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Biomedical subjects

R Speich

Publications and source records attributed to R Speich.

At least 19 recordsLinked to original sources
PubMed1999

[Pseudomonas pneumonia--an important differential pulmonary infiltration diagnosis in AIDS].

Bacterial pneumonias are the most common pulmonary complication in HIV-infected patients. Up to now, H. influenzae and S. pneumoniae have been described as the most important germs. Within a period of 4 years we diagnosed 15 cases of pneumonia caused by P. aeruginosa. All patients were in HIV stage C3; 3F, 12M; median age 34 (24-54) years; median CD4 count 10 (0-130) microliters. Except for 3 nosocomial pneumonias, all others were community-acquired. Only 3 patients had neutropenia < 1000/microliter; 7 were intravenous drug abusers. Morphologically there were 6 cases of abscess pneumonia, in 3 of which pleural drainage was necessary because of pyopneumothorax. 4 patients showed bilateral infiltrates that could not be differentiated from those of P. carinii pneumonia. Our diagnosis was based on quantitative cultures of broncho-alveolar lavage fluid (9 cases, two of them with concurrent positive blood cultures/positive cultures of the pleural fluid), pleural puncture (one case), sputum in pneumonias responding only to antipseudomonas therapy (3 cases), and autopsy (2 cases). 8 patients died of pseudomonas pneumonia within 1-3 months despite therapy. 7 patients received pseudomonas-specific combination therapy, but all died after median 9 (4-15) months of the underlying illness. In 3 cases recurrent pseudomonas pneumonia could be documented bacteriologically. We conclude that in HIV-infected patients pneumonia caused by P. aeruginosa is a significant and severe pulmonary complication.

AIDS-Related Opportunistic Infections↗
PubMed1999

Efficacy and cost effectiveness of oral ganciclovir in the prevention of cytomegalovirus disease after lung transplantation.

BACKGROUND: Cytomegalovirus is the single most frequent pulmonary pathogen in lung transplant recipients who survive at least 2 weeks. Patients at increased risk are either seropositive or have received an allograft from a donor with latent infection. Morbidity and mortality caused by cytomegalovirus disease is still considerably high. METHODS: In an open, comparative study, we evaluated the efficacy, tolerance, and cost effectiveness of postoperative ganciclovir prophylaxis: intravenous dose of 2x5 mg/kg/day for 14 days, followed by either intravenous doses of 5 mg/kg]day (five patients), or oral doses of 3x 1000 mg (nine patients) up to 90 days. Oral ganciclovir was continued until prednisone was tapered below 15 mg/day. Prophylaxed groups were compared with a historical control (eight patients) in respect to cytomegalovirus disease, in-hospital stay, overall costs, and survival. Follow-up times and the net state of immunosuppressive therapy between groups were comparable. RESULTS: Six (75%) of the non-prophylaxed patients developed cytomegalovirus disease compared to none in the intravenous and one in the oral ganciclovir group (P=0.013). The non-prophylaxed patients had a longer cytomegalovirus-related in-hospital stay (P=0.018) and nonsignificantly higher cytomegalovirus-related costs. Bronchiolitis obliterans syndrome was less frequent with prophylaxis (P=0.039), and survival tended to be better (P=0.072). The only adverse effect was a subclavian vein thrombosis in the intravenous ganciclovir group. CONCLUSIONS: In lung transplant recipients, ganciclovir prophylaxis, either intravenous or oral, is safe, well tolerated, and effective in preventing cytomegalovirus disease. Moreover, ganciclovir prophylaxis seems likely to reduce the incidence of bronchiolitis obliterans syndrome. The oral formulation might be preferable because its convenience and possibly lower costs.

Administration, Oral↗
PubMed1999

The nitric oxide synthase cofactor tetrahydrobiopterin reduces allograft ischemia-reperfusion injury after lung transplantation.

