Lack of effect of a pneumonia clinical pathway on hospital-based pneumococcal vaccination rates.
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Connecticut↗
Biomedical subjects
M L Metersky
Publications and source records attributed to M L Metersky.
Idiopathic pneumonia syndrome following myeloablative chemotherapy and autologous transplantation.
OBJECTIVE: To report the outcome as well as the clinical, radiographic, and pathologic features of idiopathic pneumonia syndrome (IPS) following autologous peripheral blood stem cell transplantation (aPBSCT). CLINICAL FINDINGS: A total of 271 patients with a variety of underlying malignancies received busulfan-containing myeloablative chemotherapy prior to aPBSCT; none of these patients received total body irradiation. Ten individuals developed IPS, with a median time of onset of 102 days after stem cell infusion. The major clinical and radiographic findings included an acute or subacute onset of dyspnea, cough, hypoxemia, and bilateral or unilateral infiltrates with or without pleural effusion. Pathologic findings consisted mainly of diffuse interstitial pneumonitis, organizing alveolitis, and cellular atypia. Nine patients diagnosed with IPS were treated with high doses of glucocorticoids parenterally. Despite heroic measures, eight patients died of IPS. The two remaining individuals recovered without experiencing significant long-term pulmonary sequelae. DISCUSSION: Chronic low-dose busulfan therapy results in lung injury in 4-6% of patients after several years of treatment and once the cumulative dosage begins to approach 3g. High-dose, short-course busulfan (16 mg/kg)-containing conditioning chemotherapy prior to aPBSCT can also be complicated by IPS. IPS differs from lung damage due to chronic busulfan therapy by its earlier onset, an acute or subacute rather than indolent presentation, characteristic clinical and radiographic features, and lack of multinucleated giant cells on pathologic review. The pathophysiology of IPS secondary to high-dose busulfan-containing myeloablative regimens is not known, but cell-mediated immune reactions and release of cytokines may contribute to the lung injury. Mortality is high (80%) despite the use of heroic measures, including mechanical ventilation. Some patients, however, can respond to high doses of parenteral corticosteroid therapy. CONCLUSIONS: IPS following high-dose, short-course busulfan-containing regimens exhibits unique clinical, radiographic, and pathologic features that differ from lung damage characteristic of chronic, low-dose busulfan therapy. Mortality from this complication is 80%, but some patients survive without long-term pulmonary sequelae following early treatment with glucocorticoids.
Adolescent↗
A comparison of induced and expectorated sputum for the microbiological diagnosis of community acquired pneumonia.
BACKGROUND: Sputum induction has proved useful in the diagnosis of Pneumocystis carinii pneumonia and mycobacterial infections but there are scant data on its use in the diagnosis of community-acquired pneumonia (CAP). OBJECTIVE: To better define the usage of sputum induction by hypertonic saline in the setting of CAP. METHODS: A retrospective review of records of patients admitted to a community teaching hospital in the year 1995 with a diagnosis of CAP. RESULTS: Of 492 patients admitted with CAP, 71 (14%) had attempted sputum induction. A group of 66 patients with CAP and attempted sputum collection by spontaneous expectoration was compared with this group. Sputum induction failed to yield a sample in 22 patients (31%). Forty-five of 49 patients (92%) with induced sputum had received prior antibiotics as compared to 23 of 34 patients (68%) with expectorated samples (p < 0.05), due to sputum induction often being attempted later in the hospital course. The diagnostic yield of sputum induction was 14 of 71 (20%) compared to 16 out of 66 (24%) for attempted spontaneously expectorated samples. Antibiotic therapy was changed for 5 of 34 patients (15%) who spontaneously expectorated samples and for 9 of 49 patients (18%) with successful induction. CONCLUSIONS: Sputum induction is effective in obtaining sputum in some patients with CAP who fail to expectorate a sample. Attempting induction early, preferably before starting antibiotics, may increase its diagnostic yield.
Administration, Inhalation↗
Process of care performance, patient characteristics, and outcomes in elderly patients hospitalized with community-acquired or nursing home-acquired pneumonia.
