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Summary Background &Aims: Trace elements act as co-factors and/or in co-enzymes in many metabolic pathways and its deficiency contributes to metabolic and infectious complications. The aim of this study was to determine serum zinc, selenium, cobalt, chromium, copper and ceruloplasmin levels for identify the need for post intensive care unit (ICU) nutritional follow-up. Methods This study was prospectively conducted in medical ICU. Adult patients (≥18 years) who stayed in ICU more than 48 hours and transferred to ward were included in the study. Blood samples of trace element levels were sampled at discharge. Results We enrolled 100 patients. The median age was 60 (40-70) years with Acute Physiology and Chronic Health Evaluation II (APACHE II) score 15 (11-21). The median C-Reactive Protein (CRP) level was 53.9(24.8-116.0) mg/L at discharge. Median serum zinc (24.4 mcg/dl:14.2-38.7) and chromium (0.22 mcg/dl:0.17-0.34,) levels were below reference values, while median copper (111.9 (73.0-152.5) mcg/dl) and selenium (54.8 (36.4-95.25) mcg/L) values were within ranges. Serum concentrations of chromium, zinc, and selenium were lower than the normal values in 98, 90, and 36% of patients, respectively. The 28-day ICU mortality were correlated with low serum selenium levels (p=0.03). Conclusion Serum chromium and zinc levels were below reference values at discharge, but this finding was in context of inflammation. Low serum selenium level observed in 36% was associated to 28-day ICU mortality.

Background/aim: Adipokines play an important role in the regulation of metabolism. In critical illness, they alter serum levels and are suspected to worsen clinical outcomes. But the effect of the route of nutrition on adipokines is not known. The purpose of this study was to evaluate the association between the route of nutrition and adipokine levels in critically ill patients. Materials and methods: This prospective study was performed in an intensive care unit ICU . Patients admitted to the ICU for least 72 h and receiving either enteral nutrition EN via tube feeding or parenteral nutrition PN were enrolled. Serum was obtained at baseline, 24 h, and 72 h for concentrations of leptin, adiponectin, resistin, glucagon-like peptide 1 GLP-1 , insulin-like growth factors 1 IGF-1 , and ghrelin. Results: A total of 26 patients were included in the study. Thirteen patients received EN and 13 patients received PN. In the PN group, leptin level significantly increased P = 0.037 , adiponectin and ghrelin significantly decreased during follow up P = 0.037, P = 0.008, respectively . There was no significant change between all adipokines in the EN group and resistin, IGF-1 and GLP-1 in the PN group during follow up. Resistin levels were markedly lower in the EN group at both 24 h P = 0.015 and 72 h P = 0.006 while GLP-1 levels were higher in the EN group at baseline, 24 h, and 72 h P = 0.018, P = 0.005, and P = 0.003, respectively . There were no differences in leptin, adiponectin, IGF-1, and ghrelin levels over time. Conclusion: The delivery of EN in critical illness was associated with decreased resistin levels and increased GLP-1 levels. Thus, the route of nutrition may impact the clinical outcome in critical illness due to adipokines.

Background/aim: Critically ill patients are at risk of developing gastrointestinal GI bleeding due to stress causing mucosal damage. Aim of the study was to determine the effect of oral/enteral nutrition with or without concomitant pantoprazole on upper GI bleeding in low risk critically ill patients. Materials and methods: This was a prospective, randomized, open-label, multicenter study conducted with intensive care unit ICU patients receiving oral/enteral nutritional support. Patients were randomly assigned into two groups including intervention group received oral/EN plus pantoprazole and control group received only oral/EN . Results: A total of 300 patients intervention group: 152, control group: 148 participated in the study. Overall, 226 75% patients were fed by orally and 74 25% patients fed by enteral tube feeding. Median duration of nutritional support 4 range: 2-33 days. Overt upper GI bleeding was noted only in one patient 0.65% who was in the intervention group. The overall length of ICU stay of 4 2-105 days, while ICU stay was significantly longer in the intervention group than in the control group P = 0.006 . Conclusions: Our findings seems to indicate that in patients who are at low risk for GI bleeding and under oral/enteral nutritional support, the use of PPIs may not reduce the risk of bleeding, however these results are imprecise because of low event GI bleeding rate and limited power.

Background/aim There is a need for a scoring system for predicting ICU prognosis of patients with ANCA-associated vasculitis (AAV), but there are limited data on it in the literature. Therefore, we aimed to determine the scores that can estimate the prognosis of patients with AAV during intensive care follow up. Materials and methods All adult patients admitted to the medical ICUs of 4 reference university hospitals in Turkey due to AAV activation and/or disease/treatment complications in the last 10 years were included in this study. Demographic data, treatments before ICU, the Birmingham Vasculitis Activity Score (BVAS) score at the time of vasculitis diagnosis, and BVAS, APACHE II, SOFA, and SAPS II scores at the ICU admission, treatments, procedures, and complications during ICU stay were recorded for all AAV patients. Results Thirty-four patients were included in the study. The median age of the patients was 60 (42–70) years, and 64.7% were male. Twenty-five patients were diagnosed with Granulomatosis with polyangiitis, and 9 were diagnosed with Microscopic polyangiitis. The most common ICU admission causes were hemorrhage (85.3%) and sepsis/septic shock (67.6%). Twenty patients (58.8%) died in the ICU follow up. There were significant differences in APACHE II (P = 0.004) and SAPS II (P = 0.044) scores between survivors and nonsurvivors, while there were no significant differences in BVAS (during diagnosis P = 0.089 and ICU admission P = 0.539) and SOFA (P = 0.097) scores. APACHE II score was found to be an independent risk factor for ICU mortality (OR = 1.231, CI 95% = 1.011–1.498, P = 0.038) according to logistic regression analysis. An APACHE II score of greater than 20.5 predicted ICU mortality with 80% sensitivity and 70% specificity (AUC = 0.8, P = 0.004, Likelihood ratio = 2.6) according to the ROC curve analysis. Conclusion APACHE II score can be used for the prediction of ICU mortality in AAV patients.

