[Lomentospora prolificans Fungemia in a Patient With T-Cell Large Granular Leukemia: A Rare Pathogen in Türkiye]. / T-hücreli Büyük Granüler Lösemili Bir Hastada Lomentospora prolificans Fungemisi: Türkiye'de Nadir Bir Etken.

Scedosporium/Lomentospora is an opportunistic fungal pathogen found worldwide. While Scedosporium apiospermum and Scedosporium boydii are commonly observed globally, Lomentospora prolificans, which mainly affects immunosuppressed individuals, is rarely encountered and is more prevalent in arid climates, particularly in Australia and Spain. L.prolificans is a fungus commonly found in environmental sources such as contaminated water and soil. This species is known as an opportunistic pathogen that can cause deep-seated fungal infections, especially in immunosuppressed individuals. In this case report, a fatal case of L.prolificans fungemia in a patient with T-cell large granular leukemia during profound neutropenia was presented. The patient admitted to the hospital with prolonged fever, neutropenia, and shortness of breath. Antibiotherapy was administered to the patient for febrile neutropenia, but the fever persisted and his clinical status rapidly deteriorated. L.prolificans was isolated from the blood culture, and considering its antifungal resistance, combination therapy of voriconazole and terbinafine was initiated. However, the patient died of septic shock and multiple organ failure. In conclusion, although L.prolificans infections are rare, they can be life-threatening, especially in immunosuppressed individuals. Diagnosis and treatment of such infections may be difficult, therefore rapid diagnostic methods and appropriate treatment protocols should be developed. Consideration of infections caused by rare fungal pathogens in patients with risk factors may be critical for patient care. The literature review revealed that the first case of L.prolificans fungemia from Türkiye was reported in 2023. This case presentation represents the second reported case. However, in our case, L.prolificans fungemia occurred in 2018, it can be considered that L.prolificans may have been an invasive fungal pathogen of significant concern in Türkiye much earlier than previously documented.

Comparison of laser speckle contrast imaging with laser Doppler perfusion imaging for tissue perfusion measurement.

OBJECTIVE: Laser-based tissue perfusion monitoring techniques have been increasingly used in animal and human research to assess blood flow. However, these techniques use arbitrary units, and knowledge about their comparability is scarce. This study aimed to model the relationship between laser speckle contrast imaging (LSCI) and laser Doppler perfusion imaging (LDPI), for measuring tissue perfusion over a wide range of blood flux values. METHODS: Fifteen healthy volunteers (53% female, median age 29 [IQR 22-40] years) were enrolled in this study. We performed iontophoresis with sodium nitroprusside on the forearm to induce regional vasodilation to increase skin blood flux. Besides, a stepwise vascular occlusion was applied on the contralateral upper arm to reduce blood flux. Both techniques were compared using a linear mixed model analysis. RESULTS: Baseline blood flux values measured by LSCI were 33 ± 6.5 arbitrary unit (AU) (Coefficient of variation [CV] = 20%) and by LDPI 60 ± 11.5 AU (CV = 19%). At the end of the iontophoresis protocol, the regional blood flux increased to 724 ± 412% and 259 ± 87% of baseline measured by LDPI and LSCI, respectively. On the other hand, during the stepwise vascular occlusion test, the blood flux reduced to 212 ± 40% and 412 ± 177% of its baseline at LDPI and LSCI, respectively. A strong correlation was found between the LSCI and LDPI instruments at increased blood flux with respect to baseline skin blood flux; however, the correlation was weak at reduced blood flux with respect to baseline. DISCUSSION: LSCI and LDPI instruments are highly linear for blood flux higher than baseline skin blood flux; however, the correlation decreased for blood flux lower than baseline. This study's findings could be a basis for using LSCI in specific patient populations, such as burn care.

Assessment of Admission COVID-19 Associated Hyperinflammation Syndrome Score in Critically-Ill COVID-19 Patients.

