2012 June 30

Influenza A 2009 (H1N1) virus in admitted and critically ill patients.

J Intensive Care Med Start a Discussion »

Jun 302012

Influenza A 2009 (H1N1) virus in admitted and critically ill patients.

J Intensive Care Med. 2012 Feb;27(1):25-31

Authors: Miller AC, Subramanian RA, Safi F, Sinert R, Zehtabchi S, Elamin EM

Abstract

INTRODUCTION: The influenza A 2009 (H1N1) virus is a pandemic respiratory infection commanding international attention. More information is needed on patient demographics, illness severity, and risk indicators.

METHODS: A total of 43 patients with H1N1 influenza A 2009 presenting to 2 urban academic medical centers during the first wave were assessed for demographics, triage vital signs, hemograms, and serum chemistries including lactate. Chest X-rays were assessed for infiltrate or effusion. Illness severity markers were recorded including anion gap (AG), strong ion gap (SIG), systemic inflammatory response syndrome score, shock index, confusion, uremia, respiratory rate, blood pressure, and age >= 65 years (CURB-65) score, and pneumonia severity index. Subgroup analysis was performed on asthmatic, pregnant, and intensive care unit (ICU) versus non-ICU patients.

RESULTS: Eighty-one percent of patients were women. Pregnancy (34.8%), asthma (39.5%), diabetes mellitus (18.6%), and sickle cell (6.98%) were the most frequent comorbidities. In all, 91% had positive influenza nasopharyngeal direct antigen test, while 9% tested positive only by viral culture or real-time reverse transcriptase polymerase chain reaction (rRT-PCR); 14% required ICU admission; and 20.8% had infiltrate on chest X-ray. A trend toward greater incidence of ICU admission existed among patients with elevated SIG (P = .08), however contrary to our prior studies in noninfluenza patients, an elevated SIG in the presence of normal AG and lactate measurements did not correlate with ICU admission.

CONCLUSION: A high percentage of patients with H1N1 presented with underlying comorbid conditions including asthma and pregnancy. Traditional markers of pneumonia severity including CURB-65 score, Pneumonia Severity Index (PSI), serum lactate, and AG did not correlate with ICU admission in patients with H1N1. Strong ion gap effectively identified significant acid-base disturbances not identified by lactate or AG, however the trend of greater ICU admission rates among patients with elevated SIG did not reach statistical significance. Further study is needed to identify clinical tools to aid in risk-stratifying H1N1 patients.

PMID: 21300671 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Crystalline nephropathies.

Arch Pathol Lab Med Start a Discussion »

Jun 302012

Crystalline nephropathies.

Arch Pathol Lab Med. 2012 Jul;136(7):713-20

Authors: Herlitz LC, D'Agati VD, Markowitz GS

Abstract

Context.-The kidney is a favored site for crystal deposition because of the high concentration of ions and molecules reached at the level of the renal tubules in the course of filtration. This review focuses on crystalline nephropathies in 4 broad categories: (1) dysproteinemia- associated, (2) drug-induced, (3) calcium-containing, and (4) metabolic or genetic. Objective.-To provide a framework for accurate identification of the diverse types of crystals encountered in the kidney in order to formulate an appropriate differential diagnosis and guide additional testing and treatment. Data Sources.-Review of pertinent published literature along with practical experience gained in a high-volume renal pathology laboratory. Conclusions.-Accurate identification of crystals encountered in the kidney is essential in detecting conditions ranging from hematologic malignancy to drug toxicity to metabolic disorders. Detailed clinical-pathologic correlation is needed to accurately diagnose the underlying cause of most crystalline nephropathies.

PMID: 22742545 [PubMed - in process]

Link to Article at PubMed

Nonneoplastic lesions that simulate primary tumors of bone.

Arch Pathol Lab Med Start a Discussion »

Jun 302012

Nonneoplastic lesions that simulate primary tumors of bone.

Arch Pathol Lab Med. 2012 Jul;136(7):772-88

Authors: Remotti F, Feldman F

Abstract

Context.-The skeletal system may be affected by a variety of nonneoplastic lesions, which may potentially be confused with primary bone tumors on clinical, radiologic, and pathologic grounds. These conditions include fractures, infections, and reactive and degenerative processes, as well as an array of quasineoplastic entities, such as intramedullary cystic lesions like unicameral and aneurysmal bone cysts; fibro-osseous lesions, such as fibrous dysplasia; and exophytic entities, like osteochondromas. Objective.-To review clinical, radiographic, and histologic features of nonneoplastic lesions of bone, discussing the difficulties in diagnosis and the differential diagnosis with primary neoplasms of bone. Data Sources.-The sources include the more relevant medical literature on the different subjects and case-derived material. Conclusions.-Because many nonneoplastic bone lesions may require biopsy or resection, the general surgical pathologist must be familiar with these lesions and be aware that review of hematoxylin-eosin slides is only one of the many steps in the diagnostic process, which also includes review of imaging studies and all available clinical information. Morphologic analysis disconnected from the clinical and radiographic context may lead to misinterpretation.

PMID: 22742550 [PubMed - in process]

Link to Article at PubMed

Ventilator-associated pneumonia and its prevention.

Curr Opin Infect Dis Start a Discussion »

Jun 302012

Ventilator-associated pneumonia and its prevention.

