Pneumonia severity indices predict prognosis in coronavirus disease-2019.

BACKGROUND: Early recognition of the severe illness is critical in coronavirus disease-19 (COVID-19) to provide best care and optimize the use of limited resources. OBJECTIVES: We aimed to determine the predictive properties of common community-acquired pneumonia (CAP) severity scores and COVID-19 specific indices. METHODS: In this retrospective cohort, COVID-19 patients hospitalized in a teaching hospital between 18 March-20 May 2020 were included. Demographic, clinical, and laboratory characteristics related to severity and mortality were measured and CURB-65, PSI, A-DROP, CALL, and COVID-GRAM scores were calculated as defined previously in the literature. Progression to severe disease and in-hospital/overall mortality during the follow-up of the patients were determined from electronic records. Kaplan-Meier, log-rank test, and Cox proportional hazard regression model was used. The discrimination capability of pneumonia severity indices was evaluated by receiver-operating-characteristic (ROC) analysis. RESULTS: Two hundred ninety-eight patients were included in the study. Sixty-two patients (20.8%) presented with severe COVID-19 while thirty-one (10.4%) developed severe COVID-19 at any time from the admission. In-hospital mortality was 39 (13.1%) while the overall mortality was 44 (14.8%). The mortality in low-risk groups that were identified to manage outside the hospital was 0 in CALL Class A, 1.67% in PSI low risk, and 2.68% in CURB-65 low-risk. However, the AUCs for the mortality prediction in COVID-19 were 0.875, 0.873, 0.859, 0.855, and 0.828 for A-DROP, PSI, CURB-65, COVID-GRAM, and CALL scores respectively. The AUCs for the prediction of progression to severe disease was 0.739, 0.711, 0,697, 0.673, and 0.668 for CURB-65, CALL, PSI, COVID-GRAM, A-DROP respectively. The hazard ratios (HR) for the tested pneumonia severity indices demonstrated that A-DROP and CURB-65 scores had the strongest association with mortality, and PSI, and COVID-GRAM scores predicted mortality independent from age and comorbidity. CONCLUSION: Community-acquired pneumonia (CAP) scores can predict in COVID-19. The indices proposed specifically to COVID-19 work less than nonspecific scoring systems surprisingly. The CALL score may be used to decide outpatient management in COVID-19.

Incidence of Late Acute Rejection in Living Donor Liver Transplant Patients, Risk Factors, and the Role of Immunosuppressive Drugs.

INTRODUCTION: Late acute rejection (LAR) is a clinical manifestation that occurs 6 months after liver transplantation, shows histopathologic features different from those of acute rejection, and is the cause of a high prevalence of morbidity and mortality. METHODS: In this study, hospital records of 211 living donor liver transplantation (LDLT) patients who underwent surgery in our clinic between June 2000 and February 2014 were reviewed retrospectively. The patients were ≥ 18 years old and were followed for ≥ 6 months. RESULTS: Of the 211 patients, 21 (9.9%; 16 males, 5 females) developed LAR. The mean age of the patients was 46 years (range, 33-58). The mean follow-up period was 61.2 months (range, 6-152) and the median time to development of LAR was 26.4 months (range, 7-77). In our study, patients who received cyclosporine and mycophenolate mofetil (MMF) treatment developed more LAR than did patients who received tacrolimus and MMF therapy (P = .05). In addition, the incidence of LAR in patients who underwent LDLT was significantly greater in the ABO-matched groups than in the ABO identical group (P = .028). CONCLUSIONS: Development of LAR and serious complications related to it can be avoided if liver transplant recipients are followed regularly and closely in outpatient clinics after transplantation.

Acute Renal Injury Evaluation After Liver Transplantation: With RIFLE Criteria.

BACKGROUND: The aim of this study was to identify acute renal injury (ARI) through the use of RIFLE (risk, injury, failure, loss, end-stage kidney disease) criteria and to investigate perioperative risk factors for ARI in liver transplantation (LT). METHODS: We reviewed medical records of adult LT patients retrospectively. Postoperative ARI was staged with RIFLE criteria by the 1st and 7th days of the surgery. RESULTS: We analyzed 440 adult LT patients, categorized as risk (R), injury (I), or failure (F) according to the RIFLE criteria. In this study, in the first postoperative day, incidence of ARI was 7.95%; all of them were R-class, and, on the 7th day, the incidence of ARI was 7.27%, as R-class 6.59% and I-class 0.68%. Significant risk factors were detected within the first postoperative day including pre-operative hemoglobin levels <9 g/dL (P = .019), intra-operative transfusion of red blood cells (RBCs) (P = .049) and fresh-frozen plasma (FFP) (P = .049), blood loss (P = .011), and post-reperfusion syndrome (P = .023). Multivariate analysis revealed risk factors for ARI as RBCs (odds ratio [OR], 1.049; P = .247) and FFP (OR, 1.017; P = .627) transfusion and blood loss (OR, 1.000; P = .021) (blood loss OR: 0.9996952300184; 95% confidence interval: 0.9994356774026 to 0.999548500399). The only significant risk factor for the 7th postoperative day was the Model for End-Stage Liver Disease (MELD) score (>20) (P = .002). CONCLUSIONS: This study showed that RBC and FFP transfusion, perioperative blood loss, and MELD score >20 are risk factors for LT-related ARI. Also normalization of hemoglobin levels with non-blood products in patients with preoperative low hemoglobin levels can diminish the need for RBC and that can prevent ARI.

