Extensive perinephric abscess complicated by herpes simplex virus 1 reactivation.

A 43-year-old man, admitted with a swollen right thigh, was diagnosed with a deep vein thrombosis. On day 6 he became septic. A CT scan demonstrated a right-sided hydronephrosis and a large retroperitoneal collection. Blood cultures and perinephric pus grew Escherichia coli resistant to amoxicillin only. On day 12 a vesicular rash appeared on the neck and herpes simplex virus 1 (HSV-1) grew on culture. On day 15 an upper leg collection was seen on CT scan. Thigh tissue specimens grew extended-spectrum beta-lactamase (ESBL) producing E coli and HSV-1 was also detected by polymerase chain reaction in the tissue. On day 18 the patient died. This case illustrates an unusual presentation and complication of a perinephric abscess. In critically ill patients herpes simplex reactivation and emergence of multiresistant organisms may occur resulting in treatment failure.

Collagen type-I degradation is related to arterial stiffness in hypertensive and normotensive subjects.

Although arterial stiffness is an independent cardiovascular risk factor associated with both aging and hypertension, relatively little is known regarding the structural changes in the vessel wall that occur with vessel stiffening. We determined if collagen type-I metabolism is related to arterial stiffening in both hypertensive and normotensive subjects. Arterial stiffness was assessed by aortic pulse wave velocity (PWV) and augmentation index (AIx) in 46 subjects (48.7 +/- 2 years, 32 hypertensives) and related to circulating markers of collagen type-I turnover. Collagen synthesis was assessed by the measurement of carboxy-terminal peptide of procollagen type-I (PIP) and collagen degradation by the measurement of carboxy-terminal telopeptide of collagen type-I (ICTP), by quantitative immunoassay. Matrix metalloproteinase-1 (MMP-1) and the tissue inhibitor of metalloproteinase-1 (TIMP-1) were also quantified by immunoassay. The ratio of collagen type-I synthesis to degradation was negatively correlated with both PWV (P<0.05) and AIx (P<0.05), whereas plasma MMP-1 levels displayed a positive correlation with both PWV (P<0.01) and AIx (P<0.01), after adjustment for age and mean arterial pressure. The relationship between collagen type-I turnover and arterial stiffness was similar in both the normotensive and hypertensive subjects. Although circulating markers of collagen synthesis were increased in the hypertensive subjects, this was not related to arterial stiffness. Collagen type-I degradation is increased in relation to collagen type-I synthesis in subjects with stiffer arteries. Matrix metalloproteinase-1, the enzyme responsible for collagen type-I degradation, is positively related to both large elastic and muscular artery stiffness in normotensive and hypertensive subjects.

The Surgical Acute Care Unit (SACU): effects on surgical workload and mortality.

BACKGROUND: A surgical acute care unit (SACU) is designed to provide level 1 care for surgical patients. The aim of the present study was to audit the effects of the introduction of a SACU in a teaching hospital surgical department. METHODS: A retrospective case-note audit of all admissions to the newly established SACU over the first 6 months was performed. Expected mortality and morbidity was calculated using POSSUM (physiological and operative severity score for the enumeration of mortality and morbidity) scores. Critical care data for the same period and the 6 months prior to the SACU opening was examined to determine any effect on critical care workload. RESULTS: The SACU admitted 131 patients during the audit period. There was no significant difference between predicted and observed mortality or morbidity. There was no effect on critical care length of stay after the SACU opened. Many patients who would have needed critical care beds before the SACU opened were admitted directly to the SACU after it opened. CONCLUSIONS: This audit demonstrates that the provision of a surgical acute care unit allows many patients who would normally need to be admitted to the critical care unit for postoperative care to be safely admitted to level 1 care beds.

Evaluation of the role of a specialist tracheostomy service. From critical care to outreach and beyond.

The impact that a new specialist tracheostomy service, designed specifically for the care of patients with tracheostomies, was assessed in terms of type of tracheostomy tube used, time to first tube change, time to decannulation, and incidence of tracheostomy related complications in a teaching hospital with no on-site ear, nose, and throat facility. A total of 170 patients were studied. After service implementation, fewer patients (17.6%, n = 21) were discharged from the intensive treatment unit to the wards with tracheostomy tubes compared with the first group (39%, n = 20) (p = 0.006), and the number of tracheostomy related complications on the wards were significantly reduced (p = 0.031).

Thermal stress in sudden infant death: Is there an ambiguity with the rebreathing hypothesis?