Curr Opin Infect Dis. 2012 Jun 28;

Authors: Bouadma L, Wolff M, Lucet JC

Abstract

PURPOSE OF REVIEW: Given that ventilator-associated pneumonia (VAP) causes substantial morbidity, mortality and costs, prevention of this infectious process is a major challenge. RECENT FINDINGS: This study provides an update on the prevention of VAP, focusing on the ability of preventive measures to improve patient outcomes and concentrating wherever possible on the data published within the past 5 years. Particular attention is be paid to the latest approach to facilitate the implementation of those prevention measures known as 'care bundles'. SUMMARY: Several preventive measures have been shown to reduce the rate of VAP but many less have demonstrated an impact on patient outcomes (noninvasive positive pressure ventilation, sedation and weaning protocols, selective digestive and oral decontamination and endotracheal tube with drainage of subglottic secretions). Patients at risk must be approached with a bundle of preventive measures. Beyond the theoretical frame, a great deal of attention must be given to the factors that might improve adherence to those preventive measures. Future clinical trials testing new strategies in preventing VAP should have patient outcomes (i.e. a reduction in the length under mechanical ventilation, in the duration of stay in healthcare settings or in antibiotic consumption) as primary end-points rather than VAP rates.

PMID: 22744316 [PubMed - as supplied by publisher]

Link to Article at PubMed

Biomarkers of therapy responsiveness in asthma: pitfalls and promises.

clin exp allergy Start a Discussion »

Jun 302012

Biomarkers of therapy responsiveness in asthma: pitfalls and promises.

Clin Exp Allergy. 2011 May;41(5):615-29

Authors: Vijverberg SJ, Koenderman L, Koster ES, van der Ent CK, Raaijmakers JA, Maitland-van der Zee AH

Abstract

Asthma is one of the most common chronic diseases worldwide. There is a large inter-individual variability in response to asthma treatment. Most patients respond well to standard therapy; however, a small proportion of the patients remain symptomatic despite treatment with high dosages of corticosteroids. Uncontrolled asthma leads to a decreased quality of life. Therefore, it is important to identify individuals who will respond poorly to standard asthma medication, especially to standard maintenance therapy with inhaled corticosteroids, at an early stage. Response to anti-inflammatory therapy is generally monitored by the assessment of clinical symptoms, which only partially correlates with underlying airway inflammation. The identification of specific inflammatory biomarkers might help to guide treatment or predict a corticosteroid response more accurately. Some inflammatory biomarkers are already finding their way into clinical practice (e.g. fraction of nitric oxide in exhaled breath), whereas others are predominantly used as a research tool (e.g. profiles of volatile organic compounds). Currently, there is no inflammatory biomarker used in routine clinical practice to predict a corticosteroid response. More knowledge on the underlying biological mechanism(s) of heterogeneous therapeutic responses could help to identify novel biomarkers. This review will focus on inflammatory patterns and genetic variations that may underlie differences in treatment response in patients with asthma, and will provide an overview of inflammatory biomarkers that could potentially serve as response predictors.

PMID: 21488995 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Does concomitant use of paracetamol potentiate the gastroduodenal mucosal injury associated with aspirin? A prospective, randomised, pilot study.

Aliment Pharmacol Ther Start a Discussion »

Jun 302012

Does concomitant use of paracetamol potentiate the gastroduodenal mucosal injury associated with aspirin? A prospective, randomised, pilot study.

Aliment Pharmacol Ther. 2012 Jun 29;

Authors: Boike JR, Kao R, Meyer D, Markle B, Rosenberg J, Niebruegge J, Stein AC, Berkes J, Goldstein JL

Abstract

BACKGROUND: Paracetamol is commonly prescribed for first-line symptomatic treatment in patients with osteoarthritis and aspirin is often co-administered for cardiovascular prophylaxis. It is not known if an interaction exists between aspirin and paracetamol in regards to gastroduodenal mucosal injury. AIM: To investigate whether or not co-administered aspirin with paracetamol results in an increased rate of endoscopic gastroduodenal mucosal injury as compared to either agent alone. METHODS: In this prospective, double-blind, randomised, three-arm, placebo- and active-controlled, parallel-group pilot study healthy adult subjects (18-75ÃÂ years old) with a normal baseline trans-nasal oesophagogastroduodenoscopy (TN-EGD), received oral paracetamol 4000ÃÂ mg q.d.s. (nÃÂ =ÃÂ 21), aspirin 325ÃÂ mg q.d.s. (nÃÂ =ÃÂ 19) or paracetamol 4000ÃÂ mg q.d.s. and aspirin 325ÃÂ mg q.d.s. (nÃÂ =ÃÂ 20). Upper gastrointestinal mucosal injury was evaluated after 7ÃÂ days of treatment with TN-EGD. RESULTS: The rate of gastric ulcers in subjects receiving paracetamol (0/21, 0%) alone or aspirin (3/19, 16%) or both (2/20, 10%) was not different. There were, however, significantly more subjects with one or more lesions (erosion or ulcer) per subject in the paracetamol and aspirin (16/20, 80%) treated subjects as compared to the aspirin (8/19, 42%, PÃÂ <ÃÂ 0.001) or the paracetamol (3/21, 14%, PÃÂ <ÃÂ 0.01) exposed subjects. The mean number of lesions per subject was also greater (7.9 vs. 0.7, PÃÂ <ÃÂ 0.01) in those treated with aspirin and paracetamol compared to paracetamol alone. CONCLUSIONS: Co-administration of paracetamol and aspirin was not associated with a significant difference in endoscopic ulcer rates compared to either drug alone. There was a strong signal for increased endoscopic erosions and ulcers in the combined group compared to either aspirin or paracetamol alone.

PMID: 22742578 [PubMed - as supplied by publisher]

Link to Article at PubMed

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