Combined Effects of Prone Positioning and Airway Pressure Release Ventilation on Oxygenation in Patients with COVID-19 ARDS.

Objective: Coronavirus disease 2019 (COVID-19) can cause acute respiratory distress syndrome (ARDS). Invasive mechanical ventilation (IMV) support and prone positioning are essential treatments for severe COVID-19 ARDS. We aimed to determine the combined effect of prone position and airway pressure release ventilation (APRV) modes on oxygen improvement in mechanically-ventilated patients with COVID-19. Methods: This prospective observational study included 40 eligible patients (13 female, 27 male). Of 40 patients, 23 (57.5%) were ventilated with APRV and 17 (42.5%) were ventilated with controlled modes. A prone position was applied when the PaO2/FiO2 ratio <150 mmHg despite IMV in COVID-19 ARDS. The numbers of patients who completed the first, second, and third prone were 40, 25, and 15, respectively. Incident barotrauma events were diagnosed by both clinical findings and radiological images. Results: After the second prone, the PaO2/FiO2 ratio of the APRV group was higher compared to the PaO2/FiO2 ratio of the control group [189 (150-237)] vs. 127 (100-146) mmHg, respectively, (P=0.025). Similarly, after the third prone, the PaO2/FiO2 ratio of the APRV group was higher compared to the PaO2/FiO2 ratio of the control group [194 (132-263)] vs. 83 (71-136) mmHg, respectively, (P=0.021). Barotrauma events were detected in 13.0% of the patients in the APRV group and 11.8% of the patients in the control group (P=1000). The 28-day mortality was not different in the APRV group than in the control group (73.9% vs. 70.6%, respectively, P=1000). Conclusion: Using the APRV mode during prone positioning improves oxygenation, especially in the second and third prone positions, without increasing the risk of barotrauma. However, no benefit on mortality was detected.

The effect of frailty on the development of acute kidney injury in critically-ill geriatric patients with COVID-19.

BACKGROUND: Acute kidney injury is strongly associated with mortality in critically ill patients with coronavirus disease 2019 (COVID-19); however, age-related risk factors for acute kidney injury are not clear yet. In this study, it was aimed to evaluate the effects of clinical factors on acute kidney injury development in an elderly COVID-19 patients. METHODS: Critically ill patients (≥65years) with COVID-19 admitted to the intensive care unit were included in the study. Primary outcome of the study was the rate of acute kidney injury, and secondary outcome was to define the effect of frailty and other risk factors on acute kidney injury development and mortality. RESULTS: A total of 132 patients (median age 76 years, 68.2% male) were assessed. Patients were divided into two groups as follows: acute kidney injury (n = 84) and nonacute kidney injury (n = 48). Frailty incidence (48.8% vs. 8.3%, p < 0.01) was higher in the acute kidney injury group. In multivariate analysis, frailty (OR, 3.32, 95% CI, 1.67-6.56), the use of vasopressors (OR, 3.06 95% CI, 1.16-8.08), and the increase in respiratory support therapy (OR, 2.60, 95% CI, 1.01-6.6) were determined to be independent risk factors for acute kidney injury development. The mortality rate was found to be 97.6% in patients with acute kidney injury. DISCUSSION: Frailty is a risk factor for acute kidney injury in geriatric patients with severe COVID-19. The evaluation of geriatric patients based on a frailty scale before intensive care unit admission may improve outcomes.

Incidence of and risk factors for postintubation hypotension in critically ill patients with COVID-19. / Incidência e fatores de risco para hipotensão pós-intubação em pacientes críticos com COVID-19.

