Pneumonia severity indices predict prognosis in coronavirus disease-2019.

BACKGROUND: Early recognition of the severe illness is critical in coronavirus disease-19 (COVID-19) to provide best care and optimize the use of limited resources. OBJECTIVES: We aimed to determine the predictive properties of common community-acquired pneumonia (CAP) severity scores and COVID-19 specific indices. METHODS: In this retrospective cohort, COVID-19 patients hospitalized in a teaching hospital between 18 March-20 May 2020 were included. Demographic, clinical, and laboratory characteristics related to severity and mortality were measured and CURB-65, PSI, A-DROP, CALL, and COVID-GRAM scores were calculated as defined previously in the literature. Progression to severe disease and in-hospital/overall mortality during the follow-up of the patients were determined from electronic records. Kaplan-Meier, log-rank test, and Cox proportional hazard regression model was used. The discrimination capability of pneumonia severity indices was evaluated by receiver-operating-characteristic (ROC) analysis. RESULTS: Two hundred ninety-eight patients were included in the study. Sixty-two patients (20.8%) presented with severe COVID-19 while thirty-one (10.4%) developed severe COVID-19 at any time from the admission. In-hospital mortality was 39 (13.1%) while the overall mortality was 44 (14.8%). The mortality in low-risk groups that were identified to manage outside the hospital was 0 in CALL Class A, 1.67% in PSI low risk, and 2.68% in CURB-65 low-risk. However, the AUCs for the mortality prediction in COVID-19 were 0.875, 0.873, 0.859, 0.855, and 0.828 for A-DROP, PSI, CURB-65, COVID-GRAM, and CALL scores respectively. The AUCs for the prediction of progression to severe disease was 0.739, 0.711, 0,697, 0.673, and 0.668 for CURB-65, CALL, PSI, COVID-GRAM, A-DROP respectively. The hazard ratios (HR) for the tested pneumonia severity indices demonstrated that A-DROP and CURB-65 scores had the strongest association with mortality, and PSI, and COVID-GRAM scores predicted mortality independent from age and comorbidity. CONCLUSION: Community-acquired pneumonia (CAP) scores can predict in COVID-19. The indices proposed specifically to COVID-19 work less than nonspecific scoring systems surprisingly. The CALL score may be used to decide outpatient management in COVID-19.

Effects of ABO incompatibility in allogeneic hematopoietic stem cell transplantation.

INTRODUCTION: The impact of ABO mismatch on outcomes following allo-HSCT remains controversial. In this study, our aim is to define the effect of ABO mismatch on post-transplant outcomes, engraftment kinetics and complications in a large cohort. PATIENTS AND METHODS: We retrospectively identified 1000 patients who underwent allo-HSCT from either bone marrow or peripheral blood stem cells at our center between 1988 and 2016. P<0.05 was considered statistically significant. RESULTS: Five hundred and ninety (59%) patient-donor pairs were ABO matched, 164 (16.4%) were ABO major mismatched (MM), 191 (19.1%) were ABO minor MM, and 55 (5.5%) were ABO bi-directionally MM. ABO matched pairs were more common in transplants from related donors (P<0.001) and using bone marrow as a stem cell source (P<0.001). In minor ABO MM transplantations, mild delayed hemolytic reaction occurred more frequently compared to major and bidirectional ABO MM transplantations (47% vs 35% and 18%, P<0.001). Neutrophil engraftment was slightly delayed in ABO MM patient-donor pairs when compared ABO matched donor pairs according to median engraftment time in all group (167/410, 41% vs 204/590, 35%, P=0.046). Pure red cell aplasia was diagnosed in 6 patients (1%). Higher risk of death was shown in ABO MM transplants compared to ABO matched transplants in overall survival (OS) analysis (HR:1.201, 95% CI:1.004-1.437, P=0.045). The non-relapse mortality (P=0.546) and cumulative incidences of acute graft versus host disease (aGVHD) and chronic (c) GVHD were comparable between ABO MM and ABO matched patient-donor pairs (for aGVHD, P=0.235; for cGVHD, P=0.137). CONCLUSION: ABO MM transplants were associated with decreased OS and slightly delayed neutrophil engraftment. NRM and the risk of GVHD were not related to ABO incompatibility.

Postoperative visual impairment after spinal fusion surgery.