Bacterial Pathogens Isolated in Liver Transplant Recipients With Surgical Site Infection and Antibiotic Treatment.

OBJECTIVE: Surgical site infection (SSI) is the most common infection after liver transplantation in our hospital. In this study, the effect of microorganisms isolated in liver transplant recipients' (LTRs') culture with SSI on antibiotic treatment has been investigated. METHOD: Between January 2003 and December 2013, microbiological data and antibiotic management of LTRs were examined from laboratory and patients' records retrospectively. For diagnosis of SSI, the Centers for Disease Control and Prevention criteria were used. Infections have been classified into 3 groups according to agent existence (culture negative, monomicrobial, or polymicrobial). The data were analyzed with the SPSS 17 program. RESULTS: In the study period, 457 liver transplantations were performed. The study included 412 adult LTRs. In 122 (29.6%) of these patients, at least 1 infection was detected within 30 days after transplantation. Seventy-one (17.2%) were SSI. Of LTRs with SSI, there were 36 (50.7%) with blood stream infection, 16 (22.5%) with pneumonia, and 10 (14.0%) with urinary tract infection together. Eighteen (25.4%) cases were polymicrobial (especially Acinetobacter baumannii and Enterococcus species), 35 (49.2%) cases were monomicrobial (firstly methicilline resistant Staphylococcus aureus), and 18 (25.4%) cases were culture negative SSI. In 60 (84%) cases, combined antibiotic treatment was used. Mortality rate was 14.0%. CONCLUSION: In LTRs with SSI, the impact of the isolation of an infectious agent on antibiotic selection could not be determined. Whether or not there are bacteria, on the basis of the local epidemiological data and patient characteristics, at least 2 or more antibiotics were combined for treatment. According to the resistance of the isolated microorganisms prior antibiotics have been changed.

Clinical and microbiological efficacy of tigecycline for complicated skin-soft-tissue and intra-abdominal infections in a Turkish university hospital.

OBJECTIVE: Tigecycline, a new glycylcycline antimicrobial agent, is indicated for the treatment of complicated skin structure infection (cSSTI), intra-abdominal infection (cIAI) and community acquired pneumonia. We aimed to evaluate the clinical and microbiological data together about tigecycline therapy. METHODS: Patients with cIAIs and cSSTIs were included in a prospective, observational follow-up. Patient follow-up forms were developed and clinical and microbiological data were recorded. RESULTS: Of the 107 patients, 67 had cSSTIs, 40 had cIAIs. Tigecycline was used empirically in 37.5% of cIAIs and in 50.7% of cSSTIs. In 85.0% of the patients with cIAI and in 73.1% of the patients with cSSTI, clinical and/or microbiological response could be achieved. A drug change was made in 26.9% and 7.5% of the patients with cSSTI and cIAI respectively. Superinfection was detected in 14.9% of the cSSTI and 7.5% of the cIAI patients. CONCLUSION: As a result, tigecycline can be safely used in the treatment of different infections. Compared with cSSTIs, the treatment response is better and the duration of treatment is shorter in cIAIs. However, MIC value must be determined at any rate if tigecycline is to be used in the treatment of Acinetobacter (MDR Acinetobacter, in particular) infections. Clinical cure and microbiological eradication rate of tigecycline therapy changes according to different clinical diagnosis and microorganism.

Risk factors for early bacterial infections in liver transplantation.