PURPOSE: We aimed to evaluate the relation between admission COVID-19 associated hyperinflammatory syndrome (cHIS) score and intensive care unit (ICU) outcomes. MATERIALS AND METHODS: Patients with laboratory confirmed COVID-19 admitted to our ICU between 20th March 2020-15th June 2021 were included. Patients who received immunomodulatory treatment except corticosteroids were excluded. Main outcomes were ICU mortality and invasive mechanical ventilation (IMV) requirement after ICU admission. RESULTS: Three hundred and seventy patients with a median (IQR) age of 66 (56-77) were analyzed. Median admission cHIS score was 3 (2-4). A cHIS score ≥3 was found to be associated with ICU mortality (sensitivity = 0.63, specificity = 0.50; p < 0.01) and IMV requirement after ICU admission (sensitivity = 0.61, specificity = 0.51; p < 0.01). Patients with an admission cHIS score ≥3 (n = 199) had worse median admission APACHEII, SOFA scores and PaO2/FiO2 ratio than others (n = 171) (p < 0.01). IMV requirement after ICU admission (38.5% vs 26.1%;p = 0.03), ICU (36.2% vs 25.1%;p = 0.02), hospital (39.1% vs 26.9%;p = 0.01) and 28th day (28.1% vs 19.1%;p = 0.04) mortality were higher in patients with admission cHIS score ≥3 than others (p < 0.01). Age <65 years, malignancy and higher admission SOFA score were independent variables associated with admission cHIS score ≥3. CONCLUSION: Critically-ill COVID-19 patients with admission cHIS score ≥3 have worse disease severity and outcomes than other patients.

Effect of Awake Prone Positioning on ROX Index in Critically-ill Patients With Respiratory Failure due to COVID-19.

COVID-19 pneumonia causes acute respiratory distress syndrome (ARDS). Prone positioning (PP) is beneficial to pulmonary physiology and improves oxygenation in patients with ARDS. We aimed to investigate the effect of the PP on oxygenation, respiratory rate (RR) and ROX index in non-intubated patients with COVID-19 associated respiratory failure and to determine whether ROX index predicts intubation. Awake critically-ill patients with confirmed diagnosis of COVID-19 who underwent PP were enrolled in the retrospective, single-center study. Oxygenation parameters were recorded 1 h before PP, during PP and 1 h after return to supine position (after PP). Intubation was defined as the endpoint. Seventy-one patients with a median age of 64 [55-73] years were enrolled in the study. PaO2/FiO2 and SpO2/FiO2 improved during PP, this improvement did not persist after PP. RR improved during and after PP in both intubated and non-intubated patients (for all P < .001). ROX index improved only in non-intubated patients (P < .001) but not in intubated patients (P = .07). Area under the curve (AUC) of ROX index for intubation before PP, during PP and after PP were 0.74 [0.61-0.88] (P = .002), 0.76 [0.62-0.91] (P = .001), and 0.76 [0.64-0.89] (P = .001), respectively. ROX index >6.83 before PP had a negative predictive value (NPV) of 0.85; ROX index >8.28 during PP had a NPV of 0.88 and ROX index >7.48 after PP had a NPV of 0.85. In logistic regression adjusted for APACHE II score, ROX index ≤6.83 before PP had an odds ratio (OR) 4.47 [1.39-14.38], ROX index ≤8.28 during PP had an OR 7.96 [2.29-27.64] and ROX index ≤7.48 had an OR 3.98 [1.25-12.61] for prediction of intubation. In conclusion, awake PP improves oxygenation and decreases RR. ROX index improved only in non- intubated patients and a higher ROX index predicts lower risk of progressing to mechanical ventilation with intubation.

Effects of end-expiratory lung volume versus PaO2 guided PEEP determination on respiratory mechanics and oxygenation in moderate to severe ARDS.

