Risk of bacteremia in patients presenting with shaking chills and vomiting - a prospective cohort study.

Chills and vomiting have traditionally been associated with severe bacterial infections and bacteremia. However, few modern studies have in a prospective way evaluated the association of these signs with bacteremia, which is the aim of this prospective, multicenter study. Patients presenting to the emergency department with at least one affected vital sign (increased respiratory rate, increased heart rate, altered mental status, decreased blood pressure or decreased oxygen saturation) were included. A total of 479 patients were prospectively enrolled. Blood cultures were obtained from 197 patients. Of the 32 patients with a positive blood culture 11 patients (34%) had experienced shaking chills compared with 23 (14%) of the 165 patients with a negative blood culture, P = 0.009. A logistic regression was fitted to show the estimated odds ratio (OR) for a positive blood culture according to shaking chills. In a univariate model shaking chills had an OR of 3.23 (95% CI 1.35-7.52) and in a multivariate model the OR was 5.9 (95% CI 2.05-17.17) for those without prior antibiotics adjusted for age, sex, and prior antibiotics. The presence of vomiting was also addressed, but neither a univariate nor a multivariate logistic regression showed any association between vomiting and bacteremia. In conclusion, among patients at the emergency department with at least one affected vital sign, shaking chills but not vomiting were associated with bacteremia.

[Biochemical and pharmacological check-up in emergency orientation]. / Bilans biochimiques and pharmacologiques d'orientation en urgence.

Biochemical and pharmacological tests usually prescribed in casualty department were reviewed taking into account their physiological significance and predictive value : ions, total proteins, carbohydrate and nitrogenous metabolites, enzymes, tissue markers, pharmacological drugs. Few blood components were kept with the first intention, ideally with a turn around time below one hour: sodium, potassium, chloride, bicarbonate, total proteins, pCO2 and pO2, creatinine, glucose, ketone compounds, calcium, bilirubin, transaminases, lipase, C-reactive protein, myoglobin, troponin, chorionic gonadotropin hormone. Those tests do not have to be systematically performed but prescribed only after the evaluation of pre-test probabilities by the clinician.

A deficiency of interstitial cells of Cajal in Chagasic megacolon.

Disordered gut motor activity is a feature of patients with Chagas' disease: colonic involvement leads to the development of megacolon and symptoms of constipation. Interstitial cells of Cajal are thought to modulate gut motility. The aim of this study was to test the hypothesis that there is an abnormality of the density of distribution of interstitial cells of Cajal in Chagasic megacolon. Interstitial cells of Cajal were identified by immunohistochemistry using an anti-c-kit antibody. Six patients with Chagasic megacolon were compared with normal controls. The density of distribution of interstitial cells of Cajal was assessed in the longitudinal and circular muscle layers, and in the intermuscular plane of the Chagasic and normal colon. Statistical analysis was performed using Fisher's exact test. The interstitial cells of Cajal density in Chagasic megacolon was much reduced in comparison to normal colonic tissue in the longitudinal muscle layer (P=0.0084), intermuscular plane (P<0.0001), and circular muscle layer (P=0.0051). The lack of interstitial cells of Cajal may play a role in the pathophysiology of the disease, leading to the development of megacolon and symptoms of constipation.

Nonsurgical pneumoperitoneum: a case report and a review.

The finding of extraluminal gas on plain radiographs is usually associated with a perforated viscus. But, as this case shows, the finding of pneumoperitoneum is not pathogenic of a perforated viscus or even of a surgical emergency, because there are many benign explanations for a pneumoperitoneum. Perhaps the most important maneuver for differentiating between the two is by performing a through history and physical examination. This in conjunction with either a diagnostic peritoneal lavage, contrast studies, or endoscopic evaluation can help prevent a patient from having needless surgery. The causes of a nonsurgical pneumoperitoneum are described as well as a treatment plan for patients presenting with a nonsurgical pneumoperitoneum.

Complication rates of tube thoracostomy.

