Comparison of the healthcare-associated infections in intensive care units in Turkey before and during COVID-19.

Background: Secondary bacterial infections are an important cause of mortality in patients with coronavirus disease 2019 (COVID-19). All healthcare providers acted with utmost care with the reflex of protecting themselves during the COVID-19 period. We aimed to compare the rates of ventilator-associated pneumonia (VAP) and bloodstream infections (BSIs) in our intensive care units (ICUs) before and during the COVID-19 outbreak surges. Methods: This multicenter, retrospective, cross-sectional study was performed in six centers in Turkey. We collected the patient demographic characteristics, comorbidities, reasons for ICU admission, mortality and morbidity scores at ICU admission, and laboratory test data. Results: A total of 558 patients who required intensive care from six centers were included in the study. Four hundred twenty-two of these patients (males (62%), whose mean age was 70 [IQR, 58-79] years) were followed up in the COVID period, and 136 (males (57%), whose mean age was 73 [IQR, 61-82] years) were followed up in the pre-COVID period. BSI and VAP rates were 20.7 (19 events in 916 patient days) and 17 (74 events in 4361 patient days) with a -3.8 difference (P = 0.463), and 33.7 (31 events in 919 patient days) and 34.6 (93 events in 2685 patient days) with a 0.9 difference (P = 0.897), respectively. The mortality rates were 71 (52%) in pre-COVID and 291 (69%) in COVID periods. Conclusion: Protective measures that prioritize healthcare workers rather than patients and exceed standard measures made no difference in terms of reducing mortality.

Bilateral papilledema caused by brucellosis mimicking pseudotumor cerebri.

In this article, we report a patient with migraine who was hospitalized with a prediagnosis of pseudotumor cerebri and diagnosed as neurobrucellosis with isolated intracranial hypertension presentation. A 22-year-old woman was admitted to emergency department with a complaint of headache. Her anamnesis indicated that she had migraine for 7 years. Neurological examination revealed bilateral papilledema. Cranial magnetic resonance imaging was normal. Cerebrospinal fluid (CSF) examination revealed 80 lymphocytes per mm3 with 178 mg/dL protein. Opening pressure was 260 mmH2O. Brucella tube agglutination and Rose Bengal tests were positive in blood and CSF. She was diagnosed as neurobrucellosis. If the systemic findings are insignificant and neurological findings are atypical such as isolated papillary edema, neurobrucellosis may not be considered and its diagnosis may be delayed. We believe that brucella serology should be included in the diagnostic protocols in endemic areas. Thus, early diagnosis and appropriate treatment can prevent complications of neurobrucellosis.

Wernicke encephalopathy with epileptic seizures during pregnancy.

A 22-year-old woman was admitted to the emergency department with headache, dizziness, and numbness on the left side of the body. Neurologic examination revealed gaze-evoked nystagmus. Cranial magnetic resonance imaging, venous and arterial magnetic resonance angiography were normal. Generalized epileptogenic activity was observed in the electroencephalography. The erythrocyte thiamine transketolase levels were found to be 13 u/L. She received intravenous thiamine. On discharge, she had no neurologic sequelae. The diagnosis of Wernicke encephalopathy in our patient is based on increased thiamine requirement due to pregnancy, nystagmus, low transketolase level, and reversal of symptoms after thiamine replacement. .

Bilateral Wrist Drop Caused by Non-invasive Continuous Monitoring of Blood Pressure During Severe COVID-19 Pneumonia: A Case Report.

Compressive peripheral nerve injury can be observed as a long-term outcome during the treatment of severe COVID-19 pneumonia. In this case study, we report a man with bilateral wrist drop due to prolonged noninvasive blood pressure monitoring. A 52-year-old man who had undergone invasive ventilation because of severe COVID-19 pneumonia was admitted with bilateral loss of function of the wrist, digital, and thumb extensors and hypoesthesia in the dorsum of the forearm and hand. The patient had not been treated with prone positioning respiratory therapy. However, he had undergone bilateral automated sphygmomanometry that measured his blood pressure every ten minutes during his ICU stay. His electrophysiological findings were compatible with the presence of bilateral radial nerve compression at the level of the spiral groove. Awareness of potential compressive peripheral nerve injury is important for rehabilitation after the treatment of COVID-19-associated pneumonia.

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

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

Neurology consultations in the intensive care units.

