BACKGROUND:Positive end-expiratory pressure (PEEP) is a crucial component of mechanical ventilation to improve oxygenation in critically ill patients with respiratory failure. The interaction between abdominal and thoracic compartment pressures is known well. Especially in intra-abdominal hypertension, lower PEEP may cause atelectotrauma by repetitive opening and closing of alveoli. AIM:In this study, it was aimed to investigate the effect of PEEP adjustment according to the intra-abdominal pressure (IAP) on oxygenation and clarify possible harms. METHOD:Patients older than 18 were mechanically ventilated due to hypoxemic respiratory failure and had normal IAP (<15 mmHg) included in the study. Patients with severe cardiovascular dysfunction were excluded. The following PEEP levels were applied: PEEPzero of 0 cmH2O, PEEPIAP/2 = 50% of IAP, and PEEPIAP = 100% of IAP. After a 30-minute equilibration period, arterial blood gases and mean arterial pressures were measured. RESULTS:One hundred thirty-eight patients (mean age 66.5 ± 15.9, 56.5% male) enrolled on the study. The mean IAP was 9.8 ± 3.4. Seventy-nine percent of the patients' PaO2/FiO2 ratio was under 300 mmHg. Figure 1 shows the change in PaO2/FiO2 ratio, PaCO2, PPlato, and MAP of the patients according to the PEEP levels. Overall increases were detected in the PaO2/FiO2 ratio (P < 0.001) and Pplato (P < 0.001), while PaCO2 and MAP did not change after increasing PEEP gradually. Pairwise analyses revealed differences in PaO2/FiO2 between PEEPzero (186.4 [85.7-265.8]) and PEEPIAP/2 (207.7 [101.7-292.9]) (t = -0.77, P < 0.001), between baseline and PEEPIAP (236.1 [121.4-351.0]) (t = -1.7, P < 0.001), and between PEEPIAP/2 and PEEPIAP (t = -1.0, P < 0.001). Plato pressures were in the safe range (<30 cmH2O) at all three PEEP levels (PEEPzero = 12 [10-15], PEEPIAP/2 = 15 [13-18], PEEPIAP = 17 [14-22]). CONCLUSION:In patients with acute hypoxemic respiratory failure and mechanically ventilated, PEEP adjustment according to the IAB improves oxygenation, especially in the settings of the limited source where other PEEP titration methods are absent.

INTRODUCTION:Our aim was to determine the efficacy of trimetazidine on experimental sepsis rat model.MATERIAL AND METHODS:Sixty rats were randomized into three groups. In Group 1, sepsis was induced. In Group 2, sepsis was induced and as a therapeutic agent trimetazidine was given. In Group 3, rats were sham operated. Serum interleukin-1 beta (IL-1ß), tumor necrosis factor alfa (TNF-α), superoxide dismutase (SOD), glutathion peroxidase (GSH-Px) and malondialdehyde (MDA) levels were determined in all groups.RESULTS:In Group 2, serum GSH-Px and SOD levels were statistically significantly higher than in Group 1 (p< 0.05) and serum MDA levels were statistically significantly lower than in group 1 (p < 0.05). Trimetazidine also significantly decreased the levels of IL-1ß and TNF-a which are the proinflammatory cytokines (p < 0.05).CONCLUSION:Trimetazidine treatment significantly improved inflammation, oxidative stress and membrane destruction in LPS-induced sepsis. As the proinflammatory cytokines are supposed to play a primary role in the pathogenesis of sepsis, we assumed that the trimetazidine treatment would give new insights into the treatment of sepsis (Tab. 1, Fig. 5, Ref. 29).

