Rheological consequences of acute infections: the rheodifference between viral and bacterial infections.

The aim of the present study was to explore the difference between viral and bacterial infections regarding the intensity of erythrocyte aggregation in the peripheral venous blood. Although a rheodifference in terms of erythrocyte aggregation between viral and bacterial infections has been shown by us in the past, the time from onset of disease was not included. We have presently included the time from the onset of disease in a group of 133 patients with an acute bacterial infection who showed a significantly enhanced erythrocyte aggregation as opposed to a group of 23 with viral ones and no increased erythrocyte aggregation despite of there being no significant difference in the time from onset of disease (55.7+/-55.6 hours in the bacterial group versus 50+/-35.2 in the viral one). In addition, we could match 22 patients with viral infections who presented the same fibrinogen concentrations (338+/-78 mg/dl) as those with acute bacterial ones (338+/-79 mg/dl). Although of borderline (p=0.06) significance, patients with an acute bacterial infection presented enhanced (vacuum radius=12.6+/-6.4 microns) erythrocyte aggregation as opposed to their isofibrinogenemic counterparts (vacuum radius=9.4+/-6.5 microns). Again, both groups presented no difference regarding the time from onset of disease. We conclude therefore that patients with acute bacterial infections present higher levels of erythrocyte aggregation. This is not a result of a shorter time interval from disease onset of the viral group. The known detrimental effects of increased erythrocyte aggregation regarding capillary slow flow, endothelial dysfunction and reduced tissue oxygenation might be therefore relevant in the context of patients with an acute infection, especially the bacterial ones.

Pain relief in major trauma patients: an Israeli perspective.

BACKGROUND: The pain of major trauma patients remains often unrelieved while in the emergency department. Our objective was to examine pain management in several trauma units, and to evaluate the impact of implementation of a trauma pain management protocol. METHODS: Current status was evaluated from questionnaires filled by trauma unit personnel of nine medical centers. In one, a pain management protocol was introduced. Staff and patients evaluated pain management before and after the protocol was instituted. RESULTS: About 80% of staff respondents from various centers were not aware of guidelines for pain management in trauma. The belief that pain assists diagnosis was the main reason (78.6%) for withholding analgesia. Large variability existed on what contraindicates analgesia, with the majority withholding analgesia in abdominal and multiple injuries. When administered, analgesia was delayed, and most commonly intramuscular meperidine was given. After the protocol's implementation, the personnel's awareness of analgesia increased, and consequently it was administered earlier and to more patients, mostly as intravenous morphine. Patients appreciated the timely analgesia (38% after vs. 14% before, p = 0.01), with fewer receiving none. Analgesia was considered beneficial by more patients (70% after vs. 23% before, p < 0.001), and enhanced cooperativity with personnel (p < 0.001). This was reflected in increased overall satisfaction with pain relief during the entire hospitalization. CONCLUSION: The importance of pain management protocols in major trauma was demonstrated by the response of personnel and patients.

Neutrophilia of infection/inflammation: are we really dealing with "inflamed" leukocytes?

We adopted whole blood flow cytometry and direct labeling of the CD11b/CD18 and CD62L antigens to study the relationship between their expression and leukocytosis in patients with infection/inflammation, acute stress and healthy volunteers. Mean +/- S.D. channel fluorescence intensity of CD11b/CD18 antigen on peripheral blood polymorphonuclears did not differ between patients with infection/ inflammation (173+/-78) and controls (167+/-72), but was significantly (p = 0.04) reduced in stress (135+/-60). No correlation was found between CD11b/CD18 antigen level and either polymorphonuclears absolute number or serum C-reactive protein. A significant negative correlation was noted between CD62L antigen expression on polymorphonuclears and their absolute number. We assume that cells with increased CD11b/CD18 surface concentrations are retained in the capillaries and that part of the leukocytes in the peripheral blood are stressed leukocytes with reduced CD11b/CD18. Thus, leukocytes detected in peripheral blood are not necessarily the most "inflamed" ones.

Down-regulation of the CD62L antigen as a possible mechanism for neutrophilia during inflammation.

The expressions of both the CD11b/CD18 and CD62L (L-selectin) antigens as well as the absolute number of white blood cells in the peripheral circulating pool of blood in 116 patients with various inflammatory conditions were determined. A highly significant (P<0.0001) negative correlation (r = -0.57) was noted between the absolute number of peripheral blood polymorphonuclear leucocytes and the expression of the CD62L antigen on their surface. In view of the role of CD62L antigen in the rolling of leucocytes along endothelial cells in the microvasculature, its down-regulation might explain, at least in part, the demargination and appearance of neutrophilia during inflammation.

Comparison of Baseline Characteristics and Outcome of Patients with Chest Pain Brought to the Hospital by Private Versus Public Mobile Intensive Care Units.

