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PubMed2000

Determining the quality of breast cancer care: do tumor registries measure up?

BACKGROUND: Hospital tumor registries, which provide data that inform health services research and cancer control policies, may be a source of information about quality of cancer care. However, the accuracy of data from such registries is unknown. OBJECTIVE: To determine the accuracy of tumor registry data by comparing it with data collected from numerous sources for a breast cancer quality improvement project. DESIGN: Retrospective cohort study. SETTING: Three teaching hospitals with tumor registries in the New York metropolitan area that had participated in the quality improvement project. PATIENTS: All women with newly diagnosed primary breast cancer (stage I or stage II) who were surgically treated at the study hospitals between 1 November 1994 and 31 August 1996. MEASUREMENTS: Sensitivity and specificity were calculated, and data from the quality improvement project were used as the gold standard. RESULTS: The tumor registries and the quality improvement project had similar information on tumor stage and surgery type. Sensitivity ranged from 0.91 to 0.96, and specificity ranged from 0.93 to 0.97. When both sources were used to calculate quality measures, the overall rate of radiation therapy after breast-conserving surgery was 80% in the quality improvement project and 48% in the tumor registries (sensitivity, 0.58; specificity, 0.94). For receipt of adjuvant systemic treatment, the rate was 78% in the quality improvement project and 22% in the tumor registries (sensitivity, 0.27; specificity, 0.97). CONCLUSIONS: Data from tumor registries provide accurate measures for hospital-based surgical treatments but not for outpatient treatments. Unverified tumor registry data should not be used to measure quality of care.

Ambulatory Care↗

PubMed2006

Transoesophageal echocardiography in critical care.

Echocardiography has evolved to become one of the most versatile modalities for diagnosing and guiding treatment of critically ill patients. Both transthoracic (TTE) and transesophageal echocardiography (TEE) provide real-time bedside information about a variety of structural and functional abnormalities of the heart as well as contractility, filling status and cardiac output, rendering it the method of choice for the assessment of cardiac function in the intensive care unit (ICU). Both approaches have its benefits and limitations. Although TTE remains the approach of choice, TEE has been shown to be of additional value in many instances in critically ill patients due to its ability to provide excellent visualisation of cardiac structures, its impact on patient management, and its low complication rate (2.6%). The present status of TEE in adult critical care is reviewed with special emphasis on its role as a diagnostic tool in several clinical scenarios, underlining its effects on clinical decision making but also as a monitoring adjunct. Conditions and settings in which TEE provides the most definitive diagnosis in the critically ill and injured are hemodynamically unstable patients with suboptimal TTE images or if mechanically ventilated, patients with suspected aortic dissection or aortic injury and other conditions in which TEE is superior to TTE (such as suspected endocarditis, cardiac or aortic source of emboli. The diagnostic, therapeutic and surgical impact on patient management in critically ill patients ranged from 44% to 99% (weighted mean 67.2%), 10% to 69% (weighted mean 36%), and 2% to 29% (weighted mean 14.1%), respectively, depending on patients and type of ICU. Since echocardiography provides different information than other devices for hemodynamic monitoring such as the pulmonary artery catheter the methods are therefore not competitive but rather complementary. The present body of evidence supporting the use of TEE in critically ill patients lacks prospective, randomized controlled studies focusing on end-points like cost-effectiveness, morbidity or mortality. However, present evidence as well as experience, points to the significant benefits which may be gained by the availability of echocardiography and especially TEE in ICUs, as well the necessity for a training of intensive care physicians.

Animals↗

PubMed1983

Evaluation and surgical treatment of pulmonary atresia and intact ventricular septum in infancy.

