Unusual causes of peritonitis in a peritoneal dialysis patient: Alcaligenes faecalis and Pantoea agglomerans

An 87 -year-old female who was undergoing peritoneal dialysis presented with peritonitis caused by Alcaligenes faecalis and Pantoea agglomerans in consecutive years. With the following report we discuss the importance of these unusual microorganisms in peritoneal dialysis patients

Unusual presentation of peritonitis with persistent clear aspirate: a case report

<p>Abstract</p> <p>Introduction</p> <p>Peritonitis is the most frequent complication of peritoneal dialysis. Diagnosis of peritonitis includes symptoms and signs of peritonitis with a cloudy aspirate of more than 100 WBC/ml, as well as positive cultures. Although sterile peritonitis has been reported in the literature, to the best of our knowledge this is the first report of an unusual presentation of peritonitis without any white blood cells in the peritoneal aspirate despite multiple positive peritoneal cultures.</p> <p>Case presentation</p> <p>An 82-year-old Caucasian man who had been on continuous cycling peritoneal dialysis for 12 years was admitted to our hospital with general malaise, loss of appetite, weight loss and somnolence. He did not describe abdominal pain or fever. Even though his peritoneal fluid was consistently negative for leukocytes and clear, he had peritonitis with different organisms consecutively.</p> <p>Conclusions</p> <p>Our case report shows that any patient on peritoneal dialysis presenting with evidence of infection (fever, peripheral leukocytosis) without an obvious cause should have aspirate cultures done even if the aspirate is clear and abdominal pain is absent. Our case report may change the initial work-up and management of these patients. We believe this report is of interest to general medicine and emergency room physicians as well as nephrologists.</p