OBJECTIVE: The aim of this prospective study was to detect risk factors for visual impairment or changes in vision following spinal fusion surgery. METHODS: A total of 68 patients aged 18-65 years, scheduled for posterior spinal fusion surgery, were included. Ophthalmic examinations were performed by an ophthalmologist on the day before surgery and repeated after the second postoperative day, within the first postoperative week. Patient characteristics were compared according to two clinical outcomes following surgery: worsening of vision during the pre- and postoperative interval (group 1) and no change in pre- and postoperative examinations (group 2). RESULTS: The mean age of patients with postoperative visual changes was significantly higher than that for patients without postoperative visual changes. Total number of female patients and use of intraoperative ephedrine to treat hypotensive episodes were significantly higher in group 1 than in group 2 patients. CONCLUSION: Older age, female gender and intraoperative hypotensive episodes are potential risk factors for postoperative visual impairment in patients who have undergone spinal fusion surgery.

Prevalence of cypress pollen sensitization and its clinical importance in Izmir, Turkey, with cypress allergy assessed by nasal provocation.

BACKGROUND AND OBJECTIVE: Pollens from the Cupressaceae family are considered important allergens in the Mediterranean area, though reports of the prevalence of allergic symptoms have ranged from 1.04% to 35.4%. Our aim was to detect the prevalence of cypress pollen sensitization and determine its clinical importance in patients with seasonal respiratory allergy. METHODS: We used skin prick tests (SPT) and serum specific IgE assays to reveal sensitization to cypress pollen. In patients who showed positive results to cypress pollen, a nasal provocation test (NPT) with pollen extract was used to assess the target organ response. RESULTS: Sixty-five (14.3%) of 455 patients showed positive SPT responses to Cupressus sempervirens extract. Only 1 patient was monosensitized while 64 patients were polysensitized. Among those, 2 pollen cosensitizations were found to be significant (86% were cosensitized to grasses and 72% were cosensitized to olive (P < .001). Serum specific IgE to cypress pollen was measured in 50 of the 65 patients; findings were positive for 37. When these 37 patients underwent NPT with C sempervirens allergen extract, only the single monosensitized patient had a positive NPT. CONCLUSION: A positive SPT to cypress pollen may not reflect the true prevalence of sensitization. We assume that in the absence of a positive NPT, positive SPT results might be related to the presence of cross-reactivity between pollen species.

The influence of epidural volume extension on spinal block with hyperbaric or plain bupivacaine for Caesarean delivery.

BACKGROUND AND OBJECTIVE: Epidural volume extension via a combined spinal-epidural is the enhancement of a small-dose intrathecal block by an epidural injection of physiological saline solution. We evaluated the effect of epidural volume extension on the combined spinal-epidural technique of providing spinal anaesthesia for Caesarean section with hyperbaric or plain 0.5% bupivacaine. METHODS: Patients (n = 240) with height >163 cm received 9 mg and patients <163 cm received 8 mg of bupivacaine. Each study drug was combined with 20 mug fentanyl. Using the combined spinal-epidural technique, Group A (n = 60) received hyperbaric bupivacaine, and Group B (n = 60) received hyperbaric bupivacaine and 10 mL saline epidurally 5 min after subarachnoid injection. Group C (n = 60) received plain bupivacaine and Group D (n = 60) received plain bupivacaine and 10 mL saline epidurally 5 min after subarachnoid injection. An anaesthetist blinded to the anaesthetic solution injected examined the level of analgesia by the pinprick method and motor block with the modified Bromage scale for 30 min after subarachnoid injection, during the intraoperative period and subsequently every 15 min for 135 min during the recovery period. RESULTS: Time to reach a sensory block at T4 was significantly shorter in Groups C and D than in Groups A (P = 0.003 and 0.017) and B (P = 0.006 and 0.048), respectively. During the intraoperative period, sensory block levels were significantly higher in Group C than in Group A. Recovery was similar in all groups; only onset was faster in Groups C and D. CONCLUSION: There was no effect of epidural volume extension on the profile of spinal anaesthesia with the combined spinal-epidural technique for Caesarean section using hyperbaric or plain bupivacaine.

Erythropoietin attenuates lipopolysaccharide-induced splenic and thymic apoptosis in rats.

