Change in species distribution and antifungal susceptibility of candidemias in an intensive care unit of a university hospital (10-year experience).

Candidemia is a nosocomial infection mostly found in critically ill patients. Our objectives were to evaluate the change in distribution and resistance profile of Candida spp. isolated from candidemic patients in our intensive care unit over two 5-year periods spanning 15 years and to evaluate the risk factors. Records from the microbiology laboratory were obtained, from January 2004 to December 2008 and from January 2013 to December 2017, retrospectively. Antifungal susceptibility was performed by E-test and evaluated according to EUCAST breakpoints. A total of 210 candidemia cases occurred; 238 Candida spp. were isolated in 197 patients (58.8% male; mean age, 59.2 ± 19.6 years). The most predominant risk factor was central venous catheter use. Species distribution rates were 32%, 28%, 17%, and 11% for C. albicans (n = 76), C. parapsilosis (n = 67), C. glabrata (n = 40), and C. tropicalis (n = 27), respectively. Resistance rate to anidulafungin was high in C. parapsilosis over both periods and increased to 73% in the second period. Fluconazole showed a remarkable decrease for susceptibility in C. parapsilosis (94 to 49%). The prevalence of MDR C. parapsilosis (6%/33%) and C. glabrata (0%/44%) increased in the second period. We observed a predominance of non-albicans Candida spp., with C. parapsilosis being the most frequent and C. glabrata infections presenting with the highest mortality. High level of echinocandin resistance in C. parapsilosis and increasing prevalences of MDR C. parapsilosis and C. glabrata seem emerging challenges in our institution.

From asymptomatic to critical illness: decoding various clinical stages of COVID-19

The clinical course of COVID-19 is variable, with clinical manifestation ranging from 81% mild course to 14% severe course along with 5% critical course in patients. The asymptomatic course is reported to potentially range between 20% and 70% (avg. 33%). A more severe course is seen in the elderly, those with various chronic diseases, and the immunosuppressed, where the case fatality rate is higher in these risk groups. The disease progresses with various symptoms, such as fever, cough, shortness of breath, malaise, myalgia, taste and smell disorders, diarrhea, sore throat, headache, and conjunctivitis. The disease begins with shortness of breath, indicative of lung damage, after an average of 7 to 10 days, and progresses in ARDS, sepsis, and septic shock. Some patients quickly enter shortness of breath, while others gradually develop shortness of breath and chest tightness and burning. The risk factors for a poor prognosis are age, comorbidities, and changes in laboratory tests. Secondary bacterial and fungal infections frequently develop with steroids and immunosuppressants, especially in the intensive care unit. Frequent complications in hospitalized patients include pneumonia (75%), ARDS (15%), acute renal failure (9%), and acute liver injury (19%). An increased incidence of heart damage is observed, including acute heart failure, arrhythmias, and myocarditis. Of the patients hospitalized due to COVID-19, 10%­25% present with prothrombotic coagulopathy, resulting in venous and arterial thromboembolic events. The most common extrapulmonary symptom is neuropsychiatric involvement, frequently accompanied by insomnia, an impediment to remembering, and an altered state of consciousness. During the course of COVID-19, patients undergo some pathological changes (severe lymphopenia, high levels of C-reactive protein, D-dimer, ferritin, etc.) depending on the condition and exposure level of the affected systems as shown by various laboratory tests. The relevant tests are the guiding elements of risk assessment, clinical monitoring, disease severity, and prognosis setting and therapy decision-making processes.

Epidemiology of urological infections: a global burden.