The initial surgical approach to the infant with pulmonary atresia and intact ventricular (PA-IVS) is to establish an adequate source of pulmonary blood flow and, when possible, relieve right ventricular (RV) outflow obstruction. The selection of patients for pulmonary valvotomy, alone or in combination with a systemic-pulmonary arterial shunt, depends on the presence of an RV outflow tract and the adequacy of the RV chamber. To evaluate the size of the RV cavity in PA-IVS, an RV index (RVI) was developed using biplane angiographic measurements of the sum of the tricuspid valve annulus and the RV inflow and the RV outflow tracts. The RVI was normalized by relating it to the aortic diameter (Ao) at the diaphragm (RVI/Ao). The RVI/Ao was 13.5 +/- 1.4 in 20 control subjects and only 7.3 +/- 2.6 in 26 PA-IVS patients (p less than 0.001), and was within the normal range in only two of the 26. Since 1976, pulmonary valvotomy plus a Blalock-Taussig shunt has been performed in 10 infants, with one death. Serial cardiac catheterizations in five of nine survivors demonstrated substantial RV growth in all, with the RVI/Ao increasing from an average of 8.0 to 12.5. In contrast, patients who underwent a shunt alone had no change in RV cavity size. We conclude that pulmonary valvotomy may be performed successfully in most PA-IVS patients, but usually must be combined with a systemic-pulmonary shunt. In a small minority of patients, a normal RV cavity, as evidenced by an RVI/Ao greater than or equal to 11, appears to be sufficient to sustain adequate pulmonary blood flow after valvotomy alone. The RVI/Ao ratio is a simple method of quantitatively evaluating RV cavity size and is helpful in planning the initial surgical approach for these infants.

Cardiac Catheterization↗

PubMed1984

Surgical management of torticollis.

Torticollis is a clinical sign of either CNS or musculoskeletal dysfunction. Thorough clinical and neuroradiographic evaluation is indicated for determination of the source, course, and exact nature of the deformity before a considered approach to surgical management is undertaken. Torticollis of neurogenic origin is managed by surgical decompression of the brainstem or cervical spinal cord when indicated, as in the presence of hydrocephalus, the Arnold-Chiari malformation, syringobulbia , syringomyelia, colloid cyst of the third ventricle, or neoplasms in the third ventricle, posterior fossa, or cervicomedullary junction. In progressive and medically refractory cases of spasmodic torticollis, neuroablative procedures, neuroaugmentive procedures, selective muscle excisions, and radical cervical muscle excisions have been used to control the dystonia. Torticollis of musculoskeletal origin is often secondary to or associated with trauma, although congenital craniocervical anomalies may be a predisposing factor. The primary goals of surgery for craniovertebral or upper cervical spine deformity are reduction of the malalignment; decompression of the brainstem, cervical spinal cord, and/or nerve roots if necessary; and stabilization of the upper cervical spine.

Arnold-Chiari Malformation↗

PubMed1995

The reliability of quantitative electroencephalography as an indicator of cerebral ischemia.

The electroencephalogram (EEG) has been used to detect episodes of cerebral ischemia during various surgical procedures. Recently, computerized systems for recording and interpreting the quantitative EEG (QEEG) have been used by anesthesiologists because of their ease of application, clarity of display, and reported ability to identify ischemic EEG changes. However, the extent to which automated techniques of QEEG interpretation reliably differentiate cerebral ischemia from the confounding effects of anesthetics and other sources of "artifact" is not completely established. In this study, EEGs were recorded before and after defibrillator testing in patients undergoing implantable cardioverter defibrillator (ICD) placement and during analogous time periods in control patients undergoing abdominal surgery. EEGs were subjected to standard visual inspection by an experienced electroencephalographer and QEEG analysis with a commercially available system was used for automated EEG interpretation in order to evaluate the reliability of this quantitative technique. The CIMON technique identified episodes which met previously defined criteria for QEEG cerebral dysfunction and ischemic pattern in both groups, despite the presumed absence of cerebral ischemia in the control patients. Since there was no evidence of cerebral ischemia in the raw EEGs of either the ICD patients or the controls, these QEEG changes were not confirmed by conventional techniques of EEG interpretation. Our results suggest that caution is warranted when using automated systems for intraoperative interpretation of EEG.

Adult↗

PubMed1996

Intraarticular foot and ankle injections to identify source of pain before arthrodesis.

