Pneumonectomy for chronic infection: fraught with danger?

Pneumonectomy for chronic lung infections has been avoided because of potential intraoperative and postoperative complications. A retrospective review of 13 cases requiring pneumonectomy for aspergillus (8), Mycobacterium tuberculosis (2), actinomycosis, Pseudomonas aeruginosa, and bronchiectasis revealed increased operating time, blood loss, and transfusion requirements. Operative records documented problems with dense adhesions, lack of an extrapleural plane, and distortion of hilar structures. Although mortality was acceptable (8%), early and late morbidity (total, 38%), especially bronchopleural fistula (23%), was significant. It is concluded that when justified, pneumonectomy for complete resection of chronic infection can be performed with acceptable risk. However, specific problems should be anticipated. This review has led to modifications in operative technique.     

The management of bereavement on intensive care units

OBJECTIVE: To investigate the management of the bereaved on Intensive Care Units (ICU) throughout the United Kingdom, and to identify inadequacies that may exist either in the provision of staff training in dealing with bereavement or in the facilities or support available for the bereaved. DESIGN: Questionnaires were sent to the senior nurse and senior doctor in all general ICUs with more than four beds nationwide. The questions asked about nursing and medical practice around the time of a patient's death, as well as about staff attitudes towards, and training in, dealing with bereavement and the support they received for this role. RESULTS: We obtained a 68% (293/430) response rate. Most ICUs had facilities for relatives, but little for the specific needs of the bereaved. Only 6% of doctors and 21% of nurses had training in dealing with bereavement and grieving. A staff support group was available in 23% of ICUs, and 75% of the remainder thought it would be useful to have one. Lack of staff training and poor facilities for relatives were identified as the major concerns of ICU staff. CONCLUSION: Many doctors and nurses working in Intensive Care Units feel inadequately trained to deal confidently with the bereaved. A minority of ICUs have support mechanisms available for their staff, inspite of the perceived need for them. Furthermore, many ICU staff feel the facilities they are able to offer the bereaved are inadequate. We have identified the major inadequacies and the needs of ICU staff for improved training. Meeting these needs would play a significant role not only in reducing staff stress but also minimising the morbidity in surviving relatives.     

Abnormal thyroid and adrenocortical function test results in intensive care patients

A prospective, cohort study of 75 consecutive patients requiring management in the medical intensive care unit (MICU) of the Singapore General Hospital was carried out over a five-month period to determine thyroid and adrenocortical profiles and evaluate their use in predicting patient outcome. Up to 88% of patients had at least one abnormal thyroid function and 77% had abnormal adrenocortical function test results. There were significantly lower triiodothyronine, thyroxine and free thyroxine, but not thyrotropin levels, and higher cortisol levels in non-survivors compared to survivors (all P < 0.01). Of the endocrine parameters, triiodothyronine and cortisol concentrations were independent predictors of outcome. The overall predictive accuracy of combining these two variables on admission into the MICU was 74%. The APACHE II (acute physiology and chronic health evaluation II) score alone predicted outcome with 71% accuracy, and in combination with triiodothyronine and cortisol levels improved accuracy to 84%. The use of dopamine alone predicted outcome with 74% accuracy, and in combination with triiodothyronine and cortisol levels, improved accuracy to 84%. Measurements of total triiodothyronine and cortisol concentrations on admission to the MICU, and consideration of the use of dopamine improve on the APACHE II score in outcome prediction.     