INTRODUCTION: Urinary tract infections (UTIs) are among the most frequent infections in clinical practice worldwide. Their frequency and burden must be higher than available data suggest because they are not among mandatory diseases to be notified. CLASSIFICATION OF URINARY INFECTIONS: Although there are many different proposals for classifying UTIs, classifications based on acquisition settings and complication status are more widely used. These include community- acquired UTIs (CAUTIs) or healthcare-associated UTIs (HAUTIs) and uncomplicated or complicated UTIs. EPIDEMIOLOGY OF UROLOGICAL INFECTIONS AND GLOBAL BURDEN: As the most frequently seen infectious disease, CAUTIs affect more than 150 million people annually. Complicated UTIs in particular constitute a huge burden on healthcare systems as a frequent reason for hospitalization. The prevalence of HAUTIs ranges between 1.4% and 5.1%, and the majority of them are catheter-related UTIs. Community-onset HAUTIs have gained importance in recent years. CONCLUSION: As frequent infectious diseases, UTIs create clinical and economic burdens on healthcare systems, and they also affect quality of life determinants.

Primary aneurysmal bone cyst of the scapula in adult patient: two case reports and a review of the literature.

Aneurysmal bone cyst (ABC) is a rare, benign but locally aggresive bone tumor of unknown origin tumor. It commonly affects children and usually occurs at the metaphysis of long bones. Scapula is a very rare location and ABCs of the scapula have been sparsely described in the literature. Differential diagnosis can be challenging as it shares common radiological and clinicopathological features with other benign and malignant bone tumors. The degree of diagnostic difficulty increases even more when an unusual tumor site has to be taken into account. Here, we describe rare and challenging cases of a primary ABC located at the scapula that was surgically treated. This is the first case report of ABC involving the scapula in adult patient.

COVID-19: pathogenesis, genetic polymorphism, clinical features and laboratory findings

COVID-19 caused by a novel agent SARS-CoV-2 progressed to a pandemic condition and resulted in a major public health concern worldwide, leading to social and economic issues at the same time. The pathogenesis of COVID-19 starts with the bonding of the virus to ACE2 receptors expressed in many tissues, and the triggered excessive immune response plays a critical role in the course of the disease. The cytokine storm that occurs upon excessive production of pro-inflammatory cytokines is considered responsible for the severe progression of the disease and the organ damage. However, the accurate pathophysiological mechanism of the disease, which progresses with various clinical presentations, is still substantially unknown. While various studies have been conducted on the effect of genetic polymorphism on the course and severity of the disease, the presence of a significant effect has not been proven yet. The clinical course of the disease is variable, with clinical representation ranging from 81% mild course to 14% severe course along with 5% critical course in patients. Asymptomatic course is considered to be higher than expected, although its frequency is not known exactly. Older adults and those with comorbidities are exposed to a more severe disease course. The disease progress with various symptoms, such as fever, cough, dyspnea, malaise, myalgia, taste and smell dysfunctions, diarrhea, and headache. A range of complications (acute respiratory distress syndrome, thromboembolic conditions, arrhythmia and cardiac events, secondary infections) could be seen during the course of the disease. Varied laboratory tests are vital to determine these verity and prognosis of the disease, along with the condition and exposure of the affected systems during thecourse of COVID-19.

Comparison of the Sensititre YeastOne antifungal method with the CLSI M27-A3 reference method to determine the activity of antifungal agents against clinical isolates of Candidaspp.

Background and aim: Infections caused by Candida species are significantly increasing today, and invasive Candida infections are generally associated with high mortality. Early diagnosis and identification of Candida spp. is important for the determination of antifungal agents that will be used for treatment. The aim of the present study was to provide a better regimen for Candida infections in the future. Materials and methods: TheSensititre YeastOne (SYO) method was compared with The Clinical Laboratory Standards Institute (CLSI) reference broth microdilution (BMD) testing method. Endpoints of minimal inhibitory concentrations (MICs) were determined for both methods. Results: By using both methods, MIC values of micafungin, caspofungin, voriconazole, and fluconazole were lower than amphotericin B. The values obtained with the SYO method were in high categorical agreement for ecinocandins and amphotericin B. The results of voriconazole and fluconazole were in low categorical agreement. The categorical agreement between the SYO and the BMD results at 24 h was 82.1% for VORI and 98.4% for AMB. Values obtained with SYO method for all antifungal agents were in high essential agreement with the data of the CLSI reference BMD method. The essential agreement between the SYO and the BMD results at 24 h was 94.0% for MFG and 99.0% for AMB. Conclusions: The SYO method was ready-to use, so it appeared to be easier and more efficient for Candida isolates.