Enkapsüle Sklerozan Peritonit Rat Modelinde İmatinib’in etkileri

ÖZETGiriş: Enkapsüle Sklerozan Peritonit (ESP) kronik periton diyalizinin (PD) uzundönemde karşılaşılan nadir ancak ölümcül olabilecek komplikasyonudur. Peritonda yenidamar oluşumu, artmış inflamasyon ve abartılı fibrosis ile karakterizedir. Bir tirozinkinaz inhibitörü olan imatinibin hem in vivo hem de in vitro antifibrotik etkileri olduğubilinmektedir. Çalışmamızda imatinibin EPS rat modelinde periton membranı üzerineetkilerini incelemeyi amaçladık.Materyal-Metod: Yirmidört üremik olmayan Wistar albino rat dört gruba ayrıldı: 3hafta 2 ml/gün serum fizyolojik intraperitoneal injeksiyon (Kontrol grubu); 3 hafta 2ml/200 g klorheksidin glukonat (%0.1) ve etanol (%15) /gün intraperitoneal injeksiyon(KG grubu); 3 hafta KG sonrasında 3 hafta bekleme (dinlenme grubu); 3 hafta KGsonrasında 3 hafta 50 mg/kg/gün dozunda imatinib mesilat (nasogastrik sonda yoluyla)(KG + İMA). Çalışma sonunda 1 saatlik periton eşitlenme testi (PET) yapıldıktan sonrahayvanlar sakrifiye edildi. Ultrafiltrasyon miktarı (UF), PET parametreleri [diyalizat/plasma üre (D/Püre); diyalizat/plasma kreatinin (D/Pkr); Diyalizat1.saat/Diyalizat0.saatglukoz (D/D0glu)] ve periton morfolojisi (periton kalılnlığı, fibroblast sayısı,inflamasyon skoru, aktive mezotel hücresi oranı, kapiller sayısı, fibrosis skoru)incelendi.Sonuçlar: Üç hafta KG injeksiyonu peritoneal membranda kontrol grubuna göreanlamlı olacak şekilde hem fonksiyonel hem de morfolojik değişiklikler yapmaktadır.KG+İMA grubu KG grubu ile kıyaslandığında UF, D/Pkr, D/D0glu ve mezotel hücreaktivasyonunda anlamlı düzelme sağlamaktadır. Ancak dinlenme grubu ilekıyaslandığında sadece aktive mezotel hücre durumunda fark bulundu. Bulgular tablo1’de özetlenmiştir.Tablo 1. Çalışma gruplarının fonkiyonel ve morfolojik bulgularının karşılaştırılmasıKontrol(n=6)KG(n=6)Dinlenme(n=6)KG + İmatinib(n=6)UF miktarı (ml) 7.15±1.2 -0.17±1.6a 3.7±4.3 6.1±3.8bD/P üre 0.83±0.08 0.72±0.04a 0.83±0.12 0.84±0.11D/P kreatinin 1.16±0.22 0.87±0.09a 1.14±0.21b 1.2±0.18bD1/D0 glukoz 0.77±0.14 0.45±0.04a 0.72±0.16b 0.67±0.1bPeriton kalınlığı (μm) 15.67±2.3 62.2±5.5a 59.7±7a 62.3±9.7aKapiller sayısı (n) 4.8±2.2 16.5±5.4a 13.7±6.6a 17.5±6.7aİnflamasyon skoru 0.17±0.1 1.5±0.22a 1.17±0.17a 1.0±0.0a,bAktif mezotel hücreoranı (%) 0 100a 83.3a 16.6b,cFibrosis skoru 0.17±0.1 2.17±0.17a 2.33±0.0a 2.0±0.0aTartışma: Uzun süre PD tedavisinin bir sonucu olabilecek EPS’nin tedavisindeimatinib umut verici bir ajan olarak dikkati çekmektedir. İmatinib ile tirozin kinazinhibisyonu peritoneal membranda fibrosisden ziyade inflamasyonu azaltmada bir hedefolabilir. Anti-fibrotik etkilerinin gösterilmesi için eş zamanlı KG+İMA verilmesi gibideneysel modelde modifikasyonlar yapılabilir.ivSUMMARYBackground: Encapsulating peritoneal sclerosis (EPS) is most serious complication ofperitoneal dialysis treatment. Depite its low rates of prevalence, EPS results highmortality. It characterizes with neovascularization, increased inflammation andexaggerated interstitial fibrosis of peritoneum. In vivo and in vitro antifibrotic effects ofimatinib, a tyrozin kinase inhibitor, has been suggested previously. In our study, weinvestigated effects of imatinib on peritoneal membrane in experimental EPS model.Material-Methods: We allocated 24 non-uremic albino Wistar rats to 4 groups: controlgroup, 2 mL isotonic saline injected intraperitoneally (IP) daily for 3 weeks; CG group,2 mL/200 g (0.1%) chlorhexidine gluconate (CG) injected IP daily and ethanol (15%)dissolved in saline, for 3 weeks; resting group, CG (weeks 0 – 3), plus peritoneal rest(weeks 3 – 6); and CG+Imatinib mesylate (IMA) , CG (weeks 0 – 3), plus 50 mg/kgimatinib mesylate diluted in drinking water via oragastric tube (weeks 3 – 6). At the endof the study, we performed a 1-hour peritoneal equilibration test with 25 mL 3.86% PDsolution, and examined the dialysate-to-plasma ratio of urea (D/P urea), dialysate-toplasmaratio of creatinin (D/P cr), end-to-initiate dialysate glucose (D1/D0 glucose),ultrafiltration (UF) volume, and morphologic change (peritoneal thickness, capillernumber, inflammation score, active mesothelial cell ratio, fibrosis score) in the parietalperitoneum.Results: KG exposure for 3weeks resulted in obvious alteration in peritoneal transportand morphology. An increased UF, D/P cr, D1/D0glucoseand decreased activemesothelial cell ratio was found in KG+IMA group comparing KG alone. FurthermoreKG+IMA group was superior than peritoneal rest group with regard to activemesothelial cell ratio. The results are shown in table 1.vTable 1. Comparison of study groups regarding functional and morphologicalternations.Kontrol(n=6)KG(n=6)Dinlenme(n=6)KG + İmatinib(n=6)UF miktarı (ml) 7.15±1.2 -0.17±1.6a 3.7±4.3 6.1±3.8bD/P üre 0.83±0.08 0.72±0.04a 0.83±0.12 0.84±0.11D/P kreatinin 1.16±0.22 0.87±0.09a 1.14±0.21b 1.2±0.18bD1/D0 glukoz 0.77±0.14 0.45±0.04a 0.72±0.16b 0.67±0.1bPeriton kalınlığı (μm) 15.67±2.3 62.2±5.5a 59.7±7a 62.3±9.7aKapiller sayısı (n) 4.8±2.2 16.5±5.4a 13.7±6.6a 17.5±6.7aİnflamasyon skoru 0.17±0.1 1.5±0.22a 1.17±0.17a 1.0±0.0a,bAktif mezotel hücreoranı (%)0 100a 83.3a 16.6b,cFibrosis skoru 0.17±0.1 2.17±0.17a 2.33±0.0a 2.0±0.0aConclusion: Imatinib has some beneficial effects on EPS. Tyrosine kinase inhibitionwith imatinib could be a pathway for decreasing mesothelial cell activity andinflammation. Peritoneal fibrosis has not decreased with imatinib in this experimentalEPS model. Simultaneous administration of KG and imatinib could be another modelfor suggest anti-fibrotic effects of imatinib on peritoneal fibrosis

