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1.
Artigo em Inglês | MEDLINE | ID: mdl-34071402

RESUMO

Detecting environmental exposures and mitigating their impacts are growing global public health challenges. Antibody tests show great promise and have emerged as fundamental tools for large-scale exposure studies. Here, we apply, demonstrate and validate the utility of a salivary antibody multiplex immunoassay in measuring antibody prevalence and immunoconversions to six pathogens commonly found in the environment. The study aimed to assess waterborne infections in consenting beachgoers recreating at an Iowa riverine beach by measuring immunoglobulin G (IgG) antibodies against select pathogens in serially collected saliva samples. Results showed that nearly 80% of beachgoers had prior exposures to at least one of the targeted pathogens at the beginning of the study. Most of these exposures were to norovirus GI.1 (59.41%), norovirus GII.4 (58.79%) and Toxoplasma gondii (22.80%) and over half (56.28%) of beachgoers had evidence of previous exposure to multiple pathogens. Of individuals who returned samples for each collection period, 6.11% immunoconverted to one or more pathogens, largely to noroviruses (GI.1: 3.82% and GII.4: 2.29%) and T. gondii (1.53%). Outcomes of this effort illustrate that the multiplex immunoassay presented here serves as an effective tool for evaluating health risks by providing valuable information on the occurrence of known and emerging pathogens in population surveillance studies.


Assuntos
Norovirus , Humanos , Imunoensaio , Imunoglobulina A Secretora , Iowa/epidemiologia , Saliva
2.
J Clin Microbiol ; 58(10)2020 09 22.
Artigo em Inglês | MEDLINE | ID: mdl-32759356

RESUMO

Hepatitis A virus (HAV) is a common infection that is transmitted through the fecal-oral route, shed in the stool of infected individuals, and spread either by direct contact or by ingesting contaminated food or water. Each year, approximately 1.4 million acute cases are reported globally with a major risk factor for exposure being low household socioeconomic status. Recent trends show a decrease in anti-HAV antibodies in the general population, with concomitant increases in the numbers of HAV outbreaks. In line with a recreational water study, this effort aims to assess the prevalence of salivary IgG antibodies against HAV and subsequent incident infections (or immunoconversions) in visitors to a tropical beach impacted by a publicly owned treatment works (POTW). We applied a multiplex immunoassay to serially collected saliva samples gathered from study participants who recreated at Boquerón Beach, Puerto Rico. Analysis of assay results revealed an immunoprevalence rate of 16.17% for HAV with 1.43% of the cohort immunoconverting to HAV. Among those who immunoconverted, 10% reported chronic gastrointestinal symptoms and none experienced diarrhea. Tests on water samples indicated good water quality with low levels of fecal indicator bacteria; however, the collection and analysis of saliva samples afforded the ability to detect HAV infections in beachgoers. This rapid assay serves as a cost-effective tool for examining exposure to environmental pathogens and can provide critical information to policy makers, water quality experts, and risk assessment professionals seeking to improve and protect recreational water and public health.


Assuntos
Vírus da Hepatite A , Hepatite A , Hepatite A/diagnóstico , Hepatite A/epidemiologia , Humanos , Imunoglobulina G , Porto Rico , Saliva
3.
Front Public Health ; 7: 231, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31482082

