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Biomedical subjects

D F Zandstra

Publications and source records attributed to D F Zandstra.

At least 19 recordsLinked to original sources
PubMed2003

Disseminated tuberculosis, pulmonary aspergillosis and cutaneous herpes simplex infection in a patient with infliximab and methotrexate.

CASE PRESENTATION: Despite chemoprophylaxis with isoniazid a 58-year-old Creole patient with mild rheumatoid arthritis developed disseminated tuberculosis, pulmonary aspergillosis and cutaneous herpes simplex infection during treatment with infliximab and methotrexate. TREATMENT: The patient received antituberculous drugs (ethambutol, isoniazid, pyrazinamide, rifampicin), amphotericin B, flucytosine, and valaciclovir, along with prolonged intensive care treatment and mechanical ventilation. CONCLUSIONS: The present case confirms that isoniazid prophylaxis (300 mg once daily, during 6 months) does not protect against the reactivation and dissemination of latent tuberculosis. It also shows that combined treatment with infliximab and methotrexate may induce severe immunosuppression with prolonged leukocytopenia and depressed cellular immunity, leading to multiple opportunistic infections. Extensive diagnostic testing, early start of antimicrobial therapy and enteral immunonutrition, and further infection prevention with selective decontamination of the digestive tract may have been the key to a good clinical outcome.

Antibodies, Monoclonal↗
PubMed2001

[Endovascular treatment of 2 patients with an aneurysm of the descending thoracic aorta].

Two men, aged 71 and 70, who had previously experienced an abdominal aneurysm were found to have thoracic aortal aneurysms of respectively 8 cm and 7.5 cm in length. For the first patient an endovascular operation was carried out due to a high operative risk: with the help of a radiograph, four endoprostheses were inserted into the thoracic descending aorta via the femoral artery, after which the aorta diameter became more normal. A month later, the patient died from persistent renal failure, which had developed as a result of the previously ruptured abdominal aneurysm. In the second patient with an aneurysm of the proximal descending aorta, a left decompensation arose following aortal clamping during open surgical repair. Ten weeks later an endoprosthesis was inserted via the femoral artery. A year later the aortal diameter had decreased to 6.5 cm; the patient functioned well. The insertion of an endoprosthesis in the thoracic aorta is a minimally invasive procedure in which the patient experiences little perioperative inconvenience.

Aged↗
PubMed2001

Enteral feeding in the critically ill: comparison between the supine and prone positions: a prospective crossover study in mechanically ventilated patients.

INTRODUCTION: Prone position is effective in mechanically ventilated patients to improve oxygenation. It is unknown if prone position affects gastric emptying and the ability of continued enteral feeding. AIM: To determine tolerance of enteral feeding by measuring gastric residual volumes in enterally fed patients during supine and prone positions. METHODS: Consecutive mechanically ventilated intensive care patients who were turned to prone position were included. All patients were studied for 6 hours in supine position, immediately followed by 6 hours in prone position, or vice versa. The rate of feeding was unchanged during the study period. Gastric residual volume was measured by suctioning the naso-gastric tube after 3 and 6 hours in the same position. Wilcoxon test and regression analysis were used for analysis. RESULTS: The median volume of administered enteral feeds was 95 ml after 6 hours in supine position and 110 ml after 6 hours in prone position (P = 0.85). In 10 patients, a greater gastric residual volume was found in prone position. In eight others a greater volume was found in supine position. In 18 of 19 patients, gastric residual volumes in both positions were > or = 150 ml in 6 hours or < or = 150 ml in 6 hours. Significantly more sedatives were used in prone position. Regression analysis excluded dopamine dose and the starting position as confounders. CONCLUSION: Our results suggest that enteral feeding can be continued when a patient is turned from supine to prone position or vice versa. The results indicate that patients with a clinically significant gastric residual volume in one position are likely to have a clinically significant gastric residual volume in the other position.

Adult↗
PubMed2001

Plasma glutamine depletion and patient outcome in acute ICU admissions.

OBJECTIVE: To evaluate whether low plasma glutamine (PG) is related to severity of illness, and actual and predicted hospital mortality. DESIGN: Prospective cohort study. SETTING: 18-bed closed format general intensive care unit (ICU) of a teaching hospital. PATIENTS: Cohort of 80 seriously ill patients non-electively admitted to the ICU. INTERVENTIONS: Blood sampling for the determination of PG at ICU admission. MEASUREMENTS AND RESULTS: Severity of illness and predicted mortality were calculated using the locally validated APACHE II, SAPS II, and MPM II 0 and 24 systems. Illness scores, and actual and predicted hospital mortality were compared between patients with total PG < 0.420 mmol/l ("low PG") and patients with PG > or = 0.420 mmol/l. Mean total PG was 0.523 mmol/l, range 0.220-1.780 mmol/l. Low PG (n = 25) was associated with higher age (P = 0.03), shock as primary diagnosis, and higher actual hospital mortality (60 % vs 29 %, P = 0.01). Normal to high PG was associated with high plasma creatine phosphokinase (P = 0.007) There was a nonsignificant trend towards higher severity of illness scores and predicted mortality rates in the low PG group. The presence of low PG significantly improved mortality prediction when added as a factor to the APACHE II predicted mortality rate (P = 0.02). CONCLUSIONS: Low PG at acute ICU admission is related to higher age, shock as primary diagnosis, and higher hospital mortality. Low PG represents a risk of poor outcome, not fully reflected in the presently used mortality prediction systems.

