Yalcin Onem

Risk assessment study of the pressure ulcers in intensive care unit patients

In this research, we studied the incidence of pressure ulcer and risk factors and screening of the patients for pressure ulcers at intensive care unit on the first day of admission in 142 patients. All patients were evaluated according to National Pressure Ulcer Advisory Panel during the ICU period strictly. Pressure ulcer risk evaluation was performed according to Norton Scale. Nutritional state was evaluated according to nutritional risk screening 2002. Age, hospitalization period, mean arterial pressure, pressure ulcer degree, hemoglobin and albumin levels, body mass index, APACHE-II scores and comorbidities were evaluated. In the following parameters, first value represents PU (+) cases, and second value represents PU (-) cases. On the admittance: 14 (9.8%) patients had PU (prevalence). NRS-2002: 5.4+/-1.9 and 4.3+/-2.1 (p<0.05), Norton score: 8.4+/-4.7 and 13.9+/-4.6 (p<0.05), albumin 2.7+/-0.7 g/dl and 3.2+/-0.8 g/dl (p<0.05). MAP and hemoglobin levels were not different (p>0.05). Mean pressure ulcer degree was 2.15. On the discharge: first values represent new developed PU (+) patients and second values represent PU (-) cases. 25 (17.6%) patients had PU. Incidence was 7.8%. NRS-2002: 6.4 and 3.6 (p<0.05), Norton score: 7.1 and 14.4 (p<0.05), albumin 2.2 g/dl and 3.0 g/dl (p<0.05). MAP 55.15+/-24.10 mm Hg and 79.76+/-18.12 mm Hg (p<0.05), APACHE-II score 22.3+/-4.2 and 18.2+/-6.2 (p<0.05). Hospitalization period: 18.3+/-10.3 days and 6.6+/-4.3 days (p<0.05) respectively. BMI and hemoglobin levels were not different (p>0.05). Two or more co morbidity, neurophyschiatric disorders, infections and medications were more prevalent in PU (+) group (p<0.05). Results of this study show us the PU incidence of ICU patients may be low if we perform PU screening all patients at the admission and put into practice NPUAP strictly. Age, low Norton score, hospitalization period, high APACHE-II score, hypotension, malnutrition and hypoalbuminemia were significant in patients with PU; however, BMI and hemoglobin were not significant. The studies focusing on the relation between the effect of optimization of these parameters from the first day of admittance and pressure ulcer are required.

Albumin, hemoglobin, body mass index, cognitive and functional performance in elderly persons living in nursing homes

The aim of this study is to produce the relation between cognitive and functional performance and some biochemical parameters in elderly population. So, we searched for the correlation between the activities of daily living (ADL), mini-mental state examination (MMSE) and body weight, age, hemoglobin, albumin, serum sodium level of 180 elderly people in five nursing homes. Face-to-face interviews and questionnaires were applied to evaluate ADL. To evaluate the cognitive function we used the MMSE. The average age of 180 people contacted was 71.5+/-5.1 (+/-S.D.), ranging 65-91 years; 112 of them were women (62.2%), 68 were men (37.8%). Of these elderly people, 25% had no medically diagnosed illnesses, whereas 17 of them (9.4%) were bedridden. There was a positive correlation between ADL and hemoglobin, albumin, body weight, cognitive function parameters and a negative one with age and serum sodium. There was a positive correlation between cognitive functions and hemoglobin, body weight, ADL and a negative one with serum sodium. Hemoglobin concentrations indicating anemia were observed in 30% of subjects, 3.9% of them had hyponatremia and 26.7% displayed a hypernatremia. There was a positive correlation between cognitive and physical function scores and hemoglobin, albumin levels in elderly patients. These results suggest that restoration of hemoglobin and albumin levels could improve cognitive and physical functional status in the elderly population.