Objective: The aim of the present study was to compare the effect of the pulmonary artery catheterization (PAC) method and the central venous catheterization (CVC) method on hemodynamic and inflammatory parameters in early goal-directed therapy (EGDT).

BACKGROUND The aim of the study was to determine serum thiamin concentrations in critically ill medical patients who required chronic diuretic drug treatment before admission to a medical intensive care unit (ICU). METHODS This prospective study was performed in a medical ICU. Subjects who received diuretic drug therapy for at least 6 months prior to ICU admission constituted the diuretic group. The control group was clinically matched adults admitted to the same ICU but without a history of diuretic therapy. RESULTS A total of 50 subjects were included (25 subjects in each of the diuretic and control groups). In the diuretic group, daily dose of furosemide prior to admission was 40 mg/d (range of 20-160 mg/d). In all subjects, the ICU admission baseline blood thiamin concentrations were 31.2 ± 27.1 ng/mL. In the diuretic group, the baseline whole blood thiamin level was significantly lower compared with levels in the control group (15.5 ± 10.7 vs 46.8 ± 29.5 ng/mL; P

Objective: Organophosphates (OPs) are widely used for pest control worldwide, leading to increased risk for human exposure. The acute hormonal effects of OP include deficiencies in the thyroid-stimulating hormone (TSH), adrenocorticotropic hormone, and insulin-like growth factor 1 hormone correlated with the levels of cholinesterase. Most patients with OP-related hormone deficiency recover at 3 months of follow-up. However, the chronic effects of these chemicals are not clear. The aim of the present study was to determine the chronic influences of OP on pituitary functions in patients who had OP poisoning. Materials and Methods: This prospective study was performed in Erciyes University Medical School. All of the patients who had OP poisoning were followed up in the medical intensive care unit (MICU). They were evaluated after discharge from the MICU after at least 6 months with regard to pituitary functions. In all patients, data were extracted from the MICU records. Baseline hormone levels were assessed, and dynamic tests (insulin tolerance test and glucagon stress test) were performed. Results: Twenty-nine adult patients (13 women and 16 men) with OP poisoning were included in the study. The mean age of the patients was 41.9+-16.7 years. The mean time from hospitalization to assessment of pituitary functions was 43.9+-15.8 months in patients with OP poisoning. All patients had normal prolactin, TSH, follicle-stimulating hormone, and luteinizing hormone levels. Women had normal estrogen levels, and men had normal total testosterone levels. Cortisol deficiency was detected in only 1 (3.4%) patient, and growth hormone (GH) insufficiency was found in 3 (10.3%) patients. Conclusion: GH and cortisol axis may be affected by OP poisoning in the long term. Thus, pituitary hormone levels should be tested following an acute period in patients with OP.

ObjectiveMedical laboratories encounter critical obstacles in External Quality Assessment (EQA) practices that are key to assessment of the analytical period. Present study aims to unveil the challenges in nationwide inter-laboratory harmonization and suggest practical solutions.Materials and methodsEQA results of 1941 laboratories participating in 18 different EQA-programs between 2010 and 2017 were examined. Standard Deviation Index (SDI) of each program calculated using 801,028 sample data from 24 different clinical chemical tests were used to conduct a process assessment.ResultsThere is a significant discrepancy in unsatisfactory performance ratio among different EAQ-programs with an average of 3.4% (27,074 cases) between 2010 and 2017 and a decreasing trend (~40–50%) in 7-years. Programs with higher SDI display lower discrepancy rates. Reasons for unaccepted results appear to be data entry errors (8.27–22.2%), material dilution errors (5–11.4%), technical problems (3.76–7.9%); while random or unidentified causes account for a major of 44.9–59.5%. In 7-years, 15.7% reduction was observed in average SDI of all tests.ConclusionWith the launch of national EQA follow-up program, increased awareness of the analytical processes led to a decrease in unaccepted results and variances in the analytical period. Staff training is suggested as a significant measure. In addition, simultaneous assessment of SDI and allowable total error rates would reduce the variation between programs.

Objective: Endotracheal intubation is a frequently performed procedure in the intensive care unit (ICU). Extremely serious complications occur during this procedure. In this study, theoretical and practical training were given to residents who started to work in the medical intensive care unit, and it was aimed to evaluate the complications following training.

Objective: Poisoning is among the common health care problems which may be fatal and 3-5% of the acutely poisoned patients need intensive care admission. The aim of this study was to examine the acutely poisoned patients admitted to intensive care unit (ICU) in terms of individual, etiological and demographical characteristics and also to determine the factors affecting mortality. Material and Methods: This study was retrospectively conducted on the patients admitted to medical ICU of a university hospital due to acute poisoning over a six year period. The patients' age, gender, comorbid disease status, sociocultural characteristics, cause of the poisoning, transfer time to hospital and to the ICU, signs and symptoms, laboratory data, Glasgow coma score, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment score, length of stay in ICU, the treatments employed and their results were analyzed. Results: The total number of the patients included in the study was 190. The median age of the patients was 28.5 (16-72) years and 97 (51%) patients were females. The mean length of stay in ICU was 4.2±3.6 days. The overall mortality rate was 8.4%. Independent risk factors for mortality were presence of concomitant physical disorders, time to ICU admission, and higher APACHE II scores. Conclusion: Individual characteristics, cause of poisoning and type of toxic agent should be clearly determined since they are predictors for mortality. Early intervention is life saving. ICU scoring systems in predicting mortality are very valuable and should be used. © 2013 by Türkiye Klinikleri.