RESUMO

Determining infections from environmental exposures, particularly from waterborne pathogens is a challenging proposition. The study design must be rigorous and account for numerous factors including study population selection, sample collection, storage, and processing, as well as data processing and analysis. These challenges are magnified when it is suspected that individuals may potentially be infected by multiple pathogens at the same time. Previous work demonstrated the effectiveness of a salivary antibody multiplex immunoassay in detecting the prevalence of immunoglobulin G (IgG) antibodies to multiple waterborne pathogens and helped identify asymptomatic norovirus infections in visitors to Boquerón Beach, Puerto Rico. In this study, we applied the immunoassay to three serially collected samples from study participants within the same population to assess immunoconversions (incident infections) to six waterborne pathogens: Helicobacter pylori, Campylobacter jejuni, Toxoplasma gondii, hepatitis A virus, and noroviruses GI. I and GII.4. Further, we examined the impact of sampling on the detection of immunoconversions by comparing the traditional immunoconversion definition based on two samples to criteria developed to capture trends in three sequential samples collected from study participants. The expansion to three samples makes it possible to capture the IgG antibody responses within the survey population to more accurately assess the frequency of immunoconversions to target pathogens. Based on the criteria developed, results showed that when only two samples from each participant were used in the analysis, 25.9% of the beachgoers immunoconverted to at least one pathogen; however, the addition of the third sample reduced immunoconversions to 6.5%. Of these incident infections, the highest levels were to noroviruses followed by T. gondii. Moreover, many individuals displayed evidence of immunoconversions to multiple pathogens. This study suggests that detection of simultaneous infections is possible, with far reaching consequences for the population. The results may lead to further studies to understand the complex interactions that occur within the body as the immune system attempts to ward off these infections. Such an approach is critical to our understanding of medically important synergistic or antagonistic interactions and may provide valuable and critical information to public health officials, water treatment personnel, and environmental managers.

4.
PLoS One ; 13(3): e0195056, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29590196

RESUMO

BACKGROUND: Swimming in fecally-contaminated waterbodies can result in gastrointestinal infections. However, the pathogenic microorganisms responsible are not well understood because sporadic cases of illness are not reported completely, exposure information is often not collected, and epidemiology studies rely on self-reported symptoms. Noroviruses are considered a likely cause because they are found in high densities in sewage, resistant to wastewater treatment and survive in the environment. In this study, saliva samples were collected from subjects at a beach in Puerto Rico and tested for evidence of norovirus-specific IgG responses as an indicator of incident norovirus infection. METHODS: Saliva samples were collected from 1298 participants using an oral swab. Samples were collected on the day of the beach visit (S1); after 10-12 days (S2); and after three weeks (S3). Saliva was tested for IgG responses to GI.1 and GII.4 noroviruses using a microsphere based multiplex salivary immunoassay. Immunoconversion was defined as a four-fold increase in median fluorescence intensity (MFI) from S1 to S2 with the S3 sample at least three times above the S1 MFI. RESULTS: Thirty-four subjects (2.6%) immunoconverted to GI.1 or GII.4 norovirus. Swimmers who immersed their head in water had a higher rate of immunoconversion (3.4%), compared to either non-swimmers (0.0%, p = 0.003) or waders and non-swimmers combined (0.4%, Odds Ratio: 5.07, 95% Confidence Interval:1.48-17.00). Immunoconversion was not associated with gastrointestinal symptoms. CONCLUSIONS: This is the first study to demonstrate an association between swimming at a beach impacted by fecal contamination and asymptomatic norovirus infection. The findings implicate recreational water as potentially important transmission pathway for norovirus infection.


Assuntos
Infecções Assintomáticas/epidemiologia , Infecções por Caliciviridae/epidemiologia , Exposição Ambiental/efeitos adversos , Fezes/microbiologia , Norovirus/patogenicidade , Saliva/microbiologia , Natação , Adolescente , Adulto , Praias , Infecções por Caliciviridae/microbiologia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Prospectivos , Porto Rico/epidemiologia , Esgotos , Microbiologia da Água , Poluição da Água , Adulto Jovem
5.
Front Public Health ; 5: 84, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28507984

RESUMO

Waterborne infectious diseases are a major public health concern worldwide. Few methods have been established that are capable of measuring human exposure to multiple waterborne pathogens simultaneously using non-invasive samples such as saliva. Most current methods measure exposure to only one pathogen at a time, require large volumes of individual samples collected using invasive procedures, and are very labor intensive. In this article, we applied a multiplex bead-based immunoassay capable of measuring IgG antibody responses to six waterborne pathogens simultaneously in human saliva to estimate immunoprevalence in beachgoers at Boquerón Beach, Puerto Rico. Further, we present approaches for determining cutoff points to assess immunoprevalence to the pathogens in the assay. For the six pathogens studied, our results show that IgG antibodies against antigens from noroviruses GI.I and GII.4 were more prevalent (60 and 51.6%, respectively) than Helicobacter pylori (21.4%), hepatitis A virus (20.2%), Campylobacter jejuni (8.7%), and Toxoplasma gondii (8%) in the saliva of the study participants. The salivary antibody multiplex immunoassay can be used to examine immunoprevalence of specific pathogens in human populations.

