Epidemiology and risk factors of 28-day mortality of hospital-acquired bloodstream infection in Turkish intensive care units: a prospective observational cohort study.

OBJECTIVES: To uncover clinical epidemiology, microbiological characteristics and outcome determinants of hospital-acquired bloodstream infections (HA-BSIs) in Turkish ICU patients. METHODS: The EUROBACT II was a prospective observational multicontinental cohort study. We performed a subanalysis of patients from 24 Turkish ICUs included in this study. Risk factors for mortality were identified using multivariable Cox frailty models. RESULTS: Of 547 patients, 58.7% were male with a median [IQR] age of 68 [55-78]. Most frequent sources of HA-BSIs were intravascular catheter [182, (33.3%)] and lower respiratory tract [175, (32.0%)]. Among isolated pathogens (n = 599), 67.1% were Gram-negative, 21.5% Gram-positive and 11.2% due to fungi. Carbapenem resistance was present in 90.4% of Acinetobacter spp., 53.1% of Klebsiella spp. and 48.8% of Pseudomonas spp. In monobacterial Gram-negative HA-BSIs (n = 329), SOFA score (aHR 1.20, 95% CI 1.14-1.27), carbapenem resistance (aHR 2.46, 95% CI 1.58-3.84), previous myocardial infarction (aHR 1.86, 95% CI 1.12-3.08), COVID-19 admission diagnosis (aHR 2.95, 95% CI 1.25-6.95) and not achieving source control (aHR 2.02, 95% CI 1.15-3.54) were associated with mortality. However, availability of clinical pharmacists (aHR 0.23, 95% CI 0.06-0.90) and source control (aHR 0.46, 95% CI 0.28-0.77) were associated with survival. In monobacterial Gram-positive HA-BSIs (n = 93), SOFA score (aHR 1.29, 95% CI 1.17-1.43) and age (aHR 1.05, 95% CI 1.03-1.08) were associated with mortality, whereas source control (aHR 0.41, 95% CI 0.20-0.87) was associated with survival. CONCLUSIONS: Considering high antimicrobial resistance rate, importance of source control and availability of clinical pharmacists, a multifaceted management programme should be adopted in Turkish ICUs.

Vaccination status of COVID-19 patients followed up in the ICU in a country with heterologous vaccination policy: A multicenter national study in Turkey.

OBJECTIVE: Vaccination against severe acute respiratory syndrome coronavirus-2 (SARS-2) prevents the development of serious diseases has been shown in many studies. However, the effect of vaccination on outcomes in COVID-19 patients requiring intensive care is not clear. METHODS: This is a retrospective multicenter study conducted in 17 intensive care unit (ICU) in Turkey between January 1, 2021, and December 31, 2021. Patients aged 18 years and older who were diagnosed with COVID-19 and followed in ICU were included in the study. Patients who have never been vaccinated and patients who have been vaccinated with a single dose were considered unvaccinated. Logistic regression models were fit for the two outcomes (28-day mortality and in-hospital mortality). RESULTS: A total of 2968 patients were included final analysis. The most of patients followed in the ICU during the study period were unvaccinated (58.5%). Vaccinated patients were older, had higher Charlson comorbidity index (CCI), and had higher APACHE-2 scores than unvaccinated patients. Risk for 28-day mortality and in-hospital mortality was similar in across the year both vaccinated and unvaccinated patients. However, risk for in-hospital mortality and 28-day mortality was higher in the unvaccinated patients in quarter 4 adjusted for gender and CCI (OR: 1.45, 95% CI: 1.06-1.99 and OR: 1.42, 95% CI: 1.03-1.96, respectively) compared to the vaccinated group. CONCLUSION: Despite effective vaccination, fully vaccinated patients may be admitted to ICU because of disease severity. Unvaccinated patients were younger and had fewer comorbid conditions. Unvaccinated patients have an increased risk of 28-day mortality when adjusted for gender and CCI.

The Relationship between the Sydney Classification and the First-Line Treatment Efficacy in Helicobacter-Associated Gastritis.

