Fat embolism syndrome: incidence, significance and early features

During the period 1968 to 1978 a total of 447 patients were treated in the Royal Newcastle Hospital for acute respiratory failure after injury. In 321 patients respiratory failure occurred after thoracic and/or long bone injury. In only 17 of these could a diagnosis of fat embolism syndrome (FES) as a sole cause of respiratory failure be substantiated when strict diagnostic criteria were applied. In a further 15 patients FES may have coexisted with other causes of respiratory failure. The outstanding features of patients with FES were: (I) all were in the younger age groups; (II) all developed respiratory symptoms within 48 hours of admission to hospital; (III) most had multiple limb fractures; (IV) more than half had been transferred from other hospitals; and (V) three were pregnant and had sustained in comparison with the others, less severe long bone injuries.     

Analysis of deaths during the course of status asthmaticus in patients treated at the Acute Asthma Center in the Pneumonology Clinic of the Warsaw Medical School in the years 1991-1996]

In the Acute Asthma Treatment Center (OLSA) in the Department of Pneumonology of Warsaw Medical School in years 1991-1996, 582 patients with status asthmaticus were treated. The causes of status asthmaticus were bronchial asthma in 317 patients and COPD in 265 patients. Status asthmaticus was the cause of death in 21 patients treated in OLSA, which accounts for 3.6% of the total. 10 subjects were admitted with symptoms of brain death, who underwent resuscitation on their way to hospital. This study retrospectively analyzes the clinical characteristics (age, sex, PaCO2, pH, PaO2, time of mechanical ventilation and duration of treatment in ICU) of patients who died in status asthmaticus. They were divided into two groups: patients with asthma and COPD. A significant difference (p < 0.01) was detected between those two groups only in patients age. Mean duration of mechanical ventilation was 151 h in asthmatic and 104 h in COPD group. Mean duration of the OLSA stay was 19.5 days in the first and 7.4 days in the second group. The following fatal complications were observed: 2 cerebral strokes, 4 cardiac infarctions, 3 pneumothoraces, 2 atelectasis, 4 pneumonia, 1 case of gastric hemorrhage and 1 hemorrhage to mediastinum.     

Electrophysiologic evaluation of denervated muscles in incomplete paraplegia using macro electromyography

OBJECTIVE: To evaluate denervated muscles in persons with incomplete paraplegia due to thoracolumbar spinal injury (TLSI) using macro electromyography in determining indications for functional electrical stimulation (FES). DESIGN: A randomized clinical trial and a criterion standard. SETTING: A department of orthopedic surgery in a university hospital. PATIENTS AND OTHER PARTICIPANTS: Eighteen patients with incomplete paraplegia, including 11 with TSLI, and 50 healthy adults. INTERVENTION: Area and amplitude of macro motor unit potential (macro MUP) were measured at the tibialis anterior, the vastus lateralis, and the vastus medialis. The normal limits of macro MUP parameters were defined based on values from healthy subjects. Abnormal denervated muscles were detected by macro EMG and conventional EMG in paralytic patients. The correlation between macro MUP parameter values and muscle forces of the tibialis anterior and quadriceps femoris induced by electrical stimulation was analyzed. MAIN OUTCOME MEASURES: The number of abnormal muscles, parameter values, and muscle force induced by electrical stimulation. RESULTS: Abnormal muscles were found only in the TLSI patients and 13 abnormal muscles were detected by macro EMG only. The abnormal muscles defined by macro EMG showed insufficient contraction induced by electrical stimulation. The increase of parameter value negatively correlated with the muscle force (tibialis anterior area r=-.797, amplitude r=-.866; quadriceps area r=-.866, amplitude r=-.893; p < .001). CONCLUSIONS: These results suggest that macro EMG is useful in detecting denervated muscles, in determining indications for FES, and in predicting FES effects before implantation of electrodes.     