6.
J Vis Exp ; (115)2016 09 12.
Artigo em Inglês | MEDLINE | ID: mdl-27685162

RESUMO

The etiology and impacts of human exposure to environmental pathogens are of major concern worldwide and, thus, the ability to assess exposure and infections using cost effective, high-throughput approaches would be indispensable. This manuscript describes the development and analysis of a bead-based multiplex immunoassay capable of measuring the presence of antibodies in human saliva to multiple pathogens simultaneously. Saliva is particularly attractive in this application because it is noninvasive, cheaper and easier to collect than serum. Antigens from environmental pathogens were coupled to carboxylated microspheres (beads) and used to measure antibodies in very small volumes of human saliva samples using a bead-based, solution-phase assay. Beads were coupled with antigens from Campylobacter jejuni, Helicobacter pylori, Toxoplasma gondii, noroviruses (G I.1 and G II.4) and hepatitis A virus. To ensure that the antigens were sufficiently coupled to the beads, coupling was confirmed using species-specific, animal-derived primary capture antibodies, followed by incubation with biotinylated anti-species secondary detection antibodies and streptavidin-R-phycoerythrin reporter (SAPE). As a control to measure non-specific binding, one bead set was treated identically to the others except it was not coupled to any antigen. The antigen-coupled and control beads were then incubated with prospectively-collected human saliva samples, measured on a high throughput analyzer based on the principles of flow cytometry, and the presence of antibodies to each antigen was measured in Median Fluorescence Intensity units (MFI). This multiplex immunoassay has a number of advantages, including more data with less sample; reduced costs and labor; and the ability to customize the assay to many targets of interest. Results indicate that the salivary multiplex immunoassay may be capable of identifying previous exposures and infections, which can be especially useful in surveillance studies involving large human populations.


Assuntos
Exposição Ambiental/análise , Imunoensaio/métodos , Animais , Anticorpos/química , Anticorpos/imunologia , Antígenos de Bactérias/análise , Antígenos de Bactérias/imunologia , Antígenos Virais/análise , Antígenos Virais/imunologia , Microbiologia Ambiental , Helicobacter pylori/imunologia , Humanos , Testes Imunológicos , Microesferas , Norovirus/imunologia , Saliva/imunologia , Toxoplasma/imunologia
7.
J Clin Microbiol ; 54(7): 1684-1685, 2016 07.
Artigo em Inglês | MEDLINE | ID: mdl-27170019

RESUMO

Rapid, cost-effective, and early determination of the serological status of potentially infected individuals, particularly pregnant women, can be critical in preventing life-threatening infections and subsequent fetal congenital abnormalities. An article in this issue of the Journal of Clinical Microbiology (X. Li, C. Pomares, G. Gonfrier, B. Koh, S. Zhu, M. Gong, J. G. Montoya, and H. Dai, J Clin Microbiol 54:1726-1733, 2016, http://dx.doi.org/10.1128/JCM.03371-15) describes an innovative multiplexed immunoassay that offers a path toward universal screening.