Aim: To detect the risk factors for ventilator associated pneumonia (VAP) and role of ventilator parameters in the development of VAP in a Medical Intensive Care Unit (MICU). Materials and Methods: This study was performed prospectively in Gevher Nesibe Hospital MICU of Erciyes University Medical Faculty between 1 January, 2003 and 1 April, 2004. The patients, who were 16 years old and over, who had been ventilated with a mechanical ventilator for more than 24 hours and who had no pulmonary infection, were included in the study. The patients’ demographic characteristics, risk factors and ventilator parametres (PEEP, ventilation mode, tidal volume, FiO2, PEAK, mean pressure, plateau pressure) were recorded. Also the hospitalization period before mechanical ventilation and up to pneumonia development, total time of ICU admission and the time of weaning were recorded. Results: A total of 106 patients were included in the study and VAP developed in 49 (46.2%) patients. When risk factors for VAP were evaluated in the univariate analysis, it was found that there was a statistically significant relationship between previous sepsis (OR=2.557, 95% CI=1.153-5.671, p=0.021), sedative drug usage (OR=2.876, 95% CI=1.168-7.075, p=0.021), tracheostomy (0R=3.602, 95% CI=1.446-8.972, p=0.006), PIP (OR=0.946, 95% CI=0.898-0.997, p=0.036), number of aspirations (OR=1.778, 95% CI=1.238-2.552, p=0.002), enteral nutrition (OR=5.440, 95% CI=2.197-13.471, p=0.000) and nasogastric tube (OR=2.510, 95% CI=1.138-5.537, p=0.023 ). When multivariate analysis was performed, previous sepsis (OR=6.291, 95% CI=1.944-20.356, p=0.002), sedative drug usage (OR=3.719, 95% CI=1.109-12.476, p=0.033), number of aspiration (OR=2.107, 95% CI=1.313-3.381, p=0.002) and enteral nutrition (OR=3.586, 95% CI=1.063-12.100, p=0.040) were determined to be independent risk factors. Ventilation modes and ventilation parameters had no effect on the development of pneumonia with multivariate logistic regression analysis. The duration of hospitalization in patients with VAP was longer than those who had no VAP (p 0.05). Conclusion: Sepsis, sedative drug usage, number of aspirations and enteral nutrition were established as risk factors, whereas ventilation modes and ventilation parameters had no effect on the development of pneumonia. Avoiding unnecessary aspiration and sedation, rapid diagnosis and treatment of infections in other systems will be effective in the prevention of VAP. (Yogun Bakim Derg 2011; 2: 34-8)

This paper describes very rare chemical poisoning and characteristics of patients with acute endosulfan mass poisoning in a rural area of Turkey and our experiences of these patients. We included 41 patients who were treated in our hospital with the diagnosis of endosulfan poisoning. After the first vital intervention they were examined in terms of age, sex, symptoms and physical examination findings, laboratory results, treatment and outcome. Forty-one patients were admitted to the emergency department (ED) after triage. Nineteen (46.3%) of the patients were female, 22 (53.7%) were male. The mean age was 279 +/- 16.0 years (1-67 years). The mean time to the ED was 4.1 +/- 0.9 h (3-6.5 h). The most common symptoms were anxiety (976%), nausea (56.1%) and vomiting (48.8%). Tests of the blood samples obtained at the ED revealed leucocytosis (11070.6 +/- 4302.5/mu l), increased blood glucose, LDH, CK and CK-MB levels. Toxicological analysis of blood and urine samples revealed endosulfan as the causative agent. Especially in the rural areas, cases with acute repetitive seizures should suggest endosulfan intoxication when the aetiology is uncertain even in the absence of any signs of intoxication. Health care professionals should understand the hazards associated with the pesticide use as well as diagnosis and treatment of these types of poisonings. European Journal of Emergency Medicine 16:53-56 (C) 2009 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

Background: Organophosphate (OP) compounds are used as insecticides. Given the widespread availability and use of these chemicals, OP poisoning is quite common following either accidental or intentional exposures. Immediate intensive care management can save lives in these patients. We aimed to investigate intensive care management provided to OP poisoning patients in a tertiary care hospital in Turkey.Subjects and Methods: This was a retrospective chart review of 62 patients, admitted to the Intensive Care Unit (ICU) with OP poisoning between 2000 and 2012.Results: Of the 62 patients studied, 40 (65%) were male, 45 (73%) were suicide attempts, 59 (95%) ingested the OP compounds, and three patients (5%) (two patients with suicide and 1 with accidental exposure) died in the ICU. There were statistically significant differences between survivors and nonsurvivors for Glasgow Coma Scale (GCS) on admission (P = 0.034), Acute Physiology and Chronic Health Evaluation II (APACHE II) score (P = 0.003), Sequential Organ Failure Assessment (SOFA) score (P = 0.024), time to initiation of treatment (P = 0.034) and serum lactate dehydrogenase (LDH) levels (P = 0.007).Conclusions: Organophosphate poisoning is a life‑threatening condition that requires immediate diagnosis and management. GCS, APACHE II score, SOFA score, and time to admission to the emergency department and LDH levels can provide prognostic information and predict outcomes.Key words: Clinical outcomes, Intensive Care Unit, mortality, organophosphate poisoning