STUDY OBJECTIVES: To compare process of care performance, patient characteristics, and outcomes in a contemporary cohort of elderly (> or = 65 years) patients hospitalized with community-acquired pneumonia (CAP) or with nursing home-acquired pneumonia (NHAP). DESIGN: State-wide retrospective cohort study. SETTING: Thirty-four acute-care hospitals in Connecticut. PATIENTS: Elderly Medicare patients hospitalized in 1995-1996 with CAP (1,131) or with NHAP (528). MEASUREMENTS: Antibiotic administration within 8 h of hospital arrival, blood culture collection within 24 h of hospital arrival, oxygenation assessment within 24 h of hospital arrival, demographic and clinical characteristics, in-hospital complications, mortality, and length of stay. RESULTS: Process of care performance rates for patients with CAP and NHAP were equivalent for antibiotic administration within 8 h of hospital arrival (76.8% vs 76.3%, respectively; p = 0.82), blood culture collection within 24 h of hospital arrival (78.1% vs 81.1%, respectively; p = 0.31), and oxygenation assessment within 24 h of hospital arrival (94.7% vs 95. 3%, respectively; p = 0.70). Patients with CAP were younger than those with NHAP (median age, 80 vs 84 years, respectively; p < 0. 001), had less cerebrovascular disease (16.8% vs 34.7%, respectively; p < or = 0.001), and lower mortality risk scores at hospital presentation (median, 100 vs 137, respectively; p < or = 0. 001) than patients with NHAP. The median length of stay was equivalent (7 days), but the in-hospital mortality rate was lower in patients with CAP than in patients with NHAP (8.0% vs 18.6%, respectively; p < or = 0.001). CONCLUSION: Initial hospital processes of care are performed at the same rate in patients hospitalized with CAP or NHAP. However, patients with CAP are younger, are less acutely and chronically ill, and have lower in-hospital mortality rates than patients with NHAP.
Aged↗
Improving the care of patients with community-acquired pneumonia: a multihospital collaborative QI project.
BACKGROUND: Performance of several processes of care was measured in eight acute care hospitals in Connecticut which provided inpatient treatment to 713 elderly patients with community-acquired pneumonia (CAP). BASELINE DATA ABSTRACTION AND FEEDBACK: Chart review feedback was provided, and the hospitals were requested to design their own quality improvement (QI) interventions, after which reexamination of process of care performance was conducted. HOSPITAL QI INTERVENTIONS: Six of the eight hospitals had submitted QI plans. The quality indicators dealing with timeliness of antibiotic delivery were specifically addressed by five hospitals. However, each hospital also picked one or two other processes of care for intervention. RESULTS: The mean time to antibiotic administration decreased from 5.5 hours (+/- 0.2) to 4.7 hours (+/- 0.3; p < 0.0001), and the percentage of patients who received antibiotics within four hours increased from 41.5% to 61.8% (p < 0.0001). DISCUSSION: This project called for obtaining buy-in from both the clinician and administrative representatives of each hospital early in the process. In this way, the targeted processes of care were likely to have relevance for each of the participating hospitals. Education of practicing physicians and other health professionals, as the method chosen by each hospital to address delays in antibiotic administration, appears to have been successful in this project as part of a multifaceted intervention. The project also helped establish a collegial environment that has served as the basis for more ambitious pneumonia QI projects. SUMMARY AND CONCLUSIONS: Widespread improvements in process of care performance can result from hospitals' participation in Quality Improvement Organization collaboration.
Aged↗
Improving the care of patients with community-acquired pneumonia: a multihospital collaborative QI project.
BACKGROUND: Performance of several processes of care was measured in eight acute care hospitals in Connecticut which provided inpatient treatment to 713 elderly patients with community-acquired pneumonia (CAP). BASELINE DATA ABSTRACTION AND FEEDBACK: Chart review feedback was provided, and the hospitals were requested to design their own quality improvement (QI) interventions, after which re-examination of process of care performance was conducted. HOSPITAL QI INTERVENTIONS: Six of the eight hospitals had submitted QI plans. The quality indicators dealing with timeliness of antibiotic delivery were specifically addressed by five hospitals. However, each hospital also picked one or two other process of care for intervention. RESULTS: The mean time to antibiotic administration decreased from 5.5 hours (+/- 0.2) to 4.7 hours (+/- 0.3; P < 0.0001), and the percentage of patients who received antibiotics within four hours increased from 41.5% to 61.6% (P < 0.0001). DISCUSSION: This project called for obtaining buy-in from both the clinician and administrative representatives of each hospital early in the process. In this way, the targeted processes of care were likely to have relevance for each of the participating hospitals. Education of practicing physicians and other health professionals, as the method chosen by each hospital to address delays in antibiotic administration, appears to have been successful in this project as part of a multifaceted intervention. The project also helped establish a collegial environment that has served as the basis for more ambitious pneumonia QI projects. SUMMARY AND CONCLUSIONS: Widespread improvements in process of care performance can result from hospitals' participation in a Quality improvement Organization collaboration.
