Granulocyte colony-stimulating factor or neutrophil-induced pulmonary toxicity: myth or reality? Systematic review of clinical case reports and experimental data.
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Animals↗
Biomedical subjects
B Schlemmer
Publications and source records attributed to B Schlemmer.
Impact of registration procedures on antibiotic policies.
There is increasing concern over antibiotic resistance and its spread in common bacterial species, such as Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae and Escherichia coli. This results in increased morbidity and mortality. Over consumption of antibiotics has been reported in many settings and underlines the need for improving antibiotic policies. Crude measures of both antibiotic use and antibiotic resistance do not share a strong cause-and-effect relationship. However, this relationship is highly suggestive at a country level, at a hospital level, at a cohort level and at an individual level. In addition to overuse, antibiotic misuse has also to be considered, because of its impact on promoting antibiotic resistance, related to choice, dosage, dosing regimen or duration of therapy [1].
Animals↗
Infection as a trigger of diabetic ketoacidosis in intensive care-unit patients.
We determined the prevalence and indicators of infection in intensive care unit (ICU) patients with diabetic ketoacidosis (DKA) by performing a retrospective analysis of 123 episodes of DKA (in 113 patients) managed in a medical ICU between 1990 and 1997. In univariate analysis, features associated with infection were female sex, neurological symptoms at admission, fever during the week before admission, a need for colloids, a high blood lactate level at admission, and lack of complete clearance of ketonuria within 12 h. Multivariate analysis identified 3 independent predictors of infection: female sex (odds ratio [OR], 2.31; confidence interval [CI], 1.05-5.35), neurological symptoms at admission (OR, 2.83; CI, 1.18-6.8), and lack of complete clearance of ketonuria within 12 h (OR, 3.73; CI, 1.58-9.09). Infection is the leading trigger of DKA in ICU patients. Neurological symptoms at admission and lack of complete clearance of ketonuria within 12 h are useful warning signals of infection.
Adult↗
Rapid diagnosis of infectious pleural effusions by use of reagent strips.
Reagent strips have not yet been tested for use in the diagnosis of infectious pleural effusions. A reagent strip was used to evaluate 82 patients with pleural effusions: 20 patients had transudative effusions, 35 had infectious exudative effusions (empyema in 14 and parapneumonic effusion in 21), and 27 had noninfectious exudative effusions. Pleural fluid protein, as evaluated by the reagent strip, proved accurate for the detection of exudative effusions (sensitivity, 93.1%; specificity, 50%; positive predictive value, 84.3%; negative predictive value, 71.5%; odds ratio [OR], 6.77; and 95% confidence interval [CI], 1.87-24). The reagent strip leukocyte esterase test effectively detected infectious exudative effusions (sensitivity, 42.8%; specificity, 91.3%; positive predictive value, 88.2%; negative predictive value, 51.2%; OR, 4.46; and 95% CI, 1.2-16.4). Pleural pH was significantly predicted by the reagent strip but was of no assistance in categorization of exudative effusions as infectious or noninfectious. Compared with physical, laboratory, and microbiological data, the reagent strip was as accurate for estimation of percentages of infectious and noninfectious exudative effusions. Thus, reagent strips may be a rapid, easy-to-use, and inexpensive technique for discriminating transudative from exudative pleural effusions and for categorizing exudative pleural effusions as infectious or noninfectious.
Adult↗
Predictors of short-term mortality in critically ill patients with solid malignancies.
