Management of a giant fluid-filled bulla by closed-chest thoracostomy tube drainage

A 53-year-old man was admitted to the hospital for management of pneumonia and a giant fluid-filled bulla. He appeared acutely ill and had persistent fever despite prolonged therapy with parenteral antibiotics and aggressive bronchial drainage. Percutaneous placement of an 8.5F catheter into the bulla enabled drainage of both fluid and air within the bulla and led to resolution of his symptoms within 24 h. This report demonstrates that drainage of giant fluid-filled bullae may lead to rapid resolution of symptoms and describes a novel management technique for this condition.     

Complication rates of tube thoracostomy

This study compared the complication rates of tube thoracostomy performed in the emergency department (ED) versus the operating room (OR) and the inpatient ward (IW). A retrospective case series of all patients at an urban, university-based level 1 trauma center hospital who received tube thoracostomy for any indication between 1/1/93 and 12/31/93 was conducted. Complications were defined as empyema, unresolved pneumothorax (persistent air leak or residual pneumothorax), persistent effusion, or incorrect placement. The data for age and duration of tube placement were weighted for analysis of variance (ANOVA). A total of 352 tube thoracostomies was placed in 239 patients. Twenty-three patients had three or more chest tubes placed, 65 had two placed, and the remaining 181 had a single tube. Ninety-nine tubes were placed in the ED, 87 in the OR, and 166 on IW. The mean age of patients in the ED was 37 years, and differed significantly (P < .015) from those in the OR (48 years) and the IW (44 years). The duration of tube placement was similar for all groups (mean = 6.5 days). The overall complication rates related to tube insertion were: ED, 14.0%; OR, 9.2%; IW, 25.3%. Significance was achieved when comparing complication rates between the ED and IW, with less complications in the ED (P = .0436). When comparing complication rates between the ED and OR, there was no significant difference (P = .3643). A power calculation indicated too small of a sample size to truly determine an insignificant difference between complication rates between the ED and OR. Placement of emergent thoracostomy tubes in the ED does not result in an increased complication rate as compared to placement in the IW.     

Randomized study of algorithms for discontinuing tube thoracostomy drainage

BACKGROUND: The optimal method for removal of chest tubes has not been determined and opinion remains divided. The purpose of this study was to determine the difference between two algorithms for the removal of chest tubes: one with continuous negative intrathoracic pressure (suction group) and the other with a trial of water seal (water-seal group). STUDY DESIGN: This study was a prospective randomized trial of 80 trauma patients requiring tube thoracostomies. RESULTS: Both methods of chest tube removal had similar incidences of recurrent pneumothorax (2.5 percent). The suction group had a shorter total chest tube time (72.2 hours versus 92.5 hours, p = 0.013) and shorter time required to remove the chest tube following air leak resolution (25.2 hours versus 35.6 hours, p = 0.034). Additionally, there were more patients requiring prolonged (greater than 36 hours) removal times in the water-seal group (p = 0.009). CONCLUSIONS: Both suction and water-seal methods for chest tube removal are effective and have similar incidences of recurrent pneumothorax. The use of the suction algorithm significantly decreased both chest tube duration and the time taken for chest tube removal. In patients hospitalized for isolated pneumo- or hemothorax, the use of the suction algorithm potentially could lead to shorter length of stay.     

Design and implementation of the quality improvement process at a community teaching hospital

Iron regulatory elements (IREs) are a family of 28 nucleotide, non-coding elements which regulate the translation of ferritin mRNA (iron storage), erythroid delta-aminolevulinic acid synthase mRNA (heme synthesis) and the stability of the transferrin receptor (TfR) mRNA (iron uptake). IREs in the 5' end control translation (ribosome binding) and IREs in the 3' end control turnover (degradation). The specific regulator protein, the IRE-BP, is a member of the aconitase family but binds RNA only in the apo form without the Fe-S cluster. Cellular iron alters the IRE/IRE-BP interaction leading to translation of ferritin and eALAS mRNAs but degradation of the TfR mRNA. IRE function requires proximity to the 5' cap, achieved either by a short leader (eALAS) or a long, base-pairing flanking region (FL) (ferritin); a conserved triplet of FL base pairs enhances repression of ferritin mRNA. TfR mRNA has five AU-rich IREs which can also form an alternate structure with inter-IRE base pairs, in the absence of the IRE-BP. Ferritin IREs regulate both translation repression (negative control-IRE-BP dependent) and enhancement (positive control-initiation factor dependent); IRE-BP binding induces conformational changes in the FL. IREs use CAGUGU/C to form a hairpin loop with specific variations in the stem such as internal or bulge loops. A current structural model obtained using metallonucleases (1,10-phenanthroline-Cu, Fe-EDTA, Fe-bleomycin) and a preliminary analysis of the NMR spectrum, is a distorted helix with folds. The effect of cellular iron, Fe-S clusters and heme on the IRE-BP/RNA is not completely understood.(ABSTRACT TRUNCATED AT 250 WORDS)     

