[Mortality prediction ability of phycians in intensive care units of Turkey (MOPAP)]. / Türkiye'de yogun bakim ünitelerinde hekimin mortaliteyi öngörebilme gücü.

INTRODUCTION: Intensive care physicians are increasingly involved in decision making about the prognosis of intensive care unit ICU patients. With this study; we aimed to evaluate the power of clinician foresight at prediction of mortality in patient at triage to intensive care and patient follow-up. MATERIALS AND METHODS: This study was conducted in ICUs located in various geographical regions of Turkey between January 1, 2017-April 30, 2017.The clinical research was planned as observational, multicenter, cross-sectional. RESULT: A total of 1169 intubated patients were followed in 37 different ICU. At the beginning of the follow-up we asked the physician who will follow the patient in the ICU to give a score for the probability of survival of the patients. Scoring included a total of 6 scores from 0 to 5, with the "0" the worst probability "5" being the best. According to this distribution, only 1 (0.9%) of 113 patients who were given 0 points survived. Three (6.1%) of 49 with the best score of 5 died. Survival rates were significantly different in each score group (r: -0.488; p<0.001). After the combined mortality estimation scores based on the clinical observations of the physicians (0 and 1 point score was combined as non-survive, 4 and 5 score was combined as survived) 320 of the 545 patients were estimated to be dead and 225 were predicted survival. Sensitivity and spesifity of scoring system to predict mortality was 91.56% (95% CI: 87.96-94.37), 76.89% (95% CI: 70.82-82.23) respectively. CONCLUSIONS: In this study, we concluded that the physicians who follow the patients in the ICU can predict the poor prognosis at the time of admission and the high mortality rate. The physician's opinion on mortality estimation should be considered in intensive care mortality scoring in addition to other laboratory and clinical parameters.

Approach of pulmonologists in Turkey to noninvasive mechanical ventilation use at home for chronic respiratory failure.

INTRODUCTION: To define approach of pulmonologists in Turkey to noninvasive mechanical ventilation (NIV) use for chronic respiratory failure (CRF), the most currently applied technique for home mechanical ventilation. PATIENTS AND METHODS: A 38-question survey, developed and tested by the authors, was distributed throughout Turkey to 2205 pulmonologists by e-mail. RESULT: Twenty-seven percent of the pulmonologists responded (n=596). Domiciliary NIV was reported to be prescribed by 340 physicians [57.1% of all responders and 81% of pulmonologists practicing NIV at clinical practice (n= 420)]. NIV prescription was associated with physician's title, type of hospital, duration of medical license, total number of patients treated with NIV during residency and current number of patients treated with NIV per week (p< 0.05). Main estimated indications were listed as chronic obstructive pulmonary disease (median, 25-75 percentile of the prescriptions: 75%, 60-85), obesity hypoventilation syndrome (10%, 2-15), overlap syndrome (10%, 0-20) and restrictive lung disease (5%, 2-10). For utilization of NIV at home, Bilevel positive airway pressure-spontaneous mode (40%, 0-80) and oronasal mask (90%, 60-100) were stated as the most frequently recommended mode and interface, respectively. Pressure settings were most often titrated based on arterial blood gas findings (79.2%). Humidifier was stated not to be prescribed by approximately half of the physicians recommending domicilliary NIV, and the main reason for this (59.2%) was being un-refundable by social security foundation. CONCLUSION: There is a wide variation in Turkey for prescription of NIV, which is supposed to improve clinical course of patients with CRF. Further studies are required to determine the possible causes of these differences, frequency of use and patient outcomes in this setting.

Approach of pulmonologists in Turkey to noninvasive mechanical ventilation use in acute respiratory failure.

INTRODUCTION: Noninvasive mechanical ventilation (NIV) has been increasingly used worldwide for acute respiratory failure (ARF), especially in patients with chronic lung disorders. We aimed to define the approach of pulmonologists in Turkey to NIV use for ARF management. MATERIALS AND METHODS: A 38-question survey, developed and tested by authors, was distributed by e-mail to a total of 2.205 pulmonologists in Turkey. RESULT: Response rate was 27% (n= 596). Seventy-one percent of responders were practicing NIV in clinic. NIV use was found to be associated with responder's academic title, age, duration of medical license, type of physician's hospital and its region, patient load, NIV experience during residency, and duration of NIV and intensive care unit (ICU) experience (p< 0.001). Based on sub-group analysis of responders using NIV, median number of NIV patients followed-up per week was 4 [interquartile range (IQR): 2-6]. Most of the NIV users reported employment of wards (90%) and/or ICUs (86%) to follow-up patients, while 8.4% of the responders were applying NIV only in ICU's. Chronic obstructive lung disease (COPD) (99.5%), obesity hypoventilation syndrome (93.7%) and restrictive lung disease (89.4%) were the most common indications. Majority of NIV users (87%) were applying NIV to > 60% of patients with COPD, and success rate in COPD was reported as over 60% by 93% of users. Oronasal mask (median and IQR 90, 80-100%, respectively) and home care NIV ventilators (median and IQR 50, 10-85%, respectively) were the most commonly utilized equipment. CONCLUSIONS: NIV use in ARF varies based on hospital type, region and, especially, experience of the physician. Although consistent with guidelines and general practice, NIV use can still be improved and increased.

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.

Survival from severe pandemic H1N1 in urban and rural Turkey: a case series.