OBJECTIVE: Helicobacter pyloriis responsible for a wide spectrum of diseases. Due to ease of use and access, the standard triple therapy is being used as first-line eradication in many areas. Intestinal metaplasia (IM) is a precancerous lesion that requires eradication therapy. Our aim is to investigate the effect of IM on the standard triple therapy success in H. pylori-positive patients. SUBJECTS AND METHODS: The patients who were referred to Düzce University Hospital and Avrasya Hospital Gastroenterohepatology clinic between January 2014 and December 2016 and diagnosed with H. pylori-positive gastritis and underwent first-line eradication were evaluated retrospectively. Biopsy specimens were evaluated according to the updated Sydney system. All patients diagnosed with H. pylori started treatment with pantoprazole 40 mg b.i.d., amoxicillin 1 g b.i.d. and clarithromycin 500 mg b.i.d. for 14 days. RESULTS: The mean age of 181 patients included in the study was 55.5 ± 7.8. The success rate of H. pylori eradication was found to be low in severe chronic inflammation (p = 0.001). The success rate was found to be high among patients with no neutrophil activity (p = 0.009). As the intensity of IM increased, density of H. pylori was found to be decreased (p = 0.019). There was no correlation between glandular atrophy, IM, and H. pylori eradication success rate (p = 0.390 and p = 0.812). CONCLUSION: The severity of chronic inflammation is the most effective Sydney criteria for success of eradication, while the presence on IM does not have any effect.

Level of adrenomedullin in cases with adrenal defficiency and its relation to mortality in patients with sepsis.

INTRODUCTION: The aim of this study was to determine the prognostic value of adrenomedullin, after evaluation of adrenal function in sepsis patients. We also evaluated other prognostic factors such as APACHE II score, proBNP, and CRP and their prediction in mortality. MATERIALS AND METHODS: This is a prospective, observational study. We enrolled 48 patients, who were admitted to the intensive care unit due to sepsis according to surviving sepsis campaign criteria. RESULT: ADM median value was 60.8 ng/L in patients with normal adrenal function, and 20.1 ng/L in patients who had adrenal deficiency. With adequate adrenal response there was a linear and statistically significant relationship between adrenomedullin and mortality (p< 0.001). The median ADM level was 41.7 ng/L among non-survivors and 13.9 ng/L among survivors (p< 0.001). The median APACHE II score was 27.8 in non-survivors and 16.9 in survivors (p= 0.001). We also done ROC curve analysis; when ADM level was > 30.19 ng/L (sensitivity: 73.0%, specificity: 100%), APACHE II score was > 21 (sensitivity: 93.3%, specificity: 84.8%), and proBNP > 3736 pg/mL (sensitivity: 73.3%, specificity: 93.9%). CONCLUSIONS: Without evaluation of adrenal function adrenomedullin should not be used, in predicting mortality of sepsis.

Renal replacement therapy in the ICU: comparison of clinical features and outcomes of patients with acute kidney injury and dialysis-dependent end-stage renal disease.

BACKGROUND: The goal of this study is to study clinical features and outcomes of the patients who had renal replacement therapy (RRT) in the intensive care unit (ICU) between 2000 and 2007. METHODS: We retrospectively studied 222 patients. RESULTS: Overall ICU mortality and invasive mechanical ventilation (IMV) rates were 58.1 and 61.3 %. The mean APACHE II score was 27.6 ± 8.3. Chronic dialysis (CD) patients formed 45.5 % of the study population. Acute kidney injury (AKI) patients had higher rates of IMV (73 vs. 51.5 %, p = 0.002), cancer (27.8 vs. 7.9 %, p ≤ 0.001) and mortality (67.8 vs. 50.5 %, p = 0.010) than CD patients. AKI patients with normal kidney function (NKF) before ICU admission had poorer prognosis than acute-on-chronic kidney disease (CKD) and CD patients (78.6, 51 and 50.5 %, respectively, p ≤ 0.001). Multivariate analysis showed that IMV (OR, 14.8; 95 % CI, 5.47-40.05; p ≤ 0.001) and having NKF before hospitalization (OR, 2.8; 95 % CI, 1.04-7.37; p = 0.041) were predictors of overall ICU mortality. Additionally, IMV is found as a prognostic factor for both AKI (OR, 18.7; 95 % CI, 4.48-77.72; p ≤ 0.001) and CD patients (OR, 8.14; 95 % CI, 2.01-33.04; p = 0.003), but APACHE II score is meaningful only for CD patients (OR, 1.13; 95 % CI, 1.02-1.26; p = 0.024). The areas under the ROC curves for APACHE II score were 0.52 (95 % CI, 0.39-0.66) for AKI and 0.78 (95 % CI, 0.55-0.89) for CD patients. CONCLUSION: The observed ICU mortality among patients requiring RRT is high and IMV is associated with mortality. AKI patients have increased mortality compared to CD patients. AKI patients with past NKF have poorer prognosis than acute-on-CKD and CD patients.