Enkapsüle Sklerozan Peritonit Rat Modelinde İmatinib’in etkileri

Giriş: Enkapsüle Sklerozan Peritonit (ESP) kronik periton diyalizinin (PD) uzun dönemde karşılaşılan nadir ancak ölümcül olabilecek komplikasyonudur. Peritonda yeni damar oluşumu, artmış inflamasyon ve abartılı fibrosis ile karakterizedir. Bir tirozin kinaz inhibitörü olan imatinibin hem in vivo hem de in vitro antifibrotik etkileri olduğu bilinmektedir. Çalışmamızda imatinibin EPS rat modelinde periton membranı üzerine etkilerini incelemeyi amaçladık. Materyal-Metod: Yirmidört üremik olmayan Wistar albino rat dört gruba ayrıldı: 3 hafta 2 ml/gün serum fizyolojik intraperitoneal injeksiyon (Kontrol grubu); 3 hafta 2 ml/200 g klorheksidin glukonat (%0.1) ve etanol (%15) /gün intraperitoneal injeksiyon (KG grubu); 3 hafta KG sonrasında 3 hafta bekleme (dinlenme grubu); 3 hafta KG sonrasında 3 hafta 50 mg/kg/gün dozunda imatinib mesilat (nasogastrik sonda yoluyla) (KG + İMA). Çalışma sonunda 1 saatlik periton eşitlenme testi (PET) yapıldıktan sonra hayvanlar sakrifiye edildi. Ultrafiltrasyon miktarı (UF), PET parametreleri [diyalizat/ plasma üre (D/Püre); diyalizat/plasma kreatinin (D/Pkr); Diyalizat1.saat/Diyalizat0.saat glukoz (D/D0glu)] ve periton morfolojisi (periton kalılnlığı, fibroblast sayısı, inflamasyon skoru, aktive mezotel hücresi oranı, kapiller sayısı, fibrosis skoru) incelendi. Sonuçlar: Üç hafta KG injeksiyonu peritoneal membranda kontrol grubuna göre anlamlı olacak şekilde hem fonksiyonel hem de morfolojik değişiklikler yapmaktadır. KG+İMA grubu KG grubu ile kıyaslandığında UF, D/Pkr, D/D0glu ve mezotel hücre aktivasyonunda anlamlı düzelme sağlamaktadır. Ancak dinlenme grubu ile kıyaslandığında sadece aktive mezotel hücre durumunda fark bulundu. Bulgular tablo 1’de lenmiştir. Tablo 1. Çalışma gruplarının fonkiyonel ve morfolojik bulgularının karşılaştırılması Kontrol (n=6) KG (n=6) Dinlenme (n=6) KG + İmatinib (n=6) UF miktarı (ml) 7.15±1.2 -0.17±1.6a 3.7±4.3 6.1±3.8b D/P üre 0.83±0.08 0.72±0.04a 0.83±0.12 0.84±0.11 D/P kreatinin 1.16±0.22 0.87±0.09a 1.14±0.21b 1.2±0.18b D1/D0 glukoz 0.77±0.14 0.45±0.04a 0.72±0.16b 0.67±0.1b Periton kalınlığı (μm) 15.67±2.3 62.2±5.5a 59.7±7a 62.3±9.7a Kapiller sayısı (n) 4.8±2.2 16.5±5.4a 13.7±6.6a 17.5±6.7a İnflamasyon skoru 0.17±0.1 1.5±0.22a 1.17±0.17a 1.0±0.0a,b Aktif mezotel hücre oranı (%) 0 100a 83.3a 16.6b,c Fibrosis skoru 0.17±0.1 2.17±0.17a 2.33±0.0a 2.0±0.0a Tartışma: Uzun süre PD tedavisinin bir sonucu olabilecek EPS’nin tedavisinde imatinib umut verici bir ajan olarak dikkati çekmektedir. İmatinib ile tirozin kinaz inhibisyonu peritoneal membranda fibrosisden ziyade inflamasyonu azaltmada bir hedef olabilir. Anti-fibrotik etkilerinin gösterilmesi için eş zamanlı KG+İMA verilmesi gibi deneysel modelde modifikasyonlar yapılabilir. iv SUMMARY Background: Encapsulating peritoneal sclerosis (EPS) is most serious complication of