Apoptosis of lymphoid tissues during sepsis is well documented and linked to the pathobiology of organ failure and death. In this study, we evaluated the effect of a single dose of recombinant erythropoietin (EPO) on thymic and splenic apoptosis in an endotoxic sepsis model. Young male Wistar rats were divided into 3 groups and administered intraperitoneally (IP) either normal saline; lipopolysaccharide (LPS) 10 mg/kg; or EPO (5000 U/kg) 30 min before lipopolysaccharide. Six hours following LPS administration animals were sacrificed. Apoptosis was assessed by hematoxylin-eosin staining, terminal deoxynucleotide transferase-mediated fluorescein-dUTP nick end labeling (TUNEL), and caspase-3 immunostaining. When compared with animals given LPS, animals pretreated with EPO displayed reduced splenic and thymic TUNEL positivity of 44+/-3 (p<0.05) and 143+/-4 (p<0.05) nuclei per high power field (hpf), respectively. Caspase-3 positivity was also significantly reduced in the spleen and thymus, with 31+/-4 (p<0.05) and 93+/-3 (p<0.05) positive stained nuclei per hpf, respectively. Serum nitrite levels were elevated in animals given lipopolysaccharide. Pretreatment with EPO attenuated the increase in nitrite levels; however, this did not reach statistical significance. We conclude that a single dose of recombinant erythropoietin can reduce thymic and splenic apoptosis associated with lipopolysaccharide administration.

Practices of anaesthesiologists with regard to withholding and withdrawal of life support from the critically ill in Turkey.

BACKGROUND: To determine practices of Turkish anaesthesiologists with regard to withholding and withdrawal of life support from the critically ill. METHODS: An anonymous questionnaire consisting of 18 questions was mailed to 439 members of the Turkish Society of Anaesthesiology and Reanimation. RESULTS: Three hundred and 69 questionnaires were returned (84% response). Over 90% of the respondents indicated that they were Muslim. We found that 66% of respondents had initiated written or oral do-not-resuscitate orders, most frequently after discussion with colleagues (82%). CONCLUSIONS: While a number of similarities were found between Turkish anaesthesiologists and those from other countries, some specific differences could be identified, particularly related to consensus decision-making and sharing information with other providers and the value of Ethics Committees in the decision-making process.

Effects of pressure- and volume-controlled inverse ratio ventilation on haemodynamic variables, intracranial pressure and cerebral perfusion pressure in rabbits: a model of subarachnoid haemorrhage under isoflurane anaesthesia.

BACKGROUND AND OBJECTIVE: An inverse I : E ratio (inspiratory time > expiratory time) may have benefits in patients suffering trauma who requiring lung ventilation. However, this application may be deleterious if there is concomitant head injury. We aimed to determine the physiological effects of pressure- and volume-controlled modes of inverse ratio (I : E = 2 : 1) ventilation of the lungs, while maintaining normocapnia, in a rabbit model of raised intracranial pressure (ICP). METHODS: New Zealand White rabbits were anaesthetized with isoflurane and a tracheostomy was performed. Subarachnoid haemorrhage was simulated in two groups by injecting blood into the cisterna magna. Groups 1 and 2 (n = 6, each), controls, were compared with Groups 3 and 4 (n = 6, each) with the simulated subarachnoid haemorrhage. Each ventilation mode was used with an I : E ratio of 2 : 1 for 30 min. Mean arterial pressure (MAP), ICP, cerebral perfusion pressure (CPP), mean airway pressure (P(AW)) and arterial blood-gas status were measured. RESULTS: Both modes increased mean P(AW) (P < 0.02). This increase was greater with the volume-controlled mode (P < 0.02). The baseline value averaged 5.8 +/- 0.4 and 5.6 +/- 0.3 mmHg in Groups 3 and 4, respectively, and increased to 7.8 +/- 0.3 and 10.8 +/- 0.4 mmHg. Inducing subarachnoid haemorrhage increased ICP and MAP (P < 0.02). Baseline ICPs were 10.3 +/- 0.5 and 10.3 +/- 0.4 mmHg in Groups 1 and 2, respectively, whereas they were 25.4 +/- 1.2 and 25.8 +/- 0.8 mmHg in Groups 3 and 4. However, ICP, MAP and CPP did not differ significantly according to the mode. CONCLUSIONS: An already raised ICP was altered by the application of induced mean PAW increases as a consequence of inverse ratio ventilation of the lungs with normocapnia.

EMLA does not permit pain-free retrobulbar injection.