OBJECTIVE: Exogenous nitric oxide reduces ischemia-reperfusion injury after solid organ transplantation. Tetrahydrobiopterin, an essential cofactor for nitric oxide synthases, may restore impaired endothelium-dependent nitric oxide synthesis. We evaluated whether tetrahydrobiopterin administration to the recipient attenuates lung reperfusion injury after transplantation in swine. METHODS: Unilateral left lung transplantation was performed in 15 weight-matched pigs (24-31 kg). Donor lungs were flushed with 1.5 L cold (1 degrees C) low-potassium-dextran solution and preserved for 20 hours. Group I animals served as controls. Group II and III animals were treated with a bolus of tetrahydrobiopterin (20 mg/kg). In addition, in group III a continuous infusion of tetrahydrobiopterin (10 mg/kg per hour over 5 hours) was given. One hour after reperfusion, the recipient right lung was occluded. Cyclic guanosine monophosphate levels were measured in the pulmonary venous and central venous blood. Extravascular lung water index, hemodynamic variables, lipid peroxidation, and neutrophil migration to the allograft were assessed. RESULTS: In group III a significant reduction of extravascular lung water was noted in comparison with the controls (P =.0047). Lipid peroxidation in lung allograft tissue was significantly reduced in group II (P =.0021) and group III ( P =. 0077) in comparison with group I. Pulmonary venous levels of cyclic guanosine monophosphate increased up to 23 +/- 1 pmol/mL at 5 hours in group II and up to 40 +/- 1 pmol/mL in group III (group I, 4.1 +/- 0.5 pmol/mL [I vs III]; P <.001), whereas central venous levels of cyclic guanosine monophosphate were unchanged in all groups. CONCLUSION: Tetrahydrobiopterin administration during lung allograft reperfusion may reduce posttransplantation lung edema and oxygen-derived free radical injury in the graft. This effect is mediated by local enhancement of the nitric oxide/cyclic guanosine monophosphate pathway.

Animals↗
PubMed1999

Complications in the native lung after single lung transplantation.

OBJECTIVES: Single lung transplantation is a viable option for patients with end-stage pulmonary disease; despite encouraging results, we observed serious complications arising in the native lung. We retrospectively reviewed 36 single lung transplants to evaluate the incidence of complications arising in the native lung, their treatment and outcome. METHODS: Between 1991 and 1997, 35 patients received 36 single lung transplants for emphysema (16), pulmonary fibrosis (14), lymphangioleiomyomatosis (4), primary pulmonary hypertension (1) and bronchiolitis obliterans (1). The clinical records were reviewed and the complications related to the native lung were divided into early (up to 6 weeks after the transplant) and late complications. RESULTS: Nineteen complications occurred in 18 patients (50%), leading to death in nine (25%). Early complications (within 6 weeks from the transplant) were bacterial pneumonia (1), overinflation (3), retention of secretions with bronchial obstruction and atelectasis (1), hemothorax (1), pneumothorax (1) and invasive aspergillosis (3); one patient showed active tuberculosis at the time of transplantation. Two patients developed bacterial pneumonia and invasive aspergillosis leading to sepsis and death. The other complications were treated with separate lung ventilation (1), bronchoscopic clearance (1), chest tube drainage (1) and wedge resection and pleurodesis (mechanical) by VATS (1). One patient with hyperinflation of the native lung eventually required pneumonectomy and died of sepsis. The patient with active tuberculosis is alive and well after 9 months of medical treatment. Late complications were recurrent pneumothorax (4), progressive overinflation with functional deterioration (2), aspergillosis (1) and pulmonary nocardiosis (1). Recurrent pneumothorax was treated with chest tube drainage alone (1), thoracoscopic wedge resection and/or pleurodesis (2) and pneumonectomy (1); hyperinflation was treated with thoracoscopic lung volume reduction in both cases; both patients with late infectious complications died. CONCLUSIONS: After single lung transplantation, the native lung can be the source of serious problems. Early and late infectious complications generally result in a fatal outcome; the other complications can be successfully treated in most cases, even if surgery is required.

Adolescent↗
PubMed1999

[Lung transplantation in advanced pulmonary emphysema].

Over the last 15 years lung transplantation developed from an experimental technique to a valid therapy for patients with end-stage pulmonary emphysema. The main reason for this progress are better defined selection criteria, improved operative technique and organ preservation, optimized peri- and postoperative management, and a more precise immunosuppressive and anti-infective therapy. Indications, technique, treatment and results of lung transplantation in emphysema patients are discussed.

Aged↗
PubMed1998

[Red fingers].

Explore the source record for details and available documents.

AIDS-Related Opportunistic Infections↗
PubMed1998

Low specificity of the bacterial index for the diagnosis of bacterial pneumonia by bronchoalveolar lavage.

The bacterial index (BI) as defined by the sum of log10 colony-forming units (cfu) of microorganisms per milliliter of bronchoalveolar lavage (BAL) fluid, i.e., a multiplication of the single cfu/ml, has been used to distinguish between polymicrobial pneumonia (BI> or =5) and colonization (BI<5). Since many false-positive results are to be expected using this parameter, the diagnostic value of the BI was studied prospectively by obtaining bacteriologic cultures of BAL fluid in 165 consecutive unselected patients. In 27 cases the diagnosis of bacterial pneumonia was established on clinical criteria. In 133 patients pneumonia could be excluded, and in five patients the diagnosis remained unclear. Using a cut-off of > or = 10(5) cfu/ml BAL fluid, sensitivity and specificity for the diagnosis of pneumonia were 33% (9/27) and 99% (132/133), respectively. Sensitivity was mainly influenced by prior treatment with antibiotics, being 70% (7/10) in untreated and 12% (2/17) in treated patients. Applying the BI methodology at a cut-off of > or =5, however, resulted in an unacceptably high rate of 16 additional false-positive results, thus lowering the specificity to 87% (116/133; P<0.0001) while increasing the sensitivity to only 41% (11/27; P = 0.77). In conclusion, given the high rate of false-positive results, the methodology of the BI is of doubtful value for the diagnosis of bacterial pneumonia by BAL in an unselected patient group. By applying the absolute number of cfu/ml BAL fluid, however, positive bacteriologic cultures of BAL fluid are highly specific for the diagnosis of pneumonia. Their sensitivity is limited by previous antibiotic therapy.