peritoneal dialysis treatment. Depite its low rates of prevalence, EPS results high mortality. It characterizes with neovascularization, increased inflammation and exaggerated interstitial fibrosis of peritoneum. In vivo and in vitro antifibrotic effects of imatinib, a tyrozin kinase inhibitor, has been suggested previously. In our study, we investigated effects of imatinib on peritoneal membrane in experimental EPS model. Material-Methods: We allocated 24 non-uremic albino Wistar rats to 4 groups: control group, 2 mL isotonic saline injected intraperitoneally (IP) daily for 3 weeks; CG group, 2 mL/200 g (0.1%) chlorhexidine gluconate (CG) injected IP daily and ethanol (15%) dissolved in saline, for 3 weeks; resting group, CG (weeks 0 – 3), plus peritoneal rest (weeks 3 – 6); and CG+Imatinib mesylate (IMA) , CG (weeks 0 – 3), plus 50 mg/kg imatinib mesylate diluted in drinking water via oragastric tube (weeks 3 – 6). At the end of the study, we performed a 1-hour peritoneal equilibration test with 25 mL 3.86% PD solution, and examined the dialysate-to-plasma ratio of urea (D/P urea), dialysate-toplasma ratio of creatinin (D/P cr), end-to-initiate dialysate glucose (D1/D0 glucose), ultrafiltration (UF) volume, and morphologic change (peritoneal thickness, capiller number, inflammation score, active mesothelial cell ratio, fibrosis score) in the parietal peritoneum. Results: KG exposure for 3weeks resulted in obvious alteration in peritoneal transport and morphology. An increased UF, D/P cr, D1/D0glucoseand decreased active mesothelial cell ratio was found in KG+IMA group comparing KG alone. Furthermore KG+IMA group was superior than peritoneal rest group with regard to active mesothelial cell ratio. The results are shown in table 1. v Table 1. Comparison of study groups regarding functional and morphologic alternations. Kontrol (n=6) KG (n=6) Dinlenme (n=6) KG + İmatinib (n=6) UF miktarı (ml) 7.15±1.2 -0.17±1.6a 3.7±4.3 6.1±3.8b D/P üre 0.83±0.08 0.72±0.04a 0.83±0.12 0.84±0.11 D/P kreatinin 1.16±0.22 0.87±0.09a 1.14±0.21b 1.2±0.18b D1/D0 glukoz 0.77±0.14 0.45±0.04a 0.72±0.16b 0.67±0.1b Periton kalınlığı (μm) 15.67±2.3 62.2±5.5a 59.7±7a 62.3±9.7a Kapiller sayısı (n) 4.8±2.2 16.5±5.4a 13.7±6.6a 17.5±6.7a İnflamasyon skoru 0.17±0.1 1.5±0.22a 1.17±0.17a 1.0±0.0a,b Aktif mezotel hücre oranı (%) 0 100a 83.3a 16.6b,c Fibrosis skoru 0.17±0.1 2.17±0.17a 2.33±0.0a 2.0±0.0a Conclusion: Imatinib has some beneficial effects on EPS. Tyrosine kinase inhibition with imatinib could be a pathway for decreasing mesothelial cell activity and inflammation. Peritoneal fibrosis has not decreased with imatinib in this experimental EPS model. Simultaneous administration of KG and imatinib could be another model for suggest anti-fibrotic effects of imatinib on peritoneal fibrosis

Prospective analysis of skin findings in surgical critically Ill patients intensive care unit

