physical examination. Based on diagnostic laboratory tests and abdominal ultrasonographic findings, cholestasis and acute acalculous cholecystitis were diagnosed. Serology performed for EBV revealed the acute EBV infection. Symptoms and clinical course gradually improved with the conservative therapy, and at the 1-month follow-up laboratory findings were normal. We reviewed 16 adult cases with EBV-associated AAC in the literature. Classic symptoms of EBV infection were not predominant and all cases experienced gastrointestinal symptoms. Only one patient underwent surgery and all other patients recovered with conservative therapy. The development of AAC should be kept in mind in patients with cholestatic hepatitis due to EBV infection to avoid unnecessary surgical therapy and overuse of antibiotics.

Unmet need in Behcet's disease: most patients in routine follow-up continue to have oral ulcers.

The clinical course of Behcet's disease (BD) as a multisystemic disorder with a remitting-relapsing nature is insufficiently explored. As complete remission should be aimed in all inflammatory diseases, we investigated the frequency of complete remission in patients with BD followed in long-term, routine practice. In this retrospective study, 258 patients with BD who were regularly followed in outpatient clinics were assessed. The demographic and clinical data for active organ manifestations and treatment protocols were evaluated, and "complete remission" for this study was defined as no sign of any disease manifestation in the current visit and the preceding month. Two hundred fifty-eight patients with BD (F/M 130/128, mean age 41.1 ± 11.5 years) were included to the study. Mucocutaneous disease was present in 48.4 % (n = 125). Mean visit number was 6.8 ± 2.7, and mean follow-up duration was 45.8 ± 36.5 months. Patients were clinically active in 67.2 % (n = 1,182) of the total visits (n = 1,757), which increased to 75.6 % (68.1-90.3) when the month preceding the visit was also included. The most common active manifestation was oral ulcers (39.4-63.2 %) followed by other mucocutaneous manifestations and musculoskeletal involvement. When multivariate analysis was performed, oral ulcers, which are the main cause of the clinical activity, negatively correlated with immunosuppressive treatments (ß = -0.356, p < 0.000) and age (ß = -0.183, p = 0.04). It is fairly difficult to achieve complete remission in BD with current therapeutic regimens. The reluctance of the clinician to be aggressive for some BD manifestations with low morbidity, such as mucocutaneous lesions and arthritis, might be influencing the continuous, low-disease activity state, especially due to oral ulcers, in BD patients.

The causes of acute Fever requiring hospitalization in geriatric patients: comparison of infectious and noninfectious etiology.

Introduction. Infectious diseases may present with atypical presentations in the geriatric patients. While fever is an important finding of infections, it may also be a sign of noninfectious etiology. Methods. Geriatric patients who were hospitalized for acute fever in our infectious diseases unit were included. Acute fever was defined as presentation within the first week of fever above 37.3°C. Results. 185 patients were included (82 males and 103 females). Mean age was 69.7 ± 7.5 years. The cause of fever was an infectious disease in 135 and noninfectious disease in 32 and unknown in 18 of the patients. The most common infectious etiologies were respiratory tract infections (n = 46), urinary tract infections (n = 26), and skin and soft tissue infections (n = 23). Noninfectious causes of fever were rheumatic diseases (n = 8), solid tumors (n = 7), hematological diseases (n = 10), and vasculitis (n = 7). A noninfectious cause of fever was present in one patient with no underlying diseases and in 31 of 130 patients with underlying diseases. Conclusion. Geriatric patients with no underlying diseases generally had infectious causes of fever while noninfectious causes were responsible from fever in an important proportion of patients with underlying diseases.

Amphotericin B-induced cutaneous leucocytoclastic vasculitis: case report.

A 37-year-old female patient was diagnosed with ulcerative colitis 8 months ago and medical treatment with oral azathioprine, low-dose corticosteroids and 5-ASA was started. Following 3 months without any symptoms, the patient had total colectomy and ileostomy. After this period, liposomal amphotericin B (3 mg kg(-1) day(-1)) was given with the diagnosis of probable fungal infection. Palpable purpuric skin lesions on the anterior surface of both legs appeared on the 55th day of amphotericin B treatment. Histological examination of a skin biopsy was consistent with leucocytoclastic vasculitis. We present a case of cutaneous leucocytoclastic vasculitis in which amphotericin B might presumably be the aetiological factor.