Antibiotic-resistant pneumococcal pneumonia.
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Humans↗
Biomedical subjects
C Feldman
Publications and source records attributed to C Feldman.
IgG subclasses in previously healthy adult patients with acute community-acquired pneumonia.
OBJECTIVE: To measure IgG antibody subclasses in previously healthy adult patients with acute community-acquired pneumonia, and to assess any association between differences of subtype levels and severity of illness or prognosis. DESIGN: Prospective study. SETTING: The intensive care unit (ICU) and general medical wards of Hillbrow Hospital, Johannesburg, an urban general hospital. PATIENTS: Sixty-six previously healthy adult patients with acute community-acquired pneumonia, of whom 47 were considered less severely ill, while 19 were admitted to an ICU. OUTCOME MEASURES: Measurement of IgG subclass levels and determination of any association between differences in subtype levels and various poor prognostic factors in pneumonia, need for ICU admission, complications of illness, and APACHE II score of ICU cases or outcome of patients. RESULTS: A number of statistically significant differences (P < 0.05) were noted between the two groups of patients (critically ill v. others) representing well-known negative prognostic factors in pneumonia. A greater degree of tachycardia and tachypnoea and extremes of white cell count, a higher serum urea concentration and multilobar pulmonary consolidation characterised the patients in the ICU. In addition, the mortality rate in the ICU patients was significantly greater (P < 0.0001). Similar findings were noted when survivors and non-survivors were compared. Few abnormalities of IgG subclass levels were noted in the various patient groups, which did not allow adequate analysis of their clinical significance. CONCLUSION: This study demonstrated a small number of abnormalities in IgG subclass levels in previously healthy adult patients with acute community-acquired pneumonia.
Acute Disease↗
Tuberculosis in the intensive care unit.
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Critical Care↗
The aetiology of severe community-acquired pneumonia and its impact on initial, empiric, antimicrobial chemotherapy.
Of 259 patients admitted to an intensive care unit with severe acute community-acquired pneumonia, 173 had primary infections and 86 had secondary infections. The commonest organism isolated in each group was Streptococcus pneumoniae (51.3 and 36.6% of known isolates in each group respectively). Klebsiella pneumoniae was the next most common isolate (31.9 and 29.3% respectively). A variety of other Gram-negative organisms and Staphylococcus aureus accounted for most of the remaining pathogens. Based on retrospective analysis of data, there appeared to be no difference in the alcohol consumption of patients with infection due to S. pneumoniae and K. pneumoniae. The overall mortality rate for the primary infections was 47.4%, with 68.4% of these infections due to K. pneumoniae and 33.9% due to the pneumococcus (P < 0.002). Among the secondary infections, the overall mortality rate was 40.8% (not significantly different to that of primary infections) with 45.5% due to K. pneumoniae and 23.1% due to the pneumococcus (not significantly different on statistical analysis, probably due to low patient numbers). Our investigation confirms that severe community-acquired pneumonia due to K. pneumoniae is extremely common, even in patients without obvious risk factors for Gram-negative colonization. This organism is contributing to the high mortality rate seen in our intensive care unit among patients with pneumonia, and our empiric therapy for such cases routinely includes a combination of agents active against this organism (e.g. a cephalosporin and an aminoglycoside).
Acute Disease↗
Community-acquired pneumonia in the ICU.
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Aminoglycosides↗
Patterns of cytokine expression in community-acquired pneumonia.
BACKGROUND: Pneumonia continues to be a major cause of disease and death among patients worldwide. Aspects of the host response to infection, such as the release of cytokines, may be contributing to the persistent morbidity and mortality. METHODS: Plasma levels of cytokines interleukin (IL)-1 beta, IL-6, and tumor necrosis factor alpha (TNF-alpha) were measured in critically ill patients with pneumonia (ICUP; n = 12) and less severely ill patients with pneumonia (NONICUP; n = 8), and in 2 additional control groups of patients, viz, severely ill postoperative patients without evidence of infection (POSTOP; n = 11) and less severely ill patients with nonpneumonia infections (NONP; n = 9). All four groups of patients were studied in a multivariate one-way analysis of variance using the parameter vector: plasma IL-1 beta, IL-6, TNF-alpha, systolic blood pressure, diastolic blood pressure, plasma urea, creatinine, and temperature. Thereafter the significance of individual parameters were assessed by univariate analysis and pairwise comparisons. RESULTS: All cytokine concentrations were highest in the ICUP group. In the case of IL-1 beta, levels were significantly higher in the ICUP group when compared with the noninfected POSTOP group. The acute physiology and chronic health evaluation (APACHE) II scores were identical in these two groups (17 +/- 3 [SD] and 10 +/- 1, respectively, not significantly different). Intermediate levels were found in those groups with intermediate levels of infection. The IL-6 levels were not significantly different between the groups and in particular, the levels in the ICUP and POSTOP groups were similar. The TNF-alpha levels tended to mimic those of IL-1 beta, although the significant difference found was between the ICUP and NONICUP groups which had significantly different APACHE II scores (17 +/- 3 vs 4.4 +/- 1, respectively). No association between cytokine levels and patient mortality was demonstrated. CONCLUSION: Among the cytokines, IL-1 beta appeared to be associated with the severity of infection, IL-6 appears to reflect severity of stress whether of infection or noninfective origin, and TNF-alpha may be a marker of severity of pneumonia.