The effects of an outpatient practice guideline at a teaching hospital: a prospective pilot study

BACKGROUND: Platelet-activating factor (PAF) is a bioactive phospholipid which is a potent hypotensive agent. To investigate the role of PAF in renovascular hypertension, we determined the PAF concentration and its production level assessed by the activity of cholinephosphotransferase (CPT) in renal tissue and examined the effect of a PAF antagonist on the mean arterial pressure (MAP) in control and two-kidney with one clipped (2K1C) hypertensive rats. MATERIALS AND METHODS: The concentration of PAF and CPT in the renal medulla and cortex were determined by radioassay. Also, the effect of a PAF antagonist, CV-6209, on MAP was also examined in both 2K1C hypertensive and normal control rats. RESULTS: The PAF concentration and CPT activity were significantly higher in the medulla than in the cortex in both 2K1C hypertensive and normal control rats, and both values in the medulla were also significantly higher in the clipped kidney than in the contralateral unclipped kidney or in control rat kidneys. We also observed a significant negative correlation between the PAF concentration in the medulla, and the medulla weight in the clipped kidney of 2K1C hypertensive rats. Infusion of the PAF antagonist, CV-6209, did not affect MAP in 2K1C hypertensive rats, but was significantly increased (P < 0.05) in control rats. CONCLUSIONS: These findings suggest that PAF, whose production is induced by renal ischemia due to renal artery stenosis, plays an important role in the renomedullary vasodepressor system, but the effect of PAF as a vasodilator in the peripheral vessels is limited in 2K1C hypertension.     

Perceptions and practice of universal blood and body fluid precautions by registered nurses at a major Sydney teaching hospital

Detection of Newcastle disease virus (NDV) and avian pathotyping of NDV isolates are extremely important because the appearance of virulent virus has significant economic consequences in terms of vaccination, eradication, and the ability to export poultry products. By using nucleotide and amino acid (aa) homology analysis, we could demonstrate that a NDV broiler isolate is a velogenic virus. This analysis was done after mean death time and intracerebral pathogenicity index tests gave inconsistent results. By establishing a nucleotide sequence dendrogram, we found that the disputed Ber-Tuvia was clearly in the same group as the known Herev-Laet, a velogenic isolate. The difference between Ber-Tuvia 92 and the Herev-Laet velogenic isolate was 6% as opposed to > 16% of the meso- and lentogenic isolates. The Ber-Tuvia isolate contains the Arg/Arg and Lys/Arg aa at positions 112, 113 and 115, 116, respectively, in the fusion protein cleavage aa sequence, which is typical for virulent NDV isolates.     

Emergence and dissemination of a highly vancomycin-resistant vanA strain of Enterococcus faecium at a large teaching hospital

We prospectively identified patients at the Massachusetts General Hospital from whom vancomycin-resistant enterococci (VRE) were isolated from a clinical specimen from 1 January 1991 through 31 December 1995. VRE strains were available from 139 (82%) of the 169 patients with clinical cases. Of these, 39 (28%) were identical or closely related by pulsed-field gel electrophoresis (i.e., VRE type A strain), including 38 (43%) of 89 VRE strains in 1995. By multivariate analysis, acquisition of the VRE type A strain was associated with receipt of clindamycin (odds ratio [OR] = 10.5), 15 or more days of hospitalization before the first isolation of VRE (OR = 2.9), and residence on one of the general medical floors (OR = 7.8). The VRE type A strain was a vanA strain of Enterococcus faecium and was highly resistant to all antimicrobial agents tested except chloramphenicol. These findings document the rapid dissemination of a highly resistant strain of E. faecium among patients and among other extant VRE strains at the Massachusetts General Hospital in 1995.     

