PURPOSE:

Pulmonary vascular dysfunction is common during acute respiratory distress syndrome (ARDS), but there is controversy concerning prevalence and prognosis of cor pulmonale during protective ventilation for ARDS.

METHODS:

This was a prospective observational study in an academic medical intensive care unit in France. Two hundred and twenty-six consecutive patients with moderate to severe ARDS (Berlin definition) ventilated with plateau pressure limited at 30 cmH2O (mean PEEP of 8.8 ± 3.6 cmH2O) underwent transesophageal echocardiography (TEE) within the first 3 days after the diagnosis of ARDS. Cor pulmonale was defined as a dilated right ventricle associated with septal dyskinesia.

RESULTS:

Cor pulmonale was detected in 49 patients (prevalence of 22 %; 95 % confidence interval, 16-27 %). Multivariate logistic regression identified infectious causes of lung injury and higher driving pressures as independent factors associated with cor pulmonale. Patients with cor pulmonale exhibited a higher incidence of shock (need for vasoactive drug) at the time of TEE and were more often managed with prone positioning and/or nitric oxide as adjunctive therapy for severe hypoxemia during ARDS course. The 28-day mortality rate was significantly higher in the group with cor pulmonale (60 vs. 36 %, p < 0.01). Multivariate logistic regression identified McCabe and Jackson class, lung injury not related to pneumonia, aspiration, or sepsis, lactic acidosis, driving pressure, and cor pulmonale as independent risk factors for 28-day mortality.

CONCLUSION:

Cor pulmonale occurrence is not negligible in ARDS patients ventilated with airway pressure limitation. Cor pulmonale was associated with sepsis and higher values of driving pressure and was an independent risk factor for 28-day mortality in our series.

BACKGROUND:

Incidence of aspiration pneumonia in hospital-acquired pneumonia and community-acquired pneumonia is high; however, many features of this disease remain imprecise. Our objective was to characterize the microbial etiology and their antibiotic resistance and to determine the prognostic factors in aspiration pneumonia among patients admitted to a respiratory intensive care unit (RICU).

METHODS:

A prospective survey was conducted in 112 patients exhibiting hospital-or community-acquired aspiration pneumonia in the RICU of a provincial general hospital from 2010-2012. Bronchoalveolar lavage sampling was collected, and then followed by standard culture and drug-sensitive test. Risk factors were analyzed by multivariate logistic analysis.

RESULTS:

One hundred twenty-eight strains were isolated in 94 patients, gram-negative bacilli (57.8%) was the predominant cultured microorganism, followed by fungus (28.9%) and gram-positive cocci (13.3%). The 5 main isolated bacteria demonstrated high and multiantibiotic resistance. The crude overall mortality was 43.8%, 50%, and 40%, respectively, in hospital- and community-acquired aspiration pneumonia group. Multivariate logistic analysis identified age older than 65 years, use of inotropic support, and ineffective initial therapy as independent risk factors of poor outcome.

CONCLUSIONS:

The predominant pathogenic bacteria of aspiration pneumonia in patients admitted to an RICU were antibiotic-resistant bacteria, and effective initial supportive management secured better prognosis.

BACKGROUND

CONTEXT:

Pedicle screws have shown to be a safe and effective method of spinal fixation, offering superior multiplanar correction compared with hooks or sublaminar wires in selected situations. Though only food and drug administration (FDA) approved in the adolescent population, they are commonly used in an off-label manner in the preadolescent population.

PURPOSE:

To determine if the complication rate of the off-label use of pedicle screws for spinal fixation in the preadolescent 0- to 12-year-old population is comparable with the complication rate in the FDA-approved 13- to 18-year-old population.

STUDY DESIGN

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SETTING:

Retrospective medical record and radiograph review. PATIENT SAMPLE: A total of 726 pediatric patients who underwent a spinal fusion procedure at a single tertiary institution between January 2003 and December 2008 were reviewed.

OUTCOME MEASURES:

Incidence of instrumentation failure, infection, neurological complication, and total complications.

METHODS:

The study population was divided into two groups based on age: the younger group included 0- to 12-year olds and the older group included 13- to 18-year olds at the time of surgery. Groups were further subdivided based on diagnosis: "A," neuromuscular scoliosis; "B," idiopathic scoliosis, and "C," other spinal deformities. Rates of neurovascular complications, infections, and instrumentation complications were compared statistically between the younger and the older groups. Only patients with greater than or equal to 1-year follow-up and greater than or equal to 2-year follow-up were included in the calculations for infection and instrumentation complication rates, respectively.