There is no ideal method for determination of positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) patients. We compared the effects of end-expiratory lung volume (EELV)-guided versus PaO2-guided PEEP determination on respiratory mechanics and oxygenation during the first 48 hours in moderate to severe ARDS.Twenty-two patients with moderate to severe ARDS admitted to an academic medical ICU were assigned to PaO2-guided (n = 11) or to EELV-guided PEEP determination (n = 11) group. First, an incremental PEEP trial was performed by increasing PEEP by 3 cmH2O steps from 8 to 20 cmH2O and in each step EELV and lung mechanics were measured in both groups. Then, oxygenation and respiratory mechanics were measured under the determined PEEP at 4, 12, 24, and 48th hours.After the incremental PEEP trial, over the 48 hours of the study period, in the EELV-guided group PaO2 and PaO2/FiO2 increased (p = 0.04 and p = 0.02; respectively), whereas they did not change in PaO2-guided group (p = 0.09 and p = 0.27; respectively). In all patients, the median value of EELV change (ΔEELV) during incremental PEEP trial was 25%. In patients with ΔEELV > 25% (n = 11) PaO2, PaO2/FiO2 and Cs increased over time in 48 hours (p = 0.03, p < 0.01, and p = 0.04; respectively), whereas they did not change in those with ΔEELV ≤ 25% (n = 11) (p = 0.73, p = 0.51, and p = 0.73; respectively).Compared to PaO2-guided PEEP determination, EELV-guided PEEP determination resulted in greater improvement in oxygenation over time. Patients who had > 25% improvement in EELV during a PEEP trial had greater improvement in oxygenation and compliance over 48 hours.Supplemental data for this article is available online at.

Tocilizumab treatment in severe COVID-19: a multicenter retrospective study with matched controls.

Coronavirus disease-2019 (COVID-19) associated pneumonia may progress into acute respiratory distress syndrome (ARDS). Some patients develop features of macrophage activation syndrome (MAS). Elevated levels of IL-6 were reported to be associated with severe disease, and anti-IL-6R tocilizumab has been shown to be effective in some patients. This retrospective multicenter case-control study aimed to evaluate the efficacy of tocilizumab in hospitalized COVID-19 patients, who received standard of care with or without tocilizumab. Primary outcome was the progression to intubation or death. PSMATCH (SAS) procedure was used to achieve exact propensity score (PS) matching. Data from 1289 patients were collected, and study population was reduced to 1073 based on inclusion-exclusion criteria. The composite outcome was observed more frequently in tocilizumab-users, but there was a significant imbalance between arms in all critical parameters. Primary analyses were carried out in 348 patients (174 in each arm) after exact PS matching according to gender, ferritin, and procalcitonin. Logistic regression models revealed that tocilizumab significantly reduced the intubation or death (OR 0.40, p = 0.0017). When intubation is considered alone, tocilizumab-users had > 60% reduction in odds of intubation. Multiple imputation approach, which increased the size of the matched patients up to 506, provided no significant difference between arms despite a similar trend for intubation alone group. Analysis of this retrospective cohort showed more frequent intubation or death in tocilizumab-users, but PS-matched analyses revealed significant results for supporting tocilizumab use overall in a subset of patients matched according to gender, ferritin and procalcitonin levels.

A screening study for COVID-19-associated pulmonary aspergillosis in critically ill patients during the third wave of the pandemic.

BACKGROUND: COVID-19-associated pulmonary aspergillosis (CAPA) has been reported as an important cause of mortality in critically ill patients with an incidence rate ranging from 5% to 35% during the first and second pandemic waves. OBJECTIVES: We aimed to evaluate the incidence, risk factors for CAPA by a screening protocol and outcome in the critically ill patients during the third wave of the pandemic. PATIENTS/METHODS: This prospective cohort study was conducted in two intensive care units (ICU) designated for patients with COVID-19 in a tertiary care university hospital between 18 November 2020 and 24 April 2021. SARS-CoV-2 PCR-positive adult patients admitted to the ICU with respiratory failure were included in the study. Serum and respiratory samples were collected periodically from ICU admission up to CAPA diagnosis, patient discharge or death. ECMM/ISHAM consensus criteria were used to diagnose and classify CAPA cases. RESULTS: A total of 302 patients were admitted to the two ICUs during the study period, and 213 were included in the study. CAPA was diagnosed in 43 (20.1%) patients (12.2% probable, 7.9% possible). In regression analysis, male sex, higher SOFA scores at ICU admission, invasive mechanical ventilation and longer ICU stay were significantly associated with CAPA development. Overall ICU mortality rate was higher significantly in CAPA group compared to those with no CAPA (67.4% vs 29.4%, p < .001). CONCLUSIONS: One fifth of critically ill patients in COVID-19 ICUs developed CAPA, and this was associated with a high mortality.