OBJECTIVE: Our aim was to determine perioperative risk factors for early bacterial infection after liver transplantation. METHODS: Retrospectively examining medical records using Centers for Disease Control and Prevention (CDC) definitions to identify nosocomial infections, we analyzed data on 367 adult patients. RESULTS: The incidence of infection was 37.3% (n = 137): namely, surgical site (n = 74; 20.2%) [corrected], blood stream (n = 64; 17.4%), pulmonary (n = 49; 13.4%), urinary system (n = 26; 7.1%). Significant risk factors within the first 30 days were as follows: deceased donor, Model for End-Stage Liver Disease (MELD) >20, albumin level <2.8 g/dL, intraoperative erythrocyte transfusion >6 U, intraoperative fresh frozen plasma >12 U, bilioenteric anastomosis, postoperative intensive care unit stay >6 days, and postoperative length of stay >21 days. Significant risk factors detected within the first 90 days were as follows: MELD >20, preoperative length of stay >7 days, reoperation, postoperative length of intensive care unit stay >6 days, and postoperative length of stay >21 days. Variability was observed in risk factors according to localization of infection. As a result, except for MELD, type of donor, and biliary anastomosis, the others are preventable factors for early bacterial infection. In addition, the same risk factors showed variability according to the site of infection.

RpoB gene mutations in rifampin-resistant Mycobacterium tuberculosis strains isolated in the Aegean region of Turkey.

Although DNA sequencing method has not been used routinely for detecting resistance of Mycobacterium tuberculosis to antituberculosis drugs, it is suggested for the investigation of gene mutations causing resistance. Using DNA sequencing (Automated Applied Biosystems), we attempted to determine mutations in the 81-bp cor region (rifampin resistance determining region) of the rpoB gene in 48 Mycobacterium tuberculosis strains found to be rifampin resistant by classical phenotypic methods. Of the 48 strains, 46 (95.8%) were found to have rpo gene mutations with 13 different types while in two (4.2%) of the 48 strains, no mutations were detected. None of the strains had mutations at more than one codon. Point mutations at the 531st (52.1%) and 526th (18.9%) codons were frequent. The most frequent point mutation was Ser531Leu, and it was found in 21 (43,8 %) of 48 strains. This is the first study from Turkey, reporting Ser522Leu point mutation in one isolate and deletion of 515th codon (ATG - Met) in two isolates.

[Results of inferior oblique muscle surgery in superior oblique paralysis]. / Les résultats de la chirurgie de l'oblique inférieur dans la paralysie de l'oblique supérieur.

The aim of this study was to evaluate the results of inferior oblique muscle recession in certain cases of superior oblique paralysis. Twenty-three patients with moderate hyperaction of the inferior oblique muscle, secondary to paralysis of the superior oblique muscle, in whom a recession of the ipsilateral inferior oblique was applied were enrolled in this study. These cases were selected among those with congenital superior oblique paralysis and infantile nontraumatic paralysis and those of unknown origin. Isolated recession of the inferior oblique muscle achieved a mean decrease in 8.69 +/- 2.05 D in hypertropia in the primary position. In 19 cases out of 23 (82.6%) who received isolated recession of the inferior oblique muscle, a vertical deviation equal to or less than 4 PD was obtained, showing the efficacy of this method in the surgical treatment of the cases with superior oblique paralysis and a moderate inferior oblique hyperaction.

[Value of MRI in the treatment of Grave's disease orbital myopathy]. / L'intérêt de l'IRM dans le traitement de la myopathie de l'orbitopathie dysthyroïdienne.

In order to evaluate the predictability of the results in the treatment of myopathy in cases with the clinical signs of muscle involvement, 177 extraocular muscles of 27 cases whose oedematous status was detected by MRI and who were given antiinflammatory treatment according to the data of this method, were studied. The nature of involvement was detected in respect with the signal intensity and thickness of each rectus muscle prior to the treatment and at the end of the sixth month following a three months' application of combined treatment of steroids and irradiation of 2000 rads. When the initial and final results were compared, the signal intensities of four involved recti showed significant decrease at the end of the treatment, as they were evaluated separately or together. Besides the thicknesses of these groups of involved recti which were evaluated separately showed significant decrease. The evaluation of the signal intensities by MRI is a way that enables noninvasive detection of the edema and prediction of the anti-inflammatory treatment's results of dysthyroid myopathy. Therefore a systematic follow up by MRI is recommended for the treatment choice in dysthyroid myopathy.

The effects of experimentally induced anisometropia on stereopsis.