Objective: Growth hormone deficiency (GHD) in adults is associated with abnormal body composition, altered lipid profile, reduced quality of life and osteoporosis. Replacement with recombinant GH results in significant improvements in most of these altered parameters. The most common cause of adult GHD in previous studies was due to pituitary tumors or their treatment. Sheehans syndrome classically refers to postpartum hypopituitarism due to pituitary necrosis occurring secondary to massive bleeding at or just after delivery. While severe GHD is a well-established feature of Sheehans syndrome, the effects of Growth hormone replacement therapy (GHRT) in these patients has not been extensively investigated. The present study was therefore designed to investigate the effects of GHD and GHRT in patients with Sheehans syndrome. Design: The study comprised 14 severely GH-deficient patients with Sheehans syndrome with a mean age of 49.4 ± 7.9 yr. Treatment with GH was started at a dose of 0.15 mg per day in month 1, was increased to 0.30 mg per day in month 2, and was maintained at 0.66 mg per day until the end of month 18. With the similar maintenance dose adequate age adjusted IGF-I levels for each patient has been achieved. Blood pressure, lipid profile, biochemical parameters, anthropometric measurements including body mass index (BMI), waist and waist to hip ratio (W/H), and bone mineral density (BMD) were investigated before and at 3, 6, 12 and 18 months of the GHRT. Results: The duration of GHD from the onset of the disease was 19.4 ± 1.6 yr. The majority of the patients (78%) had panhypopituitarism. At baseline mean total cholesterol, LDL-cholesterol and triglyceride levels were higher than the normal reference ranges but HDL-cholesterol levels were within the lower normal range. During the treatment period total cholesterol and LDLcholesterol levels decreased and HDL-cholesterol levels increased significantly (P < 0.05). Waist circumference and waist to hip ratio were decreased significantly during the GHRT when compared to basal measurements (P < 0.05). There was a significant positive correlation between the basal waist circumference and the duration of GHD (P < 0.05). Conclusions: This study clearly demonstrates that Sheehans syndrome is characterized by severe and long-standing GHD. GHRT have beneficial effects in several parameters including lipid profile and waist circumference. But we could not observe any improvement in BMD after 18 months of GHRT. However interpretations of the present results need to be made with caution because of the uncontrolled design. Further placebo controlled studies with high number of patients with Sheehans syndrome are warranted. 2005 Elsevier Ltd. All rights reserved.

Nosocomial pneumonia (NP) is the most frequent infection in intensive care units (ICUs) and has high morbidity and mortality. An important part of this entity develops in patients entubated and mechanically ventilated. The most frequent pathogens are gram-negative bacilli. Despite the usage of broad spectrum antibiotics, NP remains a serious problem in ICUs, because of increasing resistance. This is a prospective study to establish incidence, pathogens, antibiotic sensitivity and mortality of NP in ICU. Patients with NP, older than 16 years old, in the ICUs were included to study. The isolated pathogens, antibiotic sensitivity and mortality of these patients were recorded. NP developed in 231 (54 per 1000 patients admitted to the ICUs) patients of 4254. 175 (75.8%) of these cases were ventilator associated pneumonia (VAP). 305 pneumonia episodes were seen in 231 patients. The most frequent microorganisms were Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae and Staphylococcus aureus. The resistance rate of these pathogens were very high. The mortality rate was 69.7%. NP is the most frequent nosocomial infection in ICUs. The incidence have been reported 7-27% and 0.8-12.5 per 1000 patient days in several studies. In our study, the incidence was 54 per 1000 patients admitted to the ICUs. The most frequent microorganisms are gramnegative bacilli in NP. Also in this study, the most frequent pathogens were A. baumannii, P. aeruginosa and K. pneumoniae. In these pathogens, the resistance rates were very high. The severity of illness, the duration of hospital stay and inappropriate antibiotic usage are related with high antibiotic resistance rates. As the pathogens were highly resistant gram-negative bacteria, the mortality was very high in our study.

Aims: A small body size may increase the risk for hernia development in patients on continuous ambulatory peritoneal dialysis (CAPD). The present study investigates whether there is a relationship between body size and hernia development in CAPD patients. Material and methods: The records of 78 patients on CAPD were reviewed retrospectively. Body mass index (BMI), body surface area (BSA) and total body water (TBW) were calculated in all patients. Correlations between different body size indicators (BMI, BSA and TBW) and hernia development were assessed using analysis of covariance in which we adjusted for sex. Results: A total of 14 patients (17.9%) with no physical evidence of hernia before catheter insertion developed hernias. Body size was significantly lower in CAPD patients with hernias than those without hernias when adjusted for sex. Conclusions: We conclude that patients with small body size tend to have an increased risk for hernia development. A simple estimation of patients' height, weight, body surface area and total body water would be helpful to predict development of hernias or other complications related to increased intraperitoneal pressure in CAPD patients.

Non-classic congenital adrenal hyperplasia (NCAH) is a rare cause of hirsutism and it results from a defect in the biosynthetic pathway of cortisol and/or aldosterone. 250 microg ACTH test (SDT) is used in the diagnosis of this disease. Our aim was to investigate the responses of 11-deoxycortisol to 1microg ACTH (LDT) test in women with NCAH due to 11-beta hydroxylase (11- beta OH) deficiency and to compare them with the values obtained after SDT in the patients and in the control subjects. Eleven patients with NCAH due to 11- beta OH deficiency and 15 control subjects were involved in the study. The main complaint of the patients with NCAH was hirsutism and the diagnosis was made if the adrenal 11-deoxycortisol response to SDT exceed threefold the 95th percentile of controls. ACTH stimulation tests were carried out consecutively by using 250 microg and 1 microg intravenous ACTH as a bolus injection after an overnight fast, and blood samples were drawn at 0,30 and 60 min. Peak cortisol, 17-hydroxyprogesterone (17-OHP) and DHEAS responses were similar in LDT and SDT while 11-deoxycortisol responses to LDT (15.7 +/- 1.8 nmol/L) were significantly (p < 0.005) lower than the results obtained after SDT (76.3 +/- 21.4 nmol/L) in women with 11- beta OH deficiency. Peak cortisol and 17-OHP responses to LDT in patients and control subjects were similar. Peak 11-deoxycortisol responses to LDT were significantly (p < 0.05) higher in NCAH patients (15.7 +/- 1.8 nmol/L) than in the control subjects (6.5 +/- 0.8 nmol/L). However, in LDT, all patients had peak 11-deoxycortisol level lower than threefold the 95th percentile (25.8 nmol/L) of controls. This study represents the first demonstration that LDT gives similar cortisol but not 11-deoxycortisol responses to SDT in patients with 11- beta OH deficiency. This study also showed that LDT can not replace SDT in every clinical situation.