Inflammatory mediators in BAL fluid as markers of evolving pneumonia in leukocytopenic patients

STUDY OBJECTIVES: Pneumonia during chemotherapy-induced leukocytopenia is a major cause of overall treatment failure in patients with hematologic malignancies. To improve outcome in these high-risk patients, early diagnosis of pulmonary infiltrates and institution of adequate antimicrobial treatment are mandatory. To identify patients with evolving pneumonia, we have prospectively studied the prognostic value of cytokine and complement measurements in early BAL samples from febrile leukocytopenic patients. DESIGN: Prospective, comparative study. SETTING: Hematology/oncology section of a university hospital. PATIENTS: Twenty-one patients with leukocytopenia (WBC count < 1.000/microL) following cytoreductive chemotherapy for malignant disorders. INTERVENTION: Early BAL sampling primarily for microbiologic diagnostic purposes. MEASUREMENTS AND RESULTS: Proinflammatory cytokines and activated complement components were measured in the BAL aspirates and the results were related to the prevalence or subsequent evolution of overt pneumonia. Of the 21 patients studied, 10 patients presented with overt pneumonia at BAL sampling (group A), 5 patients developed objective signs of pneumonia 3 to 5 days after BAL (group B), and 6 patients remained free of pneumonia during follow-up (group C). In comparison with group C, patients in groups A and B both had distinctly elevated bronchoalveolar levels of tumor necrosis factor-alpha, interleukin-6, granulocyte colony-stimulating factor, C3a, and C5a. CONCLUSIONS: Cytokine and complement determinations in early BAL samples may aid in the identification of febrile leukocytopenic patients with evolving pneumonia 3 to 5 days prior to the manifestation of diagnostic clinical and radiographic signs.     

MR imaging for traumatic tears of the rotator cuff: high prevalence of greater tuberosity fractures and subscapularis tendon tears

OBJECTIVE: The purpose of this study was to determine whether occult bony injuries or other characteristic MR abnormalities are frequent in patients suspected of having traumatic tears of the rotator cuff. SUBJECTS AND METHODS: MR arthrography of the shoulder was performed in 24 consecutive patients with suspected traumatic tears of the rotator cuff. MR findings were analyzed with regard to abnormalities of the supraspinatus, infraspinatus, and subscapularis tendons; and the humeral head. A comparison group of 24 consecutive patients with symptoms of nontraumatic tears of the rotator cuff was included in the investigation. RESULTS: Radiographically occult fractures of the greater tuberosity were found in nine (38%) of 24 patients with clinically suspected traumatic tears of the rotator cuff (seven of which occurred in patients <40 years old). Nine partial-thickness and five full-thickness supraspinatus tears were found in the trauma group. In the comparison group, the corresponding numbers were 13 and 10, respectively. Seven partial lesions of the cranial border of the subscapularis and six complete subscapularis tears (all six in patients >40 years old) were found in the trauma group (nine and one in the comparison group). CONCLUSION: Occult greater tuberosity fractures and complete subscapularis tears are commonly seen on MR images in patients suspected of having traumatic tears of the rotator cuff. Greater tuberosity fractures should be looked for specifically in patients younger than 40 years, and subscapularis tears should be looked for specifically in patients older than 40 years.     

Traditional methods vs rigid internal fixation of mandible fractures

OBJECTIVE: To compare traditional methods (ie, intermaxillary fixation with interosseous wiring or external fixation) with newer techniques (ie, plating, use of lag screws) of open reduction and fixation of mandible fractures. DESIGN: Retrospective analysis of data from medical records. SETTING: Academic urban medical center. PATIENTS: Nonrandomized sample of 356 patients admitted to the hospital for treatment of mandible fractures from 1987 through 1991; 155 patients treated with open reduction and fixation were studied. INTERVENTIONS: Sixty-nine patients were treated with interosseous wire fixation or external fixation, 86 patients with rigid internal fixation. MAIN OUTCOME MEASURES: Presence of infection, nerve impairment, nonunion, malunion, operative time, and follow-up. RESULTS: No significant difference was noted between the two groups for sex, treating service, delay in presentation, antibiotic coverage, mechanism of injury, or type of fracture. The incidence of infection, nerve injury, and unavailability for follow-up were greater in patients treated by the newer techniques. Overall expense and operative time were greater in the group treated with plates and lag screws. CONCLUSIONS: We advocate traditional techniques for patients with mandible fractures requiring open reduction and fixation.     

