Impact of active surveillance on meticillin-resistant Staphylococcus aureus transmission and hospital resource utilisation.

The utility of active surveillance cultures (ASCs) for meticillin-resistant Staphylococcus aureus (MRSA) has been a controversial aspect of infection prevention. This prospective cohort study analyses the effect of ASCs for MRSA on hospital-acquired infections in a tertiary care hospital (hospital 1) and a community-based hospital (hospital 2). Both hospitals have high MRSA prevalence and are part of a large healthcare system in southeastern Michigan. Hospital-acquired infections in the intensive care unit (ICU) and in the rest of the hospital were compared before and after the implementation of ASCs in the ICUs. Patients in hospital 1 with evidence of MRSA colonisation from ASCs were placed in contact isolation during their stay in the ICU; patients from hospital 2 remained in contact isolation throughout their hospital stay. Prevalence of MRSA colonisation on admission to the ICU was 23% and 13% in hospitals 1 and 2, respectively. Average incidence of new colonisation during the study period was 1.85 per 1000 patient-days and 3.47 per 1000 patient-days in hospitals 1 and 2, respectively. A decrease in ventilator-associated pneumonia (VAP) occurred in both hospitals, whereas decrease in hospital-wide nosocomial MRSA infection was demonstrated only in hospital 2. We conclude that, in addition to standard infection prevention initiatives, ASC with contact precautions can be effective in reducing the incidence of VAP and nosocomial MRSA infection in healthcare communities with endemic MRSA.

Experience of Black participants in the Lung Health Study smoking cessation intervention program.

This paper evaluates the hypothesis that Black smokers will respond differently than Whites to a smoking cessation intervention program where no adjustments are made in recognition of cultural differences. The responses of Black smokers who were recruited into the Lung Health Study (LHS) to the smoking cessation intervention are described. Black quit rates are compared with those of Whites. The LHS enrolled 5887 men and women smokers, aged 35-60 years, of whom 3923 were randomized to a group cessation intervention and 1964 to usual care. Blacks and Whites from six clinics who had complete covariate data (200 Blacks and 2868 Whites) were compared on baseline smoking characteristics and subsequent smoking cessation outcomes. Logistic models were constructed to adjust for baseline smoking variables and demographic characteristics to evaluate the effect of treatment group on smoking cessation among Blacks and Whites. At baseline, Blacks reported smoking fewer cigarettes than Whites, but had higher mean levels of salivary cotinine. The adjusted odds ratio of quitting at 1 year for the smoking intervention group vs. the usual care group was 1.48 for Blacks and 5.99 for Whites. This difference between Blacks and Whites was highly significant (p = 0.002). Across 5 years, the adjusted odds ratios of quitting were 1.87 for Blacks and 3.34 for Whites (p = 0.06). Although the treatment effect was stronger for Whites than for Blacks, over the 5 years of the study there was a significant treatment effect for Blacks. Indicators of physical dependence on nicotine at baseline were inconsistent in indicating whether Blacks were more dependent. We conclude that Blacks and Whites differed significantly in their response to the LHS group smoking intervention program.

Duropleural fistula manifested as a large pleural transudate: an unusual complication of transthoracic diskectomy.

A 52-year-old patient presented with large symptomatic transudative pleural effusion 4 months following T8 to T9 transthoracic diskectomy. Anterior approach diskectomy has replaced the traditional laminectomy for treating symptomatic centrally herniated and calcified thoracic disks. We describe in this report the first case of a large cerebrospinal fluid collection in the pleural cavity caused by persistent postoperative duropleural fistula. The possibility of a duropleural fistula should be entertained in patients who present with a pleural effusion following transthoracic diskectomy.

Hyperbaric oxygen therapy for radiation-induced brain injury in children.