Mortality predictors of Staphylococcus aureus bacteremia: a prospective multicenter study.

BACKGROUND: Staphylococcus aureus is one of the causes of both community and healthcare-associated bacteremia. The attributable mortality of S. aureus bacteremia (SAB) is still higher and predictors for mortality and clinical outcomes of this condition are need to be clarified. In this prospective observational study, we aimed to examine the predictive factors for mortality in patients with SAB in eight Turkish tertiary care hospitals. METHODS: Adult patients with signs and symptoms of bacteremia with positive blood cultures for S. aureus were included. All data for episodes of SAB including demographics, clinical and laboratory findings, antibiotics, and outcome were recorded for a 3-year (2010-2012) period. Cox proportional hazard model with forward selection was used to assess the independent effect of risk factors on mortality. A 28-day mortality was the dependent variable in the Cox regression analysis. RESULTS: A total of 255 episodes of SAB were enrolled. The median age of the patients was 59 years. Fifty-five percent of the episodes were considered as primary SAB and vascular catheter was the source of 42.1 %. Healthcare associated SAB was defined in 55.7 %. Blood cultures yielded methicillin-resistant S. aureus (MRSA) as a cause of SAB in 39.2 %. Initial empirical therapy was inappropriate in 28.2 %. Although overall mortality was observed in 52 (20.4 %), 28-day mortality rate was 15.3 %. Both the numbers of initial inappropriate empirical antibiotic treatment and the median hours to start an appropriate antibiotic between the cases of fatal outcome and survivors after fever onset were found to be similar (12/39 vs 60/216 and 6 vs 12 h, respectively; p > 0.05). High Charlson comorbidity index (CCI) score (p = 0.002), MRSA (p = 0.017), intensive care unit (ICU) admission (p < 0.001) and prior exposure to antibiotics (p = 0.002) all were significantly associated with mortality. The Cox analysis defined age [Hazard Ratio (HR) 1.03; p = 0.023], ICU admission (HR 6.9; p = 0.002), and high CCI score (HR 1.32; p = 0.002) as the independent predictive factors mortality. CONCLUSIONS: The results of this prospective study showed that age, ICU stay and high CCI score of a patient were the independent predictors of mortality and MRSA was also significantly associated with mortality in SAB.

Prognostic Value of QRS Fragmentation in Patients with Acute Myocardial Infarction: A Meta-Analysis.

AIMS: Fragmented QRS has emerged as a novel electrocardiographic parameter associated with adverse clinical events in various diseases. The aim of this study was to investigate the association of fQRS with in-hospital and long-term cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI). METHODS AND RESULTS: We searched PubMed, Embase, Web of Science, and Cochrane Library up to October 2015 for eligible studies. We selected studies with fQRS defined with 12-lead ECG during the index hospitalization of STEMI/NSTEMI. Primary outcomes were in-hospital and long-term cardiovascular events. In-hospital mortality was significantly higher in fQRS (+) group (99/733; 13.5%) compared to fQRS (-) group (47/1293; 3.6%) (OR 4.03 95% CI 1.81-8.94; P = 0.0006). Long-term mortality rate was higher in fQRS (+) group (89/473; 18.8%) compared to fQRS (-) group (54/1009; 5.3%) (OR 3.93 95% CI 1.92-8.05; P = 0.0002). In addition the frequency of long-term MACE was higher in fQRS (+) group (46.9%) compared to fQRS (-) group (14.6%) (OR 5.13 95% CI 2.77-9.51; P < 0.00001) CONCLUSION: Presence of fQRS on admission ECG was found to be predictor of mortality, MACE, deterioration of LV function, and presence of multivessel disease in patients with STEMI and NSTEMI.

Changes in the prevalence of HBV infection in pregnant women in Turkey between 1995 and 2015: a 20-year evaluation.