OBJECTIVE: To assess the role of thermal stress in the cause of sudden infant death syndrome (SIDS), and to compare risk factors with those of rebreathing. METHODOLOGY: Analysis of publications concerning the epidemiology and physiology of thermal stress in SIDS. RESULTS: A strong association between thermal regulation and ventilatory control was found, specifically for prolonged apnea. Infections, excessive room heat and insulation, and prone sleeping produce significantly increased odds ratios for SIDS. Although some of the risk factors for rebreathing could be explained by the effects of thermal stress, several factors for thermal stress could not reasonably be explained by the rebreathing hypothesis. CONCLUSIONS: Although the risk of thermal stress is widely accepted abroad, it has received relatively little attention in the United States. The incidence of SIDS in the United States can likely be further reduced by educating the public against the dangers of overheating, as an integral part of the back-to-sleep campaign.

The black infant's susceptibility to sudden infant death syndrome and respiratory infection in late infancy.

Between 2 and 11 months of age, the risk of sudden infant death syndrome (SIDS) declines more slowly in black infants than in infants of other races. This phenomenon might also be a feature of certain non-SIDS causes of death. Identifying these causes may through analogy provide support for the theory that SIDS is a disease of the central nervous system, an unusual consequence of respiratory infection, or a form of suffocation. We used logistic regression analysis on details of infant deaths in the United States, 1985-1991, to examine the difference between the rates of decline with increasing age in the mortality rates of black infants and infants of other races. We defined slower rate of decline in black infants as a positive difference. The magnitude and direction (positive) of the difference for deaths due to respiratory infection were similar to those for SIDS. It is unlikely that this difference in the rates of decline for respiratory infection can be explained by diagnostic cross-misclassification between respiratory infection and SIDS. SIDS appears to be a disease of the respiratory system caused by infection that affects that system's control centers.

The influence of race and gestational age on the age of maximum risk of SIDS in infancy.

Risk of sudden infant death syndrome (SIDS) reaches a maximum in the third month. Thereafter, it decreases by half every 40 days or so. It is proposed that the relative sparing of the very young infant is a consequence of an innate (but temporary) characteristic possessed by the newborn infant. Interpretation of available data suggests that this innate characteristic is negatively associated with the infant's level of maturity. This is the basis for the hypothesis that the age at which the risk of SIDS begins to decline at a uniform rate decreases as the infant's gestational age increases. Because of a greater level of maturity at birth, the age at which this occurs in the black infant should be earlier than average. An analysis of data on 32 573 instances of SIDS within the United States between 1985 and 1991 provides support for the hypothesis.

Positive effect of bumetanide on contractile activity of ventricular cardiomyocytes.

Although the beneficial effects of loop-diuretics in relieving congestive heart failure and essential hypertension are well established, there has been limited investigation into the direct cardiac effect of these drugs. The aim of the present study was to investigate mechanical and electrophysiological effects of three loop-diuretics, namely, frusemide, bumetanide and torasemide, in ventricular cardiomyocytes isolated from rabbit myocardium. Contractile performance was assessed using a video edge detection method and effects on L-type Ca(2+) currents were determined using a 'perforated' patch-clamp technique. Unlike frusemide and torasemide, bumetanide produced concentration-dependent (3x10(-8) to 10(-5) M) increases in cell shortening and velocity of cell shortening. Neither frusemide, bumetanide nor torasemide exerted any action on peak Ca(2+) current amplitudes. In summary, the present investigation provides evidence for a direct contractile effect of the loop diuretic, bumetanide, in contrast to absence of effects by frusemide and torasemide, in ventricular cardiomyocytes isolated from rabbit myocardium.

The effect of the weekend on the risk of sudden infant death syndrome.