BACKGROUND: Retrobulbar injection can be associated with significant pain, due to both needle insertion and deposition of the local anaesthetic solution. The local anaesthetic cream EMLA (eutectic mixture of local anaesthetics) which contains a mixture of lignocaine and prilocaine has been shown to reduce the pain associated with skin puncture. The efficacy of EMLA in alleviating the pain of retrobulbar injection for cataract surgery was assessed in this study. METHODS: In this, randomised double-blind study, EMLA (n = 53) or lignocaine 5% ointment (n = 50) was administered to the inferior orbital margin at least 45 min before retrobulbar block in 103 patients. Pain assessed during retrobulbar block was marked subjectively by the patient on a 10-point numerical rating scale. RESULTS: Median verbal pain scores were 3.0 with an interquartile range of 1.5-6.5 in the control group and 3.50 with an interquartile range of 2.0-6.0 in the EMLA(R) group (P = 0.67). There was no significant difference between the EMLA group and the lignocaine ointment group according to this pain assessment. CONCLUSION: EMLA does not permit pain-free retrobulbar injection.

Effects of normovolaemic haemodilution on middle cerebral artery blood flow velocity and oxygen delivery.

BACKGROUND AND OBJECTIVE: Assessment of the effects of normovolaemic haemodilution on middle cerebral artery blood flow velocity with transcranial Doppler ultrasonography, intracranial pressure, cerebral perfusion pressure, arterial oxygen content and cerebral oxygen delivery. METHODS: Normovolaemic haemodilution was induced in rabbits under general anaesthesia, and the haematocrit was allowed to decrease to 30% in Group 1 (n = 6) and to 20% in Group 2 (n = 6). Peak systolic and diastolic velocities, mean blood flow velocity, and pulsatility and resistance indices of the middle cerebral artery were measured by transcranial Doppler ultrasonography. Changes in intracranial pressure, cerebral perfusion pressure, arterial oxygen content and cerebral oxygen delivery were also assessed. RESULTS: In Group 2, middle cerebral artery blood flow velocity increased from 0.4 +/- 0.01 to 0.51 +/- 0.02 m s(-1) after the induction of normovolaemic haemodilution (P = 0.04), while arterial oxygen content decreased from 16.2 +/- 0.1 to 8.5 +/- 0.1 mLdL(-1) (P = 0.002). The decrease in cerebral oxygen delivery from 6.5 +/- 0.2 to 4.3 +/- 0.2 was also significant (P = 0.02). However, no associated changes in intracranial pressure and cerebral perfusion pressure could be demonstrated. CONCLUSIONS: Normovolaemic haemodilution resulted in an increase in the mean blood flow velocity of the middle cerebral artery. However, this increase did not compensate for the consequences of the altered oxygen delivery to the brain when the haematocrit was reduced to 20%.

Intracranial penetrating injury associated with an intraoperative epidural haematoma caused by a spring-laden pin of a multipoise headrest.

Lack of an intermediary piece that should have been placed between the pin and spring resulted in skull penetration due to a rapid waste in the spring's compensatory capacity. Checking integrity of internal pieces should be performed regularly. Designing intermediary piece and spring as a single piece might increase safety.

Effects of CO2 pneumoperitoneum on the basilar artery.

BACKGROUND: Laparoscopic surgery provides many benefits to the patients. The purpose of this study was to evaluate cerebral blood flow changes and the possibility of ischemia-reperfusion injury occurring during carbon dioxide (CO(2)) pneumoperitoneum. METHODS: Forty-eight New Zealand white rabbits were divided into four experimental and two control groups. Rabbits were subjected to CO(2) pneumoperitoneum with an intraabdominal pressure of 8 and 15 mmHg for 60 or 180 min as designed for experimental groups. We then assessed the changes in physiological and transcranial Doppler ultrasonographic parameters, as well as brain malondialdehyde levels. RESULTS: Transcranial Doppler sonography of the basilar artery revealed elevated mean velocity and decreased resistance index and pulsatility index values with the longer-duration and higher-pressure CO(2) pneumoperitoneum. However, there were no statistically significant difference in m alondialdehyde values. CONCLUSION: Elevated intraabdominal pressure by CO(2)-pneumoperitoneum, which does not lead to ischemia-reperfusion injury of the brain tissue, results in increased cerebral blood flow and reduced cerebrovascular resistance as an autoregulatory cerebral answer for CO(2).