Adolescent↗
PubMed1998

Efficacy, safety, and tolerance of piperacillin/tazobactam compared to co-amoxiclav plus an aminoglycoside in the treatment of severe pneumonia.

An open, randomized, multicenter study was conducted to compare the efficacy and safety of piperacillin/tazobactam and co-amoxiclav plus aminoglycoside in the treatment of hospitalized patients with severe community-acquired or nosocomial pneumonia. Of the 89 patients who entered the study, 84 (94%) were clinically evaluable. A favorable clinical response was observed in 90% of the piperacillin/ tazobactam group and in 84% of the co-amoxiclav/aminoglycoside group (not significant). The bacteriological efficacy was comparable in both groups (96% vs. 92%; not significant). There was only one fatal outcome in the piperacillin/tazobactam group compared to six in the co-amoxiclav/aminoglycoside group regimen (P=0.058). The adverse event rate was non-significantly lower in the piperacillin/ tazobactam group compared to the co-amoxiclav/aminoglycoside group (2% vs. 7%; P=0.32). Piperacillin/tazobactam is safe and highly efficacious in the treatment of serious pneumonia in hospitalized patients. It compares favorably with the combination of co-amoxiclav/aminoglycoside.

Aged↗
PubMed1998

Established acute respiratory distress syndrome: benefit of corticosteroid rescue therapy.

UNLABELLED: The mortality of the acute respiratory distress syndrome (ARDS) is still very high. There is some evidence based on case series suggesting that corticosteroids may be beneficial in the chronic fibroproliferative state of the disease. In a retrospective study we analysed the data of 31 non-trauma ARDS patients who had been on mechanical ventilation for at least 7 days. Thirteen cases received corticosteroids at a dosage equivalent to 100-250 mg methylprednisolone at the discretion of the attending physician in charge. Apart from corticosteroid administration, supportive care was identical in the treated and non-treated patient subgroups. Both groups were comparable regarding the relevant demographic, clinical and physiologic data, Apache-II score, radiological score, lung injury score and multiple organ failure score. Mortality in the treatment group was 38% (5/13) as opposed to 67% (12/18) in the untreated group (p = 0.117). There was a significant improvement in the PaO2/FIO2 ratio from a median of -26 to +5 mm Hg measured in a 48-hour period before and after corticosteroid treatment (p = 0.039). The response to corticosteroid therapy could not be predicted on the basis of clinical or physiologic data. Five patients responded within 48 h, and 3 showed a delayed response after 5-6 days. There were no significant complications attributable to corticosteroid treatment. CONCLUSIONS: Although the data of this first comparative study were retrospective, they suggest a beneficial effect of corticosteroid treatment in patients with established fibroproliferative ARDS. A prospective clinical trial, however, is highly warranted in order to fully elucidate the true effect of this therapeutic approach under controlled conditions.

APACHE↗
PubMed1998

[Ulcer + ulcer].

We report on an elderly woman suffering from an acutely bleeding duodenal ulcer. Apart from old age and a history of gastrointestinal ulcer there were no risk factors detectable. However, clinical examination revealed that the patient had put a diclofenac hydroxyethylpyrrolidine plaster, which had been prescribed for lower back pain, inadvertently on a large ulcus cruris. The diclofenac serum concentration was 80 mu/l corresponding to a therapeutic serum level. This case demonstrates that false application of new pharmaceutical formulation may lead to inadvertent side-effects.

Administration, Topical↗
PubMed1998

[Clinical single case study (n-of-1 trial)].

We conducted a single case (N-of-1) randomized trial in two patients. In the first case with bronchiolitis obliterans after lung transplantation a beneficial effect of inhaled steroids could be documented. The second patient suffered from symptoms compatible with HIV-associated M. Addison improving after cortisone, but the adrenocortical function was normal. Because the patient required the cortison treatment to be continued, we performed a n-of-1 trial which demonstrated the inefficacy of cortisone. This experience underscores the feasibility and usefulness of N-of-1 randomized clinical trials in medical practice.

Addison Disease↗