OBJECTIVE: The risk of sudden infant death syndrome (SIDS) is associated strongly with socioeconomic status. However, many infants who live in one socioeconomic environment, with its attendant level of risk of SIDS over the weekend, often are exposed to a different level of risk during the work week (because of day care for the infant). If the association between SIDS and socioeconomic status acts through the quality of supervision of the infant, then there could be an immediate change in the level of risk as the infant moves from home to outside care to home again. In this scenario, infants of economically disadvantaged parents would have a higher risk of SIDS over the weekend than they do during the week. On the other hand, infants of economically advantaged parents would be at lower risk over the weekend. Therefore, the relative risk of SIDS associated with the weekend (risk over the weekend vs risk during the work week) should be found to decrease as the number of years of maternal education (a surrogate for socioeconomic status) increases. Testing this prediction is the objective of the study. METHODOLOGY: Instances of SIDS in the postneonatal period (28-364 days) among the cohort of all infants born in the United States between January 1989 and December 1991 were analyzed. The number 798.0, taken from the International Classification of Diseases, was used to identify 14 996 cases of SIDS. Deaths among hospital patients were distinguished from all other deaths. The latter were divided into four categories: 1) death occurred in the emergency department; 2) the infant was dead on arrival at the emergency department; 3) death occurred at a residence; and 4) death occurred at some other place. Maternal education was divided into four categories: <12, 12, 13 to 15, and >/=16 years. The weekend ratio was defined as the ratio of SIDS cases on Saturday and Sunday (times 5) and Monday through Friday (times 2). The predicted trend in this ratio by maternal education was tested by applying a chi(2) test-for-trend. RESULTS: The overall weekend ratio was 1.00, indicating that the risk of SIDS was no higher over the weekend than it was Monday through Friday. However, for infants of mothers with <12 years of education, the ratio was 1. 13. For infants of mothers with >/=16 years of education, it was 0. 55. The trend in the ratio as maternal education increased (1.13, 0. 99, 0.86, and 0.55) was highly significant (chi(2) = 74.2; 1 degree of freedom). Each of the four ratios, with the exception of 0.99, was significantly different from 1.00 (z = 3.74, 2.45, and 6.09, respectively). The ratios for infants of mothers with 13 to 15 and >/=16 years of education also were significantly different from each other (z = 4.57). For all causes of death combined (including the relatively small number of SIDS cases) among hospital inpatients, there was no significant trend in the weekend ratio as the level of maternal education increased. However, among deaths not attributable to SIDS or accidents occurring outside the hospital, there was a slight but significant declining trend (chi(2) = 8.4; 1 degree of freedom) The risk of an accidental death was highest over the weekend for all four maternal education categories. On an average working day, the risk of SIDS among offspring of mothers with <12 years of education was found to be 3.9 times greater than that among offspring of mothers with >/=16 years of education. At the weekend, the relative risk increased to 7.9. A plot of the weekend ratio against single years of maternal education revealed a unimodal distribution with a peak at 11 years. CONCLUSIONS: First, the results of the study are consistent with the level of risk of SIDS, changing promptly toward the risk level obtained in the baby's new environment. Variability in the observation of unusual respiratory events seems the most likely explanation. It is unlikely that confounding factors played a role in the results for tertiary-educated mothers

The immediate impact of opening an adult high dependency unit on intensive care unit occupancy.

We assessed the hourly occupancy of our intensive care and high dependency units over an 8-week period commencing on the day our high dependency unit opened. Using criteria established by the working group on 'Guidelines on Admission to and Discharge from Intensive Care and High Dependency Units' published by the National Health Service Executive, we defined each patient daily as intensive care or high dependency status. Compared with hourly occupancy figures obtained before the high dependency unit opened, occupancy of the intensive care unit by high dependency patients has been shown to decrease significantly from 21.6% to 11.2%. Use of intensive care beds became more appropriate, their occupancy increasing significantly from 63.7% to 73.4%. A significant decrease in readmissions occurred, supporting the hypothesis that having high dependency beds reduces the number of patients discharged prematurely to the wards.

Citicoline for traumatic brain injury: report of two cases, including my own.

Citicoline is an investigational new drug in this country that was provided on a compassionate use basis in two cases of traumatic brain injury after horseback riding accidents. While this report is primarily anecdotal, the behavioral observations in both cases suggested atypical patterns of improvement and perhaps greater recovery than might otherwise have been predicted. The side effect profile of this drug is negligible and previous experimental research has yielded positive findings for treatment after stroke and head trauma, as well as memory loss in aging. Consequently, Citicoline may potentially be very helpful for patients suffering traumatic brain injuries and should, in our opinion, be made available and studied further in this clinical population.

Aspartame: neuropsychologic and neurophysiologic evaluation of acute and chronic effects.

BACKGROUND: Neurobehavioral symptoms have been reported anecdotally with aspartame. OBJECTIVE: This study sought to determine whether aspartame can disrupt cognitive, neurophysiologic, or behavioral functioning in normal individuals. DESIGN: Forty-eight healthy volunteers completed a randomized, double-blind, placebo-controlled, crossover study. The first month was aspartame free. Subjects then consumed sodas and capsules with placebo, aspartame, or sucrose for 20 d each. Order was randomized and subjects were assigned to either a high- (45 mg x kg body wt(-1) x d(-1)) or low- (15 mg x kg body wt(-1) x d(-1)) dose aspartame group. Neuropsychologic and laboratory testing was done on day 10 of each treatment period to determine possible acute effects and on day 20 for possible chronic effects. RESULTS: Plasma phenylalanine concentrations increased significantly during aspartame treatment. Neuropsychologic results; adverse experiences; amino acid, insulin, and glucose values; and electroencephalograms were compared by sex and by treatment. No significant differences were found for any dependent measure. CONCLUSION: Large daily doses of aspartame had no effect on neuropsychologic, neurophysiologic, or behavioral functioning in healthy young adults.