Assuntos
Anticorpos Antiprotozoários/sangue , Toxoplasma/imunologia , Feminino , Humanos , Imunoglobulina A/sangue , Imunoglobulina G/sangue , Imunoglobulina M/sangue , Gravidez , Toxoplasmose , Toxoplasmose Congênita
8.
J Immunol Methods ; 425: 1-9, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26070441

RESUMO

There are numerous pathogens that can be transmitted through water. Identifying and understanding the routes and magnitude of exposure or infection to these microbial contaminants are critical to assessing and mitigating risk. Conventional approaches of studying immunological responses to exposure or infection such as Enzyme-Linked Immunosorbent Assays (ELISAs) and other monoplex antibody-based immunoassays can be very costly, laborious, and consume large quantities of patient sample. A major limitation of these approaches is that they can only be used to measure one analyte at a time. Multiplex immunoassays provide the ability to study multiple pathogens simultaneously in microliter volumes of samples. However, there are several challenges that must be addressed when developing these multiplex immunoassays such as selection of specific antigens and antibodies, cross-reactivity, calibration, protein-reagent interferences, and the need for rigorous optimization of protein concentrations. In this study, a Design of Experiments (DOE) approach was used to optimize reagent concentrations for coupling selected antigens to Luminex™ xMAP microspheres for use in an indirect capture, multiplex immunoassay to detect human exposure or infection from pathogens that are potentially transmitted through water. Results from Helicobacter pylori, Campylobacter jejuni, Escherichia coli O157:H7, and Salmonella typhimurium singleplexes were used to determine the mean concentrations that would be applied to the multiplex assay. Cut-offs to differentiate between exposed and non-exposed individuals were determined using finite mixed modeling (FMM). The statistical approaches developed facilitated the detection of Immunoglobulin G (IgG) antibodies to H. pylori, C. jejuni, Toxoplasma gondii, hepatitis A virus, rotavirus and noroviruses (VA387 and Norwalk strains) in fifty-four diagnostically characterized plasma samples. Of the characterized samples, the detection rate was 87.5% for H. pylori, and 100% for T. gondii assays and 89% for HAV. Further, the optimized multiplex assay revealed exposure/infection to several other environmental pathogens previously uncharacterized in the samples.


Assuntos
Bactérias/isolamento & purificação , Exposição Ambiental/análise , Imunoensaio/métodos , Água/análise , Antígenos de Bactérias/imunologia , Bactérias/imunologia , Calibragem , Reações Cruzadas , Humanos , Imunoglobulina G/imunologia , Microesferas , Microbiologia da Água
9.
Appl Environ Microbiol ; 76(15): 5140-7, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20543052

RESUMO

The effect of UV exposure on Toxoplasma gondii oocysts has not been completely defined for use in water disinfection. This study evaluated UV-irradiated oocysts by three assays: a SCID mouse bioassay, an in vitro T. gondii oocyst plaque (TOP) assay, and a quantitative reverse transcriptase real-time PCR (RT-qPCR) assay. The results from the animal bioassay show that 1- and 3-log(10) inactivation is achieved with 4 mJ/cm(2) UV and 10 mJ/cm(2) low-pressure UV, respectively. TOP assay results, but not RT-qPCR results, correlate well with bioassay results. In conclusion, a 3-log(10) inactivation of T. gondii oocysts is achieved by 10-mJ/cm(2) low-pressure UV, and the in vitro TOP assay is a promising alternative to the mouse bioassay.


Assuntos
Viabilidade Microbiana/efeitos da radiação , Oocistos/efeitos da radiação , Parasitologia/métodos , Toxoplasma/efeitos da radiação , Animais , Bioensaio/métodos , Técnicas de Cultura de Células/métodos , Camundongos , Reação em Cadeia da Polimerase Via Transcriptase Reversa/métodos , Toxoplasmose Animal/parasitologia , Purificação da Água/métodos
10.
J Microbiol Methods ; 81(3): 219-25, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20385175