OBJECTIVE: The purpose of our study was to evaluate the usefulness of diagnostic joint injections in patients with foot and ankle pain when the radiologist attempts to identify the source of pain. This study also correlated the results of injection with outcome after arthrodesis. MATERIAL AND METHODS: We retrospectively reviewed the records of 22 patients who had a foot or ankle joint injected to identify a source of pain and who later underwent arthrodesis of the painful joint. All patients had long-term foot and ankle symptoms of variable causes. Twenty-four joints were assessed: 13 subtalar, five talonavicular, four ankle, one calcaneocuboid, and one metatarsocuneiform. All patients had plain radiographs, 11 had CT studies, and five had bone scans. Contrast material was used to assess adequate positioning of the needle inside the joint before injection. All joints were injected under fluoroscopic control. Steroid was added in eight joints. After injection, patients were assessed for relief of symptoms. Patients subsequently underwent arthrodesis on the basis of the results of the injection. RESULTS: In 20 patients (22 joints), long-term follow-up showed that injections allowed us to correctly identify the source of pain and successfully guide arthrodesis. Of these 20 patients, 17 had significant pain relief after injection and fusion, whereas three patients had mild or no response. With one of these patients, we injected other joints and changed surgical plans. One of the two remaining patients had more pain relief after injection than after arthrodesis. The other patient had no relief after injection, but subsequent fusion because of persistent pain was successful. We found imaging studies to be less useful than diagnostic injections when we were attempting to identify the source of pain. CONCLUSION: Intraarticular injection of anesthetic in painful foot and ankle joints helped us confirm the source of pain in 20 of 22 patients, which in turn led to successful arthrodesis and good outcomes for these patients.

Adult↗

PubMed1990

HIV infection. Managing exposure risks for the obstetrician/gynecologist.

Human immunodeficiency virus infection in women is geographically widespread throughout the US. Infected blood is the single most important source for HIV transmission in the health care setting. Occupationally acquired HIV infection appears to be an uncommon event, with prospective studies thus far reporting an incidence of 0.6 per cent or less. Strategies for preventing transmission of HIV infection in an obstetric/gynecologic setting are a matter of appropriate barrier protection, good infection control technique, and a large measure of common sense.

Female↗

PubMed2004

Platelet-derived growth factor B, but not fibroblast growth factor 2, plasmid DNA improves survival of ischemic myocutaneous flaps.

HYPOTHESIS: Tissue flaps are commonly used for surgical reconstruction, especially to cover difficult wounds and in breast reconstruction following mastectomy. Complications due to inadequate flap perfusion are a source of morbidity and, in the lower extremity, can result in amputation. SETTING: Laboratory. INTERVENTIONS: We evaluated the ability of platelet-derived growth factor (PDGF) B and fibroblast growth factor 2 plasmid DNA, formulated in a type I collagen matrix, to promote tissue survival in a rat transverse rectus abdominis muscle flap model based on the inferior deep epigastric vascular supply. In the absence of any therapeutic agent, only about 24% of flap tissue survives in this model. The DNA/matrix formulations were delivered subcutaneously into the skin paddles 7 days before flap elevation, and tissues were harvested 7 days later. RESULTS: Our studies reveal dramatic increases in overall vascularity after treatment with PDGF-B and fibroblast growth factor 2 plasmid DNA; however, only PDGF-B increased flap survival (130% increase at 228 micro g/cm(2) of plasmid DNA vs controls; P<.01). Transdermal spectral imaging demonstrated an increase in patent vessels supporting blood flow in flaps treated with PDGF-B plasmid DNA vs the fibroblast growth factor 2 transgene. CONCLUSION: Matrix-enabled gene therapy may provide an effective nonsurgical approach for promoting flap survival and is well suited for surgical applications in which transient therapeutic transgene expression is desired.

Animals↗

PubMed1992

An outbreak of Serratia marcescens in 14 adult cardiac surgical patients associated with 12-lead electrocardiogram bulbs.