Characteristics and outcomes of patients with chronic obstructive pulmonary disease admitted to the intensive care unit due to acute hypercapnic respiratory failure.

BACKGROUND: The study aimed to describe the clinical course, outcomes, and prognostic factors of chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure. METHODS: This retrospective study involved patients with acute hypercapnic respiratory failure due to COPD of any cause admitted to the intensive care unit (ICU) for non-invasive or invasive mechanical ventilation (IMV) support between December 2015 and February 2020. RESULTS: One hundred patients were evaluated. The main causes of acute hypercapnic respiratory failure were bronchitis, pneumonia, and heart failure. The patients' mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 23.0±7.2, and their IMV rate was 43%. ICU, in-hospital, and 90-day mortality rates were 21%, 29%, and 39%, respectively. Non-survivors had more pneumonia, shock within the first 24 hours of admission, IMV, vasopressor use, and renal replacement therapy, along with higher APACHE II scores, lower admission albumin levels and PaO2/ FiO2 ratios, and longer ICU and hospital stays than survivors. Logistic regression analysis identified APACHE II score (odds ratio [OR], 1.157; 95% confidence interval [CI], 1.017-1.317; P=0.026), admission PaO2/FiO2 ratio (OR, 0.989; 95% CI, 0.978-0.999; P=0.046), and vasopressor use (OR, 8.827; 95% CI, 1.650-47.215; P=0.011) as predictors of ICU mortality. APACHE II score (OR, 1.099; 95% CI, 1.021-1.182; P=0.011) and admission albumin level (OR, 0.169; 95% CI, 0.056-0.514; P=0.002) emerged as predictors of 90-day mortality. CONCLUSIONS: APACHE II scores, the PaO2/FiO2 ratio, vasopressor use, and albumin levels are significant short-term mortality predictors in severely ill COPD patients with acute hypercapnic respiratory failure.

Alterations in neuroendocrine axes in brain-dead patients.

PURPOSE: To identify changes in anterior pituitary gland hormone levels in brain-dead patients and alterations in free triiodothyronine (fT3), free thyroxine, cortisol, testosterone, and estradiol levels. METHODS: Ten postmenopausal women and 22 men with brain death (BD) were included. The first blood sample for determination of hormones (pre-BD) was collected when the clinician observed the first signs of BD. The second blood sample (BD day) was drawn after BD certification. RESULTS: Female patients exhibited lower follicle-stimulating hormone and prolactin levels pre-BD and luteinizing hormone, follicle-stimulating hormone, and prolactin levels on BD day than the age-matched controls. Male patients' sex hormone levels were similar to those of the age-matched controls, except for testosterone levels, which were low in both consecutive measurements. All gonadotropins and prolactin levels were above the tests' lower detection limits (LDLs), except for one male patient with gonadotropin levels below the LDLs of the tests. Estradiol levels in both sexes ranged from normal to elevated. FT3 levels were significantly decreased in the two measurements. Thyroid-stimulating hormone (TSH) levels were low in eight patients and all low TSH levels were above the test's LDL. The remaining patients had normal or elevated TSH levels. The median adrenocorticotropic hormone (ACTH) and cortisol levels were within normal limits. All cortisol and ACTH levels were above the tests' LDLs, except for one patient with ACTH levels below the LDL in both measurements. CONCLUSION: This study supports the hypothesis that the anterior pituitary gland continues to function in the brain-dead state.

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.

Cases of allergic coronary syndrome (Kounis syndrome) : what we should know.

Kounis syndrome (KS) is an acute coronary syndrome that occurs with allergic, hypersensitivity, anaphylactic, or anaphylactoid reactions associated with mast cell activation, and entails significant morbidity and mortality risks. We present four cases of acute coronary syndrome developing after insect bites, chemotherapy, and coronary stent implantation. Two patients were lost due to anaphylactic shock-related multiorgan failures and sudden cardiac death. Since a wide range of drugs, foods, environmental conditions, and disease states may be associated with KS, all physicians must be aware of the syndrome.