RESUMO

Toxoplasma gondii oocysts are highly resistant to many chemical sanitizers. Methods used to determine oocyst infectivity have relied primarily on mouse, chicken, and feline bioassays. Although considered gold standards, they only provide a qualitative assessment of oocyst viability. In this study, two alternative approaches were developed to quantitate viable T. gondii oocysts following treatment with several common sanitizers. The first is a quantitative reverse transcriptase real-time PCR (RT-qPCR) assay targeting the ACT1 and SporoSAG genes to enumerate viable T. gondii oocysts. RT-qPCR C(T) values between Wescodyne(R), acidified ethanol, or heat treated oocysts were not significantly different as compared with untreated controls. By contrast, treatment with formalin or Clorox(R) resulted in a 2-log(10) reduction in C(T) values. An in vitro T. gondii oocyst plaque assay (TOP-assay) was also developed to measure oocyst viability. This assay used a combination of bead milling and bile digestion, followed by culturing the excysted sporozoites in a confluent fibroblast cell monolayer. Results showed that no significant reduction in sporozoite viability was detected in acidified ethanol or Wescodyne(R) treated oocysts while at least a 2-log(10) reduction in plaques formed was observed with Clorox(R) treated oocysts. Moreover, formalin or heat treatment of oocysts resulted in at least a 5-log(10) reduction in plaques formed. This study demonstrates that an mRNA-based PCR viability assay targeting the ACT1 or SporoSAG genes is a relatively rapid technique compared to in vitro and in vivo assays. In addition, the TOP-assay proved very effective and sensitive at quantifying oocyst viability when compared with animal bioassays.


Assuntos
Bioensaio/métodos , Desinfetantes/farmacologia , Oocistos/efeitos dos fármacos , Parasitologia/métodos , Reação em Cadeia da Polimerase Via Transcriptase Reversa/métodos , Toxoplasma/efeitos dos fármacos , Técnicas de Cultura de Células/métodos , Sobrevivência Celular/efeitos dos fármacos , Células Cultivadas , Fibroblastos/parasitologia , Humanos , Oocistos/fisiologia , Sensibilidade e Especificidade , Toxoplasma/fisiologia
11.
Infect Immun ; 74(7): 3922-9, 2006 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-16790765

RESUMO

In this work, we report the cloning and characterization of the first cell surface casein kinase II (CKII) substrate (Tc-1) of Trypanosoma cruzi, the causative agent of Chagas' disease. Analysis of the gene sequence revealed a 1,653-bp open reading frame coding for 550 amino acid residues. Northern blot analysis showed a 4.5-kb transcript that is expressed in invasive trypomastigotes but not in noninvasive epimastigote forms of T. cruzi. Southern blot analysis indicates that Tc-1 is a single-copy gene. At the amino acid level, Tc-1 displayed 95% and 99% identity to two hypothetical proteins recently reported by the T. cruzi genome project. Analysis of the translated amino acid sequence indicates that the Tc-1 gene has a putative transmembrane domain with multiple cytoplasmic and extracellular CKII phosphosites. Exogenous human CKII was able to phosphorylate serine residues on both recombinant Tc-1 and Tc-1 of intact trypomastigotes. This phosphorylation was inhibited by the CKII inhibitors heparin and 4,5,6,7,-tetrabromo-2-azabenzimidazole. Immunoblots of solubilized trypomastigotes, epimastigotes, and amastigotes probed with anti-recombinant Tc-1 immunoglobulin G revealed a 62-kDa protein that is expressed only in infective trypomastigotes. Immunoprecipitation of labeled surface proteins of trypomastigotes indicated that the 62-kDa protein is a surface protein, and we found that the protein is uniformly distributed on the surface of trypomastigotes by direct immunofluorescence. Antibodies to Tc-1 effectively blocked trypomastigote invasion of host cells and consequently reduced parasite load. Preincubation of either trypomastigotes or myoblasts with CKII inhibitors blocked T. cruzi infection. Thus, for the first time, we describe a cell surface CKII substrate of a protozoan parasite that is phosphorylated by human CKII and that is involved in cellular infection.


