Management of anesthesia in pregnant women with pulmonary hypertension.

OBJECTIVE: Pulmonary hypertension (PH) is a rare heart disease associated with high maternal and fetal mortality. This study aims to discuss anesthesia management and the fetal and maternal outcomes of patients with PH followed-up at our clinic. PATIENTS AND METHODS: This study includes a retrospective analysis of 105 pregnant women with PH. The patients were classified according to the mean pulmonary artery pressure (mPAP) values measured at rest by transthoracic echocardiography. The first group included patients with an mPAP value between 25 and 49 mmHg, considered to have a mild PH, whereas patients with an mPAB value ≥50 mmHg were considered to have severe PH and were included in the second group. RESULTS: When the patients were examined for etiology, the majority (n=84, 70.5%) were found to have type 2 PH. It was found that in pregnant women with severe PH, the diameters of the left atrium, right atrium, and right ventricle were significantly larger (p=0.008, p=0.04, and p=0.013, respectively), and the ejection fraction was also significantly lower (p=0.04). CONCLUSIONS: Although there has been a partial decrease in mortality for PH in recent years, it is still a serious condition that requires a multidisciplinary approach and well-planned obstetric treatment.

Effect of sodium-glucose co-transporter-2 inhibitors on coronary blood flow in patients with type 2 diabetes mellitus.

OBJECTIVE: Type 2 diabetes mellitus (T2DM) is known to be associated with endothelial dysfunction (ED). Reducing ED can attenuate the occurrence of cardiovascular diseases. One of the indicators of ED is decreased coronary blood flow (CBF). Sodium-glucose co-transporter 2 inhibitors (SGLT-2is) are known to directly improve ED in both euglycemic and hyperglycemic conditions and have been shown to decrease the incidence of major cardiovascular events. We aimed to investigate whether SGLT-2is improves CBF in patients with T2DM, who have angiographically normal or nearly normal coronary arteries. PATIENTS AND METHODS: In this single-center retrospective study, all patients who underwent coronary angiography between January 2017 and September 2022 were screened. We designed the study by dividing the patients into two groups - those who used conventional antidiabetic medications (CAM) together with SGLT-2is (patients using an SGLT-2 inhibitor for at least 3 months) and those who used only conventional antidiabetic medications. Of the 18,205 patients who underwent coronary angiography, 5,040 patients had T2DM. After exclusion, 288 patients were divided into two groups - those who used CAM together with SGLT-2is and those who used only CAM. CBF was assessed by thrombolysis in myocardial infarction (TIMI) frame counting. RESULTS: Two hundred eighty-eight patients who had T2DM and met the inclusion criteria were included in our study. The patients were divided into two groups - those who used CAM together with SGLT-2is (n = 75) and those who used only CAM (n = 213). The median age in the group that used CAM together with SGLT-2is was 55 (51-64), where 52 (69.3%) patients were female. The mean TIMI frame count (TFC) was 23.5 in the group using CAM + SGLT-2is and 27.5 in the group using only CAM. In the multivariable linear regression analysis, the mean TFC was significantly lower in the group using CAM together with SGLT-2is compared to the group using only CAM [ß-coefficient = -12.766, 95% Cl: -5.304; -3.887, p < 0.001]. Moreover, there was a statistically significant correlation between an increase in BMI and hemoglobin with an increase in the mean TFC [ß-coefficient = 3.018, 95% Cl 0.037-0.175, p = 0.003 and ß-coefficient = 2.316, 95% Cl 0.033-0.405, p = 0.021, respectively]. CONCLUSIONS: We have demonstrated that the use of SGLT-2is improves coronary artery blood flow in patients with T2DM who have normal or nearly normal coronary angiography.

Evaluation of the effect of bun/albumin ratio on in-hospital mortality in hypertensive COVID-19 patients.

OBJECTIVE: The impact of COVID-19 infection still continues all over the world and is an important cause of mortality. The mortality rate due to infection varies between 1-5%. The mortality rate is higher in those with cardiovascular risk factors, especially in cases with hypertension. Some studies have shown that blood urea nitrogen (BUN) and albumin levels are associated with worse prognosis in patients with COVID-19. In our study, we aimed to investigate whether the BUN/albumin (BAR) ratio has an effect on in-hospital mortality in hypertensive COVID-19 patients. PATIENTS AND METHODS: A total of 800 hypertensive COVID-19 patients, (618 of whom were alive and 182 died) were included in our study. Patients with a history of heart failure, malignancy, acute coronary syndrome, and myocarditis were excluded. RESULTS: The median age of the study population was 69 (60-77 IQR) years, and 305 (38%) of these patients were men. There was no statistically significant difference between the patients who died during follow-up and cases that remained alive in terms of comorbidities except chronic obstructive pulmonary disease (COPD) which was significantly lower in surviving group (p=0.014). Multivariable logistic regression analysis revealed that age [OR: 1.04, CI (1.01-1.06); p=0.002], male gender [OR: 1.85, CI (1.13-3.02); p=0.010], lymphocyte count [OR: 0.63, CI (0.40-0.98); p=0.038], SaO2 [OR: 0.82, CI (0.79-0.85); p<0.001] and BAR level [OR: 1.09, CI (1.04-1.16); p=0.001] were independent predictors of in-hospital mortality. ROC analysis yielded that BAR is a better predictor of in-hospital mortality compared to albumin and BUN alone. CONCLUSIONS: BUN, albumin, and BAR levels were found to be reliable predictors of in-hospital mortality in COVID-19 patients, and BAR was also found to be a more reliable predictor than BUN and albumin levels. Hypertension is one of the major risk factors for morbidity and mortality in COVID-19 and, BAR presents additional prognostic data in hypertensive COVID-19 patients that may direct physicians for treatment intensification.