Treatment of critically ill patients with acute hypercarbic respiratory failure by average volume-assured pressure support mode.

OBJECTIVES: Average volume-assured pressure support (AVAPS), a dual mode, delivers a set tidal volume (TV) per kg by adjusting the pressure between upper and lower inspiratory positive airway pressures (IPAP). Thus, ventilation is presumed to be happened effectively by sending a guaranteed TV. This study was aimed to evaluate the effectiveness of AVAPS mode in critically ill patients with acute hypercarbic respiratory failure (HRF) and compare the results with bilevel positive airway pressure-spontaneous/timed (BPAP-S/T) mode. METHODS: Sixty patients were assigned to BPAP-S/T (n = 29) and AVAPS modes (n = 31). Maximum IPAP was started at 20 cmH2 O and minimum IPAP was set at 5 cmH2 O higher than expiratory positive airway pressure (EPAP) in AVAPS mode. IPAP was started at 15 cmH2 O in BPAP-S/T mode. IPAP levels were titrated up to 30 cmH2 O during noninvasive mechanic ventilation (NIMV) with a targeted TV of 6-8 mL/kg. Patients were followed for 5 days. RESULTS: No differences were found in pH, paCO2 , HCO3 , TV and EPAP between the two groups when compared separately by days. Maximum IPAP levels were significantly high in AVAPS mode in all times (P < 0.001). The length of stay (LOS) in intensive care unit (ICU) (P = 0.994) and hospital (P = 0.509), hours of NIMV use per day (P = 0.101) and NIMV success rate (P = 0.931) were identical between the two groups. ICU (P = 0.931), hospital (P = 0.800), 6-month (P = 0.919) and 1-year (P = 0.645) mortality rates were also not different between the both groups. CONCLUSIONS: AVAPS mode had similar efficiency with BPAP-S/T mode regarding the NIMV treatment success in critically ill patients with acute HRF.

Clinical Outcomes and Independent Risk Factors for 90-Day Mortality in Critically Ill Patients with Respiratory Failure Infected with SARS-CoV-2: A Multicenter Study in Turkish Intensive Care Units.

BACKGROUND: There are limited data on the long-term outcomes of COVID-19 from different parts of the world. AIMS: To determine risk factors of 90-day mortality in critically ill patients in Turkish intensive care units (ICUs), with respiratory failure. STUDY DESIGN: Retrospective, observational cohort. METHODS: Patients with laboratory-confirmed COVID-19 and who had been followed up in the ICUs with respiratory failure for more than 24 hours were included in the study. Their demographics, clinical characteristics, laboratory variables, treatment protocols, and survival data were recorded. RESULTS: A total of 421 patients were included. The median age was 67 (IQR: 57-76) years, and 251 patients (59.6%) were men. The 90-day mortality rate was 55.1%. The factors independently associated with 90-day mortality were invasive mechanical ventilation (IMV) (HR 4.09 [95% CI: [2.20-7.63], P < .001), lactate level >2 mmol/L (2.78 [1.93-4.01], P < .001), age ≥60 years (2.45 [1.48-4.06)], P < .001), cardiac arrhythmia during ICU stay (2.01 [1.27-3.20], P = .003), vasopressor treatment (1.94 [1.32-2.84], P = .001), positive fluid balance of ≥600 mL/day (1.68 [1.21-2.34], P = .002), PaO2/FiO2 ratio of ≤150 mmHg (1.66 [1.18-2.32], P = .003), and ECOG score ≥1 (1.42 [1.00-2.02], P = .050). CONCLUSION: Long-term mortality was high in critically ill patients with COVID-19 hospitalized in intensive care units in Turkey. Invasive mechanical ventilation, lactate level, age, cardiac arrhythmia, vasopressor therapy, positive fluid balance, severe hypoxemia and ECOG score were the independent risk factors for 90-day mortality.

Evaluation of sepsis/systemic inflammatory response syndrome, acute kidney injury, and RIFLE criteria in two tertiary hospital intensive care units in Turkey.