This study compared the complication rates of tube thoracostomy performed in the emergency department (ED) versus the operating room (OR) and the inpatient ward (IW). A retrospective case series of all patients at an urban, university-based level 1 trauma center hospital who received tube thoracostomy for any indication between 1/1/93 and 12/31/93 was conducted. Complications were defined as empyema, unresolved pneumothorax (persistent air leak or residual pneumothorax), persistent effusion, or incorrect placement. The data for age and duration of tube placement were weighted for analysis of variance (ANOVA). A total of 352 tube thoracostomies was placed in 239 patients. Twenty-three patients had three or more chest tubes placed, 65 had two placed, and the remaining 181 had a single tube. Ninety-nine tubes were placed in the ED, 87 in the OR, and 166 on IW. The mean age of patients in the ED was 37 years, and differed significantly (P < .015) from those in the OR (48 years) and the IW (44 years). The duration of tube placement was similar for all groups (mean = 6.5 days). The overall complication rates related to tube insertion were: ED, 14.0%; OR, 9.2%; IW, 25.3%. Significance was achieved when comparing complication rates between the ED and IW, with less complications in the ED (P = .0436). When comparing complication rates between the ED and OR, there was no significant difference (P = .3643). A power calculation indicated too small of a sample size to truly determine an insignificant difference between complication rates between the ED and OR. Placement of emergent thoracostomy tubes in the ED does not result in an increased complication rate as compared to placement in the IW.

An in-vitro evaluation of sealer placement methods.

Successful root canal therapy is dependent upon obturating the root canal system. A critical component of the filling procedure is sealer placement. This in vitro study investigated the efficacy of six methods of sealer placement using clear plastic blocks with simulated curved canals instrumented to the apex using a step-back technique. After sealer placement and setting, the blocks were cross-sectioned at 2 mm intervals from mid-canal to apex. The sections were evaluated with a stereo operating microscope at x6 magnification for placement of an evenly distributed layer of sealer around the prepared canal walls. The lentulo spiral and the Max-i-Probe Delivery System were the most effective means of sealer placement, followed by ultrasonic and sonic files. The least effective methods were the paper point and the K file.

Comparison of fatigue for three prefabricated threaded post systems.

Post designs may have a direct effect on fracture resistance of endodontically treated teeth. This in vitro study compared the resistance of three prefabricated threaded post systems with lateral shearing forces. After endodontics were completed, prefabricated posts were inserted according to the manufacturer's instructions. A silver amalgam core was placed, and extracted human teeth were prepared to a standard size with a 1 mm gingival chamfer finished on sound dentino A cast was fabricated and cemented, and the specimens were thermocycled. The test samples were secured to an Instron testing machine and loaded until failure. Fracture patterns were recorded, fractured surface areas were measured, and compressive stresses were calculated. However, there were no statistically significant differences among threaded posts in each test group.

An in vitro evaluation of the irrigating characteristics of ultrasonic and subsonic handpieces and irrigating needles and probes.

The objective of this in vitro study was to evaluate the efficacy of a variety of endodontic irrigating devices. This study utilized plastic blocks with artificial canals to simulate the clinical setting. The canals were instrumented, and red food dye was introduced into each canal. The blocks were placed in a jig to simulate maxillary and mandibular arch orientation. Irrigation was performed with: (a) B-D 22-gauge needle; (b) Monoject Endodontic Needle 23 and 27 gauge; (c) Max-i-Probe 25-, 28-, and 30-gauge probes; (d) Cavi-Endo ultrasonic handpiece; and (e) Micromega 1500 subsonic handpiece. A Sony Camcorder was used to record the effect of irrigation on the simulated canal contents. Tape review enabled the investigators to observe dye clearance effected by each modality. The Max-i-Probe probes were the most effective instrument used to clear dye from the simulated canals in both the mandibular and maxillary positions.

Selecting a post system.

Posts retain cores when tooth structure is lost. Many posts are on the market, but root structure is the best guide to post selection.

Backscatter dose perturbation at high atomic number interfaces in megavoltage photon beams.

Most computer algorithms used clinically for photon beam treatment planning are unable to predict the effect of electron backscattering on dose distribution from high atomic number materials. It has been observed that there is a significant dose enhancement at such an interface. We define the dose enhancement in terms of backscatter dose factor (BSDF), which depends on the energy of the photon beam, thickness and width of the inhomogeneity, distance from the interface, and the atomic number of the inhomogeneity. For all energies studied, the dose fall-off is initially very rapid and disappears beyond a few millimeters upstream from the interface. Empirically derived equations are presented for dose calculation at the interfaces of various media, including bone and soft tissue, for photon energies in the range of Co-60 gamma rays to 24 MV x rays.

Oligarchic forests of economic plants in amazonia: utilization and conservation of an important tropical resource.