UNLABELLED: Admission of cancer patients with serious medical complications to the ICU remains controversial primarily because of the high short-term mortality rates in these patients. However, the cancer patient population is heterogeneous regarding age, underlying conditions, and curability of their disease, suggesting that large variations may occur in the effectiveness of intensive care within this subgroup of critically ill patients. OBJECTIVES: To identify factors predicting 30-day mortality in patients with solid tumors admitted to a medical ICU. PATIENTS AND METHODS: We conducted a retrospective study in 120 consecutive cancer patients (excluding patients with hematological malignancies) admitted to the medical ICU of a 650-bed university hospital between January 1990 and July 1997. Medical history, physical and laboratory test findings at admission, and therapeutic interventions within the first 24 h in the ICU were recorded. The study endpoint was vital status 30 days after ICU admission. Stepwise logistic regression was used to identify independent prognostic factors. RESULTS: The observed 30-day mortality rate was 58.7 % (n = 68), with most deaths (92 %) occurring in the ICU. Univariate predictors of 30-day mortality were either protective [prior surgery for the cancer (p = 0.01) and complete remission (p = 0.01)] or associated with higher mortality [Knaus scale C or D (p = 0.02), shock (p = 0.04), need for vasopressors (p = 0.0006) or for mechanical ventilation (p = 0.0001), SAPS II score greater than 36 (p = 0.0001), LOD score greater than 6 (p = 0.0001), and ODIN score > 2 (p = 0.0001)]. Three variables were independent predictors: previous surgery for the cancer (OR 0.20, 95 % CI 0.07-0.58), LOD score > 6 (OR 1.26, 95 % CI 1.09-1.44), and need for mechanical ventilation (OR 3.55, 95 % CI; 1.26-6.7). Variables previously thought to be indicative of a poor prognosis (i. e., advanced age, metastatic or progressive disease, neutropenia or bone marrow transplantation) were not predictive of outcome. CONCLUSION: When transfer to an ICU is considered an option by patients and physicians, 30-day mortality is better estimated by an evaluation of acute organ dysfunction than by the characteristics of the underlying malignancy.
APACHE↗
[Regulation of the use of antibiotics: objectives, means and perspectives].
Antibiotics account for an important fraction of hospital pharmaceutical expense, especially in intensive care units. Moreover, they represent a permanent threat for bacterial ecology. Induced resistance tends, in turn, to inflate the costs. In that way, economical point of view and concerns for quality and safety of care become convergent. Restrictive and(or) educational actions to regulate the prescriptions have therefore been settled in many centres. In the present review, based on published studies, we describe some examples of the results achieved from these actions. Computer-based networks and expert systems offer promising possibilities of improvement for the near future.
Animals↗
[Recommendations for children in the case of influenza pandemic].
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Child↗
Half the families of intensive care unit patients experience inadequate communication with physicians.
OBJECTIVE: Effective communication of simple, clear information to families of intensive care unit (ICU) patients is a vital component of quality care. The purpose of this study was to identify factors associated with poor comprehension by family members of the status of ICU patients. DESIGN: Prospective study. SETTING: University-affiliated medical intensive care unit. PATIENTS AND METHODS: A total of 102 patients admitted to an ICU for >2 days. INTERVENTION: The representatives of 76 patients who were visited by at least one person during their ICU stay were interviewed. RESULTS: Mean patient age was 54+/-17 yrs and mean Simplified Acute Physiology Score II at admission was 40+/-20. The representative was the spouse in 47 cases (62%). Among representatives, 25 (33%) were of foreign descent and 12 (16%) did not speak French. Mean duration of the first meeting with a physician was 10+/-6 mins. In 34 cases (54%), the representative failed to comprehend the diagnosis, prognosis, or treatment of the patient. Factors associated with poor comprehension by representatives included patient-related, family-related, and physician-related factors. Patient-related factors included age <50 yrs (p = .03), unemployment (p = .01), referral from a hematology or oncology ward (p = .006), admission for acute respiratory failure (p = .005) or coma (p = .01), and a relatively favorable prognosis (p = .04). Family-related factors were foreign descent (p = .007), no knowledge of French (p = .03), representative not the spouse (p = .03), and no healthcare professional in the family (p = .01). Physician-related factors were first meeting with representative <10 mins (p = .03) and failure to give the representative an information brochure (p = .02). Moreover, after the first meeting, caregivers accurately predicted poor comprehension by representatives (p = .03). CONCLUSIONS: Patient information is frequently not communicated effectively to family members by ICU physicians. Physicians should strive to identify patients and families who require special attention and to determine how their personal style of interrelating with family members may impair communication.