Introduction Multidisciplinary rounding practices in the ICU have now become the standard of care in most institutions.Few objective data are available, however, on the value each individual member of the team brings to the patient care.In our institution, pediatric pharmacists have been an integral part of the PICU rounds since 2002, although their role has evolved over the course of years.This study was undertaken with the primary aim of identifying the impact of pharmacist involvement in PICU rounds, with respect to changes in therapy.Methods Since January 2003, pharmacists have recorded their clinical interventions and outcomes of those interventions in an institutionally developed Pharmaceutical Care database (P-Care).An intervention is defi ned as any recommendation the pharmacist makes to the patient care team regarding a change in the patient management or medication therapy.P-Care is designed to assist the pharmacist to optimize medication therapy, identify medication-related problems, decrease medication costs, improve pharmacist effi ciency and document pharmacist workload.Data concerning pharmacists' interventions were extracted from the P-Care database in yearly increments via a reporting functionality that is available in the P-Care system.This study was exempted for review by the Mayo Clinic IRB.Results From 1 January 2003 through 31 December 2012 pharmacists made 24,207 clinical interventions in the PICU and 19,252 of those interventions resulted in changes in medication therapy or therapy monitoring.Interventions that were accepted by the team involved 10,361 (53.8%) drug dosing regimen changes, 292 (1.5%) drug interactions or incompatibility, 969 (5%) drug monitoring suggestions, 1,665 (8.7%) drug routes/methods of administration, 3,895 (20.2%) drug selections, and 2,070 (10.8%) medication profi le/order clarifi cations.As the pharmacist role on the PICU multidisciplinary rounds has evolved, the number of interventions has increased from 1,643 in 2003 to 3,799 in 2012.Of the 19,252 interventions that were implemented, 304 were deemed to be of potentially life-threatening consequences, 10,767 had a moderate impact, and 8,181 had minimal impact on patient outcome.Conclusion To our knowledge this is the largest reported data on pharmacist's involvement in pediatric intensive care.This can serve as background knowledge on implementing measures on novel methodologies to integrate pharmacists in intensive care practice. P4Improvement in the identifi cation and management of inadvertent hypothermia in the critically ill: an audit cycle

OBJECTIVES:18F-fluorodeoxyglucose-positron emission tomography/computed tomography (F-18 FDG PET/CT) scanning has been proposed as a new tool to assess disease activity in Takayasu Arteritis (TA). We investigated whether F-18 FDG PET/CT findings were consistent with current clinical disease status in patients with TA.METHODS:In this cross-sectional study, 22 patients with TA were enrolled. Clinical disease activity was assessed by the combination of National Institutes of Health (NIH) criteria, Disease Extent Index-Takayasu (DEI-Tak) score, physician global assessment and F-18 FDG PET/CT scans.RESULTS:At the time F-18 FDG PET/CT scans were taken, the majority of the patients (17/22) were using immunosuppressive (IS) drugs, and only four patients had clinically active disease. F-18 FDG PET/CT scans confirmed the presence of active vasculitic lesions in those four patients. In 16 out of 18 patients who were accepted to be in clinical remission, F-18 FDG PET/CT scans were also normal. There were only two patients with discordant results, i.e. active F-18 FDG PET/CT findings despite the lack of clinical activity. Interestingly, clinical exacerbation occurred four weeks later in one of them. Overall sensitivity and specificity of F-18 FDG PET/CT findings for clinical activity were 100% and 88.9%, respectively.CONCLUSIONS:We found that F-18 FDG PET/CT findings were generally consistent with clinical disease status in TA. Although use of IS drugs certainly impairs diagnostic accuracy of F-18 FDG PET/CT in TA, this imaging method may still have a potential for confirming remission or detecting disease activity in patients with TA receiving treatment.

Background Tumor Necrosis Factor-α (TNF-α) inhibitors have increased risk of reactivation of latent tuberculosis infection (LTBI). Screening for LTBI before initiating anti-TNF therapy is recommended.(1) Tuberculin skin test (TST) and in vitro interferon-γ (IFN-γ) assays; Quantiferon-TB Gold In-Tube test (QTF-IT) are used for screening LTBI.(2) In patients refractory to standart therapies in Behçet’s disease (BD) and Takayasu’s arteritis (TA), TNF-α inhibitors are new therapy options.(3) Objectives To screen for LTBI in BD and TA patients with TST and QTF-IT and to find out the agreement between two tests. Methods Forty patients with BD who fulfilled the 1990 International Study Group Criteria and 40 TA patients who fulfilled the 1990 American College of Rheumatology Classification Criteria were included in this study. As the control groups, 80 healthy subjects, age and sex-matched with patients were also included. Along with healthy controls, both BD and TA cases were evaluated for LTBI by using TST and QTF-IT tests. Results The percentage of TST positivity was significantly higher in patients group than healthy controls. TST positivity was 80% in TA patients, 65% in BD patients and 35% in healthy controls. There were no differences between BD and TA patients in TST positivity. In contrast, there were no differences between QTF-IT positivity in patients and healthy controls. QTF-IT positivity was 35% in TA patients, 25% in BD patients and 21.3% in healthy controls. There were also no differences between BD and TA patients in QTF-IT positivity. The total agreement between QTF-IT and TST was observed to be 53.33% in the whole group, 60% in BD, 50% in TA and 65.71% in healthy controls. Their level of agreement was low in all groups (κ=0.25, 0.30, 0.15, 0.23). This discordance was thought to be related to the false positive TST values according to prior BCG vaccination. Conclusions In a country with a high incidence of TB and BCG vaccination, the QTF-IT test might help to differentiate false positive TST results from LTBI. Because there is no gold standart screening test for LTBI; patients should also be evaluated with clinics and radiographic findings. Further studies are needed for patients with vasculitis. References Dixon WG, Hyrich KL et al. Drug-specific risk of tuberculosis in patients with rheumatoid arthritis treated with anti-TNF therapy:results from the British Society for Rheumatology Biologics Register (BSRBR). Ann Rheum Dis 2010;69:522-28. Lalvani A. Diagnosing tuberculosis infection in the 21st century: new tools to tackle an old enemy. Chest 2007;131(6):1898-1906. Karadag O, Aksu K et al. Assessment of latent tuberculosis infection in Takayasu arteritis with tuberculin skin test and Quantiferon-TB Gold test. Rheumatol Int 2010;30:1483-87. Disclosure of Interest None Declared

