Detection of upper airway resistance syndrome using a nasal cannula/pressure transducer.

STUDY OBJECTIVES: To determine the diagnostic utility of a nasal cannula/pressure transducer (NC), in comparison to thermistor (TH), during routine, clinical nocturnal polysomnography (NPSG). DESIGN: We analyzed the respiratory arousal index (RAI) using TH (RAI-TH) or NC (RAI-NC) in patients with suspected sleep-disordered breathing (SDB). SETTING: Sleep disorders center of a university-affiliated teaching hospital. PATIENTS: Fifty consecutive, nonselected patients referred for evaluation of suspected SDB. MEASUREMENTS AND RESULTS: Twenty patients were found to have obstructive sleep apnea/hypopnea syndrome (OSA), 25 had upper airway resistance syndrome (UARS), and 5 had primary snoring (PS). Mean RAI-NC was greater than the mean RAI-TH by 25%, 302%, and 500% in OSA, UARS, and PS, respectively. RAI-NC was >/= 14 (mean, 25.2) in UARS and < 14 (mean, 9) in PS. Mean RAI-TH was 8.4 in UARS and 1.8 in PS, with significant overlap between the two groups. CONCLUSIONS: NC is more sensitive than TH in detecting respiratory events during NPSG and may represent a simple, objective means to identify UARS among patients with a range of SDB.

The effect of mucin on bacterial translocation in I-407 fetal and Caco-2 adult enterocyte cultured cell lines.

Although the intestinal mucosa forms a crucial barrier between the host and the environment, bacterial translocation (BT) occurs frequently in neonates and may be a source of sepsis. The intestinal mucous gel layer is thought to be a vital component of the gut barrier and is composed, in part, of a family of glycoproteins known as mucins. Our aim was to study the effects of mucin on BT in an enterocyte cell-culture model using a fetal (I-407) and an adult (Caco-2) intestinal cell line. I-407 and Caco-2 cells were grown to confluence on porous filters in a two-chamber Transwell system. The integrity of the monolayers was confirmed by transepithelial electrical resistance (TEER) and permeability using the macromolecule dextran blue. Cells were treated with mucin (40 mg/ml) prior to inoculation of 1 x 10(6) Escherichia coli C25. The magnitude of BT was determined quantitatively by culturing the samples from the basal chamber of the wells and was expressed as log 10 [Colony Forming Units (CFU)/ml]. Statistical analysis was performed by the Mann-Whitney U test with statistical significance at P < 0.05. Mucin inhibited BT across both fetal and adult cultured enterocyte monolayers; however, the inhibitory effect was less on the fetal cells compared to the adult cells. Dextran-blue studies showed that monolayers were intact throughout the experiments. Despite 98% inhibition of BT, mucin had a statistically significant effect on post-bacterial inoculation TEER in Caco-2 cells and no effect in I-407 cells. The ability of mucin, a mucous-barrier glycoprotein, to inhibit BT across immature intestinal enterocytes, as in the neonate, may be diminished compared to mature adult enterocytes.

Time to detection of Mycobacterium tuberculosis in sputum culture correlates with outcome in patients receiving treatment for pulmonary tuberculosis.

STUDY OBJECTIVE: The purpose of this study was to determine whether the time to detection (TTD) of Mycobacterium tuberculosis in sputum culture correlates with the response to antituberculous treatment in patients with pulmonary tuberculosis. STUDY DESIGN: Twenty-six consecutive patients were studied who had active pulmonary tuberculosis and sufficient sputum cultures and clinical follow-up to allow adequate assessment. RESULTS: Following initiation of antituberculous therapy, 13 patients (group 1, responders) had a complete response to treatment, and the TTD of M tuberculosis using the mycobacterial growth indicator tube increased steadily. The remaining 13 patients (group 2, nonresponders) had persistent evidence of active disease and demonstrated little or no increase in the TTD with treatment unless an additional therapeutic intervention was implemented (surgery, improved compliance with medications, or a change in medications). The presence of HIV infection, intravenous drug use, multidrug resistance, treatment with second-line therapy, extensive radiographic involvement, and cavitary disease were associated with a delayed increase in the TTD. CONCLUSIONS: The TTD was superior to clinical, radiographic, or conventional bacteriologic evaluation in determining treatment outcome. The TTD closely correlates with the overall response to treatment for pulmonary tuberculosis and may represent a useful adjunct to predict outcome in these patients.

