The impact of spontaneous echo contrast on tunneled dialysis catheter patency.

BACKGROUND: Spontaneous echo contrast (SEC) is an ultrasonographic image of swirling blood flow resembling a dynamic, cigarette smoke-like image. It is mostly observed during the insertion of tunneled dialysis catheters (TDC) into internal jugular veins with ultrasound guidance, often different levels of SEC can be seen. The aim of this study is to investigate the impact of SEC detected during TDC insertion on the patency of the catheter. METHODS: Patients who had a TDC insertion in our clinic between January 2015 and December 2020 were prospectively evaluated. The patients were grouped into five groups according to the sec level and followed. RESULTS: A total of 226 patients were examined, among which 107 were male (47.3%). The mean age of all patients was 63.1 ± 9.5 years. SEC grade and catheter occlusion was evaluated, it was observed that higher SEC grades were correlated with faster catheter thrombosis postinsertion. During the follow-up period, it was found that, compared to the SEC 0 group, catheter thrombosis occurred 3.22 times faster in the SEC 1 group, 2.66 times faster in the SEC 2 group, 5.80 times faster in the SEC 3 group, and 26.33 times faster in the SEC 4 group. (HR: 3.22, 2.66, 5.80, 26.33, respectively). Hematological parameters were evaluated by regression analysis, it was observed that hemoglobin, fibrinogen, and platelet count were not risk factors for SEC formation and SEC grade. CONCLUSION: Significant relationship was found between SEC grade detected during catheter insertion and catheter thrombosis in patients undergoing hemodialysis with a TDC.

Estimating the Outcomes of Intracerebral Haemorrhage with Intracerebral Haemorrhage Score and Acute Physiology and Chronic Health Evaluation-II Score: A Multicentre Study.

OBJECTIVE: Spontaneous intracerebral haemorrhage causes mortality or leads to permanent disability in most of the survivors. Thus, determining the severity of the disease to predict mortality and morbidity is important. This study aimed to evaluate Acute Physiology and Chronic Health Evaluation-II and Intracerebral Haemorrhage scores in spontaneous intracerebral haemorrhage patients treated in intensive care units. METHODS: This multicenter study was conducted in 2 tertiary care hospitals' general intensive care units. Short- (in-hospital) and long-term (1-year) mortality and functional outcomes at discharge were evaluated using the Intracerebral Haemorrhage and Acute Physiology and Chronic Health Evaluation-II scores. RESULTS: Of the 35 spontaneous intracerebral haemorrhage patients analysed, the modified Ranking Scale was <4 in 10 (28.6%) patients and ≥4 in 25 (71.4%) patients. The in-hospital mortality was 51.4%, and 1-year mortality was 60%. The discriminative power of Acute Physiology and Chronic Health Evaluation-II was excellent (area under the curve ≥0.9), and Intracerebral Haemorrhage Score was fair (area under the curve ≥0.7) for both in-hospital mortality and poor outcomes at discharge. The area under the curve of Acute Physiology and Chronic Health Evaluation-II was significantly higher than the area under the curve of Intracerebral Haemorrhage score. CONCLUSION: Acute Physiology and Chronic Health Evaluation-II score is a better model with high sensitivity and specificity than the Intracerebral Haemorrhage score in predicting the in-hospital mortality and functional outcomes at the discharge of spontaneous intracerebral haemorrhage patients. However, the Acute Physiology and Chronic Health Evaluation-II score lacks the neuroradiologic features that are crucial for spontaneous intracerebral haemorrhage. Therefore, the Intracerebral Haemorrhage score can be used as an indicator of neurological status combined with the Acute Physiology and Chronic Health Evaluation-II score rather than as a predictive model of outcomes.

COVID-19 and Crimean-Congo Hemorrhagic Fever: Is there any Similarity in Chest Radiology?

Objective: While the coronavirus disease 2019 (COVID-19) pandemic was continuing at full speed, patients with Crimean-Congo hemorrhagic fever (CCHF), which is endemic in our region, apply to the emergency department simultaneously. The presence of computed tomography (CT) lesions suggesting COVID-19 in some CCHF patients has brought to our mind the question of whether there is CCHF lung involvement even though respiratory symptoms are not at the forefront. Methods: In this study, the findings of chest CT, demographic data and clinical symptoms of cases who had thorax tomography scan with suspicion of COVID-19 in the emergency department in the spring and summer of 2020 and were diagnosed with CCHF as a result of the evaluation and followed up in our clinic were compared with the findings of COVID-19 cases that were hospitalized and treated in the same period. Results: Seventy-seven COVID-19 and 25 CCHF cases were included in the study. Myalgia, headache, diarrhea, nausea and vomiting were significantly higher in CCHF patients ( p<0.05). Cough was significantly more common in COVID-19 patients ( p=0.034). Ground-glass opacity (GGO) was the most common tomography finding in CCHF, and cases without lung involvement were significantly higher (p=0.001). GGO, consolidation, vascularization, atelectasis band, reverse halo, air-bubble, nodule were significantly high in COVID-19 patients. Conclusion: During the epidemic period, no pathological finding was found in thoracic CT in most of the CCHF cases, and the presence of involvement in the lung tomography in cases with similar clinical and laboratory findings should primarily suggest the diagnosis of COVID-19.