Tropical forests dominated by only one or two tree species occupy tens of millions of hectares in Ammonia In many cases, the dominant species produce fruits, seeds, or oils of economic importance. Oligarchic (Gr. oligo = few, archic = dominated or ruled by) forests of six economic species, i. e., Euterpe oleracea, Grias peruviana, Jessenia bataua, Mauritia flexuosa, Myrciaria dubia, and Orbignya phalerata, were studied in Brazil and Peru Natural populations of these species contain from 100 to 3,000 conspecific adult trees/ha and produce up to 11.1 metric tons of fruit/hd/yr. These plant populations are utilized and occasionally managed, by rural inhabitants in the region. Periodic fruit harvests, if properly controlled have only a minimal impact on forest structure and function, yet can generate substantial economic returns Market-oriented extraction of the fruits produced by oligarchic forests appears to represent a promising alternative for reconciling the development and conservation of Amazonian forests.

Experimental arthritis induced by atypical strains of Streptococcus pyogenes.

Experimental arthritis was induced in Sprague-Dawley rats by intraarticular injection of whole-cell sonicates, heat-killed cells and cell-wall preparations of typical and atypical strains of Group-A streptococci (Streptococcus pyogenes). The non-haemolytic nitrosoguanidine-derived mutant and the naturally occurring Lowry strain induced a similar but less severe form of arthritis. Direct immunofluorescent staining demonstrated maximum fluorescence in the sections of articular joint taken 60 days after injection. The level of immune complexes increased for up to 90 days after injection of cell walls or whole-cell sonicates and correlated well with the development of the chronic stage of arthritis observed in haematoxylin and eosin and fluorescence staining of thin tissue sections.

Development of sleep states in normal premature and full-term newborns.

THE AIMS OF OUR STUDY WERE: 1) to answer the question "Do sleep states exist in normal premature infants;" 2) to analyze the development of sleep cycle and sleep state characteristics in premature and full-term newborns. Polygraph recordings were done on 38 normal, appropriate for gestational age newborns, born at 30 to 41 weeks (w) of gestation. All infants fell asleep in active sleep (AS). Postwaking AS was significantly shorter than the next AS. Mean sleep cycle duration increased from approximately 46 min at 31-34 w of conceptional age (CA) to 70 min. at 35-36 w CA. In all infants we observed stable, greater than 5 min AS and quiet sleep (QS) periods, as defined by EEG and REM criteria. Indeterminate sleep was about 30% of the total sleep cycle at 31-34 w; it decreased to 12% at 35-36 w. Both duration and percentage of AS and QS significantly increased at 35-36 w and remained stable up to 39-41 w CA. Values of QS were significantly reduced when defined by additional criteria (respiratory rate, tonic chin EMG or motility). Concordance of QS criteria was not significantly better in older versus younger groups of infants. At all ages, AS values were insensitive to changes in the criteria chosen to define them. The contrast, starting from 31-34 w CA, between AS and QS as defined by EEG and REM criteria could account for state differences in the control of many physiological variables in prematures.

Analysis of bronchoalveolar lavage specimens from immunocompromised patients with a protocol applicable in the microbiology laboratory.

Several studies have concluded that bronchoalveolar lavage (BAL) is a useful technique for diagnosing pulmonary disease in immunocompromised patients, but implementation of a protocol for obtaining, processing, and analyzing BAL specimens in a clinical microbiology laboratory has not been reported. We determined the utility of a laboratory protocol by analyzing 100 BAL specimens from 94 immunocompromised patients. Each BAL specimen was cultured quantitatively for bacteria. A concentrate of each specimen was cultured for fungi, viruses, mycobacteria, and Legionella sp. Slides of the BAL concentrate were prepared by cytocentrifugation and stained by a number of histochemical and fluorescence techniques. Overall diagnostic yields of 81% for infections, 90% for hemorrhage, and 13% for neoplasms were obtained with the patients studied. BAL analysis was incapable of diagnosing drug- or radiation-induced pneumonitis or idiopathic interstitial pneumonitis. After evaluation of the protocol was completed, it was successfully implemented in two university-based clinical microbiology laboratories as a routine diagnostic service.

Diagnosis of pulmonary hemorrhage in the immunocompromised host.