APACHE↗
Nursing: a human connection.
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Anecdotes as Topic↗
Oxidant-mediated ciliary dysfunction in human respiratory epithelium.
Exposure of human nasal ciliated epithelium to reactive oxidants generated by the enzymatic xanthine-xanthine oxidase superoxide/hydrogen peroxide (H2O2) and glucose-glucose oxidase H2O2-generating systems, or to reagent H2O2 or hypochlorous acid (HOCl) resulted in significant alterations in ciliary beating. The earliest change noted was the presence of ciliary slowing, progressing eventually to complete ciliary stasis in some areas. Ciliary dyskinesia was seen within the first hour, often from as early as 15 min after exposure of the cells to reactive oxidants. Using peroxidases, various antioxidant enzymes, and oxidant scavengers, we confirmed that these detrimental effects on ciliary function were mediated primarily by H2O2 and HOCl. Moreover, 3-aminobenzamide (3-ABA), an inhibitor of the DNA repair enzyme poly ADP ribose polymerase, prevented H2O2-mediated inhibition of ciliary function, indicating that oxidant-mediated damage to DNA may well be the basis of the effects of H2O2 on ciliated epithelium. Acute and chronic inflammatory responses may therefore present the possible threat of H2O2- or HOCl-inflicted injury on bystander respiratory epithelium, leading to ciliary dyskinesia and slowing.
Catalase↗
Ethnic differences in the occurrence of the M1(ala213) haplotype of alpha-1-antitrypsin in asthmatic and non-asthmatic black and white South Africans.
An ethnic study of 175 individuals, comprising 65 black and 110 white South Africans, has shown a conclusive difference in the frequency of the M1(ala213) haplotype of alpha 1-antitrypsin (P < 0.00001). The M1(ala213) haplotype occurred more frequently in the black group. In the latter group, the frequency of the M1(ala213) haplotype was the same in both controls (0.55) and asthmatics (0.53). However, there was a significant difference in the frequencies (0.19 and 0.36) for the respective white groups (P < 0.01), the frequency of the M1(ala213) haplotype being much higher in the asthmatics. Apart from the above differences, there was also a difference in the elastase-inhibitory capacities of the homozygote phenotypes M1(val213) vs M1(ala213) (P < 0.0001), this capacity being lower in the latter phenotype. We conclude that the occurrence of the M1(ala213) allele of alpha 1-antitrypsin differs in various ethnic groups and may play a role in asthma.
Adult↗
Treatment of non-small-cell lung cancer by high-dose-rate intraluminal brachytherapy.
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Aged↗
Renal and neuromuscular respiratory failure--is this a syndrome associated with cantharidin poisoning?
OBJECTIVE: To describe the clinical and laboratory features of patients with renal and neuromuscular respiratory failure due to suspected cantharidin poisoning. DESIGN: Retrospective record review of cases with neuromuscular respiratory failure. SETTING: Intensive Care Unit (ICU), Hillbrow Hospital, Johannesburg. PATIENTS: Out of a total of 47 patients with neuromuscular respiratory failure admitted to the ICU between January 1983 and December 1990, 10 with suspected cantharidin poisoning were selected and studied further. OUTCOME MEASURES: Description of clinical features, laboratory data, treatment and prognosis. RESULTS: In 10 of the 47 patients, the cause of renal and neuromuscular respiratory failure that which precipitated the need for ICU admission was suspected to be cantharidin poisoning. This was based on the history and clinical and laboratory features. In 4 cases trace amounts of cantharidin were detected in blood and/or urine, strengthening the diagnosis. There were 8 males and 2 females. All had evidence of renal injury and 9 had gastro-intestinal symptoms. All presented with fixed dilated pupils, varying cranial nerve palsies and muscle weakness, usually ascending and progressive, necessitating admission to the ICU. All but 1 of the patients were mechanically ventilated, 5 required significant inotropic support of the blood pressure, and 6 dialysed. Four patients died soon after admission and the remainder survived with relatively complete return of neurological function. CONCLUSION: This study highlights the possibility that cantharidin poisoning may be a cause of a 'Guillain-Barrè-like' syndrome.
Adult↗
Determinants of near fatality in acute severe asthma.