OBJECTIVE: To evaluate the incidence of risk factors for postintubation hypotension in critically ill patients with COVID-19. METHODS: We conducted a retrospective study of 141 patients with COVID-19 who were intubated in the intensive care unit. Postintubation hypotension was defined as the need for any vasopressor dose at any time within the 60 minutes following intubation. Patients with intubation-related cardiac arrest and hypotension before intubation were excluded from the study. RESULTS: Of the 141 included patients, 53 patients (37.5%) had postintubation hypotension, and 43.6% of the patients (n = 17) were female. The median age of the postintubation hypotension group was 75.0 (interquartile range: 67.0 - 84.0). In the multivariate analysis, shock index ≥ 0.90 (OR = 7.76; 95%CI 3.14 - 19.21; p < 0.001), albumin levels < 2.92g/dL (OR = 3.65; 95%CI 1.49 - 8.96; p = 0.005), and procalcitonin levels (OR = 1.07, 95%CI 1.01 - 1.15; p = 0.045) were independent risk factors for postintubation hypotension. Hospital mortality was similar in patients with postintubation hypotension and patients without postintubation hypotension (92.5% versus 85.2%; p = 0.29). CONCLUSION: The incidence of postintubation hypotension was 37.5% in critically ill COVID-19 patients. A shock index ≥ 0.90 and albumin levels < 2.92g/dL were independently associated with postintubation hypotension. Furthermore, a shock index ≥ 0.90 may be a practical tool to predict the increased risk of postintubation hypotension in bedside scenarios before endotracheal intubation. In this study, postintubation hypotension was not associated with increased hospital mortality in COVID-19 patients.

OBJETIVO: Avaliar a incidência de fatores de risco para hipotensão pósintubação em pacientes críticos com COVID-19. METÓDOS: Foi realizado um estudo retrospectivo com 141 pacientes com COVID-19 que foram intubados na unidade de terapia intensiva. Hipotensão pós-intubação foi definida como a necessidade de qualquer dose de vasopressor a qualquer momento em até 60 minutos após a intubação. Pacientes com parada cardiorrespiratória relacionada à intubação e hipotensão antes da intubação foram excluídos do estudo. RESULTADOS: Dos 141 pacientes incluídos, 53 pacientes (37,5%) e 43,6% dos pacientes (n = 17) eram do sexo feminino. A idade mediana do grupo com hipotensão pós-intubação foi de 75 anos (amplitude interquartil: 67,0 - 84,0). Na análise multivariada, índice de choque ≥ 0,90 (RC = 7,76; IC95% 3,14 - 19,21; p < 0,001), níveis de albumina < 2,92g/dL (RC = 3,65; IC95% 1,49 - 8,96; p = 0,005) e níveis de procalcitonina (RC = 1,07, IC95% 1,01 - 1,15; p = 0,045) foram fatores de risco independentes para hipotensão pós-intubação. A mortalidade hospitalar foi semelhante em pacientes com hipotensão pós-intubação e pacientes sem hipotensão pós-intubação (92,5% versus 85,2%; p = 0,29). CONCLUSÃO: A incidência de hipotensão pós-intubação foi de 37,5% em pacientes críticos com COVID-19. Um índice de choque ≥ 0,90 e níveis de albumina < 2,92g/ dL foram independentemente associados à hipotensão pós-intubação. Além disso, índice de choque ≥ 0,90 pode ser uma ferramenta do leito antes da intubação endotraqueal. Neste estudo, a hipotensão pós-intubação não esteve associada ao aumento da mortalidade hospitalar em pacientes com COVID-19.

COVID-19 Pneumonia After SARS-CoV-2 Vaccination with CoronaVac: A Case Series from Turkey.

Coronavirus disease 2019 is a novel viral infection that has caused a pandemic globally. Many kinds of vaccine development studies were conducted to prevent the spread and deaths. The CoronaVac is the most commonly used vaccine in Turkey. Phase 3 trials from various countries revealed that CoronaVac efficacy ranged from 50.7% to 91.25% but increased in moderate or severe cases to 100%. Additionally, it was remarkable owing to high seroconversion rates achieving up to 100%. After the vaccine campaign began in Turkey, critically ill patients continued to admit to our center's intensive care unit though they had been vaccinated with 2 doses of CoronaVac. The clinical course of these patients revealed that they are still at high risk of severe disease and death. Therefore, we aimed to share these patients' clinical characteristics and disease course, laboratory, and radiologic data.

The Predictive Values of Respiratory Rate Oxygenation Index and Chest Computed Tomography Severity Score for High-Flow Nasal Oxygen Failure in Critically Ill Patients with Coronavirus Disease-2019.