OBJECTIVE: To compare the clinical efficacy and safety of high-dose (5 mg/day) and low-dose (2.5 mg/day) finasteride in the treatment of hirsutism in women. DESIGN: A prospective, randomized and controlled clinical trial. METHODS: Fifty-six hirsute women with moderate to severe hirsutism were prospectively evaluated to see the effects of low-dose (2.5 mg/day) and high-dose (5 mg/day) finasteride. Patients were randomly divided into two treatment groups. Group I (n=29) received 2.5 mg finasteride/day and group II (n=27) received 5 mg finasteride/day orally for 1 year. Hirsutism score, body mass index and hormonal parameters (FSH, LH, estradiol, androstenedione, testosterone, free testosterone, 17alpha-hydroxyprogesterone, dehydroepiandrosterone sulfate and sex hormone-binding globulin) were measured in all the patients before treatment and repeated at six-monthly intervals. RESULTS: The hirsutism scores decreased significantly at months 6 and 12 from a mean+/-s.d. of 18.4+/-4.6 to 13.3+/-5.2 (P

Numerous parameters have been suggested for the prediction of weaning from mechanical ventilation; however, these parameters have limited success in the prediction of weaning outcome. The aim of this study is to assess the success of minute peak flow rates (spontaneous peak inspiratory flow rate (SPIF) and spontaneous peak expiratory flow rate (SPEF)) measured during a spontaneous breathing trial (SBT) in the prediction of weaning outcome.

Adrenocortical function in patients with active pulmonary tuberculosis is a debate of matter. Previous studies related to adrenocortical function in patients with active pulmonary tuberculosis demonstrated a high rate of suboptimal cortisol response to standard dose ACTH (250 mu g) stimulation test. The aim of this study was to assess the hypothalamo-pituitary-adrenal (HPA) axis in low dose (1 mu g) and standard dose ACTH (250 mu g) stimulation tests in the patients with active pulmonary tuberculosis. Twenty-seven patients and 21 healthy subjects were included in the study. Cortisol levels were measured before, 30 and 60 min after ACTH (1 (mu g or 250 mu g iv) injection. Cortisol responses to 1 mu g ACTH at 30 and 60 min were significantly higher in the patient group than in the control group (p0.05). This study shows that 1 mu g ACTH iv gives an equivalent peak cortisol value to 250 mu g ACTH in patients with activated HPA axis. The cortisol levels obtained at 08:00, 11:00, 17:00 and 24:00 h were significantly higher in the patients than in the controls. This study clearly shows that HPA axis is activated in active pulmonary tuberculosis rather than underactivated. (C) 2000, Editrice Kurtis.

Flutamide has been used successfully in the treatment of hirsutism. However, flutamide may cause important side-effects. The aim of this study was to evaluate the clinical and hormonal effects of lowest-dose flutamide therapy. Sixty-one women with hirsutism aged 18-37 years (mean +/- SD 23.4 +/- 5.9 years) were included in the study. Patients received 62.5 mg flutamide once per day for a period of 12 months. A hirsutism score was determined according to a modified Ferriman-Gallwey scoring system. Before therapy, multiscreen blood chemistry, hormonal analysis and complete blood counts were performed. These parameters and hirsutism scares were repeated at 3, 6, 9 and 12 months during therapy. The modified Ferriman-Gallwey scores significantly decreased from 19.1 +/- 4.9 to 5.8 +/- 3.3 during the study (p < 0.0001). The percentage reductions in hirsutism scores (mean +/- SD) were 60.3 +/- 14.4% at 6 months, and 70.3 +/- 13.2% at 12 months. No significant ride-effects or modifications in the menstrual cycles were observed. There were no significant differences in any of the hormone levels during therapy. In conclusion, the lowest dose of flutamide, 62.5 mg/day, is a well-tolerated therapeutic agent and can be used in the treatment of hirsutism.

Context. We investigated the effects of endosulfan intoxication on pituitary functions in three patients. Methods. This is an observational case series including three patients with endosulfan intoxication. Patients were evaluated 3 months after the acute event. Results. Based on the baseline hormonal values and dynamic endocrine tests, one patient had hypothalamo-pituitary-adrenal axis impairment and was diagnosed as ACTH deficiency (peak cortisol level was found 13.12 mu g/dl after low dose ACTH stimulation test), and another one had GH-IGF-I axis impairment and was diagnosed as GH deficiency (peak GH level was found 1.06 mu g/L after glucagon stimulation test). Conclusions. Endosulfan intoxication might cause pituitary hormone deficiencies after the acute phase. Therefore, patients with endosulfan toxicity should be followed for possible pituitary gland dysfunction., Endosulfanintoxicationmight causepituitaryhormone deficiencies after the acute phase. Therefore, patients withendosulfantoxicity should be followed for possiblepituitarygland dysfunction.