Relationship between anaemia and cognitive functions in elderly people

BACKGROUND The primary goal of the present study was to investigate the effects of anaemia on the cognitive functions and daily living activities in elderly people. METHODS This sectional study was performed using 180 elderly people. Face-to-face interviews and questionnaires were conducted to evaluate daily activities. To evaluate cognitive functions we used the Folsteins Mini-Mental State Examination (MMSE). RESULTS The mean age of the anaemic group and the nonanaemic group were 76.0+/-11.7 and 72.5+/-15.2 years, respectively. The average haemoglobin level among the anaemic population was 10.4 g/dL compared with 13.6 g/dL among the nonanaemic population; a statistically significant difference. There was more impairment in functional status (Katz ADL) (6.8+/-4.3 vs 9.3+/-3.7) and cognition (MMSE) (17.9+/-6.4 vs 21.7+/-6.7) in anaemic than nonanaemic groups, respectively. Albumin and body mass index were lower and the percentage of two or more comorbidities was higher in anaemic group compared to the nonanaemic group, which was a statistically significant variation. The anaemic group was more dependent in terms of bathing, dressing, toileting and transferring. CONCLUSION In the elderly anaemic group, the dependency for daily activities that require physical effort was higher compared to the nonanaemic group. The MMSE score in the elderly anaemic group was lower than subjects who had normal haemoglobin levels. We conclude that anaemia may impair cognitive functions and some daily living activities in the elderly.

Increasing incidence of Gram-negative organisms in bacterial agents isolated from diabetic foot ulcers

INTRODUCTION In the present study, we sought to identify the bacterial organisms associated with diabetic foot infections (DFIs) and their antibiotic sensitivity profiles. METHODOLOGY We retrospectively reviewed the records of wound cultures collected from diabetic patients with foot infections between May 2005 and July 2010. RESULTS We identified a total of 298 culture specimens (165 [55%] wound swab, 108 [36%] tissue samples, and 25 [9%] bone samples) from 107 patients (74 [69%] males and 33 [31%] females, mean age 62 ± 13 yr) with a DFI. Among all cultures 83.5% (223/267) were monomicrobial and 16.4% (44/267) were polymicrobial. Gram-negative bacterial isolates (n = 191; 61.3%) significantly outnumbered Gram-positive isolates (n = 121; 38.7%). The most frequently isolated bacteria were Pseudomonas species (29.8%), Staphylococcus aureus (16.7%), Enterococcus species (11.5%), Escherichia coli (7.1%), and Enterobacter species (7.1%), respectively. While 13.2% of the Gram-negative isolates were inducible beta-lactamase positive, 44.2% of Staphylococcus aureus isolates were methicillin resistant. CONCLUSIONS Our results support the recent view that Gram-negative organisms, depending on the geographical location, may predominate in DFIs.