Background: The prediction of high-flow nasal oxygen (HFNO) failure in patients with coronavirus disease-2019 (COVID-19) having acute respiratory failure (ARF) may prevent delayed intubation and decrease mortality. Aims: To define the related risk factors to HFNO failure and hospital mortality. Study Design: Retrospective cohort study. Methods: To this study, 85 critically ill patients (≥18 years) with COVID-19 related acute kidney injury who were treated with HFNO were enrolled. Treatment success was defined as the de-escalation of the oxygenation support to the conventional oxygen therapies. HFNO therapy failure was determined as the need for invasive mechanical ventilation or death. The patients were divided into HFNO-failure (HFNO-F) and HFNO-success (HFNO-S) groups. Electronic medical records and laboratory data were screened for all patients. Respiratory rate oxygenation (ROX) index on the first hour and chest computed tomography (CT) severity score were calculated. Factors related to HFNO therapy failure and mortality were defined. Results: This study assessed 85 patients (median age 67 years, 69.4% male) who were divided into two groups as HFNO success (n = 33) and HFNO failure (n = 52). The respiratory rate oxygenation (ROX) was measured at 1 hour and the computed tomography (CT) score indicated HFNO failure and intubation, with an area under the receiver operating characteristic of 0.695 for the ROX index and 0.628 for the CT score. A ROX index of <3.81 and a CT score of >15 in the first hour of therapy were the predictors of HFNO failure and intubation. Age, Acute Physiology and Chronic Health Evaluation II score, arterial blood gas findings "(i.e., partial pressure of oxygen [PaO2], PaO2 [fraction of inspired oxygen]/SO2 [oxygen saturation] ratio)", and D-dimer levels were also associated with HFNO failure; however, based on logistic regression analysis, a calculated ROX on the first hour of therapy of <3.81 (odds ratio [OR] = 4.78, 95% confidence interval [CI] = 1.75-13.02, P = 0.001) and a chest CT score of >15 (OR = 2.83, 95% CI = 1.01-7.88, P = <0.001) were the only independent risk factors. In logistic regression analysis, a ROX calculated on the first hour of therapy of <3.81 (OR = 4.78, [95% CI = 1.75-13.02], P = 0.001) and a chest CT score of >15 (OR 2.83, 95% CI = 1.01-7.88, P = <0.001) were the independent risk factors for the HFNO failure. The intensive care unit and hospital mortality rates were 80.2% and 82.7%, respectively, in the HFNO failure group. Conclusion: The early prediction of HFNO therapy failure is essential considering the high mortality rate in patients with HFNO therapy failure. Using the ROX index and the chest CT severity score combined with the other clinical parameters may reduce mortality. Additionally, multi-centre observational studies are needed to define the predictive value of ROX and chest CT score not only for COVID-19 but also other causes of ARF.

Incidência e fatores de risco para hipotensão pós-intubação em pacientes críticos com COVID-19 / Incidence of and risk factors for postintubation hypotension in critically ill patients with COVID-19

RESUMO Objetivo: Avaliar a incidência de fatores de risco para hipotensão pósintubação em pacientes críticos com COVID-19. Metódos: Foi realizado um estudo retrospectivo com 141 pacientes com COVID-19 que foram intubados na unidade de terapia intensiva. Hipotensão pós-intubação foi definida como a necessidade de qualquer dose de vasopressor a qualquer momento em até 60 minutos após a intubação. Pacientes com parada cardiorrespiratória relacionada à intubação e hipotensão antes da intubação foram excluídos do estudo. Resultados: Dos 141 pacientes incluídos, 53 pacientes (37,5%) e 43,6% dos pacientes (n = 17) eram do sexo feminino. A idade mediana do grupo com hipotensão pós-intubação foi de 75 anos (amplitude interquartil: 67,0 - 84,0). Na análise multivariada, índice de choque ≥ 0,90 (RC = 7,76; IC95% 3,14 - 19,21; p < 0,001), níveis de albumina < 2,92g/dL (RC = 3,65; IC95% 1,49 - 8,96; p = 0,005) e níveis de procalcitonina (RC = 1,07, IC95% 1,01 - 1,15; p = 0,045) foram fatores de risco independentes para hipotensão pós-intubação. A mortalidade hospitalar foi semelhante em pacientes com hipotensão pós-intubação e pacientes sem hipotensão pós-intubação (92,5% versus 85,2%; p = 0,29). Conclusão: A incidência de hipotensão pós-intubação foi de 37,5% em pacientes críticos com COVID-19. Um índice de choque ≥ 0,90 e níveis de albumina < 2,92g/ dL foram independentemente associados à hipotensão pós-intubação. Além disso, índice de choque ≥ 0,90 pode ser uma ferramenta do leito antes da intubação endotraqueal. Neste estudo, a hipotensão pós-intubação não esteve associada ao aumento da mortalidade hospitalar em pacientes com COVID-19.