Sepsis is a common cause of acute renal failure in intensive care units (ICU) with mortality rates as high as 60%. In this study, the clinical and laboratory predictors of acute kidney injury (AKI) in critically ill Turkish patients with sepsis/systemic inflammatory response syndrome were identified. We studied 139 (67 females/72 males) patients admitted to our ICUs with sepsis/systemic inflammatory response syndrome without renal failure. The clinical and laboratory parameters and treatments were recorded. Patients were classified as those without AKI (n = 60; 43.20%) and those with AKI (n = 79; 56.80%) based on the RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease) criteria. Those with AKI were further classified as: risk in 27 (19%), injury in 25 (17.9%), failure in 25 (17.9%), and loss in 2 (1.4%). We found that the mortality rate increased with the severity of renal involvement: 56% in risk, 68% in injury, 72% in failure, and 100% in loss categories. Patients with AKI had a more positive fluid balance, higher central venous pressure, more vasopressor use, and lower systolic blood pressure. In multivariate analysis, the sequential organ failure assessment score, blood pressure, serum creatinine, and fluid balance were risk factors for the development of AKI. In this population, the incidence of AKI was higher and contrary to previous knowledge. A positive fluid balance also carries a risk for AKI and mortality in septic ICU patients. The RIFLE criteria were found to be applicable to our ICU population.

The endocrinologic changes in critically ill chronic obstructive pulmonary disease patients.

BACKGROUND: Alterations in the neuroendocrine system occur during critical illness. Chronic obstructive pulmonary disease (COPD) itself causes hormonal changes. The aim of this study was to determine neu roendocrine hormones of COPD patients with acute respiratory failure and to investigate the relationship between hormonal changes, mortality, and morbidity. METHODS: We enrolled 21 patients (13 F/8 M) with COPD exacerbation requiring artificial airway support. Blood samples were collected on admission to the ICU, and on the day of hospital discharge. Eighteen healthy people were included as controls. RESULTS: Female patients had lower luteinizing hormone (LH), follicle stimulating hormone (FSH), and free triiodothyronine (fT3), and higher prolactin (PRL) levels than controls on admission to the ICU (FSH: 70.3 vs. 29.3 mlU/mL; LH: 26.6 vs. 6.8 mlU/mL; fT3: 2.9 vs. 2.0 pg/mL; PRL: 12.4 vs. 21.3 ng/mL). Male patients had low testosterone and TSH and high PRL but only changes in TSH and PRL reached statistical significance (testosterone: 3.5 vs. 1.5 ng/mL, TSH: 1.1 vs. 0.5 ulU/mL, PRL: 9.7 vs. 14.2 ng/mL). Female patients had lower fT3 than males (fT3(female): 2.7 vs. fT3(male): 2.0 pg/mL). On follow-up, significantly elevated FSH and fT3 and decreased estradiol concentrations were documented among recovered women (FSH: 28.4 vs. 46.6 mlU/mL, fT3(,): 2.0 vs. 2.6 pg/mL, E(2): 27.7 vs. 19.0 pg/mL). Patients had high C-reactive protein levels and acute physiologic and chronic health evaluation II scores. Mortality rate was 9.5% and a negative correlation between E(2) and duration of noninvasive mechanical ventilation and length of hospital stay was found in male patients. CONCLUSION: Men and women with acute respiratory failure in the presence of COPD develop significant changes in the neuroendocrine axis. Hormonal suppression vanishes with disease improvement.

Long length of stay in the ICU associates with a high erythrocyte transfusion rate in critically ill patients.

OBJECTIVE: This study aimed to evaluate epidemiology and outcome among critically ill patients under a restrictive transfusion practice. METHODS: One hundred sixty-nine patients who were admitted to the intensive care unit (ICU) between March 2016 to December 2017 and remained in the ICU > 24 hours were retrospectively included. RESULTS: Hemoglobin levels on admission were <12 g/dL in 85% and <9 g/dL in 37.9% of patients. The median admission hemoglobin level was decreased on the last day of the ICU stay. Erythrocyte transfusion was required for 34% of patients. Transfused patients had high Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, more requirement for invasive mechanical ventilation, vasopressors, and dialysis, long ICU and hospital stays, low hemoglobin levels, and high hospital and ICU mortality rates. Multivariate analysis showed that the likelihood of transfusion increased from 6.6 to 25.8 fold when the ICU stay extended from ≥7 to ≥15 days. Age, vasopressor use, dialysis, and erythrocyte transfusion ≥5 units were predictors of mortality. CONCLUSION: Patients receiving transfusion are severely ill and have more life support therapies. The number of erythrocyte units transfused, age, and organ support therapies are independent predictors of mortality.