Predictive value of cytokine/chemokine responses for the disease severity and management in children and adult cases with COVID-19.

The disease course of children with coronavirus disease 2019 (COVID-19) seems milder as compared with adults, however, actual reason of the pathogenesis still remains unclear. There is a growing interest on possible relationship between pathogenicity or disease severity and biomarkers including cytokines or chemokines. We wondered whether these biomarkers could be used for the prediction of the prognosis of COVID-19 and improving our understanding on the variations between pediatric and adult cases with COVID-19. The acute phase serum levels of 25 cytokines and chemokines in the serum samples from 60 COVID-19 pediatric (n = 30) and adult cases (n = 30) including 20 severe or critically ill, 25 moderate and 15 mild patients and 30 healthy pediatric (n = 15) and adult (n = 15) volunteers were measured using commercially available fluorescent bead immunoassay and analyzed in combination with clinical data. Interferon gamma-induced protein 10 (IP-10) and macrophage inflammatory protein (MIP)-3ß levels were significantly higher in patient cohort including pediatric and adult cases with COVID-19 when compared with all healthy volunteers (p ≤ .001 in each) and whereas IP-10 levels were significantly higher in both pediatric and adult cases with severe disease course, MIP-3ß were significantly lower in healthy controls. Additionally, IP-10 is an independent predictor for disease severity, particularly in children and interleukin-6 seems a relatively good predictor for disease severity in adults. IP-10 and MIP-3ß seem good research candidates to understand severity of COVID-19 in both pediatric and adult population and to investigate possible pathophysiological mechanism of COVID-19.

AI-Based Quantitative CT Analysis of Temporal Changes According to Disease Severity in COVID-19 Pneumonia.

OBJECTIVE: To quantitatively evaluate computed tomography (CT) parameters of coronavirus disease 2019 (COVID-19) pneumonia an artificial intelligence (AI)-based software in different clinical severity groups during the disease course. METHODS: From March 11 to April 15, 2020, 51 patients (age, 18-84 years; 28 men) diagnosed and hospitalized with COVID-19 pneumonia with a total of 116 CT scans were enrolled in the study. Patients were divided into mild (n = 12), moderate (n = 31), and severe (n = 8) groups based on clinical severity. An AI-based quantitative CT analysis, including lung volume, opacity score, opacity volume, percentage of opacity, and mean lung density, was performed in initial and follow-up CTs obtained at different time points. Receiver operating characteristic analysis was performed to find the diagnostic ability of quantitative CT parameters for discriminating severe from nonsevere pneumonia. RESULTS: In baseline assessment, the severe group had significantly higher opacity score, opacity volume, higher percentage of opacity, and higher mean lung density than the moderate group (all P ≤ 0.001). Through consecutive time points, the severe group had a significant decrease in lung volume (P = 0.006), a significant increase in total opacity score (P = 0.003), and percentage of opacity (P = 0.007). A significant increase in total opacity score was also observed for the mild group (P = 0.011). Residual opacities were observed in all groups. The involvement of more than 4 lobes (sensitivity, 100%; specificity, 65.26%), total opacity score greater than 4 (sensitivity, 100%; specificity, 64.21), total opacity volume greater than 337.4 mL (sensitivity, 80.95%; specificity, 84.21%), percentage of opacity greater than 11% (sensitivity, 80.95%; specificity, 88.42%), total high opacity volume greater than 10.5 mL (sensitivity, 95.24%; specificity, 66.32%), percentage of high opacity greater than 0.8% (sensitivity, 85.71%; specificity, 80.00%) and mean lung density HU greater than -705 HU (sensitivity, 57.14%; specificity, 90.53%) were related to severe pneumonia. CONCLUSIONS: An AI-based quantitative CT analysis is an objective tool in demonstrating disease severity and can also assist the clinician in follow-up by providing information about the disease course and prognosis according to different clinical severity groups.