The significance of Mycobacterium avium complex cultivation in the sputum of patients with pulmonary tuberculosis.

Mycobacterium avium-intracellulare complex (MAC) is a ubiquitous environmental microorganism whose pathogenicity ranges from innocuous colonization to disease, in immunocompetent as well as immunocompromised individuals. We sought to determine the clinical significance of MAC in sputum cultures of patients with pulmonary tuberculosis (TB). A retrospective analysis between January 1994 and March 1995 at Bellevue Hospital Center revealed both Mycobacterium tuberculosis and MAC in 35 patients (11% of all patients with TB). Of 27 patients reviewed, 52% were HIV-1 infected (median CD4 + 25 cells per microliter). Radiographic manifestations in patients with TB and MAC were similar to those seen in patients with TB alone. Both mycobacteria were cultured primarily from respiratory sources. M tuberculosis was usually cultured first or concurrent with MAC, and in nearly all cases, both species were recovered within 2 months of each other. Most patients improved clinically, bacteriologically, and radiographically with standard antituberculous therapy, except those with advanced AIDS, multidrug-resistant TB (MDR-TB), or disseminated MAC. We conclude that recovery of MAC in sputum is common in patients with pulmonary TB, regardless of HIV-1 infection, MDR-TB, or other clinical, bacteriologic, or radiographic attributes. MAC cultivation in most of these patients likely represents transient colonization, and in most cases is not clinically significant.

Successful treatment of primary cutaneous Aspergillus flavus infection of the hand with oral itraconazole.

Primary cutaneous Aspergillus flavus infections of the hand are exceedingly rare. Usually, these infections are present in severely immunocompromised patients suffering from lymphoreticular malignancies. The majority of cases result in invasive systemic infections and often culminate in death. We report a case of primary cutaneous A. flavus infection in the hand of a patient immunocompromised only by non-insulin-dependent diabetes, who ultimately was cured of this infection with oral itraconazole.

Anterolateral thigh free flap.

The descending branch of the lateral femoral circumflex artery is a large-caliber artery that passes obliquely across the upper third of the thigh and descends between the vastus lateralis and rectus femoris muscles. It sends perforators through the septum between these muscles and through the vastus lateralis muscle and supplies a large area of skin on the anterolateral aspect of the thigh. We report our experience with our first 44 consecutive anterolateral thigh flaps, which were used for a variety of soft-tissue deficits. Twenty-five of these flaps were used for lower extremity reconstruction. 10 were used in the upper extremity, and 9 were used in the head and neck. The overall success rate was 96%. Six flaps required reoperation; of these, 2 flaps were lost, one from a venous thrombosis and the other from arterial thrombosis, both of which were in the lower extremity. In approximately one third of cases, the flap was raised as a septofasciocutaneous flap, but in two thirds it was necessary to include a small segment of vastus lateralis muscle as well as fascia with the flap. The flap has been particularly useful for lower extremity reconstruction, and in patients who are not fit for general anesthesia, it is possible to perform the flap transfer with epidural anesthesia. The flap has the advantage of a long vascular pedicle with large-caliber vessels and thus is suitable as a flow-through flap. It may also be sensate and has provided a versatile soft-tissue coverage option with minimal long-term donor-site complications.

Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients.

From 1982-1989, 152 mutilated distal digits were reconstructed with microsurgical foot tissue transfers in 121 patients. These various foot tissues included wrap-around flaps or pulp from the great toe, second toe, or third toe, as well as partial toe, nail, web space skin, and other portions of the foot. The reconstructions were carried out primarily and secondarily in 78 and 74 patients respectively. The immediate success rate was 98%. Most of the patients were satisfied with both the cosmetic appearance and the functional result. This relatively minor microsurgical foot tissue transfer proved to be an ideal reconstructive option for distal digital defects.

Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus injury).