Hantavirus Infection in Istanbul, Turkey

To the Editor: More than 20 serotypes of hantavirus have been identified, and 11 infect humans. Puumala virus (PUUV), Dobrava virus (DOBV), and Seoul virus cause different forms of hemorrhagic renal syndrome (1,2). DOBV is endemic to Turkey and countries in the Balkan region. Approximately 10,000–12,000 cases of infection with PUUV and DOBV occur in European Russia each year (3). Initial case reports identified a hantavirus epidemic (laboratory confirmed) in February 2009 that involved 12 persons in Bartin and Zonguldak in western Turkey near the Black Sea. The hantavirus responsible for this epidemic was a PUUV subtype (4). We report a man infected with DOBV in Turkey who died 2 days after admission to an intensive care unit (ICU). The patient was a 22-year-old man who lived near Istanbul, Turkey. He was admitted to the Silivri State Hospital in March 2010 because of fatigue, diffuse pain, nausea, and vomiting. Approximately 2 hours after admission, ecchymotic rashes developed on his upper extremities and spread to other areas. His general condition worsened, and 15 hours later, he was transferred to the ICU of the Emergency Service of Gulhane Military Medical Academy Haydarpasa Training Hospital. His medical history did not include exposure to rodents or any travel. At admission to the ICU, his general condition was poor, and his speech was garbled and incoherent. He had a body temperature of 37.2°C, a pulse of 140 beats/min, an arterial blood pressure of 90/60 mm Hg, diffuse hemorrhagic foci, and a disseminated ecchymotic rash. Laboratory test results showed the following: 13,200 leukocytes/mm3, 92% polymorphonuclear leukocytes, hemoglobin 11.6 mg/dL, 385,000 platelets/mm3, alanine aminotransferase 62 IU/mL, aspartate aminotransferase 170 IU/mL, creatine phosphokinase 2,115 IU/L, lactate dehydrogenase 1,109 IU/L, urea 65 mg/dL, creatinine 3.78 mg/dL, prothrobin time 24.8 s, activated partial thromboplastin time 116.3 s, potassium 2.9 mEq/L, C-reactive protein 326 mg/dL, and erythrocyte sedimentation rate 132 mm/h. Subsequently, urinary output decreased and respiratory functions worsened. He then lost consciousness and was subjected to mechanic ventilation. Lumbar puncture was not performed because of risk for bleeding (high international normalized ratio values for blood coagulation and thrombocytopenia). Cranial computed tomographic scan did not show any pathologic changes. Treatment with ceftriaxone, 4 g/day intravenously, was initiated, and the dose was adjusted according to creatinine clearance because of suspected meningococcemia. A single dose of prednisolone, 80 mg intravenously, was given concomitantly. Bacterial growth was not observed in cultures of urine and blood samples. The Hanta Profile 1 EUROLINE Test (Euroimmun, Luebeck, Germany) was used to detect immunoglobulin (Ig) G and IgM against 3 hantavirus serotypes (PUUV, DOBV, and Hantaan virus). Results of a hantavirus IgM immunoblot test were positive for DOBV. The QIAamp viral RNA Mini Extraction Kit (QIAGEN, Hilden, Germany) was used for extraction of viral RNA. PUUV and DOBV RNA in serum and urine samples were investigated by using an in-house real-time PCR (Rotorgene; QIAGEN). DOBV RNA was detected in urine samples by PCR (Table). Table Detection of Dobrava virus in 22-year-old patient, Turkey* Meningococcemia, acute hemorrhagic fever, and Crimean-Congo hemorrhagic fever were considered in the differential diagnosis for the patient. Other diseases were excluded by biochemical, serologic, and microbiologic test results. Hantavirus infection was diagnosed in this patient on the basis of criteria recommended by the European Network for Diagnostics of Imported Viral Diseases (5). On the second day of treatment, the patient died of cardiopulmonary arrest. The patient had worked as a security guard in a new prison located in an area that had contained oak and hornbeam forests. DOBV is carried by rodents (Apodemus flavicollis), and the habitat of this rodent in Europe is open oak or beech forest. In a field study performed in rural areas of Turkey near the Black Sea and Aegean Sea, hantavirus was detected in Microtus spp. voles (6). In another study performed in regions near the Aegean Sea, DOBV was detected in 7 (3.5%) of 200 patients with acute or chronic renal failure (7). However, information about specific regions in Turkey in which hantavirus is endemic is limited. Hantavirus infections, which were first identified in northwestern Turkey in 2009 and subsequently in Istanbul, should be considered in the diagnosis of patients who have fever and bleeding. Because of recent emergence of hantavirus in Turkey, areas to which this virus is endemic and where risk for infection is highest have not been identified. Therefore, all inhabitants at high risk for infection (forest workers, military personnel, farmers, persons living in or near a forest, persons handling wood) should be informed about this risk.

Posttreatment with Aminoguanidine Attenuates Renal Ischemia/Reperfusion Injury in Rats

Acute renal failure secondary to ischemia/reperfusion (I/R) injury is associated with significant mortality and morbidity. Aminoguanidine (AG), an inducible nitric oxide synthase inhibitor with antioxidant properties, has been reported beneficial in renal I/R injury. The aim of the present study was to investigate the effect of AG on renal I/R injury and compare the effectiveness of different AG treatment modalities. Sprague-Dawley rats were randomly assigned to one of four groups. The control group (n = 6) received sham operation. The I/R group (n = 6), AG-I group (n = 8), and AG-II group (n = 8) received bilateral renal ischemia for 45 min followed by 24 hours of reperfusion. The AG-I group received AG (50 mg/kg) intraperitoneally four hours and 10 minutes before the induction of ischemia. The AG-II group received AG (50 mg/kg) intraperitoneally four hours and 10 minutes after the initiation of reperfusion. Serum urea and creatinine levels increased significantly in the I/R and AG-I groups compared to the control group. Kidney samples from rats in the I/R and AG-I groups revealed severe tubular damage at histopathological examination. Posttreatment with AG significantly reduced serum urea and creatinine levels and improved histopathological lesions compared with the I/R group. Although pretreatment with AG failed to protect kidneys against I/R injury in this experimental model, posttreatment with AG attenuated renal dysfunction and histopathological changes after I/R injury.