Ventilator-associated pneumonia (VAP) developed in 96 (60%) of 159 patients with 37.2 cases per 1000 ventilation-days in a medical intensive care unit (MICU). Median time for VAP development was 5.5 days (range: 2-25). The most significant risk factors for VAP were stay in hospital before MICU and length of stay in MICU. The mean length of stay in MICU for VAP patients was 23.8 +/- 19.8 days, which was four-fold higher than for non-VAP patients. The daily cost for VAP patients was half that for non-VAP patients. The total costs for VAP patients were about three-fold higher than for non-VAP patients. (C) 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

The objectives of this study were to assess the determinants of empirical antibiotic choice, prescription patterns and outcomes in patients with hospital-acquired pneumonia (HAP)/ ventilator-associated pneumonia (VAP) in Europe. We performed a prospective, observational cohort study in 27 intensive care units (ICUs) from nine European countries. 100 consecutive patients on mechanical ventilation for HAP, on mechanical ventilation .48 h or with VAP were enrolled per ICU. Admission category, sickness severity and Acinetobacter spp. prevalence .10% in pneumonia episodes determined antibiotic empirical choice. Trauma patients were more often prescribed non- anti-Pseudomonas cephalosporins (OR 2.68, 95% CI 1.50-4.78). Surgical patients received less aminoglycosides (OR 0.26, 95% CI 0.14-0.49). A significant correlation (p,0.01) was found between Simplified Acute Physiology Score II score and carbapenem prescription. Basal Acinetobacter spp. prevalence .10% dramatically increased the prescription of carbapenems (OR 3.5, 95% CI 2.0-6.1) and colistin (OR 115.7, 95% CI 6.9-1,930.9). Appropriate empirical antibiotics decreased ICU length of stay by 6 days (26.3i19.8 days versus 32.8i29.4 days; p50.04). The antibiotics that were prescribed most were carbapenems, piperacillin/tazobactam and quinolones. Median (interquartile range) duration of antibiotic therapy was 9 (6-12) days. Anti- methicillin-resistant Staphylococcus aureus agents were prescribed in 38.4% of VAP episodes. Admission category, sickness severity and basal Acinetobacter prevalence .10% in pneumonia episodes were the major determinants of antibiotic choice at the bedside. Across Europe, carbapenems were the antibiotic most prescribed for HAP/VAP.

Objective A variable association between single umbilical artery (SUA) and congenital heart disease (CHD) has been reported previously. Discrepancies in the results may be related to the populations studied. In this study we assessed the relationship between SUA and CHD in two well-defined selected and unselected populations. Methods This was a retrospective review of all cases of SUA detected antenatally in a tertiary referral center between 1997 and 2003. Umbilical arteries were routinely identified around the fetal bladder by color-flow Doppler ultrasonography. The unselected population included pregnancies from a well-defined geographical area, delivering in the same hospital. The selected group was referred from other hospitals because of suspected abnormalities or other risk factors. Major CHD was defined as CHD needing postnatal treatment or long-term follow-up. Results There were 10 fetuses with major CHD in the selected group: four cases among 25 with extracardiac defects (16%; 95% CI, 4.5–36.1%) and six cases out of 22 with no other abnormalities (27%; 95% CI, 10.7–50.2%; P = 0.35). In the unselected group there were two cases of major CHD, both among the 13 fetuses with extracardiac abnormalities (15%; 95% CI, 2–45%), while there were no major cardiac defects in the 85 fetuses with SUA and no extracardiac abnormalities (0%; 95% CI, 0–4%; P = 0.03). Conclusions The association between SUA and CHD varies dramatically with population selection criteria. The risk for CHD after the detection of SUA in an otherwise apparently normal fetus from an unselected population seems small and may not warrant specialist fetal echocardiography. Copyright © 2010 ISUOG. Published by John Wiley & Sons, Ltd.

Amac: Tum gelismelere ragmen mekanik ventilasyondan ayrilma yogun bakim unitelerinde onemli bir sorundur. Bu calismanin amaci intramukozal pH (pHi) ve gastrik sivinin pCO2 (PiCO2) daki degisiklikleri olcmek ve YBU hastalarindaki weaning basarisizliginin belirleyicisi olarak bu degiskenlerin onemini arastirmaktir. Gerec ve Yontemler: Mekanik Ventilasyondan (MV) ayrilmaya hazir oldugu dusunulen kirk hasta (20 erkek, 20 kadin) calismaya alindi. Tum hastalar weaning calismasindan once en az 2 saat icin basinc destekli MV da tutuldu. PiCO2 bir tonometre ve monitor ile degerlendirildi. Weaningin baslangicinda, MV sonlandirildi ve 2 saatlik T tup calismasi sonrasi ekstubasyon uygulandi. Hastalar en az 24 saat icin izlendi. Bulgular: 28 hasta basari ile ayrilirken 12 hastada weaning basarisiz oldu. Baslangic SaO2 seviyeleri basarili vakalarda onemli derecede yuksekti (p 0.05). pHi (7.319±0.12 ve 7.12±0.21 p=0.002) ve SaO2 seviyeleri (96.87±2.83 ve 93.92±3.47, p 0.05). Weaning basarisizligini gosteren en iyi parametreler baslangic PaCO2, son pHi, son PiCO2 seviyeleri ve ΔpHi idi. Sonuc: Weaning basarisizligi gastrik intramukozal asidoz ile iliskilidir. Weaning basarisizligi olan hastalarda PiCO2 de bir artma veya pHi de bir azalma oldugu bulundu. Bununla birlikte, gastrik tonometrik olcumlerin belirleyicilik degerleri reentubasyon karari vermek icin yeterli degildi. 6. saatten sonra gozlenen sonuclar weaning basarisizligi hakkinda fazla bilgi vermedi. Bundan dolayi, weaning gidisatini degerlendirmek icin 6 saatlik bir izlem peryodu yeterli olabilir. (Yogun Bakim Derg 2010; 3: 55-9)