Implementation of post-intensive care outpatient clinic (I-POINT) for critically ill COVID-19 survivors

Although we have enough and cumulative information about acute effects of COVID-19, our knowledge is extremely limited about long-term consequences of COVID-19, in terms of its impacts and burdens on patients, families, and the health system. Considering the underlying pathophysiological mechanisms affecting all of the organ systems in critically ill COVID-19 patients who are admitted to intensive care units, the development of post-intensive care syndrome is inevitable. This situation brings along the development of long-COVID. These patients should be followed regarding cognitive, physical, and psychiatric aspects and necessary specialist referrals should be carried out. In this article, we are presenting the experience and recommendations of our center, as a guide for the establishment process of post-intensive care outpatient clinics for the critically ill patients who required intensive care admission due to COVID-19 and could be discharged.

Outcome of noncritical COVID-19 patients with early hospitalization and early antiviral treatment outside the ICU

Background/aim: Despite the fact that the COVID-19 pandemic has been going on for over 5 months, there is yet to be a standard management policy for all patients including those with mild-to-moderate cases. We evaluated the role of early hospitalization in combination with early antiviral therapy with COVID-19 patients in a tertiary care university hospital. Materials and methods: This was a prospective, observational, single-center study on probable/confirmed COVID-19 patients hospitalized in a tertiary care hospital on COVID-19 wards between March 20 and April 30, 2020. The demographic, laboratory, and clinical data were collected. Results: We included 174 consecutive probable/confirmed COVID-19 adult patients hospitalized in the Internal Medicine wards of the University Adult Hospital between March 20 and April 30, 2020. The median age was 45.5 (19­92) years and 91 patients (52.3%) were male. One hundred and twenty (69%) were confirmed microbiologically, 41 (23.5%) were radiologically diagnosed, and 13 (7.5%) were clinically suspected (negative microbiological and radiological findings compatible with COVID-19); 35 (20.1%) had mild, 107 (61.5%) moderate disease, and 32 (18.4%) had severe pneumonia. Out of 171 cases, 130 (74.3%) showed pneumonia; 80 were typical, and 50 showed indeterminate infiltration for COVID-19. Patients were admitted within a median of 3 days (0-14 days) after symptoms appear. The median duration of hospitalization was 4 days (0-28 days). In this case series, 13.2% patients were treated with hydroxychloroquine alone, 64.9% with hydroxychloroquine plus azithromycin, and 18.4% with regimens including favipiravir. A total of 15 patients (8.5%) were transferred to the ICU. Four patients died (2.2%). Conclusion: In our series, 174 patients were admitted to the hospital wards for COVID-19, 69% were confirmed with PCR and/or antibody test. At the time of admission, nearly one fifth of the patients had severe diseases. Of the patients, 95.4% received hydroxychloroquine alone or in combination. The overall case fatality rate was 2.2%.

Outcome of Patients Admitted to Intensive Care Units due to Influenza-Related Severe Acute Respiratory Illness in 2017-2018 Flu Season: A Multicenter Study from Turkey.

BACKGROUND: Influenza can cause severe acute respiratory illness (SARI), which occurs as local outbreaks or seasonal epidemics with high intensive care unit (ICU) admission and mortality rates. Mortality is mainly due to SARI. OBJECTIVE: The aim of this study was to evaluate the outcome of patients admitted to ICU due to influenza-related SARI in 2017-2018 flu season in Turkey. METHODS: A retrospective multicenter study was conducted in 13 ICUs with a total of 216 beds from 6 cities in Turkey. All adult patients (over 18 years) admitted to the ICUs in 2017-2018 flu season (between September 1, 2017, and April 30, 2018) because of SARI and with a positive nasopharyngeal swab for influenza were included in the study. RESULTS: A total of 123 cases were included in the study. The mean age of patients was 64.5 ± 17.5 years, and 66 (53.7%) patients were older than 65 years. The ICU mortality was 33.9%, and hospital mortality was 35.6%. Invasive mechanical ventilation (IMV), acute kidney injury (AKI), hematologic malignancy, and >65 years of age were the factors affecting mortality in influenza. CONCLUSION: SARI due to influenza carries a high mortality rate, and IMV, AKI, presence of hematologic malignancy, and older age are independent risk factors for mortality.