PURPOSE: To determine the effects of experimentally induced anisometropia on stereopsis in healthy adults to assess the potentially detrimental effects of uncorrected anisometropia on the development of stereoacuity during childhood. METHODS: Twenty-one healthy adult volunteers ranging in age from 22-34 years (mean: 27 years) and free of ocular disease participated in the study. Four different types of anisometropia (unilateral myopia, unilateral hyperopia, or unilateral astigmatism [90 degrees or 45 degrees]) were induced in random order by placing trial lenses over the right eye in 1 diopter (D) increments ranging from 1-3 D. Stereoacuity was measured using the Titmus stereotest with patients placing the cross-polarizing stereoacuity glasses over their lenses or trial frames. RESULTS: Stereoacuity levels were reduced in proportion to the degree of anisometropia in all patients. One diopter of spherical anisometropia reduced stereoacuity to an average 57-59 arc seconds; 1 D of cylindrical anisometropia reduced stereoacuity to an average 51-56 arc seconds. Three diopters of anisometropia, regardless of type, produced a marked reduction of stereoacuity in all patients. CONCLUSIONS: Low levels of anisometropia, both spherical and astigmatic, can have potentially significant adverse effects on high-grade binocular interaction in adults. Foveal suppression, which is directly related to the degree of anisometropia, may be responsible for the loss of stereopsis. The data suggest the effects of anisometropia on stereopsis should be considered in the empiric correction of anisometropic refractive errors in children.

[Results of suture fixation in esotropia with non-accommodative far-near uncomitance]. / Les résultats de l'opération du fil dans les ésotropies avec incomitance loin-près non-accommodative.

PURPOSE: In esotropia, the dynamic component is the unique objective of suture fixation. The aim of this study was to assess outcome after the suture fixation used with or without other conventional methods and to determine the value of the anesthesia sign for evaluating the innervational factor of these esotropias. METHODS: Unilateral and bilateral posterior fixation sutures were applied in 54 cases exhibiting far-near incomitance between 10-20. The same procedure was applied in 14 cases with similar type of esotropia with incomitance greater than 20. RESULTS: A 100% success rate was achieved when suture fixation was used alone. When suture fixation was applied in combination with other conventional methods for cases with a static and a dynamic component the success rate was 86% (37/43 cases) in unilateral myopexy and 92% (12/13 cases) in bilateral myopexy. DISCUSSION: In cases with this type of esotropia, suture fixation, the only means of correcting a dynamic angle, gives good results as the component disclosing the apparent angle is well-documented. In addition, these findings emphasize the value of the general anesthesia sign to determine the innervational factor causing the dynamic angle.

[The angle under anesthesia and elongation of the lateral rectus muscle in primary esotropia]. / L'angle sous anesthésie et l'élongation du droit externe dans les ésotropies primitives.

PURPOSE: In a group of 34 patients with esotropia, the anesthetic sign was studied in order to decide on the selection of the eye that should be initially operated. It is based on the examination of the variation between the angle while the patient is awake and the angle under general anesthesia applied with a definite protocole. The operated eye was always the most convergent or the less divergent one under general anesthesia. METHOD: During the operation the elongation of the medial and lateral recti belonging to the operated eye were systematically measured by Rapp-Roth myometer and Péchereau ruler. RESULTS: In 58% of cases, the examination under general anesthesia revealed an equivalent deviation of the dominated and dominant eyes form the midline. In 19% of cases convergence was obvious in the dominant eye while it existed in the dominated eyes in 23% of cases. CONCLUSION: It is concluded that a significant relationship exists between the basic angle and the variation of the angle under general anesthesia as well as between the basic angle and the elongation of the lateral rectus. Besides, this study points out the absence of relationship between the angle under general anesthesia and the elongation of the lateral rectus as well as the elongation of the two recti.

[Secondary hyperactivity of the contralateral oblique muscle after unilateral weakening of the inferior oblique muscle]. / Hyperaction consécutive de l'oblique controlatéral après affaiblissement unilatéral de l'oblique inférieur.

PURPOSE: This study was designed to analyze the consecutive overaction of the contralateral inferior oblique (IO) muscle after unilateral weake in procedure of the same muscle which is a well-known but not regularly studied phenomenon. MATERIAL AND METHODS: Unilateral weakening of overactive IO muscle was performed in a group of 27 patients with esotropia (14 recessions and 13 marginal myotomias). Eleven of these patients had unilateral overaction of the IO muscle. In the remaining 16 patients the overaction was highly asymmetric. RESULTS: Postoperatively we observed only one consecutive overaction of the contralateral IO in patients with unilateral overaction. However, this condition was observed in 11 of 16 patients with asymmetric IO overaction. CONCLUSION: The innervational pathogenesis of this phenomenon is a subject of discussion. The authors emphasize the necessity of the clinical examination in order to identify the bilateral asymmetric forms and to neutralize them by convenient surgical procedures.

[Ocular site of pigmentation in oculodermal melanocytosis]. / Localisation oculaire de la pigmentation dans la mélanocytose oculodermique.

