The impact of frailty on noninvasive mechanical ventilation in elderly medical intensive care unit patients.

AIM: Many factors affecting noninvasive ventilation (NIV) in critically ill patients have been reported in the literature, but there is no study about the effect of frailty. With this study, the frailty prevalence was evaluated with two different frailty scores among the NIV population of a medical intensive care unit (ICU). Besides, the impact of frailty on NIV success and mortality and its association with NIV application problems were evaluated. METHOD: A prospective observational cohort study was performed on patients who were over 50 years of age and assigned to NIV due to hypercapnic respiratory failure. For the assessment of frailty, Clinical Frailty Scale (CFS) and The Edmonton Frailty Scale (EFS) were used and the ones with CFS ≥5 and EFS ≥8 were considered as fragile. The study population was classified and compared according to NIV success, ICU outcome (discharge or exitus) and NIV application problems. RESULTS: A total of 103 patients with the mean age of 73 ± 11 years were included. The incidence of frailty was 41% with CFS ≥5 and 36% with EFS ≥8. The NIV failure occurred in 30 (29%) patients. Among them frailty and SOFA score was higher; Glasgow Coma Scale (GCS) was lower. In multivariate analysis GCS (OR: 1.2, p: 0.042) and frailty with EFS (OR: 2.8, p: 0.027) were identified as independent risk factors of NIV failure. Sixty-five (63%) patients had NIV application problems and frailty was higher among them with both CFS and EFS (p < 0.05). Mortality occurred in 18 (17%) patients; NIV failure and frailty according to CFS were independent risk factors of mortality. CONCLUSION: The frailty is associated with higher NIV application problems, failure and mortality risk in elderly ICU patients. The CFS and EFS frailty scores can be used to predict NIV success and outcomes in ICUs.

Saccharomyces cerevisiae fungemia after probiotic treatment in an intensive care unit patient.

Saccharomyces cerevisiae is a common colonizer of the human gastrointestinal system as a benign organism. Enteral supplementation of this yeast as a probiotic product is effective in the treatment of antibiotic associated diarrhae. In rare occasions it can cause invasive infections. We present two fungemia cases in an intensive care unit following probiotic treatment containing S. boulardii. We are warning the safety of probiotic treatment in critically ill patients.

The influence of severe obesity on non-invasive ventilation (NIV) strategies and responses in patients with acute hypercapnic respiratory failure attacks in the ICU.

BACKGROUND: Obesity rates are increasing in the general population and are also prevalent in intensive care units (ICUs). Patients are sometimes admitted to ICUs for hypercapnic respiratory failure or cor pulmonale, but more often, they are admitted for pneumonia, excessive daytime sleepiness, heart failure, chronic obstructive pulmonary disease (COPD), asthma attacks or pulmonary embolism, and hypercapnic respiratory failure is coincidentally noticed during this period. The optimal noninvasive mechanical ventilation strategy is often not used during ICU treatment. The aim of this study was to assess the differences between non-invasive ventilation (NIV) strategies and the outcomes of obese and non-obese patients with acute hypercapnic respiratory failure. METHODS: In this retrospective cohort study, 73 patients who were ventilated with a face mask were studied. Patients were divided into two groups: obese (BMI>35 kg/m2) and non-obese (BMI<35 kg/m2), and the differences between these two groups in necessary pressure, volume, mode, ventilator and time to reduce PaCO2 <50 mmHg were investigated. RESULTS: The mean age of the patients was 66 ± 14 years, and the mean admission APACHE II score was 18 ± 4. Forty-one (56%) of the patients were female. For the obese patients, the reason for ICU admission was more frequently pulmonary edema and less frequently pulmonary infections, which was significantly different (P=0.003 and 0.043, respectively) than the rates for the non-obese patients. While there was no significant difference across the groups between the ventilators, modes and inspiratory pressure levels, obese patients required higher end-expiratory pressure levels and more time to reduce their PaCO2 levels below 50 mmHg than non-obese patients. The lengths of NIV and ICU stay and intubation and the mortality rates were similar in both groups. CONCLUSION: These results suggest that improvement in hypercapnia in obese patients may require higher PEEP levels and longer times than that of non-obese patients during acute hypercapnic respiratory failure attack.

Comparison of the serial surveillance with quantitative and non-quantitative tracheal aspirate in predicting ventilator-associated pneumonia etiology in patients receiving antibiotic therapy.