Influenza or other respiratory viruses: does it matter as the cause of acute respiratory failure in the critically-ill patients?

INTRODUCTION: Respiratory virus infections may cause serious respiratory failure requiring intensive care unit (ICU) admission. The objective of this study was to evaluate the clinical features and the outcome in patients with acute respiratory failure (ARF) due to viral infections comparing etiological agents. MATERIALS AND METHODS: ARF patients with positive viral serology were retrospectively recruited. Cohort was evaluated with regard to subgroups as influenza and other respiratory viruses (ORV), as well as survivors and nonsurvivors. RESULT: Out of 938 admitted patients, 319 were followed as ARF and only 149 patients had viral respiratory panel results. In 49 patients with ARF, 52 positive viral results were detected and 47 patients with single positive viral isolates of either influenza or ORV were included. Among them, 62% had ORV with quite similar characteristics with influenza group apart from diabetes mellitus which was encountered more in influenza group (p= 0.02). Overall ICU mortality was 32% and there was no difference between the two groups (p= 0.42). Acute Physiology and Chronic Health Evaluation (APACHE) II score was independently associated with ICU mortality (OR: 1.25; 95% CI: 1.04-1.51; p= 0.02). CONCLUSIONS: This study emphasizes to consider the possibility of other respiratory viruses for the cause of ARF with similar characteristics and mortality as influenza species.

Critically-ill COVID-19 patient.

Coronavirus disease 2019 (COVID-19) stands out as the major pandemic that we have experienced in the last century. As it affects every social structure, it brought the importance of intensive care support once again to the agenda of healthcare system after causing severe acute respiratory syndrome. The precautions to be taken against this virus, where our knowledge is extremely small, intensive care units take an indispensable place in pandemic planning. In this review, we aimed to emphasize the crucial points regarding intensive care management of COVID-19 patients, which we have written not only for intensivists but also for all healthcare professionals.

Value of prognostic scores in antineutrophil cytoplasmic antibody (ANCA) associated vasculitis patients in intensive care unit: a multicenter retrospective cohort study from Turkey

Background/aim: There is a need for a scoring system for predicting ICU prognosis of patients with ANCA-associated vasculitis (AAV), but there are limited data on it in the literature. Therefore, we aimed to determine the scores that can estimate the prognosis of patients with AAV during intensive care follow up. Materials and methods: All adult patients admitted to the medical ICUs of 4 reference university hospitals in Turkey due to AAV activation and/or disease/treatment complications in the last 10 years were included in this study. Demographic data, treatments before ICU, the Birmingham Vasculitis Activity Score (BVAS) score at the time of vasculitis diagnosis, and BVAS, APACHE II, SOFA, and SAPS II scores at the ICU admission, treatments, procedures, and complications during ICU stay were recorded for all AAV patients. Results: Thirty-four patients were included in the study. The median age of the patients was 60 (42­70) years, and 64.7% were male. Twenty-five patients were diagnosed with Granulomatosis with polyangiitis, and 9 were diagnosed with Microscopic polyangiitis. The most common ICU admission causes were hemorrhage (85.3%) and sepsis/septic shock (67.6%). Twenty patients (58.8%) died in the ICU follow up. There were significant differences in APACHE II (P = 0.004) and SAPS II (P = 0.044) scores between survivors and nonsurvivors, while there were no significant differences in BVAS (during diagnosis P = 0.089 and ICU admission P = 0.539) and SOFA (P = 0.097) scores. APACHE II score was found to be an independent risk factor for ICU mortality (OR = 1.231, CI 95% = 1.011­1.498, P = 0.038) according to logistic regression analysis. An APACHE II score of greater than 20.5 predicted ICU mortality with 80% sensitivity and 70% specificity (AUC = 0.8, P = 0.004, Likelihood ratio = 2.6) according to the ROC curve analysis. Conclusion: APACHE II score can be used for the prediction of ICU mortality in AAV patients.

