Prediction of cardiac risk prior to elective abdominal aortic surgery: role of multiple gated acquisition scan.

Debate continues regarding the value of cardiac testing before major vascular surgery. Studies looking at whether a low radioisotope left ventricular ejection fraction (LVEF) could reliably predict postoperative cardiac events have produced conflicting results. Technetium-99m multiple gated acquisition (MUGA) scanning was employed in 122 patients undergoing elective abdominal aortic aneurysm surgery to estimate the resting LVEF and to detect regional or global myocardial wall motion abnormalities (WMAs). Adverse cardiac outcomes were predicted using logistic regression analysis. Among this group of patients, 20 did not proceed to surgery for a variety of reasons, and 102 underwent surgical repair. More than half of the patients (55%) had a history of cardiac disease. The mean +/- SD LVEF was 55.5% +/- 11.1%. Altogether, 31 patients had WMAs, and 21 had both WMAs and an abnormal LVEF (< or = 50%). Altogether, 20 cardiac complications were encountered in 17 patients (17%). Logistic regression analysis identified four significant predictors of cardiac complications: history of cardiac disease [odds ratio (OR) 10.43; 95% confidence interval (CI) 1.3 and 80.5], the presence of WMAs (OR 10.1, CI 1.4 and 74.6), additional procedures (OR 12.1, CI 1.4 and 103.0), and reoperation during the postoperative period (OR 6.4, CI 1.4 and 30.4). This is the largest reported British series of cardiac testing using MUGA scans prior to abdominal aortic reconstruction. Only the presence of WMAs (not the resting LVEF) was useful for predicting postoperative cardiac events. A history of cardiac disease, additional procedures, and reoperation during the postoperative period also place a patient at high risk for cardiac complications. A normal LVEF is by no means reassuring that a patient is at low risk of suffering an adverse cardiac outcome.

Prediction of cardiac risk before abdominal aortic reconstruction: comparison of a revised Goldman Cardiac Risk Index and radioisotope ejection fraction.

BACKGROUND: A revised Goldman Cardiac Risk Index has been suggested to identify patients at higher risk for cardiac complications in patients who undergo major noncardiac surgery. The aim of this study was to test the usefulness of this model in an independent series of patients who underwent abdominal aortic surgery and to compare the index with the multiple gated acquisition (MUGA) scan in the prediction of cardiac complications. METHODS: We studied 77 patients who underwent MUGA scan before elective abdominal aortic reconstruction. The revised index was calculated for each patient after recording the following five risk factors: history of ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes, and creatinine level more than 2 mg/dL. Technetium-99m MUGA scan provided information about the resting left ventricular ejection fraction (LVEF) and the presence of regional wall motion abnormalities. RESULTS: Fourteen patients (18%) had cardiac complications develop. The index proved to be a satisfactory predictor of postoperative cardiac events (P =.008), and an abnormal LVEF failed to do so (P =.1). The presence of wall abnormalities, with or without an abnormal LVEF, predicted cardiac complications (P =.004 and P =.006). Patients with a higher index score showed a tendency to have a lower LVEF (Spearman rank correlation, r = -0.43; P <.001). Wall abnormalities, with or without an abnormal LVEF, were more frequent in patients with higher scores (P =.03 and P =.009). Combining the index with the LVEF or the wall abnormalities or both could further stratify the cardiac risk (P =.004, P =.0003 and P =.0006, with chi(2) test for trend). CONCLUSION: For those patients who undergo elective abdominal aortic surgery, the revised Goldman Cardiac Risk Index is a simple method of evaluating cardiac risk with minimum resource implications. MUGA scan can offer additional stratification in patients judged with the index to be at high risk.

Persistence of Pseudomonas aeruginosa strains in respiratory infection in AIDS patients.

OBJECTIVES: To establish the clinical pattern of Pseudomonas aeruginosa respiratory infections in HIV-seropositive patients and to determine whether repeated isolation of the organism represents reinfection or recurrence and to assess whether common source, nosocomial infection occurred. DESIGN AND METHODS: Evaluation of the clinical pattern of P. aeruginosa respiratory infections by case note review and epidemiological characterization of P. aeruginosa by serotype determination and Xbal DNA macrorestriction analysis. Serum sensitivity testing of strains was performed to further define phenotypic characteristics of the isolated organisms. RESULTS: Seventy-three per cent (29 out of 40) of individuals had P. aeruginosa isolated on two or more occasions in the setting of clinical respiratory infection. Overall, 85% had evidence of P. aeruginosa to within 2 months of study completion or death. Epidemiological characterization revealed persistence of unique single strains in 93% of individuals where multiple isolates were available for testing, whereas only two patients harboured a common strain. The serotype distribution of strains was similar to that reported from non-HIV-positive patients. CONCLUSIONS: Once established, eradication of P. aeruginosa from the respiratory tract of HIV-seropositive individuals with advanced immunosuppression is problematic and a chronic infective state appears common. There was no evidence of nosocomial transmission. Serotype loss and development of sensitivity to normal human serum were both observed and were highly correlated. This represents truncation of O-antigenic lipopolysaccharide on the cell surface of P. aeruginosa and may reflect progression to phenotypes commonly associated with chronic infection in other clinical settings such as cystic fibrosis.

