Variability in the time to initiation of CPR in continuously monitored pediatric ICUs.

AIM: To study the influence of patient characteristics and unit ergonomics and human factors on the time to initiation of CPR. METHODS: A single center study of children, 0 to 21 years old, admitted to an ICU who experienced cardiopulmonary arrest (CPA) requiring >1 min of chest compressions. Time of CPA was determined by analysis of continuous ECG, plethysmography, arterial blood pressure, and end-tidal CO2 (EtCO2) waveforms. Initiation of CPR was identified by the onset of cyclic artifact in the ECG waveform. Patient characteristics and unit ergonomics and human factors were examined including CPA cause, identification on the High-Risk Checklist (HRC), existing monitoring, ICU type, time of day, nursing shift change, and outcome. RESULTS: The median time from CPA to initiation of CPR was 50.5 s (IQR 26.5 to 127.5) in 36 CPAs. Forty-seven percent of patients experienced time from CPA to initiation of CPR of >1 min. There was no difference in CPA cause, ICU type, time of day, or nursing shift change. CONCLUSION: Nearly half of pediatric patients who experienced CPA in an ICU setting did not meet AHA guidelines for early initiation of CPR. This is an opportunity to study the recognition phase of CPA using continuous monitoring data with the aim of improving the understanding of and factors contributing to delays in initiation of CPR.

Advancing the development of diagnostic tests and biomarkers for tuberculosis.

High costs and limited returns on investment have hampered progress in developing new diagnostic tests and treatments for tuberculosis (TB). We need new biomarkers to develop assays that can rapidly, efficiently and reliably detect Mycobacterium tuberculosis infection and disease, identify drug resistance and expedite drug and vaccine development. This can only be accomplished through cross-disciplinary collaborations to facilitate access to human specimens. The Food and Drug Administration, Centers for Disease Control and Prevention, National Institutes of Health, the industry and academia experts came together in a June 2010 workshop to examine the field of TB diagnostic test development and biomarker discovery, identify areas of most urgent need and formulate strategies to address those needs.

Utility of blood cultures and incidence of mycobacteremia in patients with suspected tuberculosis in a South African infectious disease referral hospital.

SETTING: A 500-bed government referral institution for patients with tuberculosis and other infectious diseases in Gauteng, South Africa. OBJECTIVES: To assess the usefulness of BACTEC blood cultures over and above that of other microbiological methods for the diagnosis of tuberculosis in patients who are suspected of suffering from tuberculosis. DESIGN: Mycobacterial blood cultures were obtained from patients presenting with symptoms suspicious of tuberculosis and where there was no clinical evidence of other infectious etiologies, and from patients who had failed tuberculosis treatment. RESULTS: Sixteen (22%) of 71 patients included in the study were positive for Mycobacterium tuberculosis on blood culture, while seven (10%) were positive for M. avium complex (MAC). Twelve (75%) of the patients with tuberculosis and positive blood cultures were however also positive for acid-fast bacilli on sputum smears and eight (50%) were initially diagnosed clinically and radiographically as localized pulmonary tuberculosis. Blood cultures positive for mycobacteria were only found among patients with human immunodeficiency virus infection (HIV). CONCLUSIONS: Bacteremia with M. tuberculosis complex was detected in HIV-infected patients with suspected tuberculosis, even in patients presenting with localized pulmonary infection on initial clinical assessment. Among patients with suspected tuberculosis, blood cultures were useful in diagnosing unsuspected MAC disease, but did not add to the diagnostic yield of conventional tests for tuberculosis used routinely, namely sputum microscopy and culture, or occasional biopsy specimens.

Adjunctive salvage therapy with inhaled aminoglycosides for patients with persistent smear-positive pulmonary tuberculosis.

A proportion of patients with drug-resistant and drug-susceptible tuberculosis (TB) have sputum that is smear and culture positive for Mycobacterium tuberculosis for a prolonged period of time, despite conventional therapy. Among such patients with refractory TB, an unblinded, observational study was undertaken that used conventional TB therapy and adjunctive aerosol aminoglycosides. Patients with persistent smear- and culture-positive sputum for M. tuberculosis (despite > or =2 months of optimal systemic therapy) were selected for adjunctive treatment via inhalation with aminoglycosides, and microbiological responses were monitored. Thirteen of 19 patients converted to smear negativity during the study: 6 of 7 with drug-susceptible TB and 7 of 12 with drug-resistant TB. Among patients with drug-susceptible TB, the median time to sputum conversion was 23 days, a shorter time than for a population of historical control patients. Recurrent infection was not observed. Adjunctive aerosol aminoglycosides may expedite sterilization of sputum among certain patients with refractory TB and diminish the risk of transmission.

Tenderfoot Preemie vs a manual lancet: a clinical evaluation.

PURPOSE: To compare the amount of time required to collect a blood specimen, the number of heel punctures required, and the rate of hematology re-collections required when using a Monolet lancet vs a Tenderfoot Preemie device. DESIGN: Randomized, two-group, quasi-experimental. SAMPLE: Neonates with a birth weight >800 gm were eligible to participate in the study. Twenty subjects were randomized to the Monolet lancet (control) group and 20 to the Tenderfoot Preemie (experimental) group. A total of 157 blood specimens was collected, 89 of which were for hematology testing. RESULTS: For this sample population of preterm infants, less collection time was required, fewer heel punctures were necessary, and a lower re-collection rate occurred with use of the Tenderfoot Preemie than with use of the Monolet lancet.

Clinical and radiological features of South African patients with tuberculomas of the brain.