Prevalence of diabetic nephropathy in adult patients with chronic kidney failure

Diabetic nephropathy is a frequent cause of end-stage renal failure in patients admitted for renal replacement therapy. PURPOSE: To evaluate the prevalence of DN, as the underline disease, in patients with ESRF. METHODS: 1,303 [male (M) = 767 and female (F) = 536] patients with ESRF who were on a waiting list for cadaver kidney transplant at Nephrology Unit-University Hospital (HC-UNICAMP), from August/90 to June/93--group 1--and 193 (M = 112 and F = 81) patients admitted for renal replacement therapy in a year period (April/92 to March/93), in the city of Campinas, State of S?o Paulo, Brazil, were studied. RESULTS: The prevalence of DN was 10.1% in group 1 and 17.6% in group 2 (x2 = 7.15; p = 0.007), being the third cause of ESRF in both groups, and it was preceded by glomerulonephritis and arterial hypertension. In group 1 the reduction of number of patients with increase in duration of dialysis was significantly greater in patients with diabetic nephropathy (x2 = 30.9; p < 0.001). Among patients with DN 35 (26%) in group 1 and 6 (18%) in group 2 had less than 35 years when they were admitted for renal replacement therapy and are likely to be type 1 (insulin-dependent) diabetic patients. CONCLUSION: In our studied groups DN was a frequent cause of ESRF.     

Delayed surgical fixation of femur fractures is a risk factor for pulmonary failure independent of thoracic trauma

A recent retrospective analysis of femur fractures concluded that early surgical fixation in patients who have sustained blunt thoracic trauma (AIS score for Thorax > or = 2) was a risk factor for postoperative pulmonary failure. We conducted a review of all femur fractures admitted to a level I trauma center from November, 1988 to May, 1993. Inclusion criteria were ISS > or = 18, mid-shaft femur fractures treated with reamed intramedullary fixation, and no mortalities secondary to head trauma or hemorrhagic shock. One hundred thirty-eight patients met these criteria. Four patient groups were created: N1--no thoracic trauma (AIS score for thorax < 2), and early surgical fixation (< 24 hours after injury, n = 49); N2--no thoracic trauma and delayed fixation (> or = 24 hours, n = 8); T1--thoracic trauma (AIS score for Thorax > or = 2) and early fixation (n = 56); T2--thoracic trauma and delayed fixation (n = 25). There were no significant differences in age, Injury Severity Score, or Glasgow Coma Scale score between the four groups. Mortality rate, length of stay (LOS), LOS in the TICU, and duration of mechanical ventilation tended to be greater in patients with delayed fracture fixation, however, this was not statistically significant. The N2 patients had a pneumonia rate of 38% compared with 10% in group N1 (p = 0.07). The T2 patients had a pneumonia rate of 48% compared with 14% in group T1 (p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)     

Open capsulorrhaphy with suture anchors for recurrent anterior dislocation of the shoulder

OBJECTIVE: The aim of this study was to index the frequency of occurrence of acute stress disorder following mild traumatic brain injury and to determine its utility in predicting posttraumatic stress disorder (PTSD). METHOD: Consecutive adult patients who sustained a mild traumatic brain injury following a motor vehicle accident (N = 79) were assessed for acute stress disorder within 1 month of their trauma with the Acute Stress Disorder Inventory, a structured clinical interview based on DSM-IV criteria. Patients were followed up 6 months after the trauma (N = 63) and were administered the PTSD module of the Composite International Diagnostic Interview. RESULTS: Acute stress disorder was diagnosed in 14% of patients, and at follow-up 24% satisfied criteria for PTSD. Six months after the trauma PTSD was diagnosed in 82% of patients who had been diagnosed with acute stress disorder and in 11% of those who had not been diagnosed with acute stress disorder. CONCLUSIONS: These findings point to the frequency of PTSD following mild traumatic brain injury. While the criteria for acute stress disorder are useful in identifying those individuals who are at risk of developing chronic PTSD, the findings suggest that current criteria require modification in order to optimally predict PTSD following mild traumatic brain injury.     