ABSTRACT Objective: To evaluate the incidence of risk factors for postintubation hypotension in critically ill patients with COVID-19. Methods: We conducted a retrospective study of 141 patients with COVID-19 who were intubated in the intensive care unit. Postintubation hypotension was defined as the need for any vasopressor dose at any time within the 60 minutes following intubation. Patients with intubation-related cardiac arrest and hypotension before intubation were excluded from the study. Results: Of the 141 included patients, 53 patients (37.5%) had postintubation hypotension, and 43.6% of the patients (n = 17) were female. The median age of the postintubation hypotension group was 75.0 (interquartile range: 67.0 - 84.0). In the multivariate analysis, shock index ≥ 0.90 (OR = 7.76; 95%CI 3.14 - 19.21; p < 0.001), albumin levels < 2.92g/dL (OR = 3.65; 95%CI 1.49 - 8.96; p = 0.005), and procalcitonin levels (OR = 1.07, 95%CI 1.01 - 1.15; p = 0.045) were independent risk factors for postintubation hypotension. Hospital mortality was similar in patients with postintubation hypotension and patients without postintubation hypotension (92.5% versus 85.2%; p = 0.29). Conclusion: The incidence of postintubation hypotension was 37.5% in critically ill COVID-19 patients. A shock index ≥ 0.90 and albumin levels < 2.92g/dL were independently associated with postintubation hypotension. Furthermore, a shock index ≥ 0.90 may be a practical tool to predict the increased risk of postintubation hypotension in bedside scenarios before endotracheal intubation. In this study, postintubation hypotension was not associated with increased hospital mortality in COVID-19 patients.

Factors associated with early improvement after intravenous thrombolytic treatment in acute ischemic stroke.

OBJECTIVE: : The aim of this study was to determine the factors associated with early neurological improvement (ENI) in patients who experienced acute ischemic stroke and were treated with intravenous recombinant tissue plasminogen activator (IV rt-PA), and determine the relationship with the outcome at the first control. METHOD: : This study included 377 patients who were treated with IV rt-PA in Izmir Dokuz Eylül University Hospital between January 2010 and October 2018. ENI was defined as a 4 or more improvement in the National Institutes of Health Stroke Scale (NIHSS) score in the first hour, the twenty-fourth hour and the seventh day when compared to the pretreatment phase. The modified Rankin Scale (mRS) 0-1 score was defined as 'very good outcome'. RESULTS: : The basal NIHSS (p=0.003, p=0.003, p=0.022) was high in the first hour, twenty-fourth hour, and seventh day ENI groups. Blood urea nitrogen (BUN) level was low in the first- and twenty-fourth-hour ENI groups (p=0.007, p=0.020). Furthermore, admission glucose was low at the twenty-fourth hour and on the seventh day ENI groups (p=0.005, p=0.048). A high infarct volume was observed on magnetic resonance imaging (MRI) at the twenty-fourth hour and on the seventh day non-ENI groups (p= <0.001, p= <0.001). CONCLUSION: : Management of factors associated with ENI and determination of treatment strategies accordingly are important for obtaining a better clinical outcome. It can help quickly select patients, who, even though they will not respond to rt-PA, may be appropriate candidates for bridging therapy.

New-onset atrial fibrillation in critically ill patients with coronavirus disease 2019 (COVID-19).

Background: Mortality in critically ill patients with coronavirus disease 2019 (COVID-19) is high, therefore, it is essential to evaluate the independent effect of new-onset atrial fibrillation (NOAF) on mortality in patients with COVID-19. We aimed to determine the incidence, risk factors, and outcomes of NOAF in a cohort of critically ill patients with COVID-19. Methods: We conducted a retrospective study on patients admitted to the intensive care unit (ICU) with a diagnosis of COVID-19. NOAF was defined as atrial fibrillation that was detected after diagnosis of COVID-19 without a prior history. The primary outcome of the study was the effect of NOAF on mortality in critically ill COVID-19 patients. Results: NOAF incidence was 14.9% (n = 37), and 78% of patients (n = 29) were men in NOAF positive group. Median age of the NOAF group was 79.0 (interquartile range, 71.5-84.0). Hospital mortality was higher in the NOAF group (87% vs 67%, respectively, P = .019). However, in multivariate analysis, NOAF was not an independent risk factor for hospital mortality (OR 1.42, 95% CI 0.40-5.09, P = .582). Conclusions: The incidence of NOAF was 14.9% in critically ill COVID-19 patients. Hospital mortality was higher in the NOAF group. However, NOAF was not an independent risk factor for hospital mortality in patients with COVID-19.