From 1985 to 1990, 167 patients were treated for impaired elbow flexion caused by brachial plexus injury. Surgical procedures were divided into two categories: nerve reconstruction (128 patients) and muscle or tendon transfers (39 patients). Surgery in the nerve reconstruction group included direct suturing, nerve grafting of portions of the brachial plexus responsible for elbow flexion, or nerve transfer (intercostal, phrenic, or spinal accessory nerve) to the musculocutaneous nerve. The second category included tendon or muscle transfer or a functioning free muscle transplantation for biceps replacement. Results were assessed by the Medical Research Council grading system and weight-lifting evaluation. Functional results revealed that nerve reconstruction was superior to muscle tendon transfers, direct suturing was superior to nerve grafting, short nerve grafts (< 10 cm) were superior to long nerve grafts (> 10 cm), infraclavicular plexus injuries did better than supraclavicular injuries, vascularized ulnar nerve grafts (if indicated) were superior to conventional long nerve grafts, ruptured plexus injuries recovered better than root avulsions. Intercostal nerve transfer to the musculocutaneous nerve has satisfactory results. In the muscle tendon transfer group, Steindler flexorplasty resulted in upgrading muscle strength from level one to level two. Functioning free muscle transplantation had results similar to the latissimus dorsi transfer.

The role of the gastrointestinal tract in the development of burn sepsis.

Conceptualization of the gastrointestinal tract as the "motor" that drives sepsis and multiple-system organ failure has only recently been appreciated. Most of the investigation into the pathophysiology of gut-derived sepsis involves using animal models; however, some of the findings are already being corroborated in human studies. The gastrointestinal tract is a dynamic organ whose function as a front-line defense against infection needs to be appreciated. The development of lethal sepsis is a function of the microbial load and virulence, the status of the gastrointestinal barrier, and the magnitude of the host defense response. In assuming care of a critically ill patient, we must be judicious in the use of antibiotics in order to prevent intestinal overgrowth of potential pathogens. Providing proper nutrition by an enteral route (when possible) not only satisfies caloric needs but regulates the microflora and maintains the integrity of the mucosal barrier. Burn patients should receive enteral nutrition early, the first day if possible. This not only will protect the intestinal mucosa but also will blunt the hypermetabolic response following thermal injury. Lastly, the patient should not receive an excessive amount of narcotic or sedative, for these drugs have an inhibitory effect on gastrointestinal motility, encouraging bacterial overgrowth. In the near future, new therapeutic modalities may soon become available to protect and treat the compromised gastrointestinal barrier. These modalities may include, but certainly are not limited to, the use of glutamine and xanthine oxidase inhibitors to prevent stress-related injury to the gastrointestinal mucosa.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased gut permeability following burn trauma.

Twenty female Hartley guinea pigs, weighing 350 to 400 g, were given a 30% full-thickness burn injury. Gastrointestinal permeability was assessed before burn and on postburn days 1 through 3, 7, and 14 by administering 5 mL of an isotonic mixture of 8% lactulose and 1.15% L-rhamnose by gavage and measuring the urinary excretion for the next 7 hours. In normal guinea pigs, lactulose (molecular weight, 342d) is mostly absorbed by the paracellular route, whereas L-rhamnose (molecular weight, 164 d) is mostly absorbed by the transcellular route. Gut permeability to L-rhamnose did not increase after burn injury (211 micrograms before burn vs 230, 260, 180, 238, and 221 micrograms on days 1, 2, 3, 7, and 14, respectively, after burn). By contrast, gut permeability to lactulose increased significantly and was greatest in the first 48 hours after burn injury (60 micrograms before burn vs 380, 354, 203, 364, and 279 micrograms on days 1, 2, 3, 7, and 14, respectively, after burn). Gut permeability to low-molecular-weight compounds increases immediately after burn trauma, and this may be by a paracellular rather than transcellular mechanism.

Complications of acute appendicitis.

Acute appendicitis is best managed by early diagnosis and expeditious surgical intervention. The mortality and morbidity (primarily wound infection and abscess) rise rapidly when perforation ensues. One should ask not "Is this appendicitis?" If the answer is yes, then proceed with early operation.

Effect of intraluminal antibiotics on translocation of Candida albicans in burned guinea-pigs.