Our aim was to investigate the association between total serum homocysteine, vitamin B12 and folate levels in pregnant women with gestational diabetes mellitus (GDM), glucose intolerance and compare them with those of glucose tolerant pregnant women. Serum homocysteine, vitamin B12 and serum folate levels were prospectively measured in a total of 223 pregnant women who were grouped according to their status of glucose tolerance as gestational diabetes (abnormal 1-h and 3-h glucose tolerance test; n = 30), glucose intolerant (abnormal 1-h, but normal 3-h glucose tolerance test; n = 46) or normal controls (normal 1-h glucose test; n = 147). Mean serum homocysteine concentration of women in gestational diabetes, glucose intolerants and normal controls at 24–28 weeks of gestation was 9.0 ± 3.1, 8.1 ± 2.5 and 7.4 ± 1.6 μmol/l, respectively. The only statistically difference in homocysteine levels was observed between women with gestational diabetes and normal controls (P

Purpose: To define the cranial magnetic resonance imaging (MRI) features of the chronic stage of carbon monoxide (CO) poisoning in patients with and without neuropsychiatric sequelae. Material and Methods: Eight patients who had neither symptoms nor neurological sequelae and eight patients with neuropsychiatric sequelae were included in the study. Patients aged between 9 to 57 (mean 32.2 years). All patients had been comatose at initial admittance and awoke after normobaric 100% oxygen therapy within 1–7 days. In this study, the patients were being examined with routine cranial MRI between 1 and 10 years (mean 3.4 years) after exposure to CO. Results: The most common finding was bilateral symmetric hyperintensity of the white matter, which was more significant in the centrum semiovale, with relative sparing of the temporal lobes and anterior parts of the frontal lobes on T2‐weighted and FLAIR images in all patients. Cerebral cortical atrophy was seen in 10 patients; mild atrophy of cerebellar hemispheres in 8; and vermian atrophy in 11. Corpus callosum was atrophic in one patient. Bilateral globus pallidus lesions were seen in three patients. The lesions were hypointense on T1‐weighted images and hyperintense on T2‐weighted and FLAIR images. Conclusion: Patients with severe CO intoxication may develop persistent cerebral changes independently of their neuropsychiatric findings in the chronic stage. They may present with characteristic MRI findings as described here, even if asymptomatic. The history of CO exposure is therefore helpful for recognizing and interpreting the MRI findings of chronic stage CO intoxication.

Plasma exchange therapy has been successfully used in selected patients with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome who have organ failure or refractory to treatment. There is no prospective study regarding plasma exchange and its effect in HELLP syndrome. The aim of this study was to investigate the effects of early postpartum use of plasma exchange in patients with HELLP syndrome on outcomes. The mortality rate and the recovery times were compared in patients with HELLP syndrome treated with plasma exchange and historic control group of patients treated conservatively. During a 3-year period (between April 2000 and December 2003), 29 consecutive patients with HELLP syndrome were treated with single or multiple plasma exchange by using fresh-frozen plasma at post-partum period. The control group consist of 26 patients with HELLP syndrome treated between 1993 and 1999. Maternal mortality rate was 23.1% in the control group; there was no death in plasma exchange group; and the mortality rate was significantly higher in the control group (p=0.006). The length of stay at the intensive care unit was shorter in the plasma exchange group (p

Several tumor markers are significantly elevatedduring the course of pregnancy. The underlyingcause of this rise may be related to the tropho-blastic activity of the placenta [1]. Certain nuclearmatrix proteins (NMPs) have also been identified ascancer specific markers among human colon, breastand bone cancer. They are detectable in voidedurine [2]. Nuclear matrix protein 22 (NMP-22) hasbeen shown to be a useful tumour marker foridentifying recurrence of transitional cell carci-noma of the urinary tract [3]. However, its urinarylevel in pregnancy has not been investigated yet.Our aim was to investigate this latter issue.The urinary NMP-22 levels of 64 healthy pregnantwomen were measured at different gestationalages and 18 age matched non-pregnant healthywomen in a spot morning urine sample using thecommercially available NMP-22 test kit.Statistical analysis was performed using theStudent’s T-test and Pearson’s two-tailed method.The results are given in meansFstandard deviation(S.D.).Theageofpregnantwomeninthefirst,second, and third trimester and those of non-pregnant controls was (XFS.D.: meanFstandarddeviation; range) 25.7F4.9 (20—37), 28.7F6.2(20—42), 25.6F4.5 (18—35) and 27.9F5.8 (19—37), respectively (pN0.05). Urinary NMP-22 levelsare shown at Table 1. There was also an increaseof urinary NMP-22 with advancing gestational age(pb0.01; Fig. 1).This is the first study showing that urinary NMP-22 levels tend to increase with advancing gesta

To determine the frequency, risk factors and mortality of nosocomial pneumonia a prospective study was conducted in the intensive care units. In the study period, 2402 patients were included. The nosocomial pneumonia was defined according to the Centers for Disease Control Criteria. Overall, 163 (6.8%) of the patients developed nosocomial pneumonia and 75.5% (n = 123) of all patients with nosocomial pneumonia were ventilator-associated pneumonia. 163 patients who were admitted to the intensive care unit during the same period but had no bacteriologic or histologic evidence of pneumonia were used as a control group. The APACHE II score, coma, hypoalbuminemia, mechanical ventilation, tracheotomy, presence of nasogastric tube were found as independent risk factors. Crude and attributable mortality were 65% and 52.6%, respectively. The mortality rate was five times greater in the cases (OR: 5.2; CI 95%: 3.2–8.3). The mean length of stay in the intensive care unit and hospital in the cases were longer than controls (p < 0.0001). Patients requiring mechanical ventilation have a high frequency of nosocomial pneumonia.