Severe hypokalemia and rebound hyperkalemia during barbiturate coma in patients with severe traumatic brain injury / Hipopotasemia grave e hiperpotasemia de rebote durante el coma terapéutico inducido por barbitúricos en pacientes con lesiones cerebrales traumáticas

OBJECTIVES: To evaluate the incidence of severe potassium disturbances during barbiturate coma therapy in patients with severe traumatic brain injury (TBI), and the characteristics of these patients. METHODS: The study comprised 37 patients with severe TBI who were treated for barbiturate coma between 2015 and 2017 in level 3 intensive care units of two hospitals. RESULTS: No potassium disturbance occurred in 14 patients. Seventeen patients developed mild-moderate hypokalemia (2.6-3.5 mEq/L), and 6 patients developed severe hypokalemia (< 2.5 mEq/L) following the induction of barbiturate therapy. The incidence of mild-to-severe barbiturate-induced hypokalemia was 62.2% and the rate of severe hypokalemia was 16.2%. The mean potassium supply per day during thiopentone therapy was statistically significantly different between patients with mild-to-moderate hypokalemic and those with severe hypokalemic (p < 0.001). Four of 6 patients with severe hypokalemia developed rebound hyperkalemia exceeding 6mEq/L following the cessation of barbiturate infusion. The nadir potassium concentration was 1.5 mEq/L and the highest value was 6.8 mEq/L. The mean time to reach nadir potassium concentrations was 2.8 days. The mortality rate of the 6 patients was 66.7%. Of the 2 survivors of severe hypokalemia, the Glasgow Outcome Scale (GOS) on discharge and the extended GOS one year after the trauma were 5 and 8 respectively. CONCLUSIONS: Severe hypokalemia refractory to medical treatment and rebound hyperkalemia is a serious adverse effect of thiopentone coma therapy in patients with severe TBI. Excessive and aggressive potassium replacement during the barbiturate-induced hypokalemia period must be avoided. Weaning barbiturate treatment over time may be advantageous in the management of severe serum potassium disturbances

OBJETIVOS: Evaluar la incidencia de alteraciones graves de los niveles de potasio durante el coma terapéutico inducido por barbitúricos en pacientes con lesiones cerebrales traumáticas (LCT) graves y las características de estos pacientes. MÉTODOS: El estudio incluyó 37 pacientes con LCT grave que habían sido tratados mediante coma terapéutico inducido por barbitúricos entre 2015 y 2017 en unidades de cuidados intensivos de nivel 3 de dos hospitales. RESULTADOS: En 14 pacientes no se observaron alteraciones de los niveles de potasio. Diecisiete pacientes desarrollaron hipopotasemia leve o moderada (2,6-3,5 mEq/l), y 6 pacientes desarrollaron hipopotasemia grave (< 2,5 mEq/l) después de la inducción de la terapia con barbitúricos. La incidencia de hipopotasemia de leve a grave inducida por barbitúricos fue del 62,2% y la tasa de hipopotasemia grave fue del 16,2%. El aporte medio de potasio al día durante el tratamiento con tiopentona fue diferente de forma estadísticamente significativa entre los pacientes con hipopotasemia leve o moderada y entre los que tenían hipopotasemia grave (p < 0,001). Cuatro de los 6 pacientes con hipopotasemia grave desarrollaron hiperpotasemia de rebote que superó los 6 mEq/l después de la suspensión de la infusión de barbitúricos. La concentración mínima de potasio fue de 1,5 mEq/l y el valor máximo de potasio fue de 6,8 mEq/l. El tiempo medio hasta alcanzar las concentraciones mínimas de potasio fue de 2,8 días. La tasa de mortalidad de los 6 pacientes fue del 66,7%. En los 2 supervivientes con hipopotasemia grave, los resultados de la Escala de Resultados de Glasgow (Glasgow Outcome Scale, GOS) en el alta y la GOS extendida un año después del traumatismo fueron 5 y 8, respectivamente

Severe hypokalemia and rebound hyperkalemia during barbiturate coma in patients with severe traumatic brain injury.