Distribution of Neospora caninum within the central nervous system and other tissues of six dogs with clinical neosporosis

Six cases of neosporosis in dogs were diagnosed on the basis of clinical signs, serology and immunohistochemistry. The brains and spinal cords, at several levels, and various other tissues were examined using anti-Neospora caninum serum by an immunoperoxidase technique. Parasite density varied markedly from case to case. Although found most consistently in the cerebrum, parasites were distributed throughout the central nervous system (CNS), both within the grey and white matter and within nerve roots. Clinical signs were not related to the position of parasites. Tissue cysts were found infrequently in all areas of the CNS, but not in other tissues. Parasite density was not related to the age of the dog or whether treatment had been given. However, with the exception of the only adult dog examined, more CNS parasites were found in dogs with a longer duration of illness and with higher antibody titres. Tachyzoites were present in skeletal muscles, in the muscularis of the oesophagus, in heart, lung and, less frequently, liver, and rarely in the adrenal gland, thyroid gland and uterus; no clinical signs were seen resulting from damage to these organs. Parasites were not observed in lymphoid tissue. In visceral organs, parasites were most widely distributed in peracute cases. For post mortem diagnosis of neosporosis, the CNS, particularly the cerebrum, is the optimum tissue to examine but parasites may also be found in many other tissues, especially in acute cases. Muscle biopsy of appropriate muscles (as suggested by the clinical signs) provides the possibility of a definitive premortem diagnosis.     

An outbreak of Burkholderia (formerly Pseudomonas) cepacia respiratory tract colonization and infection associated with nebulized albuterol therapy

OBJECTIVE: To investigate an outbreak of Burkholderia (formerly Pseudomonas) cepacia respiratory tract colonization and infection in mechanically ventilated patients. DESIGN: A retrospective case-control and bacteriologic study. SETTING: Veterans Affairs medical center. PATIENTS: 42 mechanically ventilated patients who developed respiratory tract colonization or infection with B. cepacia and 135 ventilator-dependent controls who were not colonized and did not develop infections. MEASUREMENTS: Clinical and demographic data; benzalkonium chloride concentrations and pH levels in albuterol sulfate solutions; repetitive-element polymerase chain reaction (PCR)-mediated molecular fingerprinting on eight patient isolates and three environmental B. cepacia isolates that were available for study. RESULTS: 42 patients had B. cepacia respiratory tract colonization or infection. Observation of intensive care unit and respiratory care personnel showed faulty infection control procedures (for example, the same multiple-dose bottle of albuterol was used for many mechanically ventilated patients). More case patients (39 [92.9%]) than controls (95 [70.4%]; P = 0.006) received nebulized albuterol, and case patients (67.5 treatments) received more treatments than controls (18 treatments; P < 0.001). In-use albuterol solutions had pH values that were unstable, and benzalkonium chloride concentrations declined over time to levels capable of supporting bacterial growth. Medication nebulizers and in-use bottles of albuterol harbored B. cepacia. Molecular fingerprints of patient isolates and environmental B. cepacia isolates were identical using repetitive-element PCR. No further isolates of B. cepacia were identified after institution of appropriate infection control procedures. CONCLUSIONS: Multiple-dose medications and reliance on benzalkonium chloride as a medication preservative provide a mechanism for nosocomial spread of microorganisms, particularly if infection control procedures are not carefully followed. Repetitive-element PCR is a useful fingerprinting technique for molecular epidemiologic studies of B. cepacia.     

Metabolic disposition of antipyrine in patients with lung cancer

The metabolism of antipyrine (10 mg/kg i.v.) was studied in nine patients with cancer of the lung and in a cancer-free control group matched for age, sex, drug intake, and smoking and drinking history. The mean plasma clearance of antipyrine was 0.0475 +/- 0.009 liter/kg/hr in the tumor group and 0.0557 +/- 0.007 liter/kg/hr in the control group (p greater than 0.05). The antipyrine plasma elimination half-life was longer in the group with tumors (9.5 +/- 1.3 hr) compared to the control group (7.7 +/- 1.3 hr), but the difference was not statistically significant (p greater than 0.05). There was no difference between the groups in the excretion of two major antipyrine metabolites, 4-hydroxyantipyrine and N-demethylantipyrine, in a 48-hr urine sample. Thus, the presence of lung cancer in humans does not significantly alter antipyrine elimination.