Characteristics of obstetric admissions to intensive care unit: APACHE II, SOFA and the Glasgow Coma Scale.

Objective To evaluate the characteristics of obstetric admissions to an intensive care unit (ICU) and assess the utility of Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and the Glasgow Coma Scale (GCS). Methods This study is consisted of 160 patients admitted to an ICU during the antenatal period or within 7 days at the postpartum period. Clinical characteristics and ICU scores were evaluated. Results The rate of admission to the ICU was 7.8/1000 deliveries. Four cases ended with maternal mortality (2.5%). The most common hospitalization indications were hypertensive disorders of pregnancy, cardiovascular disorders and obstetric hemorrhage, at 40 (25%), 34 (21.2%), and 31 (19.3%) cases, respectively. The receiver operating characteristics (ROC) curve analysis for prediction of maternal mortality revealed area under curve (AUC) values as 0.971 both for APACHE II and predicted mortality rate (PMR), and 24.5 and 47.1 were determined as the cut-offs with sensitivities of 100%. AUCs were also 0.901 and 0.929 for the initial and worst SOFA score, respectively. The cut-off value for the initial and worst SOFA score was 3.5, with a sensitivity of 100%, and was 10 with a specificity of 98.9%, respectively. Conclusion APACHE II and PMR overpredict maternal mortality, but those higher scores predict maternal mortality. Higher SOFA scores are related with maternal mortalities with high specificity.

Mild to moderate proteinuria is a heralding sign for acute kidney injury and mortality for intensive care unit patients

Background/aim: Lack of early predictors of acute kidney injury is currently delaying timely diagnosis.This study was done to evaluate the relationship between mild to moderate proteinuria and incidence of acute kidney injury (AKI) and 28-day mortality in intensive care unit (ICU) patients. Materials and methods: This observational, retrospective study was conducted in the internal medicine ICU. A total of 796 patients were screened and 525 patients were used for this analysis. Proteinuria was measured by urine dipstick test. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Results: Patients with dipstick urine protein positivity on admission had higher proportion of AKI and 28-day mortality compared to dipstick urine protein negative group [164 (59.6%) vs. 111 (44.4%) and 101 (36.7%) vs. 54 (21.6%), P = 0.01 and P < 0.01, respectively]. Urine dipstick protein positivity was also a significant predictor of 28-day mortality in patients with GFR > 60 mL/min (hazard ratio: 1.988, 95% confidence interval 1.380­2.862). Conclusion: Proteinuria before ICU admission is a risk factor for development of AKI within seven days of ICU stay and also is a risk factor for 28-day mortality, even in patients with GFR > 60 mL/min.

A randomized placebo-controlled phase II study of a Pseudomonas vaccine in ventilated ICU patients.