Aged↗
A comparison of induced and expectorated sputum for the diagnosis of Pneumocystis carinii pneumonia.
STUDY OBJECTIVES: To compare the sensitivities of expectorated and induced sputum for the diagnosis of Pneumocystis carinii pneumonia (PCP). DESIGN: Retrospective review. SETTING: Academic medical center. PATIENTS: Forty-five patients diagnosed as having PCP who had direct fluorescent antibody testing for P carinii on either expectorated or induced sputum. RESULTS: Patients were stratified according to the method of sputum production (induced vs expectorated). The two groups were similar with respect to demographic characteristics, use of prophylaxis with aerosolized pentamidine, serum lactate dehydrogenase level, and arterial oxygen level. When only the initial sputum for each patient was analyzed, there was a similar sensitivity of induced sputum, positive in 10 of 18 samples (56%), and expectorated sputum, positive in 14 of 27 samples (52%) (p>0.05). CONCLUSION: There was no significant difference in the sensitivity of induced and expectorated sputum for the diagnosis of PCP when the direct fluorescent antibody method of staining was used.
AIDS-Related Opportunistic Infections↗
Factors inhibiting use of the pneumococcal polysaccharide vaccine: a survey of Connecticut physicians.
BACKGROUND: The pneumococcal polysaccharide vaccine (PPV) is effective in preventing invasive pneumococcal disease, but remains underutilized. Prior surveys of physicians revealed concern regarding the safety and efficacy of the vaccine, but there has been little information published in the last 10 years that sheds light on why the vaccine remains underutilized. Although there is currently emphasis on providing PPV to hospitalized patients, there is even less known about what factors prevent PPV use in the hospital setting and chronic care setting. We performed a survey of physicians in Connecticut to determine what factors prevent utilization of the vaccine in three patient care settings. METHODS: A survey of internists and family practitioners in Connecticut that ascertained their frequency of utilization of PPV and what factors inhibited utilization of PPV. RESULTS: Three hundred ninety-seven responses are included in the analysis. Forgetting to administer the vaccine (59% of respondents) and patient refusal (55% of respondents) were the factors most frequently noted as being important in preventing vaccination in the outpatient setting. In the inpatient and chronic care settings, difficulty in determining the patient's vaccine status was also noted. Concerns regarding the efficacy or safety of the vaccine did not seem to be important. The factor that correlated most closely with the respondents' reported frequency of vaccine use was forgetting to vaccinate. CONCLUSIONS: Physicians, although accepting the efficacy of PPV, are inhibited from its more frequent use by several factors.
Adolescent↗
Retrospective analysis: are fever and altered mental status indications for lumbar puncture in a hospitalized patient who has not undergone neurosurgery?
Although nosocomial meningitis is rare in nonsurgical patients, lumbar punctures are frequently performed on hospitalized medical patients who develop delirium and/or fever. A retrospective review was undertaken to determine the yield of lumbar puncture in this setting and to compare it with the yield for suspected community-acquired meningitis. Of 232 lumbar punctures studied, 51 (22%) were performed to rule out nosocomial meningitis, while 181 (78%) were done to rule out community-acquired meningitis. No lumbar puncture performed for suspected nosocomial meningitis was positive, while results of 26 (14%) of those done for suspected community-acquired meningitis were abnormal (P < .01). Patients whose lumbar punctures were positive more often had headache or meningeal signs than those whose lumbar punctures were negative, and only 11 patients (22%) who had lumbar punctures performed for suspected nosocomial meningitis had headache or meningeal signs. We conclude that lumbar punctures performed for suspected nosocomial meningitis in nonsurgical patients have a low yield and that in some low-risk patients without headache or meningeal signs, lumbar puncture may be unnecessary.
Adult↗
The role of intermittent enteral feeding in reducing gastric colonization in mechanically ventilated patients.
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Bacterial Physiological Phenomena↗
The effect of polysomnography on sleep position: possible implications on the diagnosis of positional obstructive sleep apnea.
This prospective study was designed to determine if physical constraint due to the polysomnography (PSG) apparatus affects PSG results by inducing subjects to sleep in the supine position. Twelve patients found to have positional obstructive sleep apnea (OSA) during standard PSG returned for two additional nights of study during which no PSG leads were attached. The time spent supine was 56% greater during the PSG night than the non-PSG nights, 195 +/- 88.6 min during the baseline PSG and 125 +/- 84.6 min during the non-PSG nights (p < 0.05). Therefore, PSG may overestimate the severity of OSA in some patients with positional OSA.