BACKGROUND: Radiation-induced necrosis (RIN) of the brain is a complication associated with the use of aggressive focal treatments such as radioactive implants and stereotactic radiosurgery. In an attempt to treat patients with central nervous system (CNS) RIN, ten patients received hyperbaric oxygen treatment (HBOT). METHODS: Patients presented with new or increasing neurologic deficits associated with imaging changes after radiotherapy. Necrosis was proven by biopsy in eight cases. HBOT was comprised of 20-30 sessions at 2.0 to 2.4 atmospheres, for 90 minutes-2 hours. Sites of RIN included the brain stem (n = 2), posterior fossa (n = 1), and supratentorial fossa (n 7). Histologic types included brain stem glioma (n = 2), ependymoma (n = 2), germinoma (n = 2), low grade astrocytoma (n = 1), oligodendroglioma (n = 1), glioblastoma multiforme (n = 1), and arteriovenous malformation (n = 1). RESULTS: Initial improvement or stabilization of symptoms and/or imaging findings were documented in all ten patients studied and no severe HBOT toxicity was observed. Four patients died, with the cause of death attributed to tumor progression. Five of six surviving patients were improved by clinical and imaging criteria; one patient was alive with tumor present at last follow-up. CONCLUSIONS: HBOT may prove to be an important adjunct to surgery and steroid therapy for CNS RIN.

Right ventricular dilatation, right ventricular wall thickening, and Doppler evidence of pulmonary hypertension in patients with a pure restrictive ventilatory impairment.

The purpose of this investigation was to determine the severity of pure restrictive ventilatory impairment that results in right ventricular (RV) dilatation, increased RV wall thickness, and pulmonary hypertension. Two dimensional (2-D) echocardiography, Doppler measurements of pulmonary flow, and spirometry were performed on 26 unselected patients (17 female, 9 male) with a pure restrictive ventilatory impairment. A restrictive ventilatory impairment was defined as a forced vital capacity (FVC) < or = 80 percent predicted with a normal FEV1/FVC ratio (FEV1 = 1 s forced expiratory volume). The patients were grouped according to the severity of the restrictive ventilatory defect: mild (FVC, 65 to 80 percent predicted), moderate (FVC, 51 to 64 percent predicted), and severe (FVC < or = 50 percent predicted). An increased RV area (> 20.4 cm2) was shown in 0 of 10 (0 percent) patients with a mild impairment, 6 of 12 (50 percent) patients with moderate restriction, and 2 of 4 (50 percent) patients with severe restriction. Increased RV wall thickness (> 0.5 cm) was observed in 0 of 10 (0 percent) patients with mild restrictive impairment, 3 of 12 (25 percent) with moderate impairment, and 1 of 4 (25 percent) with severe restrictive impairment. Doppler evidence of pulmonary hypertension (ACT/ET ratio < 0.32) (ACT = acceleration time, ET = ejection time) was shown in 0 of 10 (0 percent) patients with a mild restrictive impairment, 8 of 12 (66 percent) patients with moderate restriction, and 4 of 4 (100 percent) patients with severe restriction (p < 0.01 mild vs moderate and mild vs severe). The RV area by 2-D echocardiography correlated well with the FVC percent predicted (r = 0.90, p < 0.001). The ACT/ET ratio also correlated well with the FVC percent predicted (r = 0.73, p < 0.001). In conclusion, RV enlargement and pulmonary hypertension were seen only in patients with a moderate or severe restrictive ventilatory impairment. These data may be useful in the assessment of the likelihood of subtle RV enlargement in patients with occupational pleuropulmonary disease.

Chest radiographs fail to detect right ventricular enlargement and right atrial enlargement in patients with a pure restrictive ventilatory impairment.