Alterations in thyroid hormones in brain-dead patients are related to non-thyroidal illness syndrome.

INTRODUCTION: Alterations in thyroid hormone levels occur in patients with acute neurological disease states. The aim of this study is to study changes in thyroid hormones in patients with brain death (BD). MATERIAL AND METHODS: Eleven brain-dead patients were studied prospectively. Thyroid hormones were measured on admission to the intensive care unit, the day before BD diagnosis (BD before), and the day after BD diagnosis (BD day). RESULTS: Thyroid stimulating hormone (TSH) and free triiodothyronine (fT3) concentrations were found to be significantly low on ad-mission, BD before, and BD day compared to age-matched healthy controls. TSH levels were shown to be increasing on BD day. Free thyroxine (fT4) levels were within normal limits in all cases except in one case having low fT4 levels with normal TSH levels. No statisti-cally significant changes were encountered between admission thyroid hormone levels and BD-before and BD-day thyroid hormone levels. Six patients were on steroid therapy when BD-before blood samples were drawn, and no difference in thyroid hormone levels was encountered between steroid users and non-users. Correlation analysis showed a positive correlation between GCS and TSH, but a negative association between fT3 and APACHE II. CONCLUSION: We have shown that patients with BD have altered thyroid hormones days before BD diagnosis, and these alterations con-tinue until the diagnosis of BD. The changes in thyroid hormones are compatible with non-thyroidal illness syndrome.

Development and validation of a modified quick SOFA scale for risk assessment in sepsis syndrome.

Sepsis is a severe clinical syndrome owing to its high mortality. Quick Sequential Organ Failure Assessment (qSOFA) score has been proposed for the prediction of fatal outcomes in sepsis syndrome in emergency departments. Due to the low predictive performance of the qSOFA score, we propose a modification to the score by adding age. We conducted a multicenter, retrospective cohort study among regional referral centers from various regions of the country. Participants recruited data of patients admitted to emergency departments and obtained a diagnosis of sepsis syndrome. Crude in-hospital mortality was the primary endpoint. A generalized mixed-effects model with random intercepts produced estimates for adverse outcomes. Model-based recursive partitioning demonstrated the effects and thresholds of significant covariates. Scores were internally validated. The H measure compared performances of scores. A total of 580 patients from 22 centers were included for further analysis. Stages of sepsis, age, time to antibiotics, and administration of carbapenem for empirical treatment were entered the final model. Among these, severe sepsis (OR, 4.40; CIs, 2.35-8.21), septic shock (OR, 8.78; CIs, 4.37-17.66), age (OR, 1.03; CIs, 1.02-1.05) and time to antibiotics (OR, 1.05; CIs, 1.01-1.10) were significantly associated with fatal outcomes. A decision tree demonstrated the thresholds for age. We modified the quick Sequential Organ Failure Assessment (mod-qSOFA) score by adding age (> 50 years old = one point) and compared this to the conventional score. H-measures for qSOFA and mod-qSOFA were found to be 0.11 and 0.14, respectively, whereas AUCs of both scores were 0.64. We propose the use of the modified qSOFA score for early risk assessment among sepsis patients for improved triage and management of this fatal syndrome.

A case of Budd-Chiari syndrome with Behcet's disease and oral contraceptive usage.

We present a case of Budd-Chiari syndrome (BCS) having two risk factors, Behcet's disease (BD) and oral contraceptive (OC) usage. A 33-year-old woman with BD was admitted to the Emergency Unit with nausea, vomiting, abdominal pain, abdominal distention, and confusion started 12 days ago before admission. Since the patient was in a shock state, she was taken to the Intensive Care Unit (ICU) with the suspicion of abdomen-originated sepsis. Abdominal ultrasound showed massive hepatosplenomegaly and moderate ascites. Abdominal MRI revealed an inferior vena cava (IVC) obstruction starting above the renal veins and diffuse thrombosis of the right and medial hepatic veins. An extensive thrombosis of the IVC and the hepatic veins (BCS) which led to shock was diagnosed. In addition to BD, the unnotified OC usage for a year by the patient without her doctor's knowledge was recognized as possible precipitating factor of BCS. Pulse methylprenisolone was started for three consecutive days to treat active BD-induced vasculitis. IVC digital subtraction angiography (DSA) showed occlusion of the IVC below the hepatic veins with extensive collateral circulation originating at the occlusion level suggesting that obliteration had a subacute or chronic course. Since intralesional thrombolytic therapy failed, the patient was transferred to a liver transplantation center. While waiting for an appropriate donor, the patient died due to hepatic failure. Since BCS is mortal and deemed multi-factorial, every patient with a thrombotic risk factor such as BD should be questioned for other possible causes of thrombosis.