Communication↗
Gemifloxacin versus amoxicillin/clavulanate in the treatment of acute exacerbations of chronic bronchitis. The 070 Clinical Study group.
Six hundred patients were evaluated in this randomized, double-blind, double-dummy, multicenter, parallel-group study comparing the efficacy and safety of gemifloxacin (320 mg once-daily for 5 days) and amoxicillin/clavulanate (500/125 mg three-times daily for 7 days) for the treatment of acute exacerbations of chronic bronchitis (AECB). Of note, more than 90% of study participants had stage 2 disease at study entry. The two drugs were found to be equally effective, with clinical success rates of 93.6% for gemifloxacin and 93.2% on amoxicillin/clavulanate (95% CI -3.9 to 4.6). Bacteriological success rates favored gemifloxacin (90.9% compared with 79.5% for amoxicillin/clavulanate; 95% CI -3.3 to 26.0); however, this difference was not statistically significant. Gemifloxacin and amoxicillin/clavulanate were both well tolerated. In summary, gemifloxacin was found to be well tolerated and effective for the treatment of AECB, suggesting it is well suited for empirical treatment of this common respiratory condition in the current clinical environment.
Acute-Phase Reaction↗
Bacterial resistance to antibiotics in France : a public health priority.
For a few years, France has been faced to a rapid spread of anti-microbial resistance in hospitals and in general practice despite the many recommendations issued to solve this problem. In 1999, the Institut de Veille Sanitaire conducted a collective expe
Journal Article↗
[Comparative study of fixation mode in total knee arthroplasty with preservation of the posterior cruciate ligament].
PURPOSE OF THE STUDY: We performed a prospective randomized study to compare two fixation modes, with and without cement, for total knee arthroplasty. MATERIAL AND METHODS: The study series was composed of 96 cemented or noncemented total knee arthroplasties performed between May 1993 and October 1995. The only difference was the diamond interface used for cemented prostheses and the mesh interface used for uncemented prostheses. The operator was unaware of the type of fixation until the bone slices had been obtained. We assessed outcome in 73 cases with a mean follow-up of 27 months. The two populations were comparable for preoperative clinical status, bone tophicity and surgical procedure. RESULTS: The mean duration of the operation was sgnificantly longer (> 10 min) for the cemented protheses. The complication rates were comparable but we did have two mobilizations of the tibial implant in the noncemented group. The total scores (127 +/- 29 in the cemented group versus 135 +/- 20 in the uncemented group) were significantly different. There were however more cases with degradation of the controlateral knee in the cemented group although the difference was not significant. When these cases were excluded from the analysis, the total scores for two groups were similar (143 and 140 respectively). Radiographic outcome was quite different with mobilization of the tibial implant in 2 cases and the rate of lucent borders was significantly higher in the noncemented group. DISCUSSION AND CONCLUSION: While the clinical outcome was comparable, the quality of the fixation was significantly better with cemented arthroplasty, which remains the gold standard.
Aged↗
Changing use of intensive care for hematological patients: the example of multiple myeloma.
OBJECTIVE: Intensivists generally view patients with hematological malignancies as poor candidates for intensive care. Nevertheless, hematologists have recently developed more aggressive treatment protocols capable of achieving prolonged complete remissions in many of these patients. This change mandates a reappraisal of indications for ICU admission in each type of hematological disease. Improved knowledge of the prognosis is of assistance in making treatment decisions. PATIENTS AND METHODS: The records of 75 myeloma patients consecutively admitted to our ICU between 1992 and 1998 were reviewed retrospectively and predictors of 30-day mortality were identified using stepwise logistic regression. RESULTS: The median age was 56 years (37-84). Chronic health status (Knaus scale) was C or D in 39 cases. Fifty-five patients (73%) had stage III disease and 17 had a complete or partial remission. Autologous bone marrow transplantation had been performed in 28 patients (37%). ICU admission occurred between 1992 and 1995 in 41 patients (54.7%), and between 1996 and 1998 in 34 patients (45.3%). The median SAPS II and LOD scores were 60 (23-107) and 7 (0-21), respectively. Reasons for ICU admission were acute respiratory failure in 39 patients (52%) and shock in 31 (41%). Forty-six patients (61%) required mechanical ventilation. Fifty patients (66%) received vasopressors and 24 dialysis. Thirty-day mortality was 57%. Only five parameters were independently associated with 30-day mortality in the multivariate model: female gender (OR = 5.12), mechanical ventilation (OR = 16.7) and use of vasopressor agents (OR = 5.67) were associated with a higher mortality rate, whereas disease remission (OR = 0.16) and ICU admission between 1996 and 1998 (OR = 0.09) were associated with a lower one. CONCLUSION: The prognosis for myeloma patients in the ICU is improving over time. This may reflect either recent therapeutic changes in hematological departments and ICUs or changes in patient selection for ICU admission. Hematologists and intensivists should work closely together to select hematological patients likely to benefit from ICU admission.