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.

Clinical characteristics and risk factors for 28-day mortality in critically ill patients with COVID-19: a retrospective cohort study

Background: To date, the coronavirus disease 2019 (COVID-19) caused more than 2.6 million deaths all around the world. Risk factors for mortality remain unclear. The primary aim was to determine the independent risk factors for 28-day mortality. Materials and methods: In this retrospective cohort study, critically ill patients (≥ 18 years) who were admitted to the intensive care unit due to COVID-19 were included. Patient characteristics, laboratory data, radiologic findings, treatments, and complications were analyzed in the study. Results: A total of 249 patients (median age 71, 69.1% male) were included in the study. 28-day mortality was 67.9% (n = 169). The median age of deceased patients was 75 (66­81). Of them, 68.6% were male. Cerebrovascular disease, dementia, chronic kidney disease, and malignancy were significantly higher in the deceased group. In the multivariate analysis, sepsis/septic shock (OR, 15.16, 95% CI, 3.96­58.11, p < 0.001), acute kidney injury (OR, 4.73, 95% CI, 1.55­14.46, p = 0.006), acute cardiac injury (OR, 9.76, 95% CI, 1.84­51.83, p = 0.007), and chest CT score higher than 15 (OR, 4.49, 95% CI, 1.51-13.38, p = 0.007) were independent risk factors for 28-day mortality. Conclusion: Early detection of the risk factors and the use of chest CT score might improve the outcomes in patients with COVID-19.

Management of an Organ Donation Process in COVID-19 Pandemic: First Case of Turkey.

The first case of coronavirus disease 2019 (COVID-19) was defined as unexplained pneumonia on December 8, 2019, and then it rapidly caused a pandemic and affected transplantation rates negatively. Organ donation processes got more complex because the exclusion of the disease in a short period became more difficult than normal. The exclusion of the disease is vital not only for recipients but also for the medical staff, transplantation teams, and intensive care professionals to reduce the transmission risk. The main steps for diagnosis of COVID-19 are investigation of symptoms, recollection of travel and physical contact history, and testing using the real time polymerase chain reaction (RT-PCR) test. Although it has limitations such as false negative results, RT-PCR is the most accurate method to detect COVID-19, and it is mandatory before donation processes in many countries. In this case report, we aim to share our experience about the first organ donation during the COVID-19 pandemic in Turkey.

Follow-up Analysis of Serum TNF-Related Apoptosis-Inducing Ligand Protein and mRNA Expression in Peripheral Blood Mononuclear Cells from Patients with Ischemic Stroke.

Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL), which is TNF receptor superfamily member, contributes to several diseases pathogenesis. The aim of this research was to investigate the relevance of serum TRAIL protein levels and mRNA expression in peripheral blood mononuclear cells (PBMC) of patients with stroke through 6 months follow-up. We enrolled patients with first-ever acute ischemic stroke (n = 95) and healthy controls (n = 95) in this study. Follow-up blood samples were collected from patients at day 7, 28, and 180 after the onset. The stroke severity was evaluated by National Institutes of Health Stroke Scale score. TRAIL protein levels were quantified by using ELISA kits and TRAIL mRNA expression by quantitative real-time PCR. Our study showed that stroke patients have statistically significant lower levels of serum TRAIL protein (p < 0.0001) and elevated TRAIL mRNA expression (p < 0.0001) in PBMC at the disease onset. Our follow-up study revealed that TRAIL protein levels were increased while mRNA expression levels were downregulated in later periods. Overall, our findings suggest that serum TRAIL levels and mRNA expression in PBMC could reliably serve as a predictor of stroke outcome. Additionally, our study supports that TRAIL plays a role in pathogenesis and progression of ischemic stroke.

Pneumocephalus in a patient with multiple stab wounds.