Two clusters of Serratia marcescens in 14 adult cardiac surgical patients occurred over 10 months in an 876-bed teaching hospital. The 14 infections that were studied were as follows: one sternal and five leg incisions, five pneumonias, one bacteremia, one urinary tract infection, and one infected internal defibrillator site. The first cluster included four pneumonias, one urinary tract infection, and one bacteremia. Corrective actions were taken based on outbreak data through no source was identified. No further infections occurred during the following 2 months. The second cluster included one sternal and five leg incisions, an infected internal defibrillator incision site, and one pneumonia. Serratia marcescens was isolated from six electrocardiogram rubber welsh bulbs with sensitivities identical to patient isolates that indicated a common source outbreak in at least the second cluster of infections. Disposable electrocardiogram leads were introduced and the problem was resolved. We conclude that reusable electrocardiogram welsh bulbs are a vector for postoperative infections.

Aged↗

PubMedDate not supplied

Treatment of melanoma metastases in the brain.

Melanoma is prone to spread to the brain and is the third most common source of intracranial metastasis. Patients usually present with signs and symptoms of increased intracranial pressure, a new focal neurologic deficit, or seizures. Contrasted magnetic resonance imaging (MRI) is the single most valuable imaging modality. Surgical therapy is the appropriate choice for single lesions that are accessible, especially if they are causing significant mass effect or are located in the posterior fossa. Patients with several intracranial metastases who undergo resection of all lesions may have a similar prognosis to those with single resected lesion. Stereotactic radiosurgery appears to provide good local control of small lesions. External beam radiotherapy may provide some benefit to patients, and is often used in conjunction with surgery or stereotactic radiosurgery. To date, chemotherapy has been limited because of chemo-resistance and drug delivery issues. Future directions for treatment may include local sustained delivery of either chemotherapy or immunoregulatory molecules.

Antineoplastic Agents↗

PubMed2004

Update on glycopeptide use in german university hospitals.

BACKGROUND: A previous study has shown considerable variation in glycopeptide use from 1992 through 1994 among four university hospitals in southern Germany. Active antimicrobial management in one of the hospitals was associated with the containment of glycopeptide consumption in the medical and surgical service at < 1.5 defined daily doses (DDD)/100 patient days in the subsequent period. In the present study, more recent data on comparative glycopeptide use in German university hospitals were analyzed. MATERIALS AND METHODS: Hospital pharmacy records from 1998 through 2000 were evaluated. The number of DDD (definition according to the World Health Organization [WHO]/Anatomic and Therapeutic Classification [ATC] index) per 100 patient days was calculated to compare glycopeptide use in different medical and surgical service areas between eight German university hospitals. RESULTS: The 3-year averages in recent glycopeptide use for the eight hospitals ranged between 1.3 and 8.8 DDD/100 patient days in the medical services, and between 0.7 and 1.8 DDD/100 patient days in the surgical services. Only one of the eight hospitals showed medical service glycopeptide use of < 1.5 DDD/100 patient days. In most hospitals, glycopeptide use was higher in the medical intensive care units (ICU) (median 8.6; range 4.3 to 12 DDD/100 patient days, data for the year 2000) than in the surgical ICUs (median 6.7; range 1.2 to 8.6 DDD/100 patient days, data for the year 2000). High use was also observed for hematology-oncology services (median 7.5; range 2.7 to 15.7 DDD/100 patient days, data for the year 2000). CONCLUSION: These recent data from a larger hospital sample confirm large variations in glycopeptide use, identify hematology-oncology services as a significant prescribing source along with ICUs, and indicate areas of probable overuse of glycopeptide antibiotics. The data may be useful as a benchmark for further focused drug use control interventions.

Anti-Bacterial Agents↗

PubMed1999

Transcatheter uterine artery embolization for the management of symptomatic uterine leiomyomas.