BACKGROUND: Pandemic influenza A (H1N1) was a serious health problem during the winter of 2009-2010 in Turkey. OBJECTIVE: To clarify the clinical and demographic characteristics of patients who needed intensive care in our region. METHODS: We conducted a prospective cohort study from November 2009 to February 2010 of demographic characteristics, clinical course, management strategies, 28-day mortality, and stay in the intensive care unit (ICU). RESULTS: During the study period, in our ICU we followed 18 patients (10 female) with H1N1. Their median (and IQR) age was 39 y (24-52 y), their median (and IQR) Acute Physiology and Chronic Health Evaluation (APACHE II) score was 16 (10-25), and 7 (39%) of them lived in rural places. All 18 patients had acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). The most common risk factors for severe H1N1 infection were obesity (33%), COPD (16%), and pregnancy (11%). Thirteen patients (72%) needed mechanical ventilation at ICU admission. Mortality was 50% (9/18) at day 28. Significantly more survivors were urban dwellers than rural (82% vs 0%, P < .001). There were also statistically significant differences between survivors and nonsurvivors in success of noninvasive ventilation, time to confirmation of the H1N1 virus after ICU admission, creatinine, lactate dehydrogenase, pH, P(aCO(2)), and P(aO(2))/F(IO(2)). CONCLUSIONS: The most common clinical presentation was ALI/ARDS in H1N1 patients who needed intensive care. Living in rural areas might have affected those patients' access to advanced ICU facilities and early ventilatory support. Failure of noninvasive ventilation, late diagnosis, late antiviral therapy, high APACHE II score, and living in a rural area were associated with mortality.

Contributing factors to mortality rates of pulmonary tuberculosis in intensive care units.

BACKGROUND: Tuberculosis (TB) remains an important health problem worldwide. TB patients sometimes require intensive care unit (ICU) treatment. The aim of this study is to establish special features and mortality rates of pulmonary TB patients in ICUs and identify the factors contributing to ICU mortality. METHODS: Medical records of adult patients (>18 years) with a diagnosis of TB who were admitted to the ICU of a referral hospital for chest diseases between 2004 and 2010 were reviewed retrospectively. Demographic characteristics, comorbidities, APACHE II scores, symptoms, radiologic appearance of the disease, bacteriological and laboratory investigations, need and type of mechanical ventilation support (invasive, non-invasive), characteristics related to ICU stay, length of ICU stay, mortality and factors affecting mortality were recorded and analysed. RESULTS: Forty patients (33 male) with active pulmonary TB with a median age of 55 years (43-63 years) and a median APACHE II score of 22 (17-26) were followed up in the ICU. Patients who needed invasive mechanical ventilation had significantly longer ICU stays than patients who were treated with non-invasive ventilation or medical therapy (Log rank p = 0.014). Mortality was 72.5%. The only independent risk factor for mortality was having an APACHE II score ≥18. CONCLUSION: The mortality of TB patients who needed ICU support remains high. This higher mortality rate seems related to multi-organ failure, requiring invasive mechanical ventilation and high APACHE II scores.

Effectiveness of transbronchial needle aspiration in the diagnosis of exophytic endobronchial lesions and submucosal/peribronchial diseases of the lung.

The role of transbronchial needle aspiration (TBNA) in diagnosing endobronchial lung cancers has not been elucidated. The definitive combination of procedures that offers the best diagnostic yield following fiberoptic bronchoscopy remains controversial. This study was designed to investigate the diagnostic yield of transbronchial needle aspiration and other cytologic and histologic diagnostic procedures (i.e., forceps biopsy, brushing, and washing) and to assess the optimal combination for diagnosing endobronchial lung cancers. This prospective study included 95 patients presenting with visible tumors detected during bronchoscopic procedure as either an exophytic endobronchial lesion (EEL) or submucosal-peribronchial disease (SPD). Transbronchial needle aspiration, forceps biopsy, brushing, and washing were performed in all patients, and 91 patients were diagnosed. Rates of positive results were 75.8% for needle aspiration, 71.6% for forceps biopsy, 61.1% for brushing, and 32.6% for washing. Needle aspiration was used as the sole diagnostic method in 11, forceps biopsy was the sole diagnostic method in 5, and brushing was the sole diagnostic method in 4 patients. Washing was not used as the sole diagnostic method in any case. Forceps biopsy yielded the highest diagnostic rate for an EEL (86.4%); however, when compared with needle aspiration (77.9%), no significant difference was observed between these two procedures (P = 0.302). In patients with a diagnosis of SPD, needle aspiration was determined to be the sole diagnostic method in eight patients. In this group of patients, the highest rate of diagnosis was achieved with needle aspiration (72.2%), and when compared with forceps biopsy (47.2%), a significant difference between the two procedures (forceps biopsy versus needle aspiration) was observed (P = 0.049). By adding transbronchial needle aspiration to the conventional diagnostic methods (forceps biopsy, brushing, and washing), the rate of diagnosis increased from 82.1% to 95.8% (P = 0.001), and in patients with a diagnosis of SPD, this rate increased from 69.4% to 94.4% (P = 0.008). In patients with a diagnosis of an EEL, addition of needle aspiration led to an increase in diagnostic yield but this difference was not statistically significant (89.8% versus 96.6%, P = 0.250). In endobronchial lung cancers, transbronchial needle aspiration is a safe method that can be used together with conventional diagnostic procedures to increase the diagnostic yield and should be considered a valuable diagnostic tool, particularly in cases of SPD. The highest rate of diagnostic yield in this study was obtained using a combination of forceps biopsy, transbronchial needle aspiration, and brushing; washing did not contribute to this high rate.