Comparison between reagent strips used for detection of urinary tract infection in the elderly

A comparison was made between the accuracy of Ames and Boehringer reagent strips for detecting urinary tract infections in 100 elderly patients (50 acutely ill patients admitted to hospital and 50 attending the day hospital). The results for urinary nitrite, blood and protein for both strips were documented. Nitrite provided the highest sensitivities and specificities. In the acute hospital patients, the sensitivities were 83% for the Ames and Boehringer strips respectively, while for the day hospital patients the sensitivities were 90% for both strips. Specificities were 100% for both strips in each group of patients. There was thus little difference between the accuracy of the Ames and Boehringer reagent strips in detecting urinary tract infection.     

Perceived likelihood as a measure of optimism and pessimism: Support for the Future Events Scale.

The Future Events Scale (FES; S. M. Andersen, 1990) is an expectancy-based measure of optimism and pessimism, grounded in cognitive theories of depression, with implications for clinical practice. Although ample research has documented the utility of the FES in predicting important cognitive and behavioral outcomes, psychometric data on the scale are lacking. The current article presents multisample analyses to show that the FES has clear factor structure, good reliability, and a theoretically meaningful nomological network. The FES is shown to be distinct from the best known measure of optimism and pessimism, the Life Orientation Test (M. F. Scheier & C. S. Carver, 1985). Applications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Workshop on chronic pain, pain control, and patient outcomes in rheumatoid arthritis and osteoarthritis

OBJECTIVE: Coincident with a change in the physician staff in our pediatric intensive care unit (PICU), the frequency and duration of invasive monitoring were decreased. We examined the impact of this change on outcomes, complications, and hospital charges in infants admitted to the PICU with respiratory syncytial virus (RSV) infection. STUDY DESIGN: We reviewed medical records of all children less than 1 year of age who were admitted to the PICU from January 1989 to July 1993 with confirmed RSV infection. Patient characteristics, therapeutic interventions, outcomes, and hospital charges were extracted and compared. RESULTS: Seventy-eight patients were identified, 38 admitted from January 1989 through July 1991 (group 1) and 40 from July 1991 through July 1993 (group 2). The groups were well matched in age, preexisting disease, and cardiorespiratory status on admission. Group 1 had significantly greater use of invasive monitoring, pharmacologic paralysis, inotropes, blood products, antibiotics, and parenteral nutrition. Outcomes were not different, but group 1 patients had significantly longer stays, more complications, and higher hospital charges. CONCLUSIONS: Routine use of invasive monitoring of PICU patients with RSV disease was associated with increased laboratory testing, overtreatment, and significant increases in costs and morbidity without improvement in outcome.     

Age on first hospitalization of schizophrenics: A developmental approach.

Compared ages at 1st hospitalization of 3 groups of schizophrenics: 64 males in a VA hospital and 60 male and 60 female patients in a state hospital. Paranoid Ss were approximately 8 yrs older when first admitted than the nonparanoids. In both diagnostic categories males were hospitalized about 5 yrs earlier than females. Working females with a diagnosis of paranoia were hospitalized approximately 10 yrs later than the paranoid females who remained at home and the nonparanoid females of either employment status. State hospital males were younger on 1st admission than VA hospital males. The ages of the 2 diagnostic groups in the VA were comparable, whereas in the state hospital the nonparanoid group was younger than the paranoid group by about 8 yrs. The need to pay greater attention to the differences between schizophrenic males and females and to scrutinize more closely differences between state and VA hospital patients is emphasized. (48 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acute ethanol intoxication increases the risk of infection following penetrating abdominal trauma

Acute alcohol (ETOH) intoxication as a risk factor for infection in trauma victims to our knowledge has not been previously reported. To determine if ETOH intoxication increases infection risk we examined data from 365 patients with penetrating abdominal trauma who were enrolled in a multi-center antibiotic study. Ninety-four patients sustained an injury to a hollow viscus. To separate acute from chronic ETOH effects, infections were divided into two categories: (1) trauma related; infections caused by bacterial contamination at the time of injury, while blood alcohol level (BAL) was elevated. (2) nosocomial; infections caused by bacteria acquired during hospital stay, after BAL had normalized. A BAL > or = 200 mg/dL was associated with a 2.6-fold increase in trauma-related infections. There was no association between BAL and subsequent nosocomial infection. Since infection rates for intoxicated patients were not higher after BAL had normalized, acute rather than chronic effects of ETOH appear to be responsible.     