The efficacy of bronchoalveolar lavage (BAL) in diagnosing pulmonary hemorrhage was studied in 51 immunosuppressed patients with new pulmonary infiltrates. Similar studies were performed in a control group of 8 nonimmunocompromised patients. Hemosiderin content in Prussian-blue-stained alveolar macrophages obtained by BAL was graded using a numerical scale. This "hemosiderin score" correlated closely with the degree of hemorrhage seen in corresponding histologic sections in the 26 patients from whom a lung biopsy or autopsy specimen was available. Severe pulmonary hemorrhage was ultimately diagnosed in 14 cases, and a mild degree of hemorrhage was found in an additional 19 cases. Thrombocytopenia and invasive fungal infections were statistically associated with severe hemorrhage, as was an increased percentage of alveolar macrophages in the BAL sample. This study demonstrates the efficacy of BAL in diagnosing occult pulmonary hemorrhage in the immunosuppressed host and highlights risk factors associated with hemorrhage in this setting.

Diagnosing bacterial respiratory infection by bronchoalveolar lavage.

We prospectively evaluated 75 patients by fiber-optic bronchoscopy and bronchoalveolar lavage (BAL) for the presence of bacterial lower-respiratory-tract infection. BAL specimens were cultured quantitatively for aerobic bacteria, and a cell differential was obtained of the BAL cell population. In 18 "control" patients without evidence of respiratory infection, the presence of greater than 1% squamous epithelial cells (SECs) in the BAL sample accurately predicted the presence of heavy contamination of the sample by oropharyngeal flora. In the remaining "study" patients with potential infection, polymorphonuclear leukocytes were readily identified, and potential lower-respiratory-tract pathogens were recovered in concentrations greater than 10(5) colony-forming units (cfu) per milliliter in 16 of 18 patients with bacterial infection (none had greater than 1% SECs in their BAL sample). No patients without evidence of bacterial infection and with less than or equal to 1% SECs had greater than 10(5) cfu/ml in BAL cultures. These studies establish the ability of BAL techniques to diagnose bacterial respiratory infection.

The role of bronchoalveolar lavage in the diagnosis of invasive pulmonary aspergillosis.

Cultures and histochemical stains for fungi were performed on concentrated, cytocentrifuged bronchoalveolar lavage (BAL) samples from 82 immunocompromised patients undergoing bronchoscopic evaluation of new pulmonary infiltrates. Aspergillus hyphae were identified in 9 of 17 BAL samples from patients with invasive pulmonary aspergillosis and from 3 of the remaining 65 study patients without this diagnosis. Thus, the presence of Aspergillus hyphae in BAL samples had a 53% sensitivity, 97% specificity, and 75% positive predictive value for the diagnosis of invasive pulmonary aspergillosis. BAL fungal cultures were positive in only 4 of 17 cases (23% sensitivity). A combination of fungal stains and cultures yielded a diagnostic sensitivity of 58% and a specificity of 92%. Results of routine fiberoptic bronchoscopy procedures in the 17 patients with aspergillosis who had BAL and in a retrospectively identified group of 10 patients with invasive aspergillosis who had only routine bronchoscopy were tabulated. Routine bronchoscopy procedures yielded a diagnosis in 5 of 27 cases (22% overall yield), with washings diagnostic in 4 of 27 cases (15%), and transbronchial biopsies positive histologically in 2 of 11 cases (18%). BAL is a valuable first procedure for diagnosing invasive pulmonary aspergillosis in the compromised host.

Clarification of the AAPM Task Group 21 protocol.

In light of recent questions and comments from the physics community, a review is made of the AAPM protocol for high-energy x-ray and electron beam dosimetry.

Influence of breathing pattern on functional residual capacity in sleeping newborn infants.

The present study was designed to assess the influence of breathing pattern on the variations of functional residual capacity during sleep in newborn infants. Functional residual capacity was measured by the He-dilution method. Neurophysiologic criteria were used to identify sleep states. Movements of chest and abdomen were monitored. Twenty-six healthy newborn infants were studied. Sixteen were premature and 10 were at term. Functional residual capacity did not change in relation to changes in sleep states. In active sleep it was 1.48 +/- 0.07 ml/cm compared with 1.50 +/- 0.06 ml/cm in quiet sleep. Functional residual capacity decreased when rib cage and abdomen moved out-of-phase with a value of 1.38 +/- 0.09 ml/cm as compared to 1.56 +/- 0.09 ml/cm when in phase (P less than 0.01), in the 7 infants who displayed these two opposite patterns.