Mortality of operations on gallbladder and bile ducts performed in a training hospital

Human urinary Tamm-Horsfall glycoprotein, which contains 28% carbohydrate, has a monomeric molecular weight of about 80,000 but is isolated from urine in the form of intertwining helical suprastructures with molecular weights greater than 10(7). The native glycoprotein was dissociated and denatured with 6 M guanidinium chloride and was subsequently renatured by dialysis against a Tris-HCl buffer. Using sedimetation equilibrium, the renatured glycoprotein was characterized by a Mw cell of 256,800 and a Mz cell of 356,000. The ratio, Mz/Mw, of 1.39 indicates some polydispersity with regard to molecular size. There was no evidence of helical suprastructures in the renatured glycoprotein as judged by electron microscopy. Ca2+ concentrations of up to 50 mM failed to precipitate the renatured glycoprotein; in contrast, the native glycoprotein is precipitated by Ca2+ concentrations between 5-10 mM. The circular dichroic spectrum of renatured Tamm-Horsfall glycoprotein was obtained, resolved, and tentative band assignments made. The spectrum, which is quite similar to that of native Tamm-Horsfall glycoprotein, exhibited negative extrema at 269 nm (due in large part to disulfides and tyrosines) and at 215 nm (due to protein beta-structure and the N-acetylated hexosamines). The alpha-helical content of the glycoprotein was estimated to be no more than 10% and the amount of beta-structure to be about 33%; these values were not affected by the presence of Ca2+ (1 mM). A glcopeptide fraction (ca. 90% carbohydrate), prepared by extensive pronase digestion of the reduced, S-carboxymethylated glycoprotein, exhibited an ellipticity extremum at 212 nm of + 4,750 deg-cm2/dmole, referred to the concentration of (N-acetylated) hexosamines and neuraminic acid.     

Implementation of guidelines for No-CPR orders by a general medicine unit in a teaching hospital

Improvements in reconstruction of the skull base have made craniofacial surgery safe. Reconstruction of the anterior skull base must provide a seal between the cranial cavity and upper respiratory tract, as well as offer structural support for the brain. A wide variety of local flaps have been designed. The choice of flap in individual cases depends on the location and size of the defect. We report a reconstructive technique for the anterior skull base with vertical median forehead flaps which we used to treat two patients, one patient with adenocarcinoma and the other with leiomyosarcoma. Both were lesions of the ethmoid sinuses and nasal cavity.     

Operational definition of the quality of nursing care at an intensive care unit of a teaching hospital

The purpose of this study is the development of valid standards and criteria of nursing care quality for intensive care units (ICUs) based on Donabedian's approach to quality access. Eighteen standards and 219 criteria have been formulated by ICU staff nurses at a school-hospital, according to a protocol. These standards/criteria have then been evaluated by 14 experts in ICU Nursing from 5 other hospitals by means of a written questionnaire. The results indicated a high acceptance thereof and only one criterion was rejected. This showed that staff nurses and the experts involved had similar concepts about quality of ICU practice. The developed operational definition may be a basis to quality access tool. Staff nurses participation in this process is recommended.     

Piperacillin/tazobactam versus imipenem: a double-blind, randomized formulary feasibility study at a major teaching hospital

With the introduction of piperacillin/tazobactam to the North American market, hospitals have been faced with the task of making a decision regarding its formulary role. In view of its broad spectrum of activity, piperacillin/tazobactam could be considered as a formulary alternative to imipenem. To evaluate the formulary feasibility of substituting piperacillin/tazobactam for imipenem, a comparative assessment of these agents in the empiric treatment of serious bacterial infections was undertaken at this tertiary care hospital. This trial was conducted as a randomized, double-blind, single-center study. Consenting adult patients (>16 years of age) who were prescribed imipenem were randomized to receive either 4 g of i.v. piperacillin/tazobactam or imipenem 500 mg of i.v. Q6H with or without concurrent antibiotics. Doses were adjusted according to renal function. There were no restrictions regarding the use of nonstudy antibiotics before and during the study period. Patients with beta-lactam allergies or meningitis or who had received greater than 72 h of previous imipenem therapy were excluded. Patients were evaluated at the end of treatment, at discharge, and at 30 days postdischarge. Endpoints included both clinical and microbiologic efficacy as well as drug toxicity. Over the 433-day study period, 360 imipenem treatment courses were initiated. Of these, 150 treatment courses (75 piperacillin/tazobactam courses and 75 imipenem courses) met study criteria and were subsequently randomized. The distribution of prescriber services for enrolled patients was similar to that for all patients receiving imipenem during the study period (p = 0.15). Also, there were no statistically significant differences in demographic parameters between enrolled and excluded patients. For those patients enrolled in the study, demographic characteristics, treatment course indication(s), and accompanying antibiotics were similar across treatment arms. The mean duration of study drug therapy was 7.7 days (SD, 6.2) for imipenem and 7.5 days (SD, 6.7)for piperacillin/tazobactam (p = 0.84). In the majority of cases, treatment discontinuation occurred as a result of a favorable treatment course outcome, stepdown to a narrower spectrum parenteral agent, or stepdown to an oral agent and did not differ between study drugs (p = 0.73). Clinical and microbiologic treatment course outcomes were also similar across treatment arms. Clinical outcome was deemed successful or improved for 68% of imipenem and 70% of the piperacillin/tazobactam treatment courses (p = 0.54). Fifty-three percent of treatment courses were microbiologically confirmed. Of the 58 courses that were assessed for microbiological outcome, 93% demonstrated successful eradication of the causative pathogens. There was no difference between study drugs (96% imipenem; 90% piperacillin/tazobactam; p = 0.61). The proportion of treatment courses with at least one adverse event was similar between the study drugs (p = 1.0). Nausea and/or vomiting were/was observed more commonly in the imipenem arm (p = 0.03). Discontinuation of therapy due to drug toxicity occurred in 16% of imipenem and 5% of piperacillin/tazobactam treatment courses (p = 0.06). There was no statistically significant difference between the mean treatment course cost for imipenem ($762; range, $55-$3192) versus piperacillin/tazobactam ($696; range, $79-$2967; p = 0.59). In summary, piperacillin/tazobactam seems to represent a suitable alternative to imipenem for several clinical indications including intraabdominal infections, pneumonia, febrile neutropenia, and skin/soft tissue infections in which the causative pathogens are susceptible. However, in view of the prevalence of multiresistant Gram-negative aerobic pathogens at this institution, we do not believe that imipenem can be removed from the drug formulary. In addition, at the currently studied dosing regimen, there seems to be no evidence of a direct cost advantage associated with     