OBJECTIVE: Critical treatment and management have advanced over the recent decades, bringing many benefits but also causing increasing complication rates. Among these complications, neurological complications have an important place and may increase in mortality rates. The aim of our study was to find the causes of neurological consultations in the level 3 adult intensive care units (ICU). METHODS: The study population consisted of patients who were requested to have neurology consultation in the level 3 Adult ICUs between April 2013 and April 2017. The records in the hospital automation system of patients required neurology consultation were evaluated retrospectively. RESULTS: A total of 906 neurology consultations were requested in ICUs and 302 patients were included in this study. Altered consciousness and unconsciousness (32.1%), seizure (26.5%), management and treatment (15.9%) were the most common reasons for neurological consultations. Epileptic seizures (16.9%), status epilepticus (9.3%) and ischemic stroke (8.6%) were the most common final neurological diagnoses after consultation. Wernicke encephalopathy, posterior reversible encephalopathy syndrome, motor neuron disease, Creutzfeldt-Jakob disease, critical illness polyneuropathy and critical illness myopathy were less frequently diagnosed (< 1%). The diagnostic benefit was 83.1%. Treatment change following neurological consultation occurred in 56.6% of the patients. CONCLUSIONS: In our study, spanning a period of 4 years, the most common diagnoses were epileptic seizure, status epilepticus, and ischemic stroke. More frequent complications, such as stroke and seizure, as well as less common complications such as Wernicke's encephalopathy and posterior reversible encephalopathy syndrome, should be intervened immediately. In case of consultation, neurologists should be able to manage neurological complications as a consultant physician in the early period and evaluate the ICU patient systematically and be familiar with the complexity of intubation, sedation and sometimes paralyzed intensive ICU patients who have had severely limited routine clinical evaluations.

Guillain-Barré Syndrome and Swallowing Dysfunction.

PURPOSE: Patients with Guillain-Barré syndrome (GBS), especially severe cases that require treatment in intensive care units, often experience swallowing difficulties. However, the oropharyngeal function of patients with GBS not treated in intensive care units is not typically evaluated using neurophysiological techniques. METHODS: Electrophysiological techniques were used to determine dysphagia limit and sequential water swallowing values in an electromyography laboratory. RESULTS: This study assessed 18 patients with GBS who were not treated in the intensive care unit between 4 and 45 days after their hospital admission; 18 healthy volunteers were used as a control group. Of the 18 patients with GBS, 7 exhibited the clinical involvement of either a single cranial nerve or a combination of cranial nerves while 11 did not show any lower cranial nerve involvement. Clinical dysphagia was observed in seven patients and six of these cases involved a lower cranial nerve while five patients without cranial nerve involvement had silent dysphagia according to the dysphagia limit test. In addition, the duration of sequential swallowing was significantly prolonged in all patients with GBS compared with the control subjects. CONCLUSIONS: The present findings demonstrated that neurophysiological techniques are useful and easily applicable for patients with GBS and that there were no complications. Furthermore, cranial nerve involvement in patients with GBS likely increased the incidence of oropharyngeal dysphagia, and subclinical dysphagia may be present in this population as well. Therefore, neurophysiological techniques can be initially used and then repeated during follow-up visits for all types of patients with GBS.

[Posterior Reversible Encephalopathy Syndrome Triggerred By Alcohol Withdrawal]. / Alkol Yoksunlugu ile Tetiklenen Posterior Reversibl Ensefalopati Sendromu.

INTRODUCTION: Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity characterized by headache, altered mental status, epileptic seizures, visual disturbances and typically transient changes in posterior cerebral circulation areas. In this article, we present a case of alcohol withdrawal accompanied by PRES. CASE PRESENTATION: A 53-year-old male patient presented to the emergency department with visual hallucinations and meaningless speech. History from his relatives revealed that he has been consuming alcohol for about 35 years and the last consumption was 3 days before the admission. On neurological examination, there was limited cooperation and disorientation was evident to person, place and time. The speech was incoherent. No localizing sign was observed. Cranial magnetic resonance imaging (MRI) revealed bilateral hyperintense areas in medial occipital cortices and in subcortical white matter extending partly into parietal region. Treatment for alcohol withdrawal was started. Signs and symptoms regressed on the 7th day of the treatment as well as the lesions on MRI. DISCUSSION: The clinical presentation, characteristic MRI features together with the reversible nature of the syndrome suggest the diagnosis of PRES. The precise pathophysiological mechanism of PRES still remains unclear. Hypertension, clinical conditions that are associated with impaired cerebral auto-regulation as well as alcohol use which increases the levels of reactive oxygen species and nitric oxide may lead to the disruption of endothelial cells and blood-brain barrier breakdown. Overall, in our case, we think chronic alcoholism and alcohol withdrawal might have caused endothelial dysfunction leading to PRES.