Adult↗
Obstructive sleep apnea due to a carotid body paraganglioma.
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Carotid Body Tumor↗
Recurrent mediastinal bronchogenic cyst.
A patient with a new mediastinal mass 25 years after resection of a mediastinal bronchogenic cyst is presented. Computed tomography and subsequent thoracotomy revealed a recurrent bronchogenic cyst. This case illustrates that incompletely resected mediastinal bronchogenic cysts may recur many years later.
Bronchogenic Cyst↗
Kerley B lines in AIDS.
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Acquired Immunodeficiency Syndrome↗
AIDS-related spontaneous pneumothorax. Risk factors and treatment.
OBJECTIVE: To define risk factors and optimum therapy for AIDS-related spontaneous pneumothorax (PTX). DESIGN: Case-control study. SETTING: Tertiary care center. PATIENTS: Thirty-five patients with AIDS who developed spontaneous PTX between January 1, 1988 and December 31, 1991, of whom 27 (77.1%) did so in the setting of Pneumocystis carinii pneumonia (PCP). Forty-one patients who were diagnosed as having PCP and did not develop PTX served as the control group. RESULTS: Using logistic regression, a history of cigarette smoking, aerosolized pentamidine treatment, and the observation of pneumatoceles by chest radiography were associated with an increased risk of PTX. Although not associated with an increased risk of occurrence of PTX, the use of systemic corticosteroids for PCP treatment was associated with a longer requirement for chest tube drainage. Although chest tube drainage alone was often successful, chemical and surgical pleurodesis was often effective in treating prolonged air leaks and was associated with a lower incidence of recurrent PTX, although this difference did not achieve statistical significance (p = 0.07). CONCLUSIONS: Patients at high risk of developing AIDS-related spontaneous PTX can be identified. Systemic corticosteroids may increase the risk of morbidity from AIDS-related PTX. Chemical and surgical pleurodesis may be of value in short-term treatment and in reducing the risk of recurrence.
AIDS-Related Opportunistic Infections↗
Recent advances in pulmonary medicine.
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Aerosols↗
A rapid tuberculosis screening program for new mothers who have had no prenatal care.
We developed a Rapid Tuberculosis Screening Program for use in women who have not had prenatal care. All patients who presented for delivery without a documented tuberculin skin test (TBN-ST) were given a symptom questionnaire. Those who had a positive response to any of the questions received a chest roentgenogram to rule out active disease. All patients with a negative questionnaire had a TBN-ST soon after admission. The test was read at the time of discharge, whether or not 48 h had elapsed, and individuals who had 5 mm or more of induration at before 48 h and 10 mm or more induration at 48 to 72 h were considered reactors. Of 1,412 patients who received a TBN-ST, 259 were reactors. One case of active disease was diagnosed. Approximately 75 percent of "true" tuberculin reactors will be detected by this method. We suggest that by using the TBN-ST concurrently with a questionnaire, most patients infected with Mycobacterium tuberculosis can be identified.
Delivery, Obstetric↗
Resolution of vascular steal after pulmonary thromboendarterectomy.
Patients who undergo thromboendarterectomy for relief of chronic, major-vessel thromboembolic pulmonary hypertension (CT-E PH) offer a unique opportunity to evaluate potential resolution of hypertensive lesions in the small, nonelastic pulmonary arteries. Prior studies have demonstrated that, postoperatively, these patients commonly develop new perfusion scan defects. This "vascular steal" phenomenon occurs almost exclusively in lung segments which, preoperatively, were normally perfused by lung scan, were served by segmental arteries normal by pulmonary angiography, and, at surgery, were uninvolved with thrombi by direct inspection. In this study, we explored whether this intriguing "steal" phenomenon resolves over time. Twenty-nine patients who returned at 11 or more months following thromboendarterectomy were reevaluated by perfusion lung scan, repeated right heart catheterization (26 patients), and pulmonary angiography (25 patients). "Steal" of one or more lung segments occurred in 79 percent of patients in postoperative, predischarge perfusion scans. All demonstrated postoperative improvement in pulmonary hemodynamics, which persisted at follow-up. Postoperative "steal" improved in 96 percent of patients and 86 percent of the "stolen" segments. The results suggest that, in CT-E PH, hypertensive lesions in the small, nonelastic pulmonary arteries are responsible for "steal," and that, with relief of pulmonary hypertension, these lesions can resolve. The study also indicates that postoperative "steal" does not connote either new thromboembolic events or a poor hemodynamic result.
Endarterectomy↗