BACKGROUND: The aim of this study was to investigate the value of serial quantitative (QC) and non-quantitative (NQC) endotracheal aspirate (ETA) surveillance cultures in predicting the causative pathogen of ventilator associated pneumonia (VAP) in patients receiving antibiotic therapy and the factors associated with their predictive value. This was a prospective observational cohort study carried out in the Intensive Care Unit of a tertiary hospital. METHODS: The study enrolled 109 patients receiving mechanical ventilation for at least four days. Tracheal surveillance cultures were obtained routinely thrice weekly. Each sample was processed non-quantitatively and quantitatively (103 and 105 cfu/mL). The sensitivity, specificity and predictive values (true positives plus true negatives) of these cultures for the development of VAP were evaluated, and the causative pathogens were assessed. RESULTS: Sixty-eight VAP episodes were detected during this period. The NQCs and QCs detected the responsible pathogens of VAP in 63% and 28% of the VAP patients, respectively. Surveillance with NQC and QC were negative in 78% and 85% of the patients without VAP, respectively. Compared with the QC-ETAs (47%), NQC-ETAs (65%) were more predictive in all of the 109 patients. The NQC-ETA and QC-ETA predicted the causative pathogens at 3.3+/-2.7 days and 2.5+/-1.7 days prior to the development of VAP episodes, respectively. Both NQC and QC surveillance cultures were less predictive in older patients, and QCs were less predictive in A. baumannii infections. CONCLUSION: These results suggest that surveillance with NQ-ETA is better than the Q-ETA in predicting the development and causative pathogen of VAP in patients who have already been receiving antibiotic therapy.

Percutaneous balloon pericardiotomy for patients with malignant pericardial effusion including three malignant pleural mesotheliomas.

Ten patients were enrolled in this study to evaluate the therapeutic value of percutaneous balloon pericardiotomy in patients with symptomatic pericardial effusion secondary to malignant diseases. Four patients had breast cancer; 2 had lung cancer; 1 had non-Hodgkin's lymphoma; and 3 had malignant pleural mesothelioma, which is commonly seen in Central Anatolian region of Turkey. All patients underwent percutaneous balloon pericardiotomy with monofoil balloons (Mansfield, NuMed). No complication was seen during these procedures. In 3 patients, the balloon could not be expanded completely and was entered from a more lateral position by a second puncture. There was no recurrence of pericardial effusion in 6 of 7 patients without mesothelioma. After percutaneous balloon pericardiotomy, surgical subxiphoid windowing was performed due to drainage greater than 100 mL/day in a patient with lung cancer and in 1 patient with mesothelioma. In the other 2 patients with mesothelioma, recurrence of pericardial effusion was seen and then subxiphoid surgical windowing was performed due to development of cardiac tamponade in 1 of them. All the patients died 68.6 +/- 36 days later due to the primary malignancies. The survival time of patients with mesothelioma was shorter than that of the others (p < 0.05). These results suggest that percutaneous balloon pericardiotomy may be used in the treatment of patients with malignant pericardial effusion as an alternative to surgical pericardial window creation. But in patients with malignant pleural mesothelioma, the success rate of this procedure was lower than that of the others.

Hydatid cyst of the heart as a rare cause of embolization: report of 5 cases and review of published reports.

Cardiac hydatid cyst is seen infrequently, even in regions where hydatid cysts are endemic. We report 5 cases of cardiac hydatid cysts, which were diagnosed after an embolic event.

Relationship between pulmonary function and exercise tolerance in patients with ankylosing spondylitis.

OBJECTIVE: It is a well-known fact that pulmonary function is altered in ankylosing spondylitis (AS) mainly due to the restriction of chest wall movements. The objective of this study was to investigate whether alterations in pulmonary function affected exercise capacity. METHODS: Twenty male patients with definite AS and 20 age-matched healthy male controls were recruited for the study. All subjects were assessed for functional status by BASFI and physical activity level. Measurement of chest expansion and lumbar spinal flexion by the modified Schober method were performed. Pulmonary function tests and exercise testing on a treadmill using the Bruce protocol were performed. RESULTS: The physical activity level was similar in both groups. In the AS group the mean BASFI score suggested good functional capacity, while chest expansion and modified Schober measurements were significantly lower and pulmonary function tests revealed restrictive lung disease. The results of the exercise tolerance test were similar in both groups except for the rate of perceived exertion. CONCLUSION: This study demonstrated that exercise capacity in AS patients is not influenced by the limitation of chest wall movements, probably due to the maintenance of moderate physical activity along with an active life style.