RESULTS:

There were 206 patients (33% males, 67% females) in the younger group (0 to 12 years) and 520 (41% males, 59% females) in the older group (13 to 18 years). Overall, younger group had a 13.6% complication rate compared with 16.9% in the older group. Younger subjects showed a 13.4% complication rate because of instrumentation-related complications, 0.5% for neurovascular complications, and an infection rate of 9.2%. The older group showed a 15.4% complication rate because of instrumentation-related complications, 1.92% for neurovascular complications, and an infection rate of 11.0%. Complication rates were statistically insignificant between the two groups. Other complications in the younger group included one patient with aspiration pneumonia, two with ileus, and one with pulmonary and other complications in the older group included one patient with aspiration pneumonia, two with ileus, three with superior mesenteric artery syndrome, and three with wound dehiscence.

CONCLUSIONS:

The complication rates in the young pediatric population associated with the off-label use of pedicle screws for spinal fusions are not statistically different from the complication rates associated with the FDA-approved adolescent population.

Propolis is a resinous substance collected by bees as a sealant for their hives. It is also used in traditional medicine as an antioxidant and antiinflammatory agent to treat ulcers, superficial burns, and microbial diseases. In this report, a 40-year-old woman who took liquid propolis for relief of her common cold experienced severe sore throat, dysphagia, and easy choking followed by fever and chills. Descending necrotizing mediastinitis and concomitant aspiration pneumonia were evident on the image studies. We performed video-assisted thoracoscopic surgery to achieve immediate and adequate drainage, and the patient resumed normal deglutition 2 months later. Early diagnosis and prompt video-assisted thoracoscopic surgery intervention are paramount to manage this life-threatening situation.

The risk of central line associated blood stream infections (CLABSI) related to cooling catheters used for therapeutic hypothermia (TH) is unclear.We performed a retrospective analysis on 131 cardiac arrest survivors between 2007 and 2010, who underwent TH by femorally placed endovascular cooling catheter. All patients received prophylactic intravenous ampicillin-sulbactam for 72 hours to reduce the risk of aspiration pneumonia. Cooling catheter related CLABSI and other infections over a period of seven days from initiation of TH were estimated.Of a total 131 patients, 16 (12%) patients had bacteremia or infection prior to initiation of TH and were excluded. Of the remaining 115 (88%) patients, zero (0%) patients had cooling catheter related CLABSI and 23 (20%) patients had other infections during the study period.In cardiac arrest survivors undergoing TH, femorally placed endovascular cooling catheter is not associated with an increased incidence of CLABSI.

The treatment of ventilator-associated pneumonia (VAP) secondary to methicillin-resistant Staphylococcus aureus (MRSA) remains controversial.We performed a review of all blunt trauma patients diagnosed with MRSA VAP from June 2005 to June 2011. VAP for the first 3 years was diagnosed by sputum aspiration and treated with vancomycin. For the last 3 years of the study period, VAP was diagnosed with bronchoalveolar lavage and treated with linezolid.MRSA VAP patients treated with vancomycin had an average hospital length of stay (LOS) of 49 days (range 9-99 days), an average intensive care unit (ICU) LOS of 43 days (range 6-98 days), and average ventilator days of 34.4 (range 3-76 days). Seventeen MRSA VAP patients treated with linezolid had an average hospital LOS of 27 days (range 11-61), an average ICU LOS of 22 days (range 10-42) days, and average ventilator days of 16.6 (range 2-42).Trauma patients who develop MRSA VAP appear to have fewer ventilator days and shorter ICU and hospital LOS when treated with linezolid.

Healthcare-associated pneumonia (HCAP) may have a more severe course than community-acquired pneumonia (CAP); hence, it is more likely to be caused by drug-resistant bacterial pathogens and anaerobes involved in aspiration pneumonia. We compared the efficacy and safety of initial empiric therapy with piperacillin/tazobactam (PIPC/TAZ, 13.5 g/day) with that of meropenem (MEPM, 1.5 g/day) as single broad-spectrum regimens with gram-negative and anaerobic coverage in patients with HCAP in Japan. The clinical cure rate was 75.9 % (22/29 cases) in the PIPC/TAZ group and 64.3 % (18/28 cases) in the MEPM group. The clinical efficacy rate was 87.9 % (29/33 cases) in the PIPC/TAZ group and 74.2 % (23/31 cases) in the MEPM group. The bacteriological eradication rate was 94.4 % (17/18) in the PIPC/TAZ group and 87.5 % (14/16) in the MEPM group. Adverse drug reactions were seen in 22.4 % (11/49 cases) of patients in the PIPC/TAZ group and 17.4 % (8/46 cases) of patients in the MEPM group. Although not statistically different, the PIPC/TAZ group had a slightly higher efficacy rate than the MEPM group. Both treatment regimens are tolerable and might be appropriate to use as initial empiric therapy for HCAP in Japan. To investigate the differences in efficacy profiles of those two regimens, a further confirmatory study with a larger cohort as determined by a power analysis is recommended.