OBJECTIVE: To determine changes in hepatitis B virus (HBV) prevalence across three different time periods in pregnant women. METHODS: This was a retrospective study of pregnant women attending four healthcare centres between January 1995 and May 2015. Data for serum hepatitis B surface antigen (HBsAg) and anti-HBs levels were collected from routine antenatal screening records. The 20-year study was divided into three periods: 1995-2001, 2002-2008 and 2009-2015. The results are presented by the women's age and gravidity as possible determinants of HBV infection. RESULTS: 7605 pregnant women (56.0% primigravidae) (mean age 23.4±4.8 years) were tested for markers of HBV infection. 3010 pregnant women were screened between 1995 and 2001, 2995 between 2002 and 2008, and 1600 between 2009 and 2015. The overall prevalence of HBsAg and anti-HBs positivity in the 7605 pregnant women was 1.5% (n=114) and 11.5% (n=877), respectively. Regarding temporal change in the prevalence of HBV markers, HBsAg decreased significantly from 2.6% to 0.8% (p<0.01), while anti-HBs increased significantly from 9.5% to 17.5% (p<0.01), between the first and last study periods. Multigravidae and older women had higher HBsAg and anti-HBs positivity compared to primigravidae. CONCLUSIONS: The data suggest that the prevalence of HBsAg positivity is gradually decreasing among pregnant women, while the level of HBsAg antibody seropositivity is lower than expected. HBV carrier rate increases with increasing age and gravidity. In addition to the national HBV immunisation programme, the prevention of perinatal transmission should also be prioritised to decrease the HBV pool of infection.

Association of contrast-induced nephropathy with bare metal stent restenosis in STEMI patients treated with primary PCI.

BACKGROUND: Contrast induced nephropathy (CIN) has been proven as a clinical condition related to adverse cardiovascular outcomes. However, relationship between CIN and stent restenosis (SR) remains unclear. In this study, we aimed to investigate the association of CIN with SR rates after primary percutaneous coronary intervention (PCI) and bare metal stent (BMS) implantation. METHODS: A total number of 3225 patients who had undergone primary PCI for STEMI were retrospectively recruited. The medical reports of subjects were searched to find whether the patients had a control coronary angiogram (CAG) and 587 patients with control CAG were included in the study. The laboratory parameters of 587 patients were recorded and patients who developed CIN after primary PCI were defined. Contrast induced nephropathy was defined as either a 25% increase in serum creatinine from baseline or 0.5 mg/dL increase in absolute value, within 72 h of intravenous contrast administration. RESULTS: The duration between primary PCI and control CAG was median 12 months [8-24 months]. The rate of SR was significantly higher in CIN (+) group compared to CIN (-) group (64% vs. 46%, p < 0.01). In multivariate Cox regression analysis, male gender, stent length, admission WBC levels and presence of CIN (HR 1.39, 95% CI 1.06-1.82, p < 0.01) remained as the independent predictors of SR in the study population. CONCLUSION: Gender, stent length, higher serum WBC levels and presence of CIN are independently correlated with SR in STEMI patients treated with BMS implantation.

Comparison of cellular immunity in patients with chronic hepatitis B, inactive hepatitis B surface antigen carriers and spontaneously recovered individuals.

Different clinical outcomes of acute HBV infection have been partially explained by individual differences in immune response. In this study we investigated interferon gamma (IFN-γ) secretion of peripheral blood mononuclear cells (PBMC) in vitro against specific (Hepatitis B core antigen; recombinant HB-cAg) and non-specific (CMV, EBV, Influenza peptide pool; CTL CEF peptide pool "plus") antigens using enzyme linked immunospot (ELISPOT) assay in 7 patients with chronic hepatitis B (CHB group), 8 inactive carriers Of HBV (carrier group) and 8 subjects who spontaneously recovered from acute HBV infection as detected by anti-HBs positivity (immune group). Phytohemaglutinin served as the positive test control. Response against recombinant HBcAg was 88±135, 50±110, 105±150 spot forming cell (SFC)/10(5) PBMC, in CHB, carrier and immune groups, respectively. HBcAg-specific T-cell response was slightly higher in the immune group; however, statistically there was no significant difference between the groups. Assessment of cellular immunity by IFN-γ ELISPOT was not sufficient to explain the various outcomes of HBV infection such as resolution, chronicity and carriership.