Aged↗
PubMed2001

Prevalence of Helicobacter pylori infection in stress-induced gastric mucosal injury.

OBJECTIVE: To determine the role of Helicobacter pylori infection in critically ill patients admitted to the intensive care unit in the formation of gastric and duodenal mucosal injury in these patients. DESIGN AND SETTING: Prospective cohort analysis in an 18-bed mixed medical and surgical closed format ICU in a teaching hospital. PATIENTS: Fifty consecutive patients admitted to the intensive care unit for emergency reasons and requiring mechanical ventilation were included. INTERVENTIONS: H. pylori infection was detected by the laser-assisted ratio analyzer [13C]urea breath test (UBT). Gastric and duodenal mucosal lesions were assessed by upper gastrointestinal endoscopy and classified as minor (up to five erosions or submucosal hemorrhages) or major (more than five erosions or submucosal hemorrhages) mucosal injury. MEASUREMENTS AND MAIN RESULTS: Six patients were not eligible because the UBT could not be processed. Of the 44 eligible patients 22 were H. pylori positive by UBT and 22 H. pylori negative. Either minor or major gastric mucosal injury was found on endoscopy in 66 %. Of the 29 patients with minor mucosal injury 10 (34.5 %) were infected with H. pylori as indicated by positive LARA 13C-UBT. In contrast, of the 15 patients with major mucosal injury 12 (80%) were infected with H. pylori (p = 0.004). H. pylori was the only risk factor significantly associated with major mucosal injury in a multiple regression analysis (p = 0.019). CONCLUSION: The severity of gastric and duodenal mucosal injury in critically ill patients during mechanical ventilation is significantly correlated with the presence of H. pylori infection.

Adult↗
PubMed2001

Neostigmine resolves critical illness-related colonic ileus in intensive care patients with multiple organ failure--a prospective, double-blind, placebo-controlled trial.

OBJECTIVE: Critical illness-related colonic ileus (CIRCI) is characterized by the non-passage of stools in critically ill patients as a result of the absence of prokinetic movements of the colon, while the upper gastrointestinal tract functions properly and mechanical ileus is absent: We investigated whether neostigmine resulted in defecation in patients with CIRCI. DESIGN: Double-blinded, placebo-controlled prospective study. SETTING: Eighteen-bed intensive care unit. PATIENTS: Thirty ventilated patients with multiple organ failure with CIRCI for > 3 days. INTERVENTION: Continuous intravenous administration of neostigmine 0.4-0.8 mg/h over 24 h, or placebo. MEASUREMENTS AND RESULTS: Time to first defecation and adverse reactions were recorded. Thirty patients were randomized, 24 could be evaluated. The mean prestudy time was 5 days, mean APACHE II score on admission was 23.2, and mean MOF score on the day of the study was 6.4. Of the 13 patients receiving neostigmine, 11 passed stools, whereas none of the placebo-treated patients passed stools (P < 0.001). After 24 h, the non-responders received in a cross-over fashion neostigmine or placebo respectively. Eight out of the 11 neostigmine patients now passed stools (mean 11.4 h), and none of the placebo patients. Overall, in none of the patients did passage of stools occur during placebo infusion, whereas 19 of the 24 neostigmine-treated patients had defecation (79%). No acute serious adverse effects occurred, but three patients had ischemic colonic complications 7-10 days after treatment. CONCLUSION: Continuous infusion of 0.4-0.8 mg/h of neostigmine promotes defecation in ICU patients with a colonic ileus without important adverse reactions.

APACHE↗
PubMed2001

Suppression of Helicobacter pylori infection during intensive care stay: related to stress ulcer bleeding incidence?