Parkinson disease (PD) is a neurodegenerative disease primarily characterized by cardinal motor manifestations and CNS pathology. Current drug therapies can often stabilize these cardinal motor symptoms, and attention has shifted to the other motor and nonmotor symptoms of PD that are resistant to drug therapy. Dysphagia in PD is perhaps the most important drug-resistant symptom because it leads to aspiration and pneumonia, the leading cause of death. Here, we present direct evidence for degeneration of the pharyngeal motor nerves in PD. We examined the cervical vagal nerve (cranial nerve X), pharyngeal branch of nerve X, and pharyngeal plexus innervating the pharyngeal muscles in 14 postmortem specimens, that is, from 10 patients with PD and 4 age-matched control subjects. Synucleinopathy in the pharyngeal nerves was detected using an immunohistochemical method for phosphorylated α-synuclein. Alpha-synuclein aggregates were revealed in nerve X and the pharyngeal branch of nerve X, and immunoreactive intramuscular nerve twigs and axon terminals within the neuromuscular junctions were identified in all of the PD patients but in none of the controls. These findings indicate that the motor nervous system of the pharynx is involved in the pathologic process of PD. Notably, PD patients who have had dysphagia had a higher density of α-synuclein aggregates in the pharyngeal nerves than those without dysphagia. These findings indicate that motor involvement of the pharynx in PD is one of the factors leading to oropharyngeal dysphagia commonly seen in PD patients.

The Japanese guidelines for nursing- and healthcare-associated pneumonia (NHCAP) categorize patients by risk of resistant bacteria and defined antimicrobials to be used, similar to the healthcare-associated pneumonia (HCAP) guidelines of the United States. The data were collected in large-scale hospitals, possibly a cause of inconsistency with everyday practice in medium-sized community hospitals. To test the feasibility of this guideline based on a retrospective study performed in a medium-sized community hospital in Japan, the medical records of pneumonia patients were retrospectively studied [718 patients: NHCAP, 477, 66.4 %; community-acquired pneumonia (CAP), 241, 33.4 %). Factors related to patients' background, clinical and laboratory findings, treatment, and outcome were compared between NHCAP and CAP. The A-DROP system, scored by age, dehydration, respiratory failure, disorientation, and low blood pressure, evaluated the severity of pneumonia. In contrast to CAP patients, NHCAP patients included more elderly patients requiring nursing care and revealed higher rates of poor nutrition, dementia, aspiration, severe cases, detection of drug-resistant bacteria, and mortality. For NHCAP, the success rate did not differ between those receiving and not receiving proper initial treatment (76.9 vs. 78.5 %) nor did mortality rate within 30 days differ (13.1 vs. 13.8 %). Risk factors for mortality within 30 days for NHCAP were diabetes [adjusted odds ratio (AOR) 2.394, p = 0.009], albumin <2.5 g/dl (AOR 2.766, p = 0.002), A-DROP very severe (AOR 1.930, p = 0.021), and imaging showing extensive pneumonia (AOR 2.541, p = 0.002). The severity of pneumonia rather than risk of resistant bacteria should be considered, in addition to ethical concerns, in initial treatment strategy in NHCAP to avoid excessive use of broad-spectrum antimicrobials.

To characterize overall and cause-specific mortality and life expectancy among persons who have completed inpatient traumatic brain injury rehabilitation and to assess risk factors for mortality.Prospective cohort study.The Traumatic Brain Injury Model Systems.A total of 8573 individuals injured between 1988 and 2009, with survival status per December 31, 2009, determined.Not applicable.Standardized mortality ratio (SMR), life expectancy, cause of death.SMR was 2.25 overall and was significantly elevated for all age groups, both sexes, all race/ethnic groups (except Native Americans), and all injury severity groups. SMR decreased as survival time increased but remained elevated even after 10 years postinjury. SMR was elevated for all cause-of-death categories but especially so for seizures, aspiration pneumonia, sepsis, accidental poisonings, and falls. Life expectancy was shortened an average of 6.7 years. Multivariate Cox regression showed age at injury, sex, race/ethnic group, marital status and employment status at the time of injury year of injury, preinjury drug use, days unconscious, functional independence and disability on rehabilitation discharge, and comorbid spinal cord injury to be independent risk factors for death.There is an increased risk of death after moderate or severe traumatic brain injury. Risk factors and causes of death have been identified that may be amenable to intervention.