The pituitary-gonadal-thyroid and lactotroph axes in critically ill patients.

INTRODUCTION: The normal circadian rhythm of hormones in critical patients becomes chaotic causing some hormones to increase and others to decrease abnormally. The goal of this study is to evaluate hormonal changes in severely ill patients and to investigate the relationship between hormonal changes and mortality and morbidity. MATERIAL AND METHODS: We enrolled 20 patients (10 F/10 M). Blood samples were collected on day 0, day 5, and day 10. If a patient was discharged before these defined days, a sample was drawn on that day. Twenty healthy controls were included. RESULTS: Female patients had lower LH, FSH, and fT3 and higher PRL and cortisol levels than controls on admission to the intensive care unit (ICU) (pLH = 0.021, pFSH:0.001, pfT3 = 0.021, pPRL = 0.042, pCortisol <0.001, respectively). Men had significantly low testosterone and fT3, and high PRL and cortisol levels on ICU admission (pT = 0.01, pfT3 = 0.043, pPRL = 0.005, pCortisol < 0.001, respectively). The lowest levels of gonadotropins in both genders and testosterone in men were measured on day 5. Cortisol levels decreased in the patients discharged from the ICU (p = 0.01). FSH levels increased in recovered women (pFSH = 0.043). The mortality rate was 30%. There were correlations between admission TSH and NIMV duration (p = 0.006), fT3 and APACHE II (p = 0.001), and PRL and mortality (p = 0.044). Positive correlations between E2 and APACHE II (p = 0.003) in females, and PRL and APACHE II (p = 0.022) in males were also displayed. CONCLUSIONS: Critically ill patients develop significant changes in neuroendocrine axes. Alterations in hormones correlate with the disease severity and mortality. (Endokrynol Pol 2016; 67 (3): 305-312).

A severe case of systemic lupus erythematosus with increased pressure communicating hydrocephalus.

Normal/increased pressure hydrocephaly is an unusual manifestation of systemic lupus erythematosus (SLE), and the pathogenesis is still unclear. We report the case of an 18-year-old white female with severe refractory renal and pulmonary involvement who developed stupor during intensive immunosuppressive treatment. Enlarged ventricles on imaging and increased intracranial pressure with the exclusion of infectious and hemorrhagic/thrombotic processes suggested increased pressure communicating hydrocephalus associated with SLE. Few case reports are reviewed, and potential pathophysiologic mechanisms are discussed.

A prospective study: inflammation, infection and comorbidity in patients on long-term dialysis.

BACKGROUND: The goal of this study was to identify inflammatory and infectious markers and their roles in mortality. METHODS: We enrolled 111 patients on haemodialysis (HD) and collected data at three time points (baseline, 33 and 76 months). RESULTS: Rates of Chlamydophila pneumoniae IgG, CRP ≥3 mg/l, ESR >50 mm/hour and fibrinogen >4 g/l were, respectively, 63.1%, 60.4%, 48.6% and 42.3%. Mortality was 21.6% and 43.2% at 33 and 76 months where 58.3% of all deaths were cardiocerebrovascular (CCV) related. Non-survivors were older than survivors. Univariate analysis showed diabetes mellitus (DM) and cerebrovascular accident (CVA) as important for the 33-month all-cause mortality, and CRPlog , fibrinogen, ESR >50 mm/hour, cardiovascular disease (CVD) and DM for the 76-month all-cause mortality. CVA was meaningful for the 33-month CCV mortality, and CVD, DM and ESR >50 mm/hour for the 76-month CCV mortality. Kaplan-Meier revealed poorer survival for patients with ESR >50 mm/hour at 76 months. Cox regression showed CVD, CVA and age as mortality predictors. CONCLUSION: Age, CVD and CVA are predictors for mortality in patients on HD patients, but the presence of C. pneumoniae IgG and inflammation are not.