Pneumocephalus is a complication of trauma to the chest and many iatrogenic interventions. It may arise due to systemic air embolism or retrograde cerebral venous air embolism which is an extremely rare complication. We report a 26-years-old female patient who presented to the Emergency Department suffering of multiple stab wounds. She was in a state of shock and after first aid and evaluation she was operated successfully. In the early postoperative period generalized tonic clonic convulsions were observed following cardiopulmonary resuscitation due to sudden cardiovascular collapse. Brain computerized tomography demonstrated free air in intracranial and extracranial venous structures. Pneumocephalus was diagnosed which may be due to a wide spectrum of etiologies including thorax or spinal stab wounds, tube thoracostomy, cardiopulmonary resuscitation or even central venous catheterization. Unfortunately, the patient ended up with brain death despite all effort. In conclusion, we recommend physicians to be aware of this catastrophic complication while taking care of patients with stab wounds.

Analyses of the Turkish National Intravenous Thrombolysis Registry.

BACKGROUND: The relatively late approval of use of recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke in Turkey has resulted in obvious underuse of this treatment. Here we present the analyses of the nationwide registry, which was created to prompt wider use of intravenous thrombolysis, as well as to monitor safe implementation of the treatment in our country. METHODS: Patients were registered prospectively in our database between 2006 and 2013. Admission and 24-hour National Institutes of Health Stroke Scale and 3-month modified Rankin Scale scores were recorded. A "high-volume center" was defined as a center treating 10 or more patients with rt-PA per year. RESULTS: A total of 1133 patients were enrolled into the registry by 38 centers in 18 cities. A nearly 4-fold increase in the study population and in the number of participating centers was observed over the 6 years of the study. The mean baseline NIHSS score was 14.5 ± 5.7, and the prevalence of symptomatic hemorrhage was 4.9%. Mortality at 3 months decreased from 22% to 11% in the 6 years of enrollment, and 65% of cases were functionally independent. Age older than 70 years, an NIHSS score higher than 14 upon hospital admission, and intracranial hemorrhage were independently associated with mortality, and being treated in a high-volume center was related to good outcome. CONCLUSIONS: We observed a decreasing trend in mortality and an acceptable prevalence of symptomatic hemorrhage over 6 years with continuous addition of new centers to the registry. The first results of this prospective study are encouraging and will stimulate our efforts at increasing the use of intravenous thrombolysis in Turkey.

Management of free-floating thrombus within the arcus aorta and supra-aortic arteries.

INTRODUCTION: Clinical management strategy and the best treatment option of free floating thrombus (FFT), detected in patients with acute ischemic cerebrovascular diseases is still uncertain due to the rarity of these conditions. Recent studies emphasize that FFT within cerebral vessels may not be a surgical emergency since complete dissolution without any further neurologic progression occurred in 86% of patients treated medically. The aim of this study was to investigate the effect of medical treatment on the fate of thrombus and the clinical status in acute cerebrovascular event patients with detected FFT in the artery feeding the compromised brain territory at the time of diagnosis. MATERIALS AND METHODS: We have retrospectively reviewed the initial and follow up computed tomography angiography, diffusion-weighted magnetic resonance imaging examinations of 37 acute ischemic stroke patients with detected FFT and treated medically. The patients were evaluated for any change of the FFT, residual stenosis after the FFT shrunk or disappeared and neurologic outcome. RESULTS: FFT was located in cervical carotid artery, intracranial artery and arcus aorta in 23, 6 and 5 of the patients respectively. Dissection accompanied the FFT in 3 patients. Recanalization was maintained in 34 patients however, three of them suffered from new infarctions. A total occlusion was detected in three patients. Two of them had new infarcts while one was stable during clinical follow-up period. CONCLUSION: The results of our retrospective study have shown that FFT in the proximal aorta and supra-aortic arteries tend to resolve with anticoagulant and/or antiplatelet treatment without causing recurrent adverse events in most of the cases. Furthermore, resolution of the clot seems to provide a safer ground for a recanalization procedure like stenting or endarterectomy if needed.

Prevalence and risk factors of depression among community dwelling elderly.