OBJECTIVES: To evaluate the incidence of severe potassium disturbances during barbiturate coma therapy in patients with severe traumatic brain injury (TBI), and the characteristics of these patients. METHODS: The study comprised 37 patients with severe TBI who were treated for barbiturate coma between 2015 and 2017 in level 3 intensive care units of two hospitals. RESULTS: No potassium disturbance occurred in 14 patients. Seventeen patients developed mild-moderate hypokalemia (2.6-3.5mEq/L), and 6 patients developed severe hypokalemia (<2.5mEq/L) following the induction of barbiturate therapy. The incidence of mild-to-severe barbiturate-induced hypokalemia was 62.2% and the rate of severe hypokalemia was 16.2%. The mean potassium supply per day during thiopentone therapy was statistically significantly different between patients with mild-to-moderate hypokalemic and those with severe hypokalemic (p<0.001). Four of 6 patients with severe hypokalemia developed rebound hyperkalemia exceeding 6mEq/L following the cessation of barbiturate infusion. The nadir potassium concentration was 1.5mEq/L and the highest value was 6.8mEq/L. The mean time to reach nadir potassium concentrations was 2.8 days. The mortality rate of the 6 patients was 66.7%. Of the 2 survivors of severe hypokalemia, the Glasgow Outcome Scale (GOS) on discharge and the extended GOS one year after the trauma were 5 and 8 respectively. CONCLUSIONS: Severe hypokalemia refractory to medical treatment and rebound hyperkalemia is a serious adverse effect of thiopentone coma therapy in patients with severe TBI. Excessive and aggressive potassium replacement during the barbiturate-induced hypokalemia period must be avoided. Weaning barbiturate treatment over time may be advantageous in the management of severe serum potassium disturbances.

Refractive outcome comparison between vitreomacular interface disorders after phacovitrectomy.

PURPOSE: To compare the refractive accuracy of intraocular lens (IOL) power calculations between patients with vitreomacular interface disorders who had phacovitrectomy for vitreomacular traction (VMT), epiretinal membranes (ERM), and macular holes. SETTING: Baskent University Department of Ophthalmology, Ankara, Turkey. DESIGN: Retrospective case series. METHODS: Refraction results 8 weeks postoperatively were compared between phacovitrectomy (3 study groups comprising eyes with VMT with intrafoveal pseudocysts, ERM, or medium-to-large macular holes) and phacoemulsification (control group comprising eyes having phacoemulsification only). The IOLMaster 700 partial coherence interferometry (PCI) device and Haigis formula were used for all calculations. RESULTS: This study included 100 eyes (100 patients), 25 in each of the 4 groups. There was no statistically significant difference in axial length (AL) between the groups (P = .305). Differences in the preoperative macular thickness were statistically significant between all groups except between the macular hole and VMT groups. Most eyes (92%) in the VMT and macular hole groups and all eyes in the VMT and phacoemulsification groups achieved a final refraction within ±1.00 diopter of the refractive aim. The mean prediction error and the mean absolute error did not differ significantly between the groups. In all groups, there was no significant correlation between prediction error and age, AL, preoperative refractive error, or preoperative or postoperative macular thickness (P > .05). CONCLUSIONS: The IOL power calculation with PCI yielded no difference in postoperative refraction errors between the vitreomacular interface disorders. There was no correlation with preoperative refraction, age, or preoperative or postoperative macular thickness.

Phenytoin induced toxic epidermal necrolysis.

Toxic Epidermal Necrolysis (TEN) which is characterized by the detachment of the epidermis from the dermis is a rare (1.89/1.000.000 annually) and potentially life-threatening condition. The overall mortality is 20 - 30%. TEN is characterized by sudden apoptosis of keratinocytes leading to mucous membrane erosions and epidermal detachment; detachment of less than 10% of the total body surface area defines Stevens-Johnson Syndrome (SJS); when greater than 30%, it defines TEN, while intermediate cases are called SJS/TEN overlap. Many drugs, including prednisolone, cyclosporin, and intravenous immunoglobulin (IVIG), have been used in an attempt to halt the disease process. The use of phenytoin as a prophylactic anticonvulsant after brain surgery, particularly for brain tumors, is a common practice, regardless of whether the patient has a previous history of convulsions. This report described a case of haemorrhagic stroke where phenytoin use induced TEN.

Intraoperative low-dose ketamine infusion reduces acute postoperative pain following total knee replacement surgery: a prospective, randomized double-blind placebo-controlled trial.

OBJECTIVE: To evaluate the effect of intraoperative low-dose ketamine with general anesthesia on postoperative pain after total knee replacement surgery. STUDY DESIGN: A randomized, double-blind comparative study. PLACE AND DURATION OF STUDY: Ankara Numune Training and Research Hospital, Turkey, from January and June 2011. METHODOLOGY: Sixty adults undergoing total knee arthroplasty were enrolled in this study. The patients were randomly allocated into two groups of equal size to receive either racemic ketamine infusion (6 µg/kg/minute) or the same volume of saline. A visual analogue scale (VAS) was used to measure each patient's level of pain at 1, 3, 6, 12, and 24 hours after surgery. Time to first analgesic request, postoperative morphine consumption and the incidence of side effects were also recorded. RESULTS: Low-dose ketamine infusion prolonged the time to first analgesic request. It also reduced postoperative cumulative morphine consumption at 1, 3, 6, 12, and 24 hours postsurgery (p < 0.001). Postoperative VAS scores were also significantly lower in the ketamine group than placebo, at all observation times. Incidences of side effects were similar in both study groups. CONCLUSION: Intraoperative continuous low-dose ketamine infusion reduced pain and postoperative analgesic consumption without affecting the incidence of side effects.