Objective: To describe the role of plasmapheresis in management of organophosphate poisonings. Design: Case report. Setting: A medical intensive care unit of a medical faculty. Patient: A patient with organophosphate poisoning whose cholinesterase levels continuously decline and then increase up to a normal level after plasmapheresis is performed for his sepsis. Interventions: Plasmapheresis with fresh frozen plasma. Measurements and main results: Baseline plasma cholinesterase (ChE) level was 4001 IU/L (normal values: 4000-10000 IU/L). Aspiration pneumonia was developed on day 3, and sepsis occurred on day 5. During this period, ChE levels gradually decreased. On day 5, plasmapheresis was performed for sepsis. Interestingly, plasma ChE levels increased from 2101 IU/L to 6144 IU/L after plasmapheresis. Atropine and pralidoxime were stopped, and a high level of ChE continued during hospitalization. The patient was successfully weaned from mechanical ventilation 3 days after plasmapheresis. Conclusion: Plasma exchange therapy may be considered for patients with organophosphate poisoning unresponsive to atropine and pralidoxime.

Objectives: We evaluated the value of hydrosonography in screening for intracavitary pathologies in infertile patients. Methods: A total of 93 infertile women with suspected intracavitary lesions on transvaginal ultrasonography (TVS) underwent hydrosonography. Specimens obtained either by dilatation and curettage or hysteroscopic resection were compared with findings on TVS and hydrosonography. Results: Pathology confirmed the presence of sonographically diagnosed intracavitary lesions in 40 out of 66 (60%) women. The sensitivity, specificity, positive predictive value, and negative predictive value of TVS for the detection of endometrial cavity lesions were 78%, 38%, 61%, and 59%, respectively. Forty-six out of 71 (65%) women who were found to have intracavitary lesions on hydrosonography were pathologically confirmed. The sensitivity, specificity, positive and negative predictive value of hydrosonography in the detection of endometrial cavity lesions were 90%, 40%, 65%, and 77%, respectively. Conclusions: Hydrosonography is a useful procedure in screening for intracavitary pathologies and allows differentiation of intracavitary, endometrial, and submucosal abnormalities.

This study was performed to confirm the therapeutic effects of low-dose, (2.5 mg/day) finasteride in hirsute women. Our study was a non-randomized prospective clinical trial. Twenty-nine patients with hirustism were included in the study. The patients received 2.5 mg finasteride once a day over a period of 12 months. Follicle stimulating hormone, luteinizing hormone, sex hormone binding globulin, 17 alpha-hydroxyprogesterone, estradiol, androstenedione, total and free testosterone, dehydroepiandrosterone sulfate levels and hirsutism scores were determined in all patients before treatment and at every 6 months during the therapy. The hirsutism score decreased from a mean of 18.4 +/- 4.6 to 8.4 +/- 4.2 during the study. The per cent reduction in hirsutism score (mean +/- SD) at 6 and 12 months was 29.2 +/- 14.5 and 55.7 +/- 14.9%, respectively. There were no significant differences in any of the hormone levels and no serious side-effects were observed during the treatment. In conclusion, low-dose finasteride (2.5 mg/day) is a cost-effective, well-tolerated therapeutic agent without significant abnormal biochemical findings and can be used in place of high-dose (5 mg/day) finasteride in the treatment of hirsutism.

Objective: The aim of this study is to determine the effects of fresh frozen plasma, as a source of cholinesterase, on butyrylcholinesterase (BuChE; plasma or pseudo cholinesterase) levels and outcomes in patients with organophosphate poisoning. Materials and Methods: This prospective study was performed at the Department of Intensive Care of Erciyes University Medical School. Over 2 yrs, patients admitted to the ICU for OP poisoning were entered into the study. OP poisoning was diagnosed on the basis of history and BuChE levels. All patients received atropine. Fresh frozen plasma was given to 12 patients. The study was approved by the Ethical Committee, and verbal informed consent was obtained. Results: Thirty-three patients were included in the study. BuChE levels measured at admission and the pralidoxime and atropine doses administered were not different between groups (p>0.05). Although intermediate syndrome developed in 28.6% of patients receiving pralidoxime, there were no intermediate syndrome cases in patients receiving plasma prior to developing intermediate syndrome. The mortality rates were 14.3% in the pralidoxime group and 0% in the plasma+ atropine+ pralidoxime group. Two patients received plasma after developing the intermediate syndrome, and one patient who received only atropine died. BuChE levels of fresh frozen plasma were 4069.5 +/- 565.1 IU/L. Every two bags of plasma provided an increase in BuChE levels of approximately 461.7 +/- 142.1 IU/L. Conclusion: Fresh frozen plasma therapy increases BuChE levels in patients with organophosphate poisonings. The administration of plasma may also prevent the development of intermediate syndrome and related mortality. Plasma (fresh frozen or freshly prepared) therapy may be used as an alternative or adjunctive treatment method in patients with organophosphate pesticide poisoning, especially in cases not given pralidoxime. Further randomized controlled and animal studies are required to infer a definitive result.

To describe MR imaging findings of the chronic stage of carbon monoxide poisoning in asymptomatic patients.Clinical data of 34 patients, who had been admitted to our hospital for carbon monoxide poisoning were reviewed and invited for control evaluation. Of the patients who accepted, ten who had no symptoms and neurological sequelae in the physical examination were included in the study. All patients had been in coma on initial admittance and had awakened after normobaric 100% oxygen therapy 1-10 years ago. Their ages were between 22-57 years (mean, 36.2 years). All patients were examined with cranial MR imaging.The most common finding was bilateral symmetric hyperintensity of the white matter more evident in the centrum semiovale with relative sparing of temporal lobes and anterior parts of frontal lobes on T2-weighted and FLAIR images in all patients. Subcortical U-fibers were intact in all patients. Cerebral cortical atrophy of variable degrees was seen in eight patients, mild atrophy of cerebellar hemispheres in seven patients, and vermian atrophy in nine patients. Corpus callosum was atrophic in two patients. Bilateral globus pallidus lesions were seen in three patients as hypointense on T1-weighted and hyperintense on T2-weighted and FLAIR images.Cerebral changes may be present in patients with severe CO poisoning even when the patient becomes asymptomatic. Knowledge of these findings would be helpful when evaluating these patients for follow-up or for other reasons.