The baseline characteristics and outcome of patients with acute chest pain who were brought to the hospital by public versus private mobile intensive care units were compared. Of 283 patients brought to the Department of Emergency Medicine at the Tel Aviv Sourasky Medical Center by mobile units in July and September of 1995, 163 were transported by the private service and 120 by the public service. Patients who were brought by the private service were older and had significantly more comorbidities, especially cardiac history. However, a significantly higher proportion of patients brought by the public service suffered confirmed myocardial infarction, and were hospitalized in the intensive coronary care unit. In addition, mortality in this group was significantly higher (4.0% vs. 2.2%). Possible explanations for this finding are greater accessibility or bias in the prehospital management of patients channeled through the private mobile service.

Neuroleptic malignant syndrome in the elderly.

Four cases of neuroleptic malignant syndrome (NMS) were identified in a general hospital over a 5-year period. Two cases presented to the psychiatric consultation liaison service, and two were found by a computerized review of discharge diagnoses. Cases were examined for age, sex, administered neuroleptic potency and dose, premorbid history, prodromal symptoms, methods of treatment, and clinical outcome. The mean age of cases was found to be 14 years greater than the age of the non-NMS patient population. All NMS cases had premorbid neuropsychiatric disorders and recognizable prodromal symptoms. The mean neuroleptic dose was significantly lower than in previously reported cases. A systems model integrating premorbid factors, intercurrent illness, and drug effects in pathogenesis is presented.

Physiologic benefits of a stress reduction program for healthy middle-aged Army officers.

Stress reduction programs (SRPs) can reduce morbidity and mortality in patients with coronary artery disease (CAD). This study evaluated the effect of an SRP on metabolic and hormonal risk factors for CAD. Twenty army officers participating in an SRP, Group I, and a comparison group of seventeen SRP nonparticipants, Group C, volunteered to undergo measurement of dehydroepiandrosterone-sulfate (DHEA-S), cortisol, DHEA-S/cortisol ratio, testosterone, apolipoprotein-A1, apolipoprotein-B, triglycerides, cholesterol, fibrinogen, and leukocyte count both before and after the SRP period. No differences in the changes in biochemical risk factors for CAD were found between participant and nonparticipant except for DHEA-S. While Group C had a marked reduction in DHEA-S levels, Group I had a small increase. Previous studies indicate DHEA-S is inversely associated with extent of CAD and age-adjusted DHEA-S levels below 3.78 mumol/l confer an increased risk for CAD mortality. SRP participation appears to effect DHEA-S levels, possibly partially accounting for the benefits observed in SRPs among CAD patients.

Psychological and behavioral benefits of a stress/type A behavior reduction program for healthy middle-aged army officers.

Twenty army officers who participated in a stress/type A behavior reduction program and a comparison group of 17 officer nonparticipants volunteered to undergo a battery of psychological and behavioral tests before and after the program. Following the program, participants displayed a significantly greater reduction in average daily caloric intake and levels of perceived stress, anxiety, hostility, depression, psychological distress, and type A behavior as compared to the officers who did not participate in it. Given the fact that most of these psychological and behavioral factors have been found in previous studies to be related to an increased risk for coronary artery disease, it seems that the changes reported by the participants in the program are potentially healthful.

Topical mechlorethamine therapy for early stage mycosis fungoides.

One hundred seventeen patients with mycosis fungoides were treated with topical mechlorethamine hydrochloride. The probability of achieving a clinically apparent remission within 2 years of therapy was 75.8% in patients with stage I disease, 44.6% in patients with stage II disease, and 48.6% in patients with stage III disease. Patients with stage I disease achieved complete remission sooner (median, 6.5 months) than patients with stage II (median, 41.1 months) or stage III (median, 39.1 months) disease. The median time to relapse was 44.5 months. Sixty-eight patients (58.1%) developed a delayed hypersensitivity reaction, but only one patient had to discontinue therapy as a consequence. No appreciable differences were seen in the probability to achieve complete remission or time to complete remission as stratified by gender, substage, or the development of a delayed hypersensitivity reaction. Survival analysis revealed that the probability of surviving at 5 years was 89% for all patients. These findings compare favorably with results with other treatments for early stage mycosis fungoides.

Neuroendocrine correlates of the type A behavior pattern: a review and new hypotheses.

Various studies have tried to identify the possible neuroendocrine correlates of the action/emotion complex defined as Type A behavior pattern. Type A subjects have been observed quite consistently to respond to laboratory stressors with a greater sympathetic nervous system response than Type B subjects. There also seems to be a trend towards a hyperactivity of the hypothalamic-pituitary-adrenocortical axis in Type A individuals. The clinical relevance of these findings lies in the fact that there is an increasing clinical and laboratory evidence of a pathogenic role of catecholamines in coronary artery disease (CAD) and that some of these neuroendocrine correlates might actually be the mediators of the risk of CAD conferred by the Type A behavior pattern. We hypothesize that dehydroepiandrosterone-sulfate (DHEA-S), an adrenal weak androgen, is inversely correlated with the degree of Type A behavior pattern and this hypothesis seems to be confirmed by the results of a preliminary investigation that we have conducted.