Experience with a clinical pharmacological service in a teaching hospital

The clinical functions of our Pharmacology department involves teaching, research and patient service. Patient service is rendered at two levels. 1. Clinical Pharmacologists: These are medically trained people and one of them is available for 24 hours a day for therapeutic and toxicological consultation, for channeling requests for laboratory aid and for interpretation and distribution of laboratory results. At the time of preparing this report we received an average of 34 consultations per day (1/3 therapeutic, 2/3 toxicological) of which about 38% are personally seen. 2. Laboratory based Pharmacologists: These people have basic training in Pharmacology, Chemistry and Biochemistry and are involved in qualitative and quantitative investigation of body fluids in cases of poisoning and therapeutic problems. A laboratory-based pharmacologist is available for 24 hours per day but clinicians do not have direct access to him but have to channel their requests through the clinical pharmacologist on call. The laboratory handled 2302 specimens of body fluids during 1975 of which about 75% were of a therapeutic and 25% of a toxicological nature.     

Building a nursing management analysis capacity in a teaching hospital

The authors describe one institution's efforts to create the capacity to use standard hospital information systems to address clinical and operational nursing questions. This work involved not only technical aspects of information management system creation but also building the human currency to make the information available and useful. Because the information available to nursing comes from the same data sources that feed operational management and finance departments, nursing can now speak in the same language at the policy tables.     

Utilisation of family planning services at the teaching hospital in Blantyre, Malawi

In the whole of 1993, there were a total of 1533 new clients who attended the family planning clinic at the Queen Elizabeth Central Teaching Hospital in Blantyre, Malawi. They formed 23.0% of the total client-visits for the year. 305 women had surgical contraception (bilateral tubal ligation) for various reasons, but mainly on request for family limitation. The ages of the new clients ranged from 15 to 49 years. Adolescents (< 20 years old) formed only 9.0%, while those aged > 35 years formed 22.0%. Their parity ranged from 0 to 11, with 58.0% of them being para 1 to 4. The grandmultiparae (para > 5) formed 31.0%. The oral pill was the most favoured method (42.0%), followed by depo-provera (31.0%) and sterilisation (21.0%). Though the majority of the clients who chose the oral pill were aged less than 30 years, about 6.0% were aged > 35 years. Likewise about 15.0% of those who took oral pills were para > 5, i.e. grandmultiparae. These are women who should have either stopped producing a long time back or been counselled to have tubal ligation rather than these temporary methods, when seen in the clinic then. Amongst all the client-visits for the year, oral pill and depo-provera were the two most popular methods, 42.0% and 41.0%, respectively. The ratio, between the clients who discontinued the method they were on and the new clients was 1:6.8, and that of drop-out/new clients was 1:2.4, which are quite high. The rate of absenteeism was also high at 29.0% of the total client-visits.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hepatic amebiasis among patients in a public teaching hospital

A peptide fraction of low molecular weight (Vueffe) prepared from bovine Factor VIII by enzymatic hydrolysis with trypsin, reduces significantly (p<0.05) membrane bound protein kinase C (PKC) activity in cultured bovine pulmonary artery endothelial cells grown with enhanced glucose levels (22.2 mM) or stimulated by phorbol 12-myristate 13-acetate (PMA). The activation of PKC is a common pathway by which mediators increase transendothelial permeability during tissue inflammation and in the development of diabetic vascular complications. Our results suggest that the antihaemorrhagic properties of Vueffe could be related to a decrease in endothelial permeability mediated by PKC.     