Effect of Hyperbaric Oxygen on Cyclosporine-Induced Nephrotoxicity and Oxidative Stress in Rats

Reactive oxygen species have been suggested to be involved in cyclosporine nephrotoxicity. Hyperbaric oxygen is known to induce the generation of reactive oxygen species in tissues. The aim of this study was to investigate whether the use of hyperbaric oxygen concurrently with cyclosporine potentiates cyclosporine nephrotoxicity by inducing oxidative stress in kidneys. The study consisted of four groups of rats: a control group, a cyclosporine group (15 mg/kg/day intraperitoneally for 14 days), a hyperbaric oxygen group (60 min. every day for five days at 2.5 atmosphere absolute), and a cyclosporine + hyperbaric oxygen group (cyclosporine 15 mg/kg/day intraperitoneally for 14 days + hyperbaric oxygen for 60 min at 2.5 atmosphere absolute every day for five days on the last five days of cyclosporine treatment). Oxidative stress was determined by measuring renal thiobarbituric acid-reactive substances content, renal superoxide dismutase, and glutathione peroxidase activities. Cyclosporine increased serum urea and creatinine levels, indicating the development of nephrotoxicity, and induced significant oxidative stress in rat kidneys. Hyperbaric oxygen alone did not alter any of the biochemical and oxidative stress parameters compared to the control group. When used concurrently with cyclosporine, hyperbaric oxygen significantly reduced cyclosporine-induced oxidative stress, but it neither attenuated nor aggravated cyclosporine-induced nephrotoxicity. These results suggest that reactive oxygen species are involved in cyclosporine nephrotoxicity, but are not the direct cause of the toxicity. Although concurrent use of cyclosporine and hyperbaric oxygen did not exacerbate cyclosporine nephrotoxicity in this model, we recommend that the renal functions of patients be monitored periodically when these treatments are used concurrently.

Hyperbaric Oxygen Therapy Does Not Potentiate Doxorubicin‐Induced Cardiotoxicity in Rats

The current use of doxorubicin is regarded as an absolute contraindication for hyperbaric oxygen (HBO2) therapy because of the increased risk of cardiotoxicity. The aim of this study was to investigate whether additional exposure to HBO2 during the course of doxorubicin treatment would further increase the cardiotoxicity of doxorubicin in rats. Female Wistar rats were treated with either HBO2 (n = 10) or doxorubicin (n = 8) or a combination of both treatments (n = 10) for 4 consecutive weeks and followed up for an additional 4 weeks. Cardiomyopathy was evaluated using two-dimensional and M-mode echocardiography at baseline, at the fourth, sixth and eighth weeks, and by histopathological investigation of the rat hearts at the eighth week. Doxorubicin treatment significantly reduced ejection fraction and fractional shortening (P < 0.001) and caused severe histopathological injury (P < 0.05) indicating development of cardiotoxicity. Although the combination of doxorubicin and HBO(2) also markedly reduced ejection fraction and fractional shortening (P < 0.001), this reduction was significantly less than that of doxorubicin treatment (P < 0.05). HBO2 therapy also attenuated doxorubicin-induced histopathological changes in rat hearts (P < 0.05). HBO2 alone did not alter echocardiographic parameters or histopathological findings (P > 0.05). In conclusion, HBO2 therapy does not potentiate doxorubicin-induced cardiotoxicity in rats. Cardioprotection conferred by HBO2 against doxorubicin warrants further investigation.

Piperacillin/tazobactam-induced neutropenia, thrombocytopenia, and fever during treatment of a diabetic foot infection.

Abstract Piperacillin/tazobactam (PTZ) is frequently used in patients with diabetic foot infections. Herein, we report a patient who developed severe neutropenia, thrombocytopenia, and fever while receiving PTZ for a diabetic foot infection. We recommend vigilance when long-term PTZ use is planned in patients with diabetic foot infections.

Analyses of Subjects with Hypokalemic Metabolic Alkolosis, Gitelman's and Bartter's Syndrome

The two most common forms of inherited normotensive hypokalemic metabolic alkalosis are Bartters and Gitelmans syndromes. Bartters is mostly seen in children, while Gittelmans is mostly seen in adolescents and adults. We analyze three subjects of adult-onset Gitelmans and Bartters syndrome. The patients applied to our hospital due to severe hypokalemia with little clinical expression (paresthesia, cramp, polyuria, polydipsia, and/or weakness). All had normal blood pressure, hypokalemia, hyperreninemic hyperaldosteronism, and a decrease in the fractional chloride reabsorption. Key elements in differential diagnosis of chronic hypokalemia are blood pressure assessment, acid base equilibrium, serum calcium concentration, and 24-hour urine potassium and calcium excretion.