A cost comparison of balloon angioplasty and stenting versus endarterectomy for the treatment of carotid artery stenosis

PURPOSE: Percutaneous transluminal angioplasty with stenting (PTAS) of the carotid artery has been advocated as an alternative treatment for high-grade stenosis. Rationale for this approach includes less morbidity, shorter recovery, and lower cost when compared with carotid endarterectomy (CEA). METHODS: The clinical results and hospital charges of patients who underwent elective treatment for carotid stenosis were reviewed. During a concurrent 14-month period, 218 patients were admitted 229 times for 234 procedures for the treatment of 239 carotid bifurcation stenoses, 109 by PTAS and 130 by CEA. Hospital charges were reviewed for each hospitalization and were categorized according to radiology, operating room, cardiac catheterization laboratory, and all other hospital charges. RESULTS: The combined incidence of postprocedure strokes and deaths were: PTAS, eight strokes (7.7%) and one death (0.9%); CEA, two strokes (1.5%) and two deaths (1.5%). Total hospital charges per admission for the two groups were $30,140 for PTAS and $21,670 for CEA. The average postprocedure length of stay for PTAS was 2.9 days (median, 2 days) and for CEA was 3.1 days (median, 3 days). Cardiac catheterization laboratory charges for the PTAS group were $12,968, whereas the operating room charges for the CEA group were $4263. When hospitalizations that were extended by complications were excluded, the average total charges for the PTAS group (n = 84) dropped to $24,848 (mean length of stay, 1.9 days) and for the CEA group (n = 111) to $19,247 (mean length of stay, 2.6 days). CONCLUSIONS: After evaluating hospital charges, PTAS for the treatment of carotid stenosis cannot currently be justified on the basis of reduced costs alone. With future cost-containing measures, total hospital charges can be reduced in both groups.     

Endoscopic papillary balloon dilation for the management of common bile duct stones: experience of 226 cases

PURPOSE: The purpose of this study was to assess the efficacy of the free fibula flap in patients who had failed prior attempts at bony reconstruction. PATIENTS AND METHODS: The records of all patients who had undergone free fibula reconstruction for segmental mandibular resections between 1993 and 1995 were retrospectively reviewed. Patients were divided into group I (14 patients who had failed previous bony reconstruction attempts) and group II (50 patients who had no previous reconstruction), and the two groups were compared. RESULTS: No statistical differences were found between group I and group II for mean age, mean hospital stay, mean intensive care unit stay, mean operating room time, mean intraoperative blood loss, mean colloid usage, or mean blood units transfused. Although group I had a statistically higher proportion of both patients with osteoradionecrosis and those receiving hyperbaric oxygen therapy (HBO), the number with a history of radiation therapy was not different in the two groups. Wound complication rates were not statistically different between groups I and II for all patients, or between those group I patients who did or did not receive HBO therapy. CONCLUSION: There was no increase in wound complications in the patients who had failed prior bony reconstructive attempts who underwent free fibula flaps. The free fibula flap is suggested as the reconstructive method of choice in this patient population.     