Guinea-pigs were pretreated orally with various antibiotics and given 3 x 10(10) Candida albicans by gastric lavage followed by a 40 per cent TBSA full skin thickness burn. The mesenteric lymph nodes, liver and spleen were cultured for the presence of viable organisms. Caecal contents were quantitatively cultured for aerobic bacteria and C. albicans. Clindamycin and penicillin G were the greatest promoters of translocation followed by the combination streptomycin/bacitracin. The mechanism for antibiotic-induced translocation is multifactorial centering on intestinal flora, anaerobic spectrum of the antibiotic and host defense as well as microbe virulence. The systemic use of broad-spectrum antibiotics, particularly those with strong anaerobic activity, should not be taken too lightly. A severely immunocompromised patient on this type of therapy may be prone to a severe fungal infection. This study reaffirms the concept that translocation from the gastrointestinal barrier is a potential source of life-threatening nosocomial infection.

Prevention of yeast translocation across the gut by a single enteral feeding after burn injury.

Recently, burn injury has been shown to facilitate the ability of enteric Candida albicans (CA) to penetrate the gut epithelium and translocate to the mesenteric lymph nodes (MLN) during the first 24 hr after injury. Guinea pigs were given 3 X 10(10) CA intragastrically before inflicting a 50% burn to determine if a single enteral feeding could affect CA translocation to the MLN. A bolus infusion (20 kcal/kg, 12 ml in volume) of liquid meal, consisting of 68% carbohydrate, 20% protein, and 12% lipid, was administered either at 3-hr or 12-hr postburn. Control groups received no food or a similar amount of saline by bolus infusion. All animals were allowed water ad libitum until 24-hr postburn when their MLN and intestinal segments were harvested for enumeration of viable CA. Blood was also collected for determination of serum IgG, C3, cortisol, and albumin. Compared to nonfeed animals, those with a single enteral feeding at 12-hr postburn had reduced numbers of CA translocating to the MLN (970 +/- 220 vs 7,120 +/- 2,130 CFU/g, p less than 0.02) and colonizing in the ileum (27,000 +/- 6,770 vs 104,000 +/- 23,550 CFU/g, p less than 0.01). Bolus feeding at 12 hr was associated with a lower cortisol level (237 +/- 55% of normal controls) than bolus feeding at 3 hr (310 +/- 58, p less than 0.02) or the nonfed group (326 +/- 66, p less than 0.01). Regardless of dietary treatment, serum cortisol levels correlated positively with the extent to which CA translocated to the MLN and negatively with C3 levels.

The effect of donor-specific blood transfusion, cyclosporine, and dietary prostaglandin precursors on rat cardiac allograft survival. II. Effectiveness of a 24-hour induction period with DST and CsA in inducing long-term graft survival.

We investigated the effect of donor-specific transfusion given 24 hours pretransplant, a short course of low-dose cyclosporine, and dietary enrichment with the prostaglandin precursor linoleic acid (LA) to see which of the modalities could act synergistically on cardiac allograft survival in a stringent animal model. ACI male rats (RT1a) were used as blood and heart donors, and Lewis male rats (RT1l) were used as recipients. DST alone (1 ml) given 24 hr pretransplant or LA alone started 24 hr pretransplant and given daily p.o. until rejection prolonged cardiac allograft survival slightly but significantly, from 6 to 8 days. CsA alone started at the time of transplant at a dose of 5 mg/kg/day s.c. and given daily for 14 days prolonged cardiac survival to 11.8 days. However, when CsA was started 24 hr pretransplant and continued for two weeks, there was a significantly prolonged allograft survival to 55 days. CsA given together with DST 24 hr pretransplant and continued for two weeks posttransplant significantly prolonged cardiac allograft survival to 80 days and resulted in permanent tolerance in some animals. The addition of LA to a DST and CSA treatment regimen did not further improve allograft survival. CsA blood levels were determined in a separate group of Lewis rats. Three dosages of CsA were administered s.c. for 2 weeks: 2.5 mg/kg/day, 5 mg/kg/day, and 10 mg/kg/day. One injection of the three CsA doses did not achieve what are considered therapeutic levels in man. After 5 days, all three doses of CsA achieved significant blood levels. Significant blood levels were still present one week, but not 3 weeks after CsA was stopped. We conclude that DST given 24 hr before transplant and a 2-week course of low-dose CsA started one day pretransplant have strong synergism in inducing long-term graft survival in this rat model. Linoleic acid started 24 hr pretransplant, together with DST and CsA, did not contribute significantly to graft survival compared with the group given CsA and DST alone. Prolonged heart allograft survival was not due to persistently high CsA levels after the drug was discontinued.