UNLABELLED: Transcatheter arterial embolization has been applied traditionally in obstetrics and gynecology for the emergency control of pelvic hemorrhage, usually after failure of conventional surgical measures. Pelvic trauma is the most common, nongynecologic etiology of uncontrollable pelvic hemorrhage requiring use of this hemostatic technique. Recently, elective transcatheter arterial embolization of uterine leiomyomas has been performed to decrease related symptomatology in an attempt to avoid surgical intervention. Our objective was to review current pertinent data regarding this new therapeutic modality. To this goal, all manuscripts published in the literature regarding this topic obtained from a MEDLINE search for 1966 through September 1998 were selected and reviewed. Additional sources were identified through cross-referencing. Currently, approximately 193 patients worldwide have been managed with this investigational procedure. Main indications include symptomatic uterine leiomyomata with menometrorrhagia, anemia, or pain. Success rates seem promising with a very low failure rate. This procedure results in significant (uterine and leiomyoma) volume reduction of between 20 and 80 percent. Postprocedural pain is common during the first day after the procedure, often requiring intravenous nonsteroidal antiinflammatory drugs and narcotic analgesia. Rare complications include endometritis, pyometra, and uterine necrosis, which may require hysterectomy. Reported follow-up time ranges between 6 and 60 months. Implications on subsequent fertility have not been established. Although successful pregnancies subsequent to this procedure have been reported, because of the unknown long-term effect of this procedure on fertility or perinatal outcome, this technique should not be performed when future fertility is desired. This review suggests that although not currently accepted as standard of care, transcatheter embolization of the uterine arteries can be considered as a nonsurgical technique for the management of appropriately selected patients. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to explain the current indications and contraindications of transcatheter uterine artery embolization of leiomyomas; to identify the various complications of the procedure and the type of embolic materials used; and to estimate the success rate of this procedure in the current literature.

Adult↗

PubMed1999

Metarrhizium anisopliae as a cause of sinusitis in immunocompetent hosts.

Metarrhizium anisopliae is a common pathogen of insects and has even been used to control insect populations. It is rarely isolated from human or animal sources, but recently, there have been three reported cases of disease, two in humans and one in a cat. We present our experience with five isolates from human sources, including two that were the apparent causes of two cases of sinusitis in immunocompetent hosts. The first patient was a 36-year-old male with frontal and ethmoid sinusitis, and the second was a 79-year-old female with chronic sinusitis. Both patients underwent surgery, and pathology of the surgical specimens revealed branching hyphae. Cultures grew only Metarrhizium species. Neither patient received antifungal therapy, and both did well postoperatively. The other three isolates were cultured from bronchoalveolar lavage specimens but were not felt to be clinically significant. Antifungal susceptibility testing using the National Committee for Clinical Laboratory Standards macrobroth method revealed that all isolates were resistant to amphotericin B, 5-flucytosine, and fluconazole. Itraconazole and newer azole compounds were more active. Metarrhizium species may cause disease in humans, even those without evidence of immunosuppression, and are apparently highly resistant to amphotericin B in vitro.

Adult↗

PubMed2001

Physician practice volume and alternative surgical treatment for breast cancer in Florida.

OBJECTIVE: To determine whether surgeon procedure volume is related to the selection of a surgical option (mastectomy versus breast-conserving surgery) for breast cancer treatment . STUDY SETTING/STUDY DESIGN: Secondary data sources were used to study surgical procedures performed for female breast cancer in Florida during the years 1997-98 in a retrospective population-based analysis. DATA EXTRACTION: Surgical procedures for female breast cancer in Florida were identified during 1997 and 1998 (N = 28,380) by combining data from the Florida Acute Hospital and Short-term Psychiatric Inpatient Data Collection and the Ambulatory Outpatient Data Collection. A total of 1,320 physicians who provided breast surgical procedures in Florida during the two-year study period were identified. PRINCIPAL FINDINGS: After controlling for selected patient and physician characteristics, the lowest volume surgeons were nearly twice as likely to perform mastectomies rather th an breast-conserving surgery compared with the highest volume group. Patients with Medicaid as an insurer were also nearly twice as likely to receive mastectomies. Patient demographic factors such as age, while statistically significant, were shown to be far less predictive of procedure choice. Forty-two percent of the physicians performed fewer than two surgeries on average per year. CONCLUSIONS: Patients treated by lower volume physicians have a greater likelihood of receiving mastectomies than do those patients treated by higher volume physicians.