PURPOSE: The data extrapolated from cases of acute severe asthma that narrowly miss being fatal may prove valuable in the identification of the factors implicated in mortality. The purpose of this study was, therefore, to identify determinants of near fatality in patients with acute severe asthma. PATIENTS AND METHODS: We studied 81 patients with acute severe asthma in whom mechanical ventilation was required. Near fatality was defined as the occurrence of respiratory arrest and/or coma necessitating emergency tracheal intubation and resuscitation. In the cases that were not regarded as near fatal, tracheal intubation was performed electively because of deteriorating arterial blood gas values and/or the anticipation of exhaustion. Various continuous and categorical variables were compared in these two groups of patients. Patients with a hyperacute attack (period from onset of attack to mechanical ventilation less than 3 hours) were specifically sought and studied to determine the impact of such a course on near fatality. RESULTS: The "attack duration" (period from onset of attack to mechanical ventilation) was an important determinant of near fatality and of the subsequent clinical course. It was shorter in the group with a near-fatal episode (p < 0.03), and hyperacute attacks were uniformly near fatal. The attack duration correlated positively with the duration of the requirement for mechanical ventilation (p < 0.01). A longer attack duration was associated with an increased likelihood of the occurrence of major atelectasis (p < 0.01). There was no evidence of a relationship between near fatality and the side effects of bronchodilators as regards hypokalemia, arrhythmias, or cardiotoxicity. There was evidence of considerable under-treatment in the patient population as a whole, particularly in regard to the use of corticosteroids. CONCLUSIONS: A short attack duration is associated with an increased risk of near fatality in acute severe asthma. This is particularly evident in hyperacute attacks. Hyperacute attacks resolve rapidly once bronchodilator therapy has been instituted, suggesting that smooth muscle spasm is the predominant pathogenetic mechanism. The importance of routine anti-inflammatory therapy in mild to moderate asthma requires re-emphasis but, in addition, all patients should be provided with, and educated in the use of, bronchodilator rescue therapy, which should be available at all times. Despite current trends, the use of regular, prophylactic bronchodilator therapy in strict conjunction with anti-inflammatory agents may still be indicated. There is little evidence in the present data obtained from near-fatal cases to support the concept that cardiotoxicity related to bronchodilators contributes significantly to mortality from asthma.
Acute Disease↗
A study of acute community-acquired pneumonia, including details of cardiac changes.
We prospectively studied 102 patients, aged 15-50 years, with acute community-acquired lobar pneumonia without underlying cardiorespiratory illness, admitted to Baragwanath Hospital May 1990-April 1991. Demographic, clinical, microbiological and laboratory data and negative prognostic features of these patients are described. In particular, we documented electrocardiographic changes and studied their possible relevance in patients with pneumonia. Electrocardiographic changes occurred in 32 patients (31%). The commonest changes were clockwise rotation (16%), followed by P. pulmonale (9.8%) and S1 Q3 T3 pattern (7.8%) Other changes included right axis deviation (n = 6), right bundle branch block (n = 3), ventricular extrasystoles (n = 2), atrial fibrillation (n = 1) and nodal rhythm (n = 1). These changes returned to normal in survivors after a mean of 2 days. The S1 Q3 T3 pattern was associated with cardiac enzyme leak (CK-MB fraction), hypoxia and a high Simplified Acute Physiology Score (SAPS). In addition, P. pulmonale, right axis deviation and clockwise rotation correlated with hypoxia and a high SAPS score. Clockwise rotation also correlated with serum (including cardiac fraction) enzymes leak (LDH and CK-MB fraction), and pulmonary artery pressure. The overall mortality rate was 10.8%, with no association between electrocardiographic changes and mortality. The negative prognostic factors documented were hypoxia (p < 0.0001), multilobar pulmonary consolidation (p < 0.0001), tachycardia (p = 0.0001), tachypnoea (p = 0.0002), renal dysfunction function (p = 0.0009), hypotension (systolic p < 0.02, diastolic p < 0.003), bacteraemia (p = 0.003), and serum (including cardiac fraction) enzymes leak: LDH (p < 0.02), CK (p < 0.002) and CK-MB fraction (p = 0.0002). These factors, with the exception of renal dysfunction, also correlated with the need for intensive care unit admission. Acute and reversible electrocardiographic changes are common in acute community-acquired lobar pneumonia. Electrocardiographic changes, especially those compatible with acute cor pulmonale and accompanied by cardiac enzyme (CK-MB fraction) leak, correlated with severity of illness but not with mortality.
Adolescent↗
Decision making in case management of home healthcare clients.
Public health nurses face ethical decision-making dilemmas in their everyday practice, but how well are they prepared to make these decisions? This research study examined the decision-making capabilities of nurses in case management in regard to terminating and maintaining services in difficult client situations. The results showed that nurses varied in their decision-making capabilities and that their beliefs about case management were not always carried out in actual practice.