Early burn wound excision and skin grafting postburn trauma restores in vivo neutrophil delivery to inflammatory lesions.

This study assessed the effect of early vs delayed postburn wound excision and skin grafting on the in vivo neutrophil delivery to a delayed-type hypersensitivity (DTH) reaction and a bacterial skin lesion (BSL). Male Lewis rats were presensitized to keyhole-limpet hemocyanin. Group 1 comprised sham controls. Groups 2 through 4 were given a 30% 3 degrees scald burn, but the burn wounds were excised, and skin was grafted on days 1, 3, and 7, respectively, after the burn. Group 5 comprised burn controls. Twelve days after burn trauma, all rats were injected at different intervals (during a 24-hour period) with a trio of intradermal injections of keyhole-limpet hemocyanin, Staphylococcus aureus 502A, and saline at different sites. In vivo neutrophil delivery to these dermal lesions was determined by injecting indium in 111 oxyquinoline-labeled neutrophils isolated from similarly treated groups of rats. Neutrophil delivery to DTH and BSL lesions was restored to normal by excision and skin grafting of the burn wound one day after burn trauma. Waiting three days after burn trauma to excise and skin graft the wound partially, but not completely, restored the in vivo neutrophil delivery to DTH and BSL lesions. Waiting one week to excise and skin graft a burn wound resulted in no improvement in neutrophil delivery to DTH and BSL dermal lesions. It was concluded that burn wound excision and skin grafting immediately after burn trauma restored in vivo neutrophil delivery to a BSL and DTH dermal lesion. This may, in part, explain the beneficial effect of early aggressive burn wound debridement in patients with burn injuries.

Traumatic rupture of the extensor pollicis longus tendon.

Rupture of the extensor pollicis longus tendon is rather rare, attributable in about half of all cases to rheumatoid arthritis affecting the wrist or to a Colles' fracture. In the remainder of cases, either a direct closed injury to the wrist or a hyperextension injury of the wrist is most often responsible. Far more unusual is a rotational injury which can cause complete avulsion of the EPL tendon at the musculotendinous junction. A delayed rupture is most probably caused by an avascular necrosis secondary to traumatic disruption of the mesotendon. Surgical correction of the injury is best accomplished by tendon transfer, using the extensor indicis proprius. Postoperative immobilization, hyperextension of the thumb, and adequate resting tension are all necessary to assure good return of function. Postoperatively, the patient may experience a slight decrease in extensor strength of the index finger which may or may not be accompanied by a minimal loss in extensor range.

Age-related responses to stimulation of cardiopulmonary receptors in swine.

Cardiovascular responses to stimulation of cardiopulmonary receptors were evaluated in standard breed developing swine (1-2 days, 1-2 wk, and 2 mo of age) and sexually mature miniswine anesthetized with 0.25-0.50% halothane in O2. Cryptenamine, a mixture of veratrum viride alkaloids (VVA), was administered as right atrial or left ventricular bolus injections in doses of 5-20 micrograms/kg. In developing swine, mean aortic pressure (AoP) decreased after 10-20 micrograms/kg VVA in 1- to 2-wk olds and after 5-20 micrograms/kg VVA in 2-mo olds. Bradycardia was always elicited. Renal (Ren) and femoral (Fem) vasodilation occurred in the 1- to 2-wk-old and 2-mo-old groups after 5-20 micrograms/kg VVA. Mesenteric (Mes) vasodilation was elicited with 10-20 micrograms/kg VVA in the 1- to 2-wk-old group and with 5-20 micrograms/kg VVA in 2-mo olds. In the 1- to 2-day-old group, VVA did not significantly alter Ren, Fem, and Mes vascular resistance. In mature miniswine, 20 micrograms/kg VVA elicited decreases in AoP and heart rate that were similar in magnitude to responses obtained with only 5 micrograms/kg VVA in dogs. Cardiovascular responses to VVA were abolished after bilateral vagotomy but were not altered after denervation of the carotid sinuses. The results indicate postnatal maturation of the Bezold-Jarisch reflex in swine.