Age Factors↗

PubMed1998

[Radiotherapy alone in endometrial neoplasms. The authors' own experience].

INTRODUCTION: Adenocarcinoma of the endometrium is the most common invasive genital malignancy in women and the majority of the cases are in stage I (80-85%) at the time of diagnosis. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the treatment of choice for most patients with uterine carcinoma. However, a number of women with endometrial cancer cannot undergo surgical treatment because of poor medical conditions. In these patients, who cannot tolerate surgery, radiation therapy is the only effective alternative. It is performed either as external treatment plus intracavitary brachytherapy or as brachytherapy alone. This retrospective study reports our data on survival, complications and local control in a consecutive series of patients treated with curative radiotherapy. MATERIAL AND METHODS: From January, 1985, to December 1995, at the Radiotherapy Department of "Casa Sollievo della Sofferenza" Hospital in San Giovanni Rotondo (Foggia, Italy), 60 patients were treated with combined external beam radiation therapy (ERT) and high-dose-rate intracavitary brachytherapy (HDR-BRT) or with high dose rate intracavitary brachytherapy alone. The average age of patients was 69 years (range 50-90). FIGO stage distribution was: 41 patients in stage I, 11 in stage II and 8 in stage III. The ERT was given by means of 6-8 MV linear accelerator, with conventional technique (with two opposed AP-PA pelvic fields in 15 patients, with the four fields-box technique in 41 patients) and a daily fraction to a total dose of 45-50 Gy. HDR-BRT was delivered by means of an HDR remote afterloading unit, containing a linear source of 192-Iridium (370 Gbq). The dose was specified to Point A in 32 patients and to uterine outline in 26. 2-3 intracavitary insertions (mean dose 6-8 Gy per fraction) were performed with weekly intervals. RESULTS: At the time of the analysis, all the patients were available for follow-up. Median follow-up was 25 months. 60% of patients were alive and well with no evidence of disease; 3.3% were alive with disease; 20% had died of this and 16.7% of other diseases. Five-year actuarial specific survival, obtained with the Kaplan and Meier method, was 77.7% in stage I, 90% in stage II, and 75% in stage III. Local relapses were observed in 14 patients. Complications (grade 2-3) scored with the French-Italian Glossary, were gastrointestinal in 10% of cases and genital in 6.6%. CONCLUSIONS: Radical radiotherapy achieved acceptable specific survival, local control and complications rates in patients with medically or surgically inoperable uterine carcinomas. Complications and survival rates, in our experience, are consistent with the literature data. The treatment is comfortable for the patients, because there is no need for long immobilization and it can frequently be performed on an outpatient basis. Besides, the completely standardized procedure was carried out easily with remote control allowing maximal radiation protection.

Aged↗

PubMed1982

Cardiac-catheterization and cardiac-surgical facilities: use, trends, and future requirements.

Cardiac catheterizations and cardiac operations were evaluated in the population of Olmsted County, Minnesota, from 1973 through 1980, and trends in this region were compared with nationwide trends based on data from several sources. The rates of coronary arteriography and coronary-artery bypass operations in Olmsted county have increased over time, but overall, the rates of catheterization and operation appeared to be leveling off. For the country as a whole, the data appear to show similar trends, but there are wide differences among regions in the rates of operation and catheterization. In 1980 40 per cent of hospitals with cardiac-catheterization laboratories and 55 per cent of those with facilities for open-heart surgery were doing fewer than the suggested minimum numbers of these procedures necessary to achieve optimum results. The data support the view that further growth in the number of cardiac centers should be avoided. We believe there is a need for continued evaluation of the use of cardiac services if quality is to be protected and costs controlled.

Adult↗

PubMed2005

Nosocomial bloodstream infections in ICU and non-ICU patients.