Adult↗
Corticosteroids as adjunctive therapy for severe Pneumocystis carinii pneumonia in non-human immunodeficiency virus-infected patients: retrospective study of 31 patients.
The aim of this retrospective study was to assess whether corticosteroid adjunctive therapy (CAT) could prevent death in immunocompromised patients with severe Pneumocystis carinii pneumonia (PCP) who do not have human immunodeficiency virus (HIV) infection, similarly to what has been demonstrated for HIV-infected patients. The charts of all non-HIV-infected patients who were admitted to two medical intensive care units between 1988 and 1996 because of severe PCP, defined by an arterial oxygen pressure (determined while the patient was breathing room air) of <70 mm Hg, and who were treated with trimethoprim-sulfamethoxazole were analyzed retrospectively. Thirty-one patients met the study criteria, of whom 23 received CAT (within 72 hours of antibiotic therapy) and eight did not receive CAT. The need for mechanical ventilation (10 [43%] of 23 vs. 4 [50%] of 8) and the mortality rate (9 [39%] of 23 vs. 4 [50%] of 8) were similar for the two groups. Although this small study does not have a statistical power high enough to rule out the possibility of a difference, the results suggest that CAT does not improve the survival of non-HIV-infected patients as has been described for HIV-infected patients with severe PCP.
Adolescent↗
[Experimental comparative study of 3 systems of osteosynthesis for proximal humeral fractures. Preliminary study of the mechanical properties of conserved trabecular bone].
PURPOSE OF THE STUDY: We have compared three systems for osteosynthesis of proximal humeral fractures on a four-fragment fracture model: Plate with tuberosity screwing (P), Kirschner wires with bone sutures (K) and an original implant, the "bilboquet" (Stryker) (B), composed of a hook for the head supported on a diaphyseal stem. MATERIAL AND METHODS: Because of the unavailability of fresh human material, we have turned to embalmed bones after having shown, on cancellous femoral head bone, the little influence of our method Vs freezing conservation. Settings were tested in compression. We measured their mechanical resistance judged on the ultimate strength and on the slope (displacement/load), to this limit. We similarly analyzed by video recording displacement of the different fragments according to four components (head slipping, its lateral displacement, its see-saw and the separation of tuberosities), to show the weak points of the three systems. RESULTS AND DISCUSSION: K was more deformable (p < 0.001) that P and B (average slopes in mm/100N to 0.67 for K, 0.42 for P and 0.43 for B). The ultimate strength differed but not significantly (average values in Newton to 1223 for K, 1601 for P and 1721 for B). We also showed for the three techniques, the significant correlation between slopes and bony densities. Video analysis showed that P opposed lateral displacement of the head and separation of tuberosities better, the resistance to slipping and see-saw seems to be improvable by greater divergence of screws or a modification of the plate (mini canon). B opposed slipping and see-saw better but its weak point was the risk of articular break-in of the hook, by defect of resistance to lateral displacement, that for us could be limited by a less peripheral position of teeth or a modification of their form. K is indeed the least effective of the four components but we think that it would be improvable by using, for example, a centro-medullary technique, allowing an internal cortical support.
Bone Density↗
Fulminant Pneumocystis carinii pneumonia in 4 patients with dermatomyositis.