Depression in the elderly is associated with increased morbidity and mortality. The purpose of this study was to determine the prevalence and risk factors of depression among community-dwelling older population in an urban setting in Turkey. This cross-sectional study was conducted among 482 elderly individuals 65 years and over in an urban area. Cluster sampling method was used for sample size. Depression in the elderly had been diagnosed by a clinical interview and Geriatric Depression Scale. Data were collected by door-to-door survey. Chi square test was used for statistical analysis. P value, which was calculated by the results of chi square test and coefficient of phi (φ), below 0.05 was included in the analysis of logistic regression. Depression was significantly associated with female gender, being single or divorced, lower educational status, low income, unemployment, and lack of health insurance. However, logistic regression analysis revealed higher depression rates in the elderly with chronic obstructive pulmonary disease, psychiatric disease, cerebrovascular disease, low income and being dependent. Depression is common among community-dwelling older people in an urban area of Izmir, Turkey. Older adults living in community should be cautiously screened to prevent or manage depression.

Low-frequency repetitive transcranial magnetic stimulation for dyskinesia and motor performance in Parkinson's disease.

Dyskinesias are one of the most frequent and disabling complications of the long-term treatment of Parkinson's disease (PD). Although the cause is not completely understood, it appears that an imbalance between excitatory and inhibitory inputs from the basal ganglia to the motor cortex leads to overactivation of motor and premotor areas. Overactivation of the supplementary motor area (SMA) has been observed in neuroimaging studies in dyskinetic PD patients. We investigated the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) of the SMA on levodopa-induced dyskinesias (LID) and motor performance in PD. We tested whether longer duration (10days) and higher number of total pulses (1800 pulses) would enhance the beneficial effect. Seventeen dyskinetic PD patients were randomly assigned to real rTMS or sham (placebo) rTMS, and 1Hz rTMS or sham rTMS was applied over the SMA for 10 consecutive days. Patients were assessed at baseline and 1day after the last rTMS with a levodopa challenge test, and video recordings were taken. Dyskinesias and motor performance were rated off-line by two blinded raters using video recordings. After 10days of treatment with rTMS, we observed that 1Hz rTMS delivered over the SMA had decreased LID lasting for 24hours without a change in motor performance, whereas sham rTMS induced no significant change in dyskinesia scores. These results support a possible therapeutic effect of low-frequency rTMS in LID. However, in order to suggest rTMS as an effective treatment, long-term observations and further investigations with a larger patient population are essential.

Vestibular rehabilitation in acute central vestibulopathy: a randomized controlled trial.

OBJECTIVE: To investigate the effects of two different rehabilitation programs in acute central vestibulopathy secondary to posterior circulation stroke. METHOD: A prospective randomized controlled study was conducted on 25 patients with posterior circulation stroke. Patients were instructed in routine balance and mobility exercises during the acute hospitalization period. At discharge, patients were assigned to either a rehabilitation or home exercise group. The home exercise group was instructed to perform the same exercise program provided in the course of hospitalization period. The rehabilitation group was randomized into the visual feedback posturography training or vestibular rehabilitation group. The balance and gait performance were assessed with clinical and objective measurements before and after 6 weeks of training. RESULTS: The balance and gait scores were significantly improved in both rehabilitation groups and in the home exercise group (p< 0.05), but no significant difference was found between the groups in terms of post-treatment values (p> 0.05). CONCLUSION: The improvements of balance and gait function in rehabilitation groups did not differ from the home exercise group. Rehabilitation programs were equally effective to improve the recovery in acute central vestibulopathy.

Ability of emergency physicians to detect early ischemic changes of acute ischemic stroke on cranial computed tomography.

OBJECTIVE: The objective of this study was to evaluate the ability of emergency physicians (EPs) to diagnose early ischemic changes due acute ischemic stroke on cranial computed tomography (CT). SUBJECTS AND METHODS: Three EPs interpreted CT scans obtained within 3 h of symptom onset in 50 patients with acute stroke. The CT scans were interpreted by the EPs and compared to official neuroradiologist reports as a gold standard. ĸ statistics were calculated to determine agreement among the three readers. Sensitivities and specificities were analyzed for each reader. RESULTS: The EPs' sensitivities were 50, 45.5, and 45.5%, and specificities were 64.3, 82.1, and 64.3%, respectively. Focal parenchymal hypodensity was the criterion for which the EPs were the most sensitive (77.3%). The ability of EPs to recognize early ischemic changes on CT scans in acute ischemic stroke was moderate based on sensitivities. CONCLUSION: Based on this study, EPs must be trained especially for recognizing early ischemic changes in acute ischemic stroke to improve their accuracy of interpretation.