Background: Intensive Care Units (ICUs) are places where critically ill patients are managed. Aim: We aimed to investigate skin disorders that developed in critically ill surgical patients during their stay in the ICU. Methods: The prevalence of dermatological disorders and factors affecting their clinical features was prospectively analyzed in surgical ICU patients. We recorded age, sex, type of ICU, comorbidities, skin disorders, time to consultation, duration of ICU stay, and mortality rate. Results: Our study included 605 patients (mean age of 60.1 ± 20.2 years; 56.4% males). Seventy-three (12.1%) patients were consulted with the Dermatology Department, among which 28.8% had infectious dermatological lesions, 26% dermatoses, and 45.2% drug reactions. The most common infectious dermatological disorder was wound infection (55.6%), the most common drug reaction was maculopapular drug eruption (75.8%), and the most common dermatosis was frictional blisters (47.4%). Multiple comorbidities, hypertension, diabetes mellitus, coronary artery disease, Parkinson disease, and stroke increased dermatological disorders (P < 0.05). The consulted patients had a median ICU stay of 7 days (range 2–53 days); consultation was significantly more common when it exceeded 10 days (74% vs. 26%, P < 0.05). The consulted patients died more commonly (P < 0.05). Infectious dermatological disorders and dermatoses were more common in patients older and younger than 50 years, respectively (P < 0.05). Dermatoses were more common among women (P < 0.05). The median time to consultation was 6 (2–30) days; it was longest for dermatological infections and shortest for dermatoses (P < 0.05). Infectious dermatological disorders were significantly more common among the deceased patients (P < 0.05). Conclusion: Multiple factors including multiple comorbidities, duration of ICU stay, time to consultation, and mortality increase dermatological disorders among surgical ICU patients

Burnout Among Intensive Care Physicians

GİRİŞ: Tükenmenin iş davranışlarında, özellikle de ağır çalışma koşulları olan sağlık çalışanlarında ciddi sorunlara yol açtığı rapor edilmektedir. AMAÇ: Tanımlayıcı tipteki bu çalışma ile yoğun bakım uzmanı hekimlerin tükenme düzeylerini belirlemek amaçlanmaktadır. YÖNTEM: Veriler Sağlık Bakanlığı tarafından düzenlenen bir toplantı sırasında Türkiye'nin yedi coğrafi bölgesinden ve farklı illerinden gelen toplam 96 hekimin 64'ünden toplanmıştır.Tükenme düzeyi, duygusal tükenme, duyarsızlaşma ve kişisel başarı olmak üzere üç alt boyutta, 22 madde içeren Maslach Tükenme Ölçeği ile ölçülmüştür. Ayrıca hekimlerin demografik verilerini toplamak üzere 16 sorudan oluşan bir soru formu daha eklenmiştir.BULGULAR: Katılımcıların "duyarsızlaşma" (5,08±3,18) alt boyutundan aldıkları ortalama puan düşük tükenme düzeyine işaret etmektedir. Yoğun bakım uzmanı hekimlerin diğer iki alt boyuttan aldıkları puanlar incelendiğinde "duygusal tükenme" (15,56±6,26) ve "kişisel başarı" (22,44±3,69) alt boyutlarında orta düzeyde tükenme deneyimledikleri söylenebilir. SONUÇ: Yoğun bakım hekimleri orta düzeyde "duygusal tükenme" ve kişisel başarısızlık deneyimlemektedirler. Bu nedenle çalışma koşullarının iyileştirilmesi, kendilerini işlerinde daha başarılı hissetmelerinde etkili olabilir.INTRODUCTION: It is reported that burnout provokes serious problems in occupational behaviour especially among health care professionals who are working in heavy working conditions.AIM: This descriptive study aims to identify the burnout levels of intensive care physicians.METHODS: Data were collected from 64 of 96 intensive care physicians who had come from different cities and seven geographical regions of Turkey during a meeting held by Ministry of Health. Level of burnout was measured by using the Maslach Burnout Inventory that has 22 items consisting of three subscales, namely emotional exhaustion, depersonalization and personal accomplishment. Besides, one more questionnaire with 16 questions was added in order to collect demographic data of the physicians. RESULTS: The average score of the participants got from the &quot;depersonalization&quot; subscale (5.08&plusmn;3.18) indicates low burnout level. When the average scores of intensive care physicians got from the other two subscales were evaluated, it can be said that they had experienced moderate levels of burnout at &quot;emotional exhaustion&quot; (15.56&plusmn;6.26) and &quot;personal accomplishment&quot; (22.44&plusmn;3.69) subscales.CONCLUSION: Intensive care physicians experienced moderate levels of burnout at &quot;emotional exhaustion&quot; and &quot;personal failure&quot; subscales. Therefore, improvement of working conditions may be effective in their feeling of more successful