INTRODUCTION:Although physiopathology of acute pancreatitis (AP) is not fully understood, the roles of reactive oxygen species (ROS) and changes of cytokines have been determined.AIM:To investigate anti-inflammatory and anti-oxidant effects of glycyrrhizin (GL) on taurocholate-induced AP in rats.MATERIALS AND METHODS:Thirty six rats were randomly divided into three groups as sham, AP and AP+GL (n=12 per group). AP was induced by 1 ml/kg body weight using 5% taurocholate injection into the biliopancreatic duct in groups II and III after clamping the hepatic duct. In groups III, GL (20 mg/kg) was given by oral gavage twice daily for 4 days. Group I and II did not receive any treatment. After the rats were killed; blood samples were taken to measure amylase, lipase, calcium, albumin, urea, glucose, AST and LDH assays before killing. Pancreatic tissue samples were also taken for biochemical analyses and histopathology.RESULTS:Amylase, lipase, AST and urea levels were significantly lower in the AP+GL group than in the AP group. Cytokines including IL-6, TNF-α and MPO levels were significantly lower in the AP+GL group than in the AP group. Even so there is no statistically difference between in the AP+GL group and the AP group in terms of pancreatic tissue IL-1β, IL-6 and TNF-α levels.DISCUSSION:GL treatment significantly decreased pancreatic tissue MPO activities and MDA levels in the AP+GL group compared with the other groups (p = 0.001 and p = 0.05, respectively). Acinar cell necrosis, hemorrhage, and edema determined that were significantly lower in the AP+GL group than in the AP group (p < 0.001).CONCLUSIONS:GL treatment for acute necrotizing pancreatitis in rats suppressed the levels of pro-inflammatory cytokines, and caused a clear recovery of histological changes.

Classification of respiratory distress has been dependent on PaO2/FiO2; that is, <300 acute lung injury (ALI) and <200 acute respiratory distress syndrome (ARDS). In this study, PaO2/FiO2 was analyzed for predicting ICU patients' length of stay (LOS).

The aim of this study was to investigate and compare Ranson criteria (RC) and RC + serum CRP levels as a feasible, practical and precise method in acute pancreatitis (AP) cases admitted to the ICU in respect of length of stay (LOS) predicting severity of disease.