Intracranial tuberculomas are a rare complication of tuberculosis that typically occurs in immunocompromised patients not treated previously for tuberculosis. We identified tuberculomas in 12 patients (11 of whom were infected with human immunodeficiency virus) at a hospital in Johannesburg, South Africa. Responses to antituberculous therapy were good, often despite the presence of large lesions, and surgery was not considered necessary in any of the patients.

Phylogenetic analysis of the 5' subterminal region of isolates of Leishmania RNA virus-1.

Leishmania RNA virus-1 (LRV1) is a double-stranded RNA virus present in some Leishmania species. The virus genome consists of a 450-nucleotide, 5' untranslated region (UTR) followed by the coat gene and the RNA-dependent RNA polymerase (RDRP). It has been shown that the 5' end UTR of the genome promotes internal initiation of translation in an in-vitro assay, indicating the presence of an internal ribosomal entry site (IRES) element upstream of the coat gene. The nucleotide sequences of the 5' subterminal regions of six new isolates of LRV1, of different geographical origins, have now been determined. The RNA folding of the 5' subterminal region of LRV1 has been predicted, using a combination of thermodynamic parameters and folding constraints based on nucleotide substitutions. Furthermore, a putative pyrimidine-rich region (a feature unique to all IRES elements), which is complementary to the Leishmania 18S rRNA, has been identified. The significance and relevance of these findings in the context of the function of the 5' UTR of LRV1 as an IRES element are discussed.

Osseodistraction after traumatic amputation of the little finger in a young musician.

We lengthened the stump of a traumatically amputated little finger by osseodistraction in a young musician, who required a widened span to enable him to reach the octave on the piano. A mini external distraction device was used. No major complications occurred. The bone lengthening gave a good functional and cosmetic result.

A comparison of outbreak- and nonoutbreak-related multidrug-resistant tuberculosis among human immunodeficiency virus-infected patients in a South African hospital.

Nosocomial multidrug-resistant tuberculosis (MDR-TB) in human immunodeficiency virus (HIV)-infected people is recognized in Europe and America. We report the first such outbreak in South Africa. Six hospitalized women, identified by DNA fingerprinting, were infected with an outbreak strain of MDR-TB while receiving treatment for drug-susceptible tuberculosis. The putative source case was identified as an HIV-positive woman who underwent prolonged hospitalization for chronic cavitary tuberculosis. Compared with other HIV-positive patients in the hospital, outbreak patients were more immunocompromised, had fewer cavitary lung changes, and were less likely to have been treated before. They had high fevers, infiltrative patterns on chest radiographs, and a mean survival of 43 days. When individual isolation is not possible, separating highly immunocompromised patients with first-time tuberculosis from previously treated patients with cavitary lesions and from those with established drug resistance may reduce nosocomial transmission.

Leadership 99. Interview by Terese Hudson.

Cost control, customer service and collaboration among health care sectors rank as top concerns with panelists in H&HN's annual Leadership Report. Efforts to improve community health are a priority, too, but are often frustrated by financial and other constraints. The 16 panelists represent managed care, physicians, and hospitals and health systems.

Primary HIV infection diagnosed in South Africa masquerading as another tropical disease.

Eleven patients referred to a hospital in South Africa with suspected tropical diseases such as malaria, typhoid fever and South African tick bite fever were found to be suffering from primary human immunodeficiency virus (HIV) infection. Hospital records were reviewed retrospectively in those acutely ill, febrile patients where a clinical suspicion of HIV seroconversion existed and no other diagnosis could be found. A history of recent travel, particularly to malarious areas, was given by most of these patients. The clinical presentation was dominated by high fevers and headaches. The most helpful pointers to primary HIV infection included a characteristic palatal enanthem, leucopenia and thrombocytopenia. Ironically, the history of recent travel appeared to have confounded the diagnosis despite the fact that travel has often been associated with the acquisition of HIV in Africa. Recognition of primary HIV infection masquerading as a tropical disease may result in more frequent diagnosis of this serious condition.

Factors related to in-hospital deaths in patients with tuberculosis.

BACKGROUND: Deaths from tuberculosis (TB) continue to occur despite the availability of effective antimicrobial agents. Multidrug resistance, human immunodeficiency virus (HIV) infection, and delayed therapy have been implicated. OBJECTIVE: To examine clinical factors associated with in-hospital death in patients with active TB. METHODS: A retrospective case-control study was performed on patients admitted to a government hospital in Johannesburg, South Africa, used as a referral center for patients with TB. Eighty patients admitted with TB who died during hospitalization were matched with 80 similar patients with TB who survived hospitalization. Clinical, demographic, and radiological characteristics of each group were compared. RESULTS: In-hospital fatalities were associated with female sex (P=.01), lower admission hemoglobin level (P<.01), and weight (P<.01), and a trend to more extensive infiltrative patterns on chest radiographs. Multidrug resistance, extrapulmonary disease, and HIV infection were unexpectedly not related to in-hospital mortality. High mortality in the first weeks of admission suggested that late presentation was a major factor for in-hospital death. The HIV-infected participants in the study showed less drug resistance than HIV-negative patients (P=.07), equivalent extents of infiltrative patterns on chest radiographs, but much less cavitation and fibrosis (P<.01). CONCLUSIONS: Clinical predictors of early mortality from TB included anemia, low body weight, and extensive infiltrates, while multidrug resistance and HIV infection were not significant factors. Previous exposure to TB and delayed presentation may have influenced our findings. Since patients present late in their illness, aggressive case finding would be important in controlling TB in this population.