The validity of measurements of the cardiac silhouette on chest radiographs for the evaluation of right ventricular enlargement and right atrial enlargement in patients with a pure restrictive ventilatory impairment was investigated in 19 patients. The forced vital capacity (FVC) percent predicted in these patients was 59 +/- 12 percent (mean +/- SD) (range, 29 to 79 percent). Right ventricular enlargement, by two-dimensional echocardiography, was defined as a right ventricular area > 20.4 cm2 and right atrial enlargement was defined as a right atrial area > 15.3 cm2. Chest radiographic measurements in the posteroanterior (PA) projection included distance from the midline to the farthest point of the right border of the cardiac silhouette, transverse cardiac diameter, and cardiothoracic ratio. Measurements in the lateral projection included the lateral horizontal transverse diameter, ventral portion of the lateral broad diameter, and obliteration of the retrosternal space. Neither the right ventricular area nor the right atrial area correlated with any of these radiographic measurements. There were no differences in these chest radiographic measurements among patients with normal right ventricular and right atrial dimensions, patients with right ventricular enlargement, and patients with right atrial enlargement. We conclude, therefore, that PA and lateral chest radiographs do not reliably detect right ventricular enlargement or right atrial enlargement in patients with a pure restrictive ventilatory impairment.

Bioelectrical impedance assessment of nutritional status in critically ill patients.

The objective of this study was to assess the utility of bioelectrical impedance analysis (BIA) in determining nutritional status in critically ill patients in the intensive care unit (ICU). Data were collected prospectively in 33 mechanically ventilated medical and surgical ICU patients requiring nutrition as part of their care. BIA, with subsequent calculation of body-composition indexes, was performed every other day for the duration of ICU stay. Body cell mass (BCM) changes correlated with energy and protein intakes (r2 = 0.87, P < 0.001 and r2 = 0.67, P < 0.001, respectively). Maintenance of BCM was achieved by a daily provision of 125.5 kJ.kg-1.d-1 (30 kcal.kg-1.d-1) and 1.5 g protein/kg whereas greater intakes allowed restoration of BCM. The mean ratios of exchangeable sodium to potassium (Nae:Ke) improved only in patients achieving positive nitrogen balance (P = 0.013). Body-composition changes determined by BIA represent a feasible adjunctive method for evaluating and monitoring nutritional status in ICU patients.

Hypercapnic respiratory failure due to L-tryptophan-induced eosinophilic polymyositis.

A 24-year-old man presenting with fever, rash, and myalgias subsequently developed hypercapnic respiratory failure and severe limb muscle weakness. Muscle biopsy revealed eosinophilic myositis, due to the ingestion of large quantities of L-tryptophan as a dietary supplement. Complete recovery occurred with corticosteroid administration. Significant involvement of the respiratory muscles can be a predominant feature of this newly described disease entity.

Respiratory failure and death following acute inhalation of mercury vapor. A clinical and histologic perspective.

A family of four was exposed to toxic levels of mercury vapor while attempting to extract silver from mercury amalgam. All four suffered respiratory failure and subsequent death despite chelation therapy with dimercaprol. Histologic findings at autopsy were similar in all four cases demonstrating a progression of acute lung injury that appeared related to postexposure day survival. There were no clinical signs of extrapulmonary manifestations despite toxic serum mercury levels. Although serum mercury levels decreased in response to the mercury chelating agent dimercaprol, serum levels remained in the toxic range and no clinical response was observed. Acute inhalational exposure to high concentrations of mercury vapor causes pneumonitis that can lead to respiratory failure and death. This continues to be a health hazard in both the workplace and the home environment.

Active tuberculosis in the medical intensive care unit: a 15-year retrospective analysis.

Of approximately 6000 admissions to the Henry Ford Hospital medical ICU between October 1969 and September 1984, 61 (1%) had active tuberculosis (TB). Forty-three (70%) of these 61 had acute respiratory failure (ARF). TB was considered to be the sole cause of ARF in 12 and contributory in 31. Eighteen patients with TB but without ARF were admitted for treatment of other critical illnesses. Alcoholism was present in 31 (51%) of the TB patients. Only one of 12 whose ARF was caused primarily by TB had a history of known TB at the time of admission. Important factors contributing to ARF in TB patients included Gram-negative pneumonia and/or sepsis, chronic obstructive pulmonary disease, prior TB with anti-TB medication noncompliance, and malignancy. Six patients were not suspected of having TB when admitted to the medical ICU; three patients who had not been treated for TB were found to have TB on autopsy. The inhospital mortality rate for all patients with TB requiring intensive care was 67%, but was 81% in those with ARF.