Assuntos
Caseína Quinase II/metabolismo , Clonagem Molecular , Proteínas de Membrana/genética , Mioblastos Cardíacos/parasitologia , Proteínas de Protozoários/genética , Trypanosoma cruzi/genética , Trypanosoma cruzi/metabolismo , Sequência de Aminoácidos , Animais , Caseína Quinase II/química , Caseína Quinase II/genética , Caseína Quinase II/isolamento & purificação , Humanos , Proteínas de Membrana/isolamento & purificação , Proteínas de Membrana/metabolismo , Dados de Sequência Molecular , Peso Molecular , Mioblastos Cardíacos/enzimologia , Fosforilação , Proteínas de Protozoários/isolamento & purificação , Proteínas de Protozoários/metabolismo , Ratos , Especificidade por Substrato , Trypanosoma cruzi/crescimento & desenvolvimento , Trypanosoma cruzi/patogenicidade , Fatores de Virulência/genética , Fatores de Virulência/isolamento & purificação
12.
Chest ; 110(6): 1394-8, 1996 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-8989051

RESUMO

OBJECTIVE: To determine whether information available 1 week after surgery correlates with long-term function in patients who suffer major complications after coronary artery bypass graft (CABG) surgery. DESIGN: An inception cohort study. SETTING: A 526-bed community teaching hospital. PATIENTS: All 67 patients who required at least 7 days of CT-ICU care following 2,751 consecutive CABG operations. MAIN OUTCOMES: Hospital survival, long-term survival, and functional ability at long-term follow-up. RESULTS: Forty-three patients survived hospitalization (64%), while 24 died 37 +/- 45 days (range, 7 to 190 days) after surgery. When 42 patients were surveyed 22 +/- 9 months after surgery, 21 of the survivors enjoyed excellent, independent function, 7 were moderately impaired but living at home, 6 were institutionalized with severe limitations, and 8 had died. Patients with very severe cardiac or neurologic dysfunction 1 week after surgery had an extremely poor outcome. When mechanical ventilation was required for causes other than primary failure of the respiratory system, long-term function and hospital survival were poor. Twelve of 14 patients with pulmonary complications survived hospitalization, and all 12 were alive at long-term follow-up. CONCLUSION: More than half of patients requiring 7 days or more of ICU treatment after CABG surgery survive, and many enjoy excellent long-term function. However, those with very severe cardiac or neurologic dysfunction 1 week after surgery have little chance for independent recovery.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Baixo Débito Cardíaco/etiologia , Ponte de Artéria Coronária/mortalidade , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Balão Intra-Aórtico , Pneumopatias/etiologia , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/etiologia , Doenças do Sistema Nervoso/etiologia , Respiração Artificial , Estudos Retrospectivos , Taxa de Sobrevida
13.
Chest ; 105(6): 1813-6, 1994 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-8205882

RESUMO

It has been stated that positive pressure ventilation (PPV) may cause false positive impedance plethysmography (IPG) results because PPV can decrease venous outflow. We studied 36 patients who were being weaned from mechanical ventilation to determine the effect of PPV on IPG. Patients had IPGs performed during spontaneous ventilation and while receiving mechanical ventilation in the assist/control (A/C) mode without positive end expiratory pressure (PEEP) and with 10 cm H2O PEEP. No patient developed a positive IPG with institution of PPV (mean airway pressure = 6.8 cm H2O), or with PEEP (mean airway pressure = 14.9 cm H2O). The IPG values for venous capacitance and venous outflow did not change during either mode of mechanical ventilation. There also was no tendency for positive pressure ventilation to move IPG results in the direction of a positive test. In summary, PPV does not cause IPG results to be false positive, nor does it move IPG results toward the discriminant line that separates normal from abnormal results.


Assuntos
Pletismografia de Impedância , Respiração com Pressão Positiva , Tromboflebite/diagnóstico , Idoso , Reações Falso-Positivas , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Sensibilidade e Especificidade , Tromboflebite/epidemiologia , Desmame do Respirador
14.
JAMA ; 271(17): 1358-61, 1994 May 04.
Artigo em Inglês | MEDLINE | ID: mdl-8158822