Surgical wound infection in a teaching hospital in Ethiopia

The magnitude and pattern of surgical wound infection in a teaching hospital in Gondar, northwest Ethiopia, was studied prospectively over a one year period. Out of 129 abdominal surgical wounds from 129 patients, fifty (38.7%) yielded pathogenic organisms on culture. The wound infection rate was 21% on clinical grounds alone. Wound infection was significantly associated with class of wound; with the highest rate being 61.4% for contaminated or dirty wound. There was no difference in infection rate between emergency and elective operations. Staphylococcus aureus and Escherichia coli were the leading aetiologic agents with rates of 28.8% and 27.1% of pathogenic isolates respectively. Surgical wound infection accounted for delay in the discharge of 14.7% of patients. This study has shown that the surgical wound infection rate in this teaching and tertiary level care hospital is high and control measures should be re-evaluated.     

Infective endocarditis at a large community teaching hospital, 1980-1990. A review of 210 episodes

We studied 210 episodes of infective endocarditis in 204 patients. The prevalence of this disease in our series ranged from 0.32 to 1.30 (mean, 0.75) episodes per 1000 admissions per year. There were 115 male and 89 female patients, whose ages ranged from newborn to 91 years (median, 60-70). One-hundred-and-forty-eight episodes involved host valves and another 33 episodes occurred in intravenous drug users. There were 2 episodes of early and 27 episodes of late prosthetic valve endocarditis. Staphylococcus aureus accounted for 99 episodes (47.1%), alpha-hemolytic streptococci for 29 episodes (13.8%), enterococci for 11 episodes (5.2%), culture-negative endocarditis for 11 episodes (5.2%), and other organisms for 60 episodes (28.6%). Severe back pain was the chief complaint in 15 patients. 2-D echocardiography was performed in 164 episodes, results in 67 (40.9%) of which were positive. Valve surgery was performed in 29 episodes (23 host valves and 6 prosthetic valves). The overall mortality was 21.4%. Autopsy was performed in 22 of the 45 patients who died (48.9%). The mortality rate increased with age, (10.1% and 31.5% for patients < 60 years old and 60 years or older, respectively (p < 0.001).     

Secular trends in the etiology of nosocomial infection at a teaching hospital in Taiwan, 1981-1994

Surveillance system of nosocomial infection was established in 1980 at the National Taiwan University Hospital (NTUH). To identify pathogens and the secular trends in the etiology of nosocomial infection from 1981 to 1994, the prospective, hospital-wide nosocomial surveillance data were analysed. During this period, 22,146 pathogens causing nosocomial infections were isolated. Gram-negative aerobic bacteria remained the major pathogens, but gram-positive cocci and fungi increased rapidly in the past 14 years. When the overall pathogen distribution is examined, Pseudomonas areuginosa was the most frequently isolated pathogen, but Candida albicans and other yeasts have taken the leading position since 1993. Staphylococcus aureus and coagulase-negative staphylococci also increase significantly in recent years. When the pathogens causing infection at the 4 major sites were examined. P. aeruginosa was the pathogen most often associated with respiratory tract and surgical wound infections. In blood stream and urinary tract infections, we observed Escherichia coli was replaced by C. albicans and other yeasts as a most common isolate in these years. In addition, C. albicans and other yeasts and methicillin-resistant S. aureus (MRSA) are emerging as major nosocomial pathogens at NTUH. C. albicans and other yeast increased from 1.8% in 1981 to 14.9% in 1994 in the overall nosocomial infection. The increase was found in the blood stream (2.1% to 16.2%) and urinary tract infections (5.4% to 24.7%). Of 1,742 nosocomial S. aureus isolates, the percentage of MRSA rose from 12.5% in 1981 to 55.2% in 1994. The high percentage of MRSA was observed at 4 major anatomic sites of infection. In summary, significant shifts in the pathogens of nosocomial infection have occurred in the past 14 years at NTUH, and the distribution of nosocomial pathogens was similar to those reported in the United States in recent years.