BACKGROUND: Nosocomial bloodstream infections (BSI) create a serious health problem in hospitals all over the world. The objectives of our study were to explore putative disease markers and potential risk factors with nosocomial BSI in patients in intensive care units (ICU) and non-ICU patients and to determine risk factors associated with increased 28-day mortality rate in patients with nosocomial BSI acquired in combined medical-surgical ICU. However, the major purposes of this report were to identify epidemiologic differences between nosocomial BSI acquired in ICU and non-ICU, as well as analyses outcomes for patients with nosocomial BSI acquired in ICU. METHODS: A 1-year prospective cohort study was performed to determine the incidence of nosocomial BSI in hospitalized patients. Patient characteristics, risk factors related to health care, and source of infection of patients with BSI acquired in non-ICU were compared with those patient with BSI acquired in ICU. Also, nested case-control study of patients to nosocomial BSI acquired in ICU was performed to evaluate outcome. Patients were identified by active surveillance and positive blood culture during the study period. RESULTS: The incidence of nosocomial BSI was 2.2 per 1000 admission in non-ICU patients and 17.4 per 1000 admission in ICU patients. The 28-day crude mortality rate was 69% in ICU patients. A multivariate model showed that nasogastric tube (RR, 25.1; 95% CI: 3.845-163.85; P=.001), mechanical ventilation (RR, 13.04; 95% CI: 1.974-96.136; P=.008), and H2 blockers (RR, 12.16; 95% CI: 1.748-84.623; P=.012) were more prevalent among patients with BSI acquired in ICU, and aggressive procedures (RR, 8.65; 95% CI: 1.70-44.00; P=.009) were more prevalent among patients with BSI acquired in non-ICU patients. Risk factors independently associated with increased 28-day mortality rate in ICU patients were mechanical ventilation (OR, 8.63; 95% CI: 1.5-49.8; P=.016) and SAPS II >40 (OR, 6.0; 95% CI: 1.0-35.7; P=.049). The most common isolated nosocomial BSI pathogens (in both groups of patients) were coagulase-negative staphylococci (21%), Staphylococcus aureus (14%), and Klebsiella species (13%). Klebsiella species was the only organism independently influencing the poor outcome of nosocomial BSI in ICU patients (OR, 4.3; 95% CI: 1.2-15.3; P=.022). CONCLUSIONS: Our results show epidemiologic differences between non-ICU and ICU BSI. Also, this study suggests that severity of underlying host conditions, mechanical ventilation, and microbial agents (Klebsiella species) affect the outcome of NBI in patients in ICU.

Adolescent↗

PubMed2003

Acute down-regulation of antibody production following spinal cord injury: role of systemic catecholamines.

We investigated whether antibody production to antigens arising in the subarachnoid space is depressed acutely after spinal cord injury (SCI), and whether such depression is due to abnormal catecholamine levels. To assess antibody responses, ovalbumin (OVA) was injected into the spinal subarachnoid space (i.t.) of rats via an indwelling catheter after SCI at T4 or laminectomy (LAM). Antibody responses tested at days 0, 7, and 14 (d0, d7, d14) postinjury revealed that SCI animals exhibited an antibody response significantly lower than LAM animals on d7, but one that reached control levels by d14. ELISPOT assays indicated that the cervical lymph nodes, known to be innervated by superior cervical ganglia (SCG), processed i.t. OVA. The reduction in antibody production after SCI could not be mimicked with surgical deafferentation of the SCG. However, blockade of beta-adrenergic receptors prior to SCI did reverse the decrease, suggesting an adverse effect of the surge of catecholamines that accompanies the injury. Surgical removal of sympathetic inputs to the cervical lymph nodes prior to SCI failed to reverse the effect on antibody production, suggesting a systemic source of catecholamines. We conclude that antibody responses against i.t. antigens are attenuated acutely after SCI due to the massive release of systemic catecholamines that accompanies SCI.

Adrenergic beta-Antagonists↗