RESUMO

OBJECTIVE: To describe the process and outcomes of withdrawing life-sustaining interventions in a medical intensive care unit (MICU). DESIGN: Retrospective case series. SETTING: Medical intensive care unit in a community teaching hospital. PATIENTS: Consecutive series of 28 patients in whom mechanical ventilation, dialysis, and/or vasopressors were withdrawn. We distinguished physiological, neurological, and functional rationales for care withdrawal. MAIN OUTCOME MEASURES: Duration of discussions, MICU length of stay, and hospital survival. RESULTS: Mean +/- SD Acute Physiology and Chronic Health Evaluation (APACHE II) score was 27.1 +/- 7.3 on MICU admission, and average +/- SD predicted hospital mortality was 61% +/- 22%. Discussions leading to withdrawal of care occurred over an average +/- SD of 5.2 +/- 5.5 days, with decisions achieved soonest in cases with poor neurological prognosis. Average +/- SD MICU length of stay was 1.4 +/- 1.8 days following a decision to withdraw MICU care, and only four patients received more than 48 hours of additional MICU care. Four patients were discharged alive from the hospital. CONCLUSIONS: Patients and their surrogates willingly considered outcomes in addition to mortality when considering withdrawal of life-sustaining interventions. Finding an accommodation between physician judgments and patient preferences took time and effort but was an effective means of limiting ineffective life-sustaining efforts. Withdrawing futile or unwanted care was not always fatal.


Assuntos
Eutanásia Passiva , Cuidados para Prolongar a Vida , Avaliação de Processos e Resultados em Cuidados de Saúde , Ordens quanto à Conduta (Ética Médica) , Assistência Terminal , Suspensão de Tratamento , Tomada de Decisões , Eutanásia Passiva/psicologia , Mortalidade Hospitalar , Hospitais Comunitários , Hospitais de Ensino , Humanos , Unidades de Terapia Intensiva/normas , Tempo de Internação , New York , Participação do Paciente , Estudos Retrospectivos , Medição de Risco
15.
Chest ; 105(3): 949-50, 1994 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-8131574

RESUMO

Centrally mediated hypoventilation causes respiratory failure without respiratory distress. We present a case of recurrent acoustic neuroma at the cerebellopontine angle causing acute and chronic respiratory failure. Tumor resection eliminated recurrence of respiratory failure.


Assuntos
Recidiva Local de Neoplasia/complicações , Neuroma Acústico/complicações , Síndromes da Apneia do Sono/etiologia , Idoso , Tronco Encefálico/patologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/cirurgia , Neuroma Acústico/diagnóstico , Neuroma Acústico/cirurgia
16.
Arch Intern Med ; 153(14): 1657-62, 1993 Jul 26.
Artigo em Inglês | MEDLINE | ID: mdl-8333803

RESUMO

BACKGROUND: Concerns about rendering futile care, the financial costs of mechanical ventilation, and aging of the population make it important to analyze the benefit of aggressive therapy for respiratory failure in the elderly. METHODS: This study is a retrospective review of 1860 patients treated with mechanical ventilation in the medical intensive care unit for more than 3 hours between 1974 and 1985. Patients were assigned to one of nine diagnostic groups, and 10 premorbid chronic illnesses or organ system dysfunctions were recorded. Survival to discharge was determined for all patients, and the duration of survival after discharge was determined for patients aged 80 years and older. Two hundred eighty-two patients aged 80 years and older were compared with 1578 patients less than 80 years of age. RESULTS: Fifteen percent of patients treated with mechanical ventilation were 80 years of age or older. Forty-four percent of patients younger than 80 years, and 30.9% of patients aged 80 years and older survived to discharge. Patients aged 80 years or older with preexisting renal disease, liver disease, cancer, systemic illness, or chronic gastrointestinal disease with malnutrition had only a 7% survival compared with 29% for younger patients. For patients without these premorbid conditions (80% of both the younger and older groups) survival among the elderly was better, even though it was still poorer than for younger patients (38% vs 49%). Elderly patients requiring more than 15 days of mechanical ventilation had a 9% survival compared with 36% for younger patients. CONCLUSIONS: A subgroup of patients 80 years of age or older can be identified whose chance for survival from respiratory failure is so poor that withholding or withdrawing treatment with mechanical ventilation may be appropriate. For the majority of elderly patients, short-term survival is nearly as good as in younger patients. Further studies are needed that assess long-term survival and functional recovery after treatment for respiratory failure so that elderly patients and their physicians can better decide whether or not to choose treatment with mechanical ventilation.


