title: Survival from severe pandemic H1N1 in urban and rural Turkey: a case series.
abstract: BACKGROUND
  Pandemic influenza A (H1N1) was a serious health problem during the winter of 2009-2010 in Turkey.
  
  
  OBJECTIVE
  To clarify the clinical and demographic characteristics of patients who needed intensive care in our region.
  
  
  METHODS
  We conducted a prospective cohort study from November 2009 to February 2010 of demographic characteristics, clinical course, management strategies, 28-day mortality, and stay in the intensive care unit (ICU).
  
  
  RESULTS
  During the study period, in our ICU we followed 18 patients (10 female) with H1N1. Their median (and IQR) age was 39 y (24-52 y), their median (and IQR) Acute Physiology and Chronic Health Evaluation (APACHE II) score was 16 (10-25), and 7 (39%) of them lived in rural places. All 18 patients had acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). The most common risk factors for severe H1N1 infection were obesity (33%), COPD (16%), and pregnancy (11%). Thirteen patients (72%) needed mechanical ventilation at ICU admission. Mortality was 50% (9/18) at day 28. Significantly more survivors were urban dwellers than rural (82% vs 0%, P < .001). There were also statistically significant differences between survivors and nonsurvivors in success of noninvasive ventilation, time to confirmation of the H1N1 virus after ICU admission, creatinine, lactate dehydrogenase, pH, P(aCO(2)), and P(aO(2))/F(IO(2)).
  
  
  CONCLUSIONS
  The most common clinical presentation was ALI/ARDS in H1N1 patients who needed intensive care. Living in rural areas might have affected those patients' access to advanced ICU facilities and early ventilatory support. Failure of noninvasive ventilation, late diagnosis, late antiviral therapy, high APACHE II score, and living in a rural area were associated with mortality.
authors.affiliation: Intensive Care Unit, Izmir Training and Research Hospital for Thoracic Medicine and Surgery, Izmir, Turkey. ckirakli@hotmail.com
authors.forename: Cenk
authors.initials: C
authors.lastname: Kirakli
authors.forename: Dursun
authors.initials: D
authors.lastname: Tatar
authors.forename: Pinar
authors.initials: P
authors.lastname: Cimen
authors.forename: Ozlem
authors.initials: O
authors.lastname: Edipoglu
authors.forename: Meral
authors.initials: M
authors.lastname: Coskun
authors.forename: Emel
authors.initials: E
authors.lastname: Celikten
authors.forename: Ayse
authors.initials: A
authors.lastname: Ozsoz
mesh_terms: D018806:APACHE; D000328:Adult; D004196:Disease Outbreaks; D005260:Female; D006801:Humans; D053118:Influenza A Virus, H1N1 Subtype; D007251:Influenza, Human / Q000382:microbiology* / Q000821:virology; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D012424:Rural Population; D012621:Seasons; D018709:Statistics, Nonparametric; D014421:Turkey / Q000453:epidemiology; D014505:Urban Population