Cyclops syndrome following anterior cruciate ligament reconstruction: Can relapse occur after surgery?

Symptomatic cyclops lesions are complications that can be seen at rates of up to approximately 10% after anterior cruciate ligament reconstruction. However, recurrent cyclops lesions have rarely been documented. There are case rare series in the literature regarding the treatment of recurrent cyclops lesion. Future large studies are needed to investigate factors contributing to the development of cyclops lesions and syndrome and treatment options.

Indication and surgical approach for reconstruction with endoprosthesis in bone-associated soft tissue sarcomas: Appropriate case management is vital.

It is important for surgeons performing sarcoma surgery to know that bone resection and tumor prosthesis applications in soft tissue sarcomas (STS) have unique features in terms of indication, surgical approach and follow-up, in terms of the management of these cases. Some STS are associated with bone and major neurovascular structures. Bone-associated STS are generally relatively large and relatively deep-seated. Additionally, the tendency for metastasis is high. In some cases, the decision about which structures to resect is difficult. These cases are often accompanied by poor oncological and surgical outcomes. Management of cases should be done by a multidisciplinary team in advanced centers specialized in this field. The surgical team must have sufficient knowledge and experience in the field of limb-sparing surgery. Preoperative evaluation and especially good planning of bone and soft tissue reconstruction are vital.

Expandable endoprostheses in skeletally immature patients: Where we are.

Approximately 45 percent of malignant bone tumors are seen under the age of 16 and one of the important results of growth plate sacrification in patients with immature skeletons is limb inequality. Until the early 1990s, the treatment options for these patients were rotationplasty or amputation. Multimodal approaches that combine imaging, chemotherapy, and surgical techniques have enabled the development of limb-preserving methods with satisfactory results. In order to overcome inequality problems, expandable prostheses have been developed in the 1980s. Extendable endoprosthesis replacements have been improved over the years and are now an established and safe alternative. Noninvasive prostheses appear to be advantageous compared to minimally invasive expandable prostheses that require multiple surgical procedures, but the complication rate remains high. Therefore, although expandable prostheses are not the definitive answer to the treatment of bone sarcomas in skeletally immature children, they are still a suitable interim choice until full adulthood is achieved. Due to reported high complication rates, the procedures require significant experience and are recommended for use only in specialized cancer centers.

Cortical hypertrophy in intramuscular hemangioma mimicking bone tumor.

Although hemangiomas are the most common soft tissue tumors, intramuscular hemangiomas account for only 0.8% of all vascular tumors. These lesions are rarely located adjacent to the bone and cause changes in the adjacent bone. They are often mistakenly diagnosed as bone tumors. In this study, a case of a 19-year-old male patient with intramuscular hemangioma causing cortical thickening was reported.

Management of Giant Cell Tumors in Hand and Foot.

The aim of this study is to determine the treatment modalities and clinical characteristics of 12 patients diagnosed with giant cell tumor (GCT) of the hand and foot. The clinical findings, treatment modalities, and treatment failures of 12 patients with giant cell tumors of the hand and foot bones between 2007 and 2018 years were evaluated retrospectively. The average age at diagnosis was 29.2 ± 14.9 std. (between 16 and 62 years old), 8 males (66.6%) and 4 females (33.3%). Tumor was more frequently located in the talus, metacarpal, and metatarsal bones. The mean tumor size was 3.1 ± 1.1 cm (between 2.2 and 5.3 cm). The mean post-operative follow-up period was 76.3 ± 42.5 (between 12 and 139 months). The most of patients' (58.3%) common complaints were pain. The most commonly used surgical method was curettage + autografting (91.7%). Infection was seen in one patient after relapse surgery. Recurrence occurred in 33.3% of the patients in the first year. Only one patient was detected to have knee and lung metastases. Swelling and pain in the hand and foot should be examined for tumor lesions. When a bone lesion is detected, the giant cell tumor of the bone should be included in the differential diagnosis. Patients with giant cell tumors should be followed closely for recurrence and metastasis after treatment.