Is ventricular repolarization heterogeneity a cause of serious ventricular tachyarrhythmias in aortic valve stenosis?

BACKGROUND: It is well known that there is a close relation between sudden cardiac death and serious ventricular tachyarrhythmias in patients with aortic valve stenosis (AS). QT dispersion (QTd) reflects the ventricular repolarization heterogeneity and has been proposed as an indicator for ventricular arrhythmias. HYPOTHESIS: This study investigated the QTd and its relevance to the clinical and echocardiographic variables. METHODS: In all, 51 patients (33 men, 18 women, mean age 56 +/- 12) with isolated AS and 51 age- and gender-matched healthy controls comprised the study group. Left ventricular mass index (LVMI) was calculated by the Devereux formula, and we used continuous-wave Doppler (n = 15) and cardiac catheterization (n = 36) for the determination of the maximum aortic valve pressure gradient (PG). RESULTS: Corrected QTd (QTcd) (89 +/- 39 vs. 49 +/- 15 ms, p < 0.001) and LVMI (176 +/- 69 g/m2 vs. 101 +/- 28 g/m2, p < 0.001) in patients with AS were significantly different from those in the control group. The group of 21 patients had a significantly greater number of 24-h mean ventricular premature beats (VPB) and mean number of couplet VT episodes than did the control group (p < 0.05). QTcd also correlated significantly well with LVMI (r = 0.58, p < 0.001), PG (r = 0.41, p = 0.003), and number of 24-h VPB (r = 0.56, p = 0.008). With respect to symptoms (e.g., angina, syncope, and dyspnea) patients without symptoms (n = 19) displayed less QTcd (71 +/- 31 vs. 100 +/- 39 ms, p = 0.007) and less LVMI (144 +/- 80 g/m2 vs. 195 +/- 57 g/m2, p = 0.01) than patients with symptoms. Statistical analysis was similar for all variables with uncorrected QTd values. CONCLUSION: We found that ventricular repolarization heterogeneity was greater in patients with AS than in controls. Our findings also showed that QTd in the patient group correlates well with LVMI, severity of AS, and PG. The present results suggest that serious ventricular arrhythmias in patients with AS may be due to spatial ventricular repolarization abnormality.

Effects of inactivated influenza virus vaccination on bronchial reactivity symptom scores and peak expiratory flow variability in patients with asthma.

Even though annual influenza vaccinations are recommended by many authorities, some doctors may be reluctant to vaccinate asthmatic patients because of the risk of inducing bronchial reactivity and exacerbating the asthma. In this study we investigated the effect of inactivated trivalent influenza vaccine on airway reactivity symptom scores and peak expiratory flow (PEF) variability in 24 patients with mild stable asthma. Baseline spirometry and methacholine challenge tests were performed on all patients. Patients were then asked to record their peak expiratory flow every morning and evening, complete daily symptom score charts (morning tightness, daytime asthma, cough, and night asthma), and note bronchodilator usage for 1 week. After baseline measurements, the patients were allocated to inactivated vaccine and placebo in a random and single-blind manner. The lung function measurements and methacholine challenge tests were repeated 1 week after vaccination and placebo administration at the same time of day. PD20 (mg/mL) methacholine doses were 3.06+/-3.0 mg/mL before vaccination, 2.96+/-3.2 mg/mL after vaccination, and 2.76+/-2.91 mg/mL after placebo administration. There were no significant changes in PD20 methacholine after influenza vaccination (p>0.05). There were also no significant changes in symptom scores, bronchodilator usage, and PEFR after vaccination (p>0.05). None of the patients experienced significant local or systemic side effects after vaccination. Immunization with inactivated influenza vaccine does not induce clinical exacerbations of asthma or airway hyperreactivity in patients with mild asthma.

Hospital based survey of lung cancer in Turkey, a developing country, where smoking is highly prevalent.