Better at home: a continuous health care program for patients with advanced chronic respiratory disease

The objective of this study was to analyze the effect of continuous health care on the frequency of readmissions of patients with advanced chronic respiratory disease. The study was prospective, enrolling 26 patients (16 with COPD, 7 with bronchiectasis and 3 with pachypleuritis) who had been admitted at least 3 times within the past year. The patients were assigned to 3 groups: group A was the ambulatory monitoring group, with 8 patients who were able to travel to the hospital for monthly outpatient checkups; group B was the ambulatory pulmonary rehabilitation group, with 10 patients who were able to travel to the hospital and who needed rebreathing training (one weekly group session); and group C was the home care group, with 8 patients who were unable to travel to the hospital and who received weekly or biweekly house calls. All patients had telephone contact with the program team. Mean lung function values for the whole population were FVC 40 (11)%, FEV1 23 (7)% of reference, PaO2 55 (7) and PaCO2 55 (10) mmHg. A significant decrease in number of admissions (79 versus 18, p < 0.0001) was observed in both the first and second halves of the year in all three treatment groups: A, 25 to 2; B, 28 to 8; and C, 26 to 8 (p < 0.001). The reduction in health care costs over the previous year's expenditure was calculated to be 22,751,402 pesetas. We conclude that specialized health care that is continuous and personalized reduces the number of hospital readmissions of patients with advanced chronic respiratory disease. Moreover, the overall cost of care, without the need to make house calls to all patients.     

Quantification of excessive length of hospital stay ('wrong bed problem'); hip fractures in the elderly

OBJECTIVE: To assess the magnitude of hospital bed misoccupation by elderly patients admitted because of a hip fracture. DESIGN: Prospective clinical study. SETTING: Department of surgery-traumatology of Leiden University Hospital, the Netherlands. METHOD: All patients with a hip fracture admitted from January 1991 to April 1993 were registered for age, ability level, pre-existent disease, housing situation, social environment, morbidity, mortality and duration of hospital stay. The misexploitation of hospital beds was calculated based on an optimal hospital stay of 9 days. When complications occurred, necessitating longer medical treatment, this optimum was adjusted in each individual case. RESULTS: The mean hospital stay in 123 patients who had to be transferred to a nursing home when they had previously lived in their own homes or in an old people's home was 23.8 days, and 11.6 days above the optimum; for patients who could return to their previous housing situation these figures were 13.5 and 4.2 respectively (p < or = 0.05). Age, ability level, pre-existent disease and less importantly the social environment influenced the possibilities for a patient to return to his/her own home. Use of a clinimetric scale, which objectively assessed the probability of resocialisation, decreased the mean hospital stay from 28-30 days to less than 17. CONCLUSION: To minimize the duration of unnecessary hospital stay, use of a clinimetric scale on admission to assess the probability of rapid resocialisation can be useful.     

Pulmonary Wegener''s granulomatosis: correlation between high-resolution CT findings and clinical scoring of disease activity

STUDY OBJECTIVE: To evaluate the usefulness of high-resolution CT (HRCT) for monitoring pulmonary disease activity in Wegener's granulomatosis (WG). DESIGN: Prospective study of CT and clinical data. SETTING: Main referral hospital for rheumatic diseases and department of diagnostic radiology of collaborating university hospital. PATIENTS: Seventy-three patients with WG underwent 98 staging examinations using HRCT. The status of pulmonary disease activity at the time of examination was scored according to clinical, bronchoscopic, BAL, and radiographic findings as follows: activity (n=25, group 1), past activity (n=45, group 2) and lack of any pulmonary disease (n=28, group 3). HRCT findings were correlated with the clinical scoring of pulmonary disease activity. RESULTS: Of 98 staging examinations 78 (79.6%) revealed abnormal CT scans showing the following main abnormalities: (a) nodules or masses (group 1: 16 [60.4%], group 2: 9 [20%]); (b) parenchymal bands (group 1: 12 [48%], group 2: 27 [60%], group 3: 6 [21.5%]); (c) septal thickening (group 1: 8 [32%], group 2: 6 [13.3%]); (d) parenchymal opacification (group 1: 7 [28%], group 2: 4 [8.9%]); and (e) pleural irregularity (group 1: 14 [56%], group 2: 22 [49%], group 3: 9 [32%]). Nodules/masses and areas of parenchymal opacification were significantly associated with florid disease activity of the lungs. Parenchymal bands and septal thickening were observed in both groups with pulmonary involvement, but statistical analysis revealed no significant difference. Pleural irregularities were nonspecific. CONCLUSION: HRCT may be a useful adjunct to clinical scoring of pulmonary disease activity in patients with WG and suspected lung involvement.