OBJECTIVE:Behçet's disease (BD) is a unique systemic vasculitis involving both arteries and veins of all sizes. Since Fcgamma receptors (FcgammaR) are important in mediating various immune effector functions, FcgammaR gene polymorphisms may affect the susceptibility to systemic inflammatory diseases such as BD. The aim of this study was to show the distribution of FcgammaRIIa, IIIa ve IIIb receptor gene polymorphisms in BD, and to investigate possible genotype-phenotype relationships.METHODS:In this cross-sectional study, FcgammaRIIa (H/H131, H/R131, R/R131), IIIa (F/F158, F/V158, V/V158), and IIIb (NA1/NA1, NA1/NA2, and NA2/NA2) receptor gene polymorphisms were investigated in 216 unrelated Turkish BD patients (M/F: 130/86) and in 241 healthy subjects, using an allele-specific polymerase chain reaction.RESULTS:The FcgammaRIIa R/R131 (p=0.019) and FcgammaRIIIa F/F158 genotypes (p=0.001) were found to be significantly more frequent in BD compared with healthy controls, whereas the FcgammaRIIIb genotypes were not (p=0.108). Allele analysis showed that the FcgammaRIIIa 158 (p=0.001) and FcgammaRIIIb NA2 (p=0.016) alleles were more frequent in BD than in healthy controls. In BD patients the FcgammaRIIIa V/V158 genotype was significantly associated with the presence of arthritis (p=0.002) and with an earlier disease onset (p=0.008), while the FcgammaRIIIb NA2/NA2 genotype was significantly associated with disease severity (p=0.02), vascular involvement (p=0.014), and pathergy positivity (p=0.02).CONCLUSION:We found that the genotype frequencies and allelic distributions of the FcgammaRIIa, FcgammaRIIIa and FcgammaRIIIb gene polymorphisms were significantly different between BD patients and healthy controls. In addition, certain FcgammaRIIIa and FcgammaRIIIb gene polymorphisms appear to be associated with an early disease onset, disease severity, the presence of arthritis, and vascular involvement in BD.

The aim of this study was to evaluate the effects of N-acetylcysteine (NAC) and desferoxamine (DFO) administered alone or in combination together in rats with doxorubicin (DOX)-induced nephrotic syndrome, by monitoring oxidative stress parameters and trace elements in renal tissue and erythrocytes. Fifty-four male Sprague-Dawley rats were included the study. Equal volume of isotonic saline was injected to control rats. After DOX administration, the animals were divided into four experimental groups: (a) rats given only DOX; (b) rats treated with NAC; (c) rats treated with DFO; (d) rats treated with NAC plus DFO. The combination of N-acetylcysteine and DFO has no beneficial effect on reducing proteinuria in experimentally nephrotic rats, although both of these agents ameliorate the condition when administered separately. It seems likely that detrimental effects of NAC plus DFO could be secondary to its effects on erythrocyte selenium levels demonstrated here. Consequently, the results may propose caution to the use of antioxidant therapeutic strategies such as NAC plus DFO against nephropathy.

The aim of this study was to evaluate the effects of N-acetylcysteine (NAC) and desferoxamine (DFO) administered alone or in combination together in rats with doxorubicin(DOX)-induced nephrotic syndrome, by monitoring oxidative stress parameters and trace elements in renal tissue and erythrocytes. Fifty-four male Sprague-Dawley rats were included the study. Equal volume of isotonic saline was injected to control rats. After DOX administration, the animals were divided into four experimental groups: ( a) rats given only DOX; (b) rats treated with NAC; (c) rats treated with DFO; (d) rats treated with NAC plus DFO. The combination of N-acetylcysteine and DFO has no beneficial effect on reducing proteinuria in experimentally nephrotic rats, although both of these agents ameliorate the condition when administered separately. It seems likely that detrimental effects of NAC plus DFO could be secondary to its effects on erythrocyte selenium levels demonstrated here. Consequently, the results may propose caution to the use of antioxidant therapeutic strategies such as NAC plus DFO against nephropathy.

1Sifa University Medical Faculty, Department of Nuclear Medicine, Bornova/Izmir; 2Ege University Medical Faculty, Department of Internal Medicine, Division of Rheumatology, Izmir; 3Ege University Medical Faculty, Department of Nuclear Medicine, Izmir; 4Celal Bayar University Medical Faculty, Department of Internal Medicine, Division of Rheumatology, Manisa, Turkey. Inanc Karapolat, MD, Assist. Professor Melike Kalfa, MD Gokhan Keser, MD, Professor Murat Yalçin, MD, Assist. Professor Vedat Inal, MD, Assoc. Professor Kamil Kumanlioglu, MD, Professor Timur Pirildar, MD, Professor Kenan Aksu, MD, Professor Please address correspondence and reprint requests to: Prof. Inanc Karapolat, Sifa University Medical Faculty, Department of Nuclear Medicine, 35100 Bornova/Izmir, Turkey. E-mail: inanckarapolat@hotmail.com Received on August 6, 2012; accepted in revised form on October 9, 2012. Clin Exp Rheumatol 2013; 31 (Suppl. 75): S15-S21. © Copyright CLINICAL AND EXPERIMENTAL RHEUMATOLOGY 2013.