While the trend of cigarette consumption in some developed countries is on the decline, it has been noted that in many developing countries, smoking is on the increase. Compared to developed countries, there are more male smokers than female smokers in these countries. The aim of this study was to investigate the prevalence and characteristics of the smoking habit in patients having lung cancer (LC) and to find out if there is any relationship with the smoking habit and the pathological diagnosis in our patient population. This hospital-based study was carried out between 1990 and 1996 in two major medical centres. LC was diagnosed in 1046 patients, 966 of whom were males (93%), and the remaining 80 (7%) of whom were females. Upon diagnosing the male patients, it was noted that 83% were current smokers (CS), 12% were ex-smokers (ES defined as abstinence from smoking at least for 1 year), and the remaining 5% were non-smokers (NS). In the female population the findings were as follows, 16% were CS; 8% were ES, and 76% were NS. The period of abstinence in the ES was 10 years or less in 77% of the patients. Among the male patients, squamous cell carcinoma was the most common tumor type seen in the CS group (46%) while adenocarcinoma (45%) was the most commonly seen tumor in the NS group. On the other hand, in the females, CS, the most commonly noted tumor types were small cell (54%), and adenocarcinoma (39%) was most frequently found in NS group. These results indicate that ES patients having LC in this study was quite low. On the other hand, in contrast to the findings of many other studies, from developed countries, the majority of male LC patients were in the CS group, however the majority of female LC patients were in the NS group. This smoking habit data obtained from our LC patients suggests that, similar to underdeveloped or developing countries, smoking cessation rates are very low in men during the past decade, and interestingly smoking rates may increase in women in the near future in our country.

Comparison of sputum and serum eosinophil cationic protein (ECP) levels in nonatopic asthma and chronic obstructive pulmonary disease.

The aim of the present study was to investigate whether sputum eosinophil cationic protein (ECP) concentrations could be a useful marker in the differential diagnosis between intrinsic asthma and chronic obstructive pulmonary disease (COPD). For this purpose total blood eosinophil counts were obtained and concentrations of serum and sputum ECP from 10 nonatopic asthmatics with a mild attack and 9 COPD patients with acute exacerbation were measured by radioimmunoassay. Mean serum ECP concentration was 54.3 +/- 23.0 micrograms/L in the asthmatic group and 83.3 +/- 79.2 micrograms/L in the COPD group (p: n.s.). In the group of asthmatics mean sputum ECP level was 984.5 +/- 1245.5 micrograms/L/g sputum and in the COPD group it was 417.5 +/- 363.5 micrograms/L/g sputum. There was no significant difference in sputum ECP levels between patients with asthma and COPD. We conclude that neither sputum nor serum ECP levels are useful markers in differential diagnosis of asthma attack and acute exacerbation of COPD.

Tumor necrosis factor-alpha (TNF-alpha) in pleural fluids.

Our study was undertaken to investigate the role of tumor necrosis factor-alpha (TNF-alpha) at the site of disease activity in tuberculous pleuritis (TP). Concentrations of TNF-alpha were measured directly by radioimmunoassay (RIA) in the pleural fluid (PF) and plasma (P) of patients with TP (n = 14), malignant effusions (n = 18) and transudates (n = 7). Among these three groups mean plasma levels of TNF-alpha were not statistically significant (P > 0.05), but in the TP group mean levels of TNF-alpha in PF were significantly higher than in the cancer and transudate groups (P < 0.001), and there was no significant difference between the cancer and transudate groups (P > 0.05). These results may indicate a local synthesis of TNF-alpha by cells within the pleural cavity in this disease.

Postoperative arrhythmias in open-heart surgery, A study on fifty cases.

50 consecutive patients undergone open heart surgery were analyzed regarding postoperative arrhythmias in the first postoperative 3 days. Disturbances of rhythm occurred in each case of our group, serious or not serious (100%). Ventricular premature beats were the most frequent type of arrhythmia in the first and second postoperative days (80%). Two cases expired postoperatively. In one of them complete atrioventricular block developed after double valvular replacements (mitral and tricuspid). The other died of low cardiac output syndrome. Etiology of the arrhythmias after open heart surgery is not clear in the absence of electrolyte and metabolic disturbances, digitalis intoxication and surgical trauma to the conduction system and coronary arteries. Low cardiac output syndrome, hypotension and hypoxia can also be blamed in the formation of these arrhythmias. Other factors such as the prolongation of anoxic arrest, irritation of the ventricular septum by valvular prostheses, cardiac irritation by thoracic tubes, psychologic trauma, halothane anesthesia and coronary arterial disease in the old age group may be the possible predisposing factors in these patients.