PURPOSE: To assess the prevalence of active Helicobacter pylori infection in patients admitted to the intensive care unit, to determine the effect of selective gut decontamination on the persistence of this organism, and to explore the possible relationship between H. pylori infection and stress ulcer bleeding incidence. MATERIALS AND METHODS: We determined in a prospective observational study of 300 consecutive, mechanically ventilated patients the activity of H. pylori infection and the incidence of stress ulcer-related upper gastrointestinal bleeding over time. H. pylori infection was detected by Laser-Assisted Ratio Analyzer (LARA)- (13)C-urea breath test (Alimenterics, Inc., NJ) and serology. Stress ulcer prophylaxis was not prescribed. Endoscopy was performed in cases of upper gastrointestinal bleeding. RESULTS: The prevalence of active H. pylori infection on admission was 38% as detected by urea breath test, and declined to 8% on the third day, and to 0% on the seventh day after admission as a result of antibiotic treatment. Stress ulcer-related upper gastrointestinal bleeding occurred in 1.0% (3 of 300) of the patients; none were infected with H. pylori on admission or at the time of bleeding. CONCLUSIONS: H. pylori infection monitored by LARA- (13)C-urea breath test was rapidly suppressed during intensive care treatment, which can be explained by the routine use of antibiotics for gut decontamination.The low incidence of stress ulcer-related bleeding might be related to the prevention of H. pylori-associated stress lesions by effective suppression of this microorganism, but further studies are warranted to test this hypothesis.

Breath Tests↗
PubMed2001

Gut decontamination of critically ill patients reduces Helicobacter pylori acquisition by intensive care nurses.

The prevalence of Helicobacter pylori is increased in healthcare workers and in intensive care nurses. Exposure to H. pylori from gastric secretions and faeces are probably the main sources of transmission to healthcare workers. Routine use of selective decontamination of digestive tract (SDD) in an intensive care unit suppresses H. pylori in critically ill patients. It was questioned whether this suppression and the subsequent decreased exposure to H. pylori for intensive care nurses would lead to a lower prevalence of H. pylori infection. Helicobacter pylori infection prevalence in intensive care nurses from a unit routinely using SDD (group I) was compared to that of nurses from a unit not using SDD (group II). Heathcare workers from other departments of the hospital where no SDD was used (group III) served as a control group. Persons using proton pump inhibitors were excluded. Helicobacter pylori was detected by Laser Assisted Ratio Analyser(13)C-urea breath test (UBT) and serology. This could not be performed in three out of 64 in group I, five out of 55 in group II and five out of 55 in group III (total UBTs = 169). The prevalence of H. pylori infection was 11% (7/61) in group I and 25.5% (14/50) in group II (P= 0.027). In group III, the prevalence of H. pylori infection was 16% (8/45), which was not significantly different from both group I and II. Sero-prevalence in group I was 18.6%, 27% in group II (ns) and 24% in group III. Mean age in the three groups was 35.9, 37.8 and 36.6 years, respectively (ns). In conclusion, the prevalence of H. pylori infection among intensive care nurses is lower in nurses from a unit using SDD compared to a non SDD-using unit. Acquisition of H. pylori by transmission from critically ill patients appears to be diminished through SDD use.

Adult↗
PubMed2001

Selective decontamination of the digestive tract as infection prevention in the critically ill. Does it lead to resistance?

Several meta-analysis showed the efficacy of selective decontamination of the digestive tract (SDD) in the reduction of infections in critically ill patients, particularly for ventilator associated pneumonia and bloodstream infections, thereby reducing mortality and morbidity. The principle of SDD is that by means of application of non-absorbable antibiotics in the intestinal canal and oropharyngeal cavity, potentially pathogenic microorganisms are eliminated, thereby reducing the incidence of organ site infections. The endogenous anaerobic flora is preserved as a factor contributing to defence against colonization. The potential induction of antibiotic resistance (AR) due to SDD is a major concern in ICU. This review evaluates the onset of clinically relevant AR after SDD. The results of a recent meta-analysis and of several studies, which confirmed the virtual absence of any reported AR with SDD and that did not find AR after stopping SDD, are presented. The eradication of the reservoir of abnormal bacteria located in the gut by topical non-absorbable antibiotics appears to significantly reduce morbidity, mortality and resistance. Using only systemic antibiotics in ICU may contribute to maintain an abnormal population of bacteria among which AR is encouraged.

Acute Disease↗
PubMed2000

In vitro susceptibility of Helicobacter pylori to, and in vivo suppression by, antimicrobials used in selective decontamination of the digestive tract.

The incidence of bleeding related to stress ulcers is reduced in critically ill patients in whom gut decontamination has been performed; this may be a result of suppression of Helicobacter pylori infection. We determined the susceptibility of H. pylori to the applied antibiotics. In nine of 10 critically ill patients (using intravenous cefotaxime and topical polymyxin, tobramycin and amphotericin B (PTA) given by nasogastric tube) and all six volunteers (using PTA alone), H. pylori was suppressed as long as the topical antibiotics were ingested. The in vitro studies revealed that all strains were susceptible to cefotaxime and tobramycin. The strains were not susceptible to polymyxin or amphotericin B.

Administration, Topical↗