Between 1989 and 1996, 4 cases of Pneumocystis carinii pneumonia (PCP) were observed in patients seronegative for the human immunodeficiency virus who were receiving corticosteroid therapy for dermatomyositis in our institution. These cases were considered unusual in light of the short delay of their onset after initiation of immunosuppressive therapy and their fulminant course: 3 of these patients died of PCP occurring during the first month of treatment with prednisone. In all 4 patients lymphopenia was observed before the initiation of corticosteroid treatment and low CD4 and CD8 cell counts were evident at the time of PCP. These observations support the view of an increase in both the severity and incidence of PCP in patients without human immunodeficiency virus infection and question the need for a primary prophylaxis in patients with connective tissue diseases receiving high-dose corticosteroid therapy.
Adult↗
Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis.
Colonization of the digestive tract has been supposed to be the source of many hospital-acquired infections, especially nosocomial pneumonia. To assess the relationship between oropharyngeal and gastric colonization and subsequent occurrence of nosocomial pneumonia, we prospectively studied 86 ventilated, intensive care unit (ICU) patients. Oropharyngeal or gastric colonizations were detected and quantified on admission and twice weekly during ICU stay. When nosocomial pneumonia was suspected on clinical grounds (new chest X-ray infiltrate and purulent tracheal secretions), diagnosis was assessed on fiberoptic bronchoscopy with quantitative cultures of a protected specimen brush sampling and/or a plugged telescoping catheter sampling yielding > or = 10(3) cfu/ml of at least one microorganism. Bacterial strains responsible for colonization and infection (Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacteriaceae, and Staphylococcus aureus) were compared using pulsed-field electrophoresis. A total of 31 cases (36%) of pneumonia were diagnosed. Oropharyngeal colonization, detected either on admission or from subsequent samples, was a predominant factor of nosocomial pneumonia as compared with gastric colonization. For instance, oropharyngeal colonization with A. baumannii yielded a 7.45-fold estimated increased risk of pneumonia as compared with patients not yet or not identically colonized (p = 0.0004). DNA genomic analysis demonstrated that an identical strain was isolated from oropharyngeal or gastric samples and bronchial samples in all but three cases of pneumonia, due to S. aureus. These findings provide better knowledge of the pathophysiology of nosocomial pneumonia in mechanically ventilated patients.
Adult↗
Short and longterm outcomes for patients with systemic rheumatic diseases admitted to intensive care units: a prognostic study of 181 patients.
OBJECTIVE: To determine short and longterm outcomes and prognostic factors for patients with systemic rheumatic diseases admitted to intensive care units in 4 teaching hospitals. METHODS: All adult intensive care unit admissions over a 12 year period for systemic rheumatic diseases were retrospectively assessed. One hundred and eighty-one patients with a mean age of 57 +/- 17 years were studied. RESULTS: The death rate in intensive care units was 33% (59/181) and in-hospital mortality was 43% (77/181). One hundred and four patients were discharged alive from hospital; 40 died during followup (mean 105 +/- 7 mo). The estimated 5 year survival rate for the discharged patients was 69%. The 4 factors significantly associated with in-hospital mortality by multivariate analysis were simplified acute physiologic score (p = 10(-4)), poor prior health status (p = 10(-4)), corticosteroid administration (p = 0.005), and the reason for admission; mortality was higher in the group admitted to intensive care for infectious complication (55 versus 34% for others; p = 0.006). In contrast, in-hospital mortality was not influenced by age or by systemic rheumatic diseases. Using Cox's model, only age over 60 years was a prognostic factor significantly associated with an increase in longterm mortality (p = 10(-4)). CONCLUSION: The short term outcome for patients with systemic rheumatic diseases in intensive care units was poor. The longterm prognosis after hospital discharge appeared fair, although the standardized mortality ratio was 5-fold that of a nonselected population. Short and longterm prognoses were similar for different systemic rheumatic disease groups.
Adult↗
Falciparum malaria: an infectious cause of rhabdomyolysis and acute renal failure.
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Acute Kidney Injury↗