Is surgical indication in multiple myeloma a poor prognosis sign? SEER database analysis.

AIM: This study aims to investigate demographic data, survival rates, and the relationship of these rates with surgery in a large case series including multiple myeloma (MM) patients. METHOD: MM cases were analyzed retrospectively using the latest version of the SEER database published in April 2020. This version covers January 1975 to December 2017. Patients were classified according to gender, age, and race/ethnicity. Tumors were classified according to their localization, grade, year of diagnosis, and follow-up results. RESULTS: There were 60,239 patients diagnosed with Plasma Cell Myeloma. While 670 patients (1.2%) were operated on, 43,976 patients (76.7%) did not indicate operation, and 12,670 patients (22.1%) could not be operated on despite the recommendation. The mean survival was 62 months in those without an indication for surgery, and 42 months in patients with an indication but could not be operated on, and the difference was significant (p = 0.001). The mean survival was 58 months in the operated patients, and 42 months in the patients who could not be operated on despite the indication, and the difference was significant (p = 0.001). There was no difference between those who did not indicate surgery and those who were operated on with an indication (p = 0.243). CONCLUSION: In multiple myeloma, the best prognosis is in the group of patients who received medical treatments without any indication for operation, while an indication for operation indicates a worse prognosis. A worse prognosis should be expected in patients who do not accept the operation or who cannot be operated on compared to the operated patients.

Do metastatic volumes measured in breast cancer patients with bone metastases correlate with the numbers of skeletal and extraskeletal events?

OBJECTIVES: The study aimed to investigate the relationship between metastatic volume measurement, skeletal-related events, and survival in women diagnosed with breast cancer and bone metastases. PATIENTS AND METHODS: This retrospective study was conducted with 82 female breast cancer patients (mean age: 53±14.3 years; range, 23 to 87 years) diagnosed, treated, and followed up between January 2005 and December 2019. The collected data included information on metastasis sites and the presence of skeletal-related events. Metastatic volume was measured in two ways: the number of metastases (high to low) and their localization (the first, second, and third groups). The first group consisted of vertebrae, ribs, sternum, and calvarial bones; the second group included scapula, clavicle, proximal humerus, and proximal femur regions; the third group consisted of femur and humerus diaphyseal and distal regions, as well as metastasis regions in other long bones. RESULTS: Sixty-three (76.8%) patients were diagnosed with ductal carcinoma. Half of the patients had bone metastases at the time of initial diagnosis, while 62 (75.6%) experienced skeletal-related events, with at least three events occurring in 30 (36.6%) patients. Bone pain was the most common skeletal-related event. No correlation was found between metastatic volume measurement based on the localization of bone metastases and the number of bones and the occurrence of skeletal-related events (p>0.05 for each). Patients' survival time spanned from one to 231 months (median: 56.8 months) from their first diagnosis. Patients with high metastatic volume, those in the third group, those whose pelvis and lung were involved, and elderly patients had a shorter survival time (p<0.05 for each). CONCLUSION: The study indicates that measuring metastatic volume may be a critical factor in evaluating the survival of breast cancer patients with bone metastases. Future prospective and randomized controlled studies can explore the potential of this measurement to create practical clinical tools.

A challenging case of an adamantinoma of fibula with soft tissue mass harboring distinct histopathology.

We present a case of adamantinoma that originated from the fibula and had a large soft tissue component measuring approximately 6 cm. Clinical, radiological, and pathological investigations initially suggested that the tumor might be a bone-invading synovial sarcoma. To the best of our knowledge, no other case of fibular adamantinoma with such a large soft tissue component has been reported in the literature.