BACKGROUND: Currently, no vaccine against Pseudomonas is available. IC43 is a new, recombinant, protein (OprF/I)-based vaccine against the opportunistic pathogen, Pseudomonas aeruginosa, a major cause of serious hospital-acquired infections. IC43 has proven immunogenicity and tolerability in healthy volunteers, patients with burns, and patients with chronic lung diseases. In order to assess the immunogenicity and safety of IC43 in patients who are most at risk of acquiring Pseudomonas infections, it was evaluated in mechanically ventilated ICU patients. METHODS: We conducted a randomized, placebo-controlled, partially blinded study in mechanically ventilated ICU patients. The immunogenicity of IC43 at day 14 was determined as the primary endpoint, and safety, efficacy against P. aeruginosa infections, and all-cause mortality were evaluated as secondary endpoints. Vaccinations (100 µg or 200 µg IC43 with adjuvant, or 100 µg IC43 without adjuvant, or placebo) were given twice in a 7-day interval and patients were followed up for 90 days. RESULTS: Higher OprF/I IgG antibody titers were seen at day 14 for all IC43 groups versus placebo (P < 0.0001). Seroconversion (≥4-fold increase in OprF/I IgG titer from days 0 to 14) was highest with 100 µg IC43 without adjuvant (80.6%). There were no significant differences in P. aeruginosa infection rates, with a low rate of invasive infections (pneumonia or bacteremia) in the IC43 groups (11.2-14.0%). Serious adverse events (SAEs) considered possibly related to therapy were reported by 2 patients (1.9%) in the group of 100 µg IC43 with adjuvant. Both SAEs resolved and no deaths were related to study treatment. Local tolerability symptoms were mild and rare (<5% of patients), a low rate of treatment-related treatment-emergent adverse events (3.1-10.6%) was observed in the IC43 groups. CONCLUSION: This phase II study has shown that IC43 vaccination of ventilated ICU patients produced a significant immunogenic effect. P. aeruginosa infection rates did not differ significantly between groups. In the absence of any difference in immune response following administration of 100 µg IC43 without adjuvant compared with 200 µg IC43 with adjuvant, the 100 µg dose without adjuvant was considered for further testing of its possible benefit of improved outcomes. There were no safety or mortality concerns. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00876252 . Registered on 3 April 2009.

Acute eosinophilic pneumonia secondary to heroin inhalation.

Smoking heroin (chasing the dragon), is a method of inhaling heroin via heating the drug on a tin-foil above a flame. It also has been associated both with the indirect effects of heroin overdose and with direct pulmonary toxicity. We describe a case of acute eosinophilic pneumonia secondary to heroin inhalation in our medical intensive care unit. She presented with fever, cough, dyspnea and pleuritic chest pain. Chest radiograph showed bilateral infiltrations. Examination of bronchoalveolar lavage fluid revealed significant eosinophilia. She was diagnosed with acute eosinophilic pneumonia. After heroin abstinence and corticosteroid therapy, remission was achieved rapidly and the patient was discharge on the fourth day of her hospital stay.

Serum Procalcitonin as a Biomarker for the Prediction of Bacterial Exacerbation and Mortality in Severe COPD Exacerbations Requiring Mechanical Ventilation.

BACKGROUND: Procalcitonin (PCT) is being used as a marker of bacterial infections. Although there are several studies showing the diagnostic yield of PCT to differentiate bacterial involvement in chronic obstructive pulmonary disease exacerbations (COPDE), the prognostic yield of PCT in severe COPDE has been studied less. OBJECTIVES: The primary aim was to determine whether the level of serum PCT at admission in severe COPDE serves as a prognostic biomarker for hospital mortality. The secondary aim was to determine the role of PCT in identifying a bacterial exacerbation. METHODS: A total of 63 COPDE patients (median age 71 years; male 58.7%) were retrospectively analyzed from our intensive care unit database. RESULTS: The hospital mortality rate was 23.8%. Admission PCT levels were higher in patients who died during hospitalization (0.66 vs. 0.17 ng/ml; p = 0.014). This association between hospital mortality and serum PCT level remained significant in a multivariate analysis; for every 1 ng/ml increase in PCT level, hospital mortality increased 1.85 times (odds ratio; 95% confidence interval: 1.07-3.19; p = 0.026). The optimal admission PCT threshold was 0.25 ng/ml in order to discern patients who had bacterial exacerbation with a sensitivity of 63%, a specificity of 67%, and a negative predictive value of 80%. The negative predictive value increased to 89% when both the admission and follow-up PCT levels remained <0.25 ng/ml. CONCLUSION: This study shows that admission PCT levels have a prognostic importance in estimating hospital mortality among patients with severe COPDE. A PCT level <0.25 ng/ml at the time of admission and during follow-up is suggestive of the absence of a bacterial cause of COPDE.