Sixteen patients with oculodermal melanocytosis (Nevus of Ota, congenital ocular melanocytosis) were investigated for the location and the density of the ocular pigmentation, the increase in intraocular location and the malignant transformation. In all cases, conjunctivo-scleral dispersion pattern appeared as dispersed patches without any predominant site but a diffuse involvement of the angle. This finding points out that ODM may exhibit a characteristic dispersion pattern of pigmentation which is characteristic for ODM. For 14 patients intraocular pressures were < or = 18 mmHg, and for remaining 2 patients 21 and 22 mm Hg. Glaucomatous optic disc or perimetric changes were not found in any patient. In one case, a histologically verified ciliary-choroidal melanoma at a superior-temporal site co-existed at the same location as the ODM.

[Malignant melanoma of the choroid in vivo. Comparative biometry using RX scanner and MRI]. / Contribution à l'étude du mélanome malin de la choroïde in vivo. Biométrie comparée par scanner RX et IRM.

Uveal melanomas are unique among the malignant tumors of the eye investigated by MRI in that both T1 and T2 are relatively shortened due to the paramagnetic effect of melanin. Bearing in mind this property, we conducted a comparative study between MRI and CT in 11 patients with histologically proven choroidal malignant melanoma. The results of this study confirm that MRI is far superior to CT in both differential diagnosis and in determining the extent of the tumor which is crucial if conservative treatment is to be undertaken.

A controlled trial of azathioprine in Behçet's syndrome.

Cytotoxic agents have long been used in Behçet's syndrome, especially for eye involvement, but their effectiveness has been uncertain. We conducted a two-year randomized, placebo-controlled, double-blind trial of azathioprine (2.5 mg per kilogram of body weight per day) in Turkish men with Behçet's syndrome without eye disease (group 1; n = 25) or with eye disease (group 2; n = 48). Corticosteroid treatment remained available to all the patients. All six patients withdrawn from the study because of severe eye disease were receiving placebo (P less than 0.001). Azathioprine was superior to placebo in the prevention of new eye disease in group 1 (1 vs. 8 patients; P less than 0.01) and in group 2 among the 14 patients who at entry had disease in only one eye (P less than 0.001). There were fewer episodes of hypopyon uveitis (1 vs. 15; P less than 0.001) among the group 2 patients who took azathioprine. The patients taking azathioprine also had less frequent oral ulcers, genital ulcers, and arthritis. There were no serious side effects attributable to azathioprine. We conclude that azathioprine is effective in controlling the progression of Behçet's syndrome, especially its most serious manifestation, eye disease.

[Value of angiography in the surveillance of choroid melanoma treated by cobalt disk]. / Intérêt de l'angiographie dans la surveillance des mélanomes choroïdiens traités par disque de cobalt.

Conservative management of choroidal melanoma by radioactive plaques or protonbeam is widely used since 1968. The treatment of these tumors at Curie Institute has been done with cobalt plaques since 1968. Indications were first monophthalmic patients but are now much wide. We have been treating since 1981 all patients with tumor diameter less than 17 mm and tumor height less than 12 mm. The technic includes general anesthesia to place the disc with localisation of the tumor by transillumination or by indirect ophthalmoscopy. A dose of 70 to 90 grays is delivered to the apex of the tumor. We report two cases of patients treated by cobalt 60 plaque for choroïdal melanoma. The first patient has a 5 mm high choroïdal melanoma temporal to the macula. After treatment by cobalt plaque, he showed no echographic changes but angiograms revealed an hypofluorescent zone in the central part of the tumor. The second patient has an 8 mm tumor that after plaque showed only angiographic changes. Evolution after treatment of choroïdal melanoma by radioactive plaque is variable. Echographic changes are very low and it is frequent to observe no modification in the height of the tumor for a long time for this reason, repeated angiograms can be very useful in the follow up of these patients. They frequently show hypofluorescent spot in the central part of a tumor that was hyperfluorescent before treatment. Sometimes there is diffuse lowering of the fluorescence. We think that these modifications of fluorescence can be due to diminution of the vascularisation of the tumor or may be to central necrosis of the tumor.(ABSTRACT TRUNCATED AT 250 WORDS)

[Foveal displacement after weakening of the inferior muscle. Study using retinophotography]. / Déplacement de la fovéa après affaiblissement du muscle petit oblique. Etude sur rétinophotographies.

Among oculomotor disturbances, the cyclotorsions are difficult to quantify. The most accurate and objective method seems to be the retinophotography, which give the measure of the displacement of the fovea relative to the horizontal line lying through the papillary center. The authors have compared this measure over 16 eyes, before and after inferior oblique weakening. A reduction of the cyclotorsion is established in all cases. However, no correlation has been noted between this result and the pre-surgical state.