Adult↗
Relation of vessel wall shear stress to atherosclerosis progression in human coronary arteries.
The purpose of this study was to determine the relation between vessel wall shear stress and the rate of atherosclerosis progression. Quantitative angiography was used to calculate the change in coronary arterial diameter over 3.0 years in patients enrolled in the Harvard Atherosclerosis Reversibility Project pilot study (n = 20 arterial segments). Vessel wall shear stress was calculated by means of a validated finite-difference model of the Navier-Stokes' equation that assumes a coronary flow rate of 8 ml/sec. The correlation between vessel wall shear stress and the change in arterial diameter at multiple points (mean, 70) along the length of the artery was then calculated for each of the 20 segments with a focal stenosis. In 15 of the 20 arterial segments there was a significant correlation (p < 0.05) between low shear stress and an increased rate of atherosclerosis progression. A Fisher's z transformation was then used to combine the correlation coefficients from all 20 segments. Low shear stress was significantly correlated (z = 0.37 +/- 0.00074, p < 0.0001) with an increased rate of atherosclerosis progression. This serial quantitative evaluation of human coronary arteries is consistent with previous data that have suggested that low shear stress promotes atherosclerosis progression. Variations in local vessel wall shear stress may explain the previously reported near-independent rate of atherosclerosis progression in multiple lesions within the same patient despite exposure to the same circulating lipoprotein values and systemic hemodynamics.
Computer Simulation↗
Factors associated with airway colonisation and invasion due to Klebsiella spp.
The clinical significance of a heavy growth of Klebsiella spp. in sputum was studied in 54 patients. All but 3 patients had significant factors potentially associated with respiratory tract colonisation or invasion. Risk factors identified for colonisation of the airway and for invasive disease were similar. Patients with community-acquired Klebsiella infections were more likely to have underlying chronic respiratory diseases. Prior antibiotic use was a risk factor for nosocomial infections which occurred more commonly with antibiotic-resistant organisms. The most common diagnoses were airway colonisation, acute community-acquired chest infections, and nosocomial chest infections. Primary acute community-acquired pneumonia was uncommon. The sensitivity and specificity of the sputum Gram stain (in the setting of positive sputum cultures) in suggesting the presence of invasive disease due to Klebsiella spp. were 42% and 69% respectively.
Adolescent↗
A study of immunoglobulin G subclass levels in black and white patients with various forms of obstructive lung disease.
The association of various respiratory disorders with disturbances in immunoglobulin G (IgG) subclass levels is increasingly being recognised. This was a prospective study of the IgG subclass levels in 71 patients (37 white, 34 black) with various respiratory disorders associated with obstructive airways disease. Ten white patients with adult cystic fibrosis were studied, 4 of whom were colonised with Pseudomonas aeruginosa. Alterations in individual subclass levels were seen in these patients and abnormalities noted included a decrease in IgG3 and/or an increase in IgG1 and/or IgG2 levels. Of the 17 black and 16 white patients with asthma, 2 had absent IgG4 levels associated with severe and recurrent respiratory infections, 2 had deficient IgG3 and 1 decreased IgG1 levels. Several patients had increased levels of several IgG subclasses, of which IgG1 was the most commonly affected. Both atopy and recurrent chest infections occurred most often in the latter group of patients. In the studies of 17 black and 11 white patients with bronchiectasis, all but 3 white patients were shown to have some alteration in IgG subclass levels. The commonest deficiencies were an absence of IgG4 (3 cases), and an absence of all subclasses (2 cases). One of the latter patients had an associated deficiency of total IgG and IgM, and the other demonstrated pan-hypogammaglobulinaemia. Abnormalities of IgG subclass levels appear to be commonly associated with several respiratory disorders including recurrent infections, atopy and bronchiectasis.
Adolescent↗
The clinical significance of Haemophilus influenzae and H. parainfluenzae isolated from the sputum of adult patients at an urban general hospital.
Fifty-seven patients, from whose sputum Haemophilus influenzae (49 cases) or Haemophilus parainfluenzae (8 cases) was isolated during a 7-month period, were studied. In the majority of cases there were well-defined predisposing factors to respiratory tract colonisation or infection with the isolates, in particular bronchiectasis and chronic obstructive airways disease. Colonisation of the airways, bronchopneumonia in patients with underlying lung disease, acute lobar pneumonia, and postoperative chest infections were the commonest clinical diagnoses. Primary acute lobar pneumonia with these organisms alone was uncommon. All of the H. influenzae isolates were nontypeable, and there was a wide range of biotypes of both organisms. Three H. influenzae isolates produced beta-lactamase, and there was, in general, a low incidence of resistance to a wide range of antimicrobial agents on disc susceptibility testing.
Adult↗