Initial combination therapy with YAG laser photoresection and irradiation for inoperable non-small cell carcinoma of the lung. A preliminary report.

Patients presenting with inoperable non-small cell carcinoma of the lung and major symptomatic bronchial obstruction were treated initially with debulking of the airways by YAG laser, followed by conventional external-beam radiotherapy. The former method was used to minimize postobstructive pneumonitis or respiratory failure (or both) that often complicates major brochial obstruction and also to lessen the burden of tumor to be treated by radiotherapy. The preliminary results of 19 patients treated in this manner are reported, emphasizing the impact of this combined method on morbidity and mortality.

The Sézary syndrome with rapid pulmonary dissemination.

The authors report the case of a patient with long-standing Sézary syndrome who developed the acute onset of bilateral pulmonary infiltration, severe hypoxemia, and hypotension. Initial diagnostic considerations centered around infection, but an open-lung biopsy revealed "mycosis fungoides" without evidence of an infectious process. The patient showed striking improvement when given vincristine and cyclophosphamide, but ultimately died 3 months later of a nonpulmonary catheter-related infection. This rare clinical association stresses the value of open lung biopsy as a diagnostic measure even in desperately ill individuals.

Alterations in theophylline protein binding in acutely ill patients with COPD.

We investigated the role of decreased theophylline protein binding as a possible explanation for observed decreases in total theophylline concentrations (TC) in acutely-ill patients (AIP). Multiple blood samples were obtained from nine AIP with underlying chronic obstructive pulmonary disease (COPD) and from 13 stable COPD patients. The mean albumin concentration +/- SD was 2.7 +/- .61 mg/dl in the AIP vs 4.0 +/- 0.52 mg/dl in the stable COPD patients (p less than 0.005). Total (TC) and unbound theophylline concentrations (UTC) were determined. Theophylline protein binding was assessed at room temperature by centrifugal ultrafiltration of the patients' sera. The TC was 13.7 +/- 4.8 micrograms/ml in the stable COPD patients vs 11.8 +/- 4.1 micrograms/ml in the AIP although the mean dose was larger (17.21 +/- 5.41 vs 10.7 +/- 4.09 mg/kg/day of theophylline) in the AIP (p less than 0.005). There was no difference in UTC between the two groups (7.4 +/- 2.5 micrograms/ml and 8.1 +/- 2.6 micrograms/ml); however, the unbound fraction was higher in the AIP (p less than 0.005). We conclude that theophylline protein binding appears altered in AIP and that the altered binding relates predominantly to the severity of the clinical illness.

YAG laser photoresection of lesions obstructing the central airways.

Some patients with cancer and others with benign lesions which obstruct the central airways (larynx, trachea, major bronchi) can be treated with a laser. Ninety-nine patients were considered for treatment during the first 18 months of experience with a YAG (yttrium aluminum garnet) laser at Henry Ford Hospital; 55 patients were treated 82 times. Results were satisfactory (surgery was avoided) in eight of ten patients with benign lesions. Satisfactory results (doubling of airway size with relief of dyspnea/drainage of obstructive pneumonia) were obtained in 12 of 13 patients with bronchogenic carcinoma managed initially with the laser, and in 22 of 32 (69 percent) patients with recurrent malignancies. There were five minor and seven major complications, including two deaths. We conclude that laser treatment can relieve central airways obstruction with its associated symptoms of dyspnea and infection. Avoidance of complications requires a skillful approach, careful anesthetic management, and availability of back-up posttreatment intensive care.

Abnormal breathholding in association with carotid body dysfunction mimicking sleep apnea.

Apneic episodes lasting as long as 126 s were observed in a previously well 22-yr-old woman and were felt to result from voluntary breathholding superimposed on a blunt hypoxic ventilatory drive secondary to carotid body dysfunction. Distinguishing features between this life-threatening voluntary apnea, sleep apnea, and nonconvulsive epilepsy are discussed as well as a theoretical review of breathholding per se.