Predictors of hospital-onset Clostridioides difficile infection in children with antibiotic-associated diarrhea.

BACKGROUND: This study aimed to determine the predictors of hospital-onset Clostridioides difficile infection (CDI) in pediatric patients with antibiotic-associated diarrhea (AAD) and to develop a predictive scoring system to identify at-risk patients. METHODS: This retrospective case-control study included patients aged ≥2-18 years with AAD who underwent C. difficile polymerase chain reaction testing >3 days after hospital admission. Patients with hospital-onset CDI were selected as cases and matched with the control patients without CDI. Univariate and multivariate logistic regressions were used to determine predictors of CDI and to construct a prediction score for the outcomes of interest. RESULTS: Sixty-five patients with hospital-onset CDI and 130 controls were enrolled. Independent predictors for CDI identified and combined into the prediction score included abdominal pain (adjusted odds ratio [95% confidence interval]: 7.940 [3.254-19.374]), hospitalization for ≥14 days before the onset of diarrhea (3.441 [1.034-11.454]), antibiotic use for ≥10 days before the onset of diarrhea (6.775 [1.882-24.388]), receipt of meropenem (4.001 [1.098-14.577]) and clindamycin (14.842 [4.496-49.000]). The area under the receiver operating characteristic curve for this score was 0.883. CONCLUSIONS: The presented scoring system can be easily applied by clinicians at the bedside to decide which patients with AAD are likely to have CDI.

Ventilator associated pneumonia due to carbapenem resistant microorganisms in children.

BACKGROUND: Infections due to carbapenem resistant pathogens have become a major health threat especially for hospitalized patients. Acinetobacter baumanii (AB) and Pseudomonas aeruginosa (PA) are important pathogens causing ventilator-associated pneumonia (VAP) with a trend of high resistance to carbapenems. The aim of this study is to investigate the risk factors for VAP due to carbapenem resistant Acinetobacter baumanii (CRAB) and Pseudomonas aeruginosa (CRPA) in children. METHODS: Between 2009 and 2013, an active, prospective observational study was conducted in Gazi University Hospital. Patients from Pediatric Intensive Care Unit (PICU), between 1 month and 12 years of age with VAP due to AB and PA were included. RESULTS: During this period, 74 children experienced 126 VAP episodes due to Acinetobacter baumanii (N.=58) and Pseudomonas aeruginosa (N.=68). Among these, 93.1% (N.=54) of AB and 51.5% (N.=35) of PA were carbapenem resistant. In univariate analysis, length of stay in PICU until the diagnosis of VAP, presence of central venous catheters, prior use of cefepime, ciprofloxacin, colistin, and teicoplanin were associated with VAP due to CRPA (P=0.02, P=0.02, P=0.006, P=0.01, P=0.001, and P=0.009 respectively). Significant association was not found between the development of VAP due to CRAB and the investigated risk factors. Regression analyses revealed previous use of cefepime (OR, 2.11; 95% CI, 0.016-0.595, P=0.039) and colistin (OR: 2.33; 95% CI: 0.061-0.789, P=0.023) to be independently associated with VAP due to CRPA. CONCLUSIONS: This study suggests that broad spectrum antibiotic usage was the most important risk factor for the development of VAP due to CRPA.

Various clinical conditions can mimic Crimean-Congo hemorrhagic fever in pediatric patients in endemic regions.

Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne disease with high mortality. Many disorders can mimic CCHF. It is important to recognize the condition and to perform differential diagnosis in endemic countries. Twenty-one children aged 18 years or less with a preliminary diagnosis of CCHF were retrospectively evaluated. Real-time PCR and a confirmatory indirect immunofluorescence assay for negative results were performed. The diagnoses determined that 9 patients had (42.9%) CCHF; 7 patients had (33.3%) viral upper respiratory tract infections (URTI); 2 patients had (9.5%) brucellosis; 1 patients had (4.7%) periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome episode; 1 patient had (4.7%) cerebral palsy, diabetes insipidus, acute gastroenteritis, and hypernatremic dehydration; and 1 patient had (4.7%) cellulitis after a tick bite. The mean age of patients with CCHF was greater than that of the other patients (116.1±53.6 vs. 94.1±52.1 months, p=0.02). Seventeen (81%) of the children included had a history of tick bites, 2 (9.5%) had a history of contact with a patient with CCHF, and 2 (9.5%) had no exposure, but were living in an endemic region. Three patients had an underlying disorder: cerebral palsy and diabetes insipidus, epilepsy, or PFAPA. All of the children experienced fever. Other frequent symptoms were malaise, diarrhea, vomiting, and abdominal pain, but none of these differed statistically between the patient groups. CCHF patients had a longer mean duration of symptoms (10.56±1.42 vs. 6.75±3.62 days, p=0.008) and a longer mean length of hospitalization (8.00±2.08 vs. 3.58±1.56 days, p<0.001) than the other patients. At laboratory examination, patients with CCHF had statistically significant lower leukocyte and platelet counts, more prolonged coagulation parameters, and greater AST, ALT, LDH, and CK levels than the other patients. No mortality or complications occurred in the study. Both infectious causes, such as URTI, cellulitis, and brucellosis, and non-infectious causes may resemble CCHF. Although they are not pathognomonic, some indicators, including a longer symptom duration and hospitalization, cytopenia, elevated liver enzymes, creatine kinase and prolonged coagulation parameters, were found to be in favor of CCHF.