Assuntos
Avaliação de Resultados em Cuidados de Saúde , Respiração Artificial , Insuficiência Respiratória/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitais com 300 a 499 Leitos , Hospitais Comunitários , Humanos , Masculino , Pessoa de Meia-Idade , New York , Insuficiência Respiratória/etiologia , Análise de Sobrevida , Fatores de Tempo
17.
Ann Thorac Surg ; 56(1): 104-7, 1993 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-8328838

RESUMO

To determine whether age or obstructive lung disease affects pulmonary function changes caused by uncomplicated coronary artery bypass grafting, we measured pulmonary function before operation and then 3 or 4 days, 7 days, and 17 +/- 2.2 weeks after operation in elderly patients (age, 74.8 +/- 3.3 years) and patients with obstructive lung disease (ratio of forced expiratory volume in 1 second to forced vital capacity, 0.60 +/- 8.8) and compared the results with those of a "normal" group. In all three groups a severe restrictive defect developed on day 3 (vital capacity, 61% +/- 20% of the preoperative value). Vital capacity recovered to 76.4% +/- 18.5% of the preoperative value on day 7. Three months after coronary artery bypass grafting, lung function had recovered to preoperative baseline (p > 0.2). The percent change from baseline in vital capacity, forced expiratory volume in 1 second, total lung capacity, and diffusing capacity for carbon monoxide was the same in all three groups throughout the study. A severe, reversible restrictive pulmonary function change follows coronary artery bypass grafting. This change is not affected by age or preexisting moderately severe obstructive lung disease.


Assuntos
Ponte de Artéria Coronária , Pneumopatias Obstrutivas/fisiopatologia , Mecânica Respiratória , Fatores Etários , Idoso , Doença das Coronárias/complicações , Feminino , Humanos , Pneumopatias Obstrutivas/complicações , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias
20.
Chest ; 99(5): 1220-6, 1991 May.
Artigo em Inglês | MEDLINE | ID: mdl-2019182

RESUMO

We reviewed 88 episodes of cardiogenic pulmonary edema (CPE) treated with mechanical ventilation to define the clinical features that predict in-hospital mortality. Fifty-six patients survived to hospital discharge. APACHE II scores were not helpful in prediction. Multiple logistic regression models to predict outcome were developed using variables present at the time of intubation and 24 hours later. The model at the time of intubation indicated mortality was related to systolic blood pressure less than 130 mm Hg, the presence of anterior myocardial infarction, use of calcium channel blockers, age, and absence of prior hospitalization for CPE. A model using additional variables available 24 hours later showed that mortality was related only to the need for vasopressor medication at 24 hours, and systolic blood pressure at intubation less than 130 mm Hg. The predictive power of these models was confirmed by applying them to 46 additional patients. The variables contained in these models suggest that the prognosis of patients with CPE treated with mechanical ventilation depends primarily on the severity of acute left ventricular injury. Variables relating the degree of respiratory failure, however, were not predictive of mortality. These multiple logistic regression models provide a means to compare patients with CPE for quality assessment purposes and for studies of treatment regimens, and may also provide information useful to patient and family counseling regarding the value of continued aggressive intensive care.


Assuntos
Insuficiência Cardíaca/mortalidade , Edema Pulmonar/mortalidade , Respiração Artificial , Idoso , Feminino , Insuficiência Cardíaca/terapia , Humanos , Hipotensão/mortalidade , Modelos Logísticos , Masculino , Infarto do Miocárdio/mortalidade , Prognóstico , Edema Pulmonar/terapia , Curva ROC , Fatores de Risco , Análise de Sobrevida , Fatores de Tempo , Função Ventricular Esquerda/fisiologia
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