An outbreak of Salmonella enteritidis in a maternity and neonatal intensive care unit.

An outbreak of Salmonella enteritidis in a maternity and neonatal intensive care unit is described. The outbreak involved six babies and three mothers over a period of 23 days. The index case presented with premature labour with chorioamnionitis caused by S. enteritidis. There was no history of diarrhoea at the time of her admission of during her pregnancy. The absence of illness led to a delay in instituting standard isolation procedures until S. enteritidis had been isolated from the placenta four days after delivery. It appeared that the resuscitator in the labour ward operating theatre acted as a reservoir for the initial transmission with secondary person-to-person spread. Early introduction of universal infection control measures including handwashing and appropriate disinfection of equipment would have prevented the outbreak.

Staphylococcal scalded skin syndrome in an HIV-1 seropositive man.

The staphylococcal scalded skin syndrome (SSSS) is very rare in adults. Renal impairment and immunocompromise are predisposing causes. We report a 38-year-old HIV-1 seropositive intravenous drug abuser who developed SSSS due to staphylococcal pneumonia. An exfoliating toxin-releasing Staphylococcus aureus, phage type II type 3C, was isolated from the sputum and from blood cultures. This is the third case of adult SSSS to be reported in the context of HIV disease.

Northwick Park Infection Consultation Service. Part I. The aims and operation of the service and the general distribution of infection identified by the service between September 1987 and July 1990 [see comment].

The Northwick Park Infection Consultation Service (ICS) is a collaborative service operated by the departments of Medical Microbiology and Infectious Diseases where personnel and skills are combined. Its aim is to improve the availability and effectiveness of consultation for infection-related problems. This paper sets out the framework for establishing an ICS and also details the general distribution of infection identified by the Northwick Park ICS in a study carried out between September 1987 and July 1990. Part II assesses the contribution that the ICS made to the management of infection. One thousand and thirty-eight (1038) patients were seen on the ICS. Seventy-five per cent (776) were judged to be infected and in 691 this was a probable or certain diagnosis. Skin and subcutaneous tissue, respiratory tract, and genito-urinary tract infections accounted for 64% of the total. Eighty-seven per cent of infections required treatment with intravenous antibiotics, 22% were associated with concomitant bacteraemia, and 2.7% of patients died as a direct result of their infection. Sixty-four per cent of consultations were unsolicited and arose from laboratory results or the clinical information on the form accompanying the specimen: over one quarter were initiated before results were available. These infections were no different in either severity or nature from those identified by solicited requests to either department. Fifty-three per cent of consultations had a moderate to high clinical component. The results emphasise the importance of infection in hospitals and highlight the advantages of a collaborative approach from the departments of Medical Microbiology and Infectious Diseases.

Northwick Park Infection Consultation Service. Part II. Contribution of the service to patient management: an analysis of results between September 1987 and July 1990.

The establishment of Infectious Disease teams combining microbiological and clinical expertise has recently been recommended by a joint working part of the Royal College of Physicians and the Royal College of Pathologists. The Northwick Park Infection Consultation Service (ICS) has been operating on these lines since 1983; details are given in Part I. Part II assesses the contribution that the ICS has made to the management of infection in a study of 1038 patients undertaken between September 1987 and July 1990. The areas of patient diagnosis, treatment, investigation and isolation were examined to assess the appropriateness of the attending doctor's management of infection and the benefits resulting from recommendations made by the ICS. At the time of consultation the correct diagnosis had already been made or considered in 93% of patients, essential investigations needed to confirm or refute the diagnosis performed in 92%, and side-room isolation correctly instituted in 81% of patients requiring it. However, 41% of 776 infected patients were receiving suboptimal treatment: this was significantly more frequent in unsolicited consultations (P less than 0.05). Advice was given following consultation in 893 of 1038 patients (86%) and related to treatment (66%), investigation (41%), diagnosis (30%) and patient isolation (4%). Of 844 patients where receipt of advice could be accurately assessed, it was taken fully in 708 (84%), partly in III (13%), and went unheeded in 25 (3%). Advice on diagnosis or investigation enabled the correct diagnosis to be reached in 30% of consultations and in a further 47 patients (5%), the diagnosis was proposed by the ICS on initial consultation.(ABSTRACT TRUNCATED AT 250 WORDS)