Faculty Bibliography

Background:In hospital settings, inadequate recognition of futility of aggressive medical management in patients with terminal disease and lack of the timely transition to palliative care may lead to both excessive and potentially harmful treatment and unnecessary burden on hospital resources. In order to better understand the outcomes of futile medical management and recognize the need for more appropriate end-of-life care, we evaluated the survival of particularly vulnerable cohort of patients in a community hospital who had survived at least 1 cardiorespiratory arrest (CRA) but whose medical problems led to subsequent arrests. METHODS: In this retrospective cohort study, we have reviewed the annual cardiopulmonary resuscitation (CPR) data in a community hospital in urban settings. RESULTS: Analyzing the population of all patients who had CRA, 22.4% had more than 1 CRA episode and had multiple CPRs (42% of all inpatient CPR were performed on this group of patients). Overall survival at the discharge of patients who had single CRA is significantly better than survival at the discharge of patients who had more than 1 CRA episode (31% vs 4.5%). Only 18.5% of the patients who initially survived CPR after CRA were transitioned to "do not resuscitate" status subsequently, while vast majority had continued aggressive resuscitative efforts.Conclusion:Adjusting medical care based on futility assessment in patients with chronic illness who survive CRA is often neglected, but crucially relevant step in the optimization of health care system management.

An 85-year-old-woman presenting with low back pain developed shortness of breath and right-sided chest pain. She was found to have perfusion defects indicative of pulmonary embolus (PE). Heparin was at first employed, but had to be discontinued because of gastrointestinal bleeding. Caval filtration was the obvious course, but it was found on computed tomography (CT) scan that the suprarenal portion of the inferior vena cava was 55 mm in diameter, and the infrarenal portion 44 mm. These measurements were too large for insertion of a Greenfield filter, for which the maximum diameter should be 28 mm. The right common iliac vein was 28 mm in diameter, and the left external iliac vein 25 mm. Two filters were inserted percutaneously in these vessels. The patient was followed for 9 months. No clinical evidence of recurrent PE or venous insufficiency occurred

In a retrospective review, a group of seven patients were found to have a sputum culture positive for Hafnia alvei. Hafnia alvei is a Gram-negative enteric and oropharyngeal bacillus and usually is nonpathogenic. All our patients had a chronic underlying illness and one of the patients was endotracheally intubated at the time of the isolation of this organism. Six of seven patients had other organisms isolated along with H alvei, and only one patient had a pure growth of H alvei confirmed by a culture obtained from a bronchoscopic protected brush specimen. All isolates displayed resistance to conventional antibiotics including cephalosporins and penicillins. Although rare, H alvei may be a potential pathogen in a patient with a chronic underlying illness

We report a case of a 47-year-old man with AIDS who presented with fever, cough and a lingular infiltrate. Flexible fiberoptic bronchoscopy revealed an endobronchial exophytic mass with extensive purulent exudate which on Gram stain and cytology from bronchial washings revealed Actinomyces infection. There was a clinical response to penicillin therapy, and on repeat bronchoscopic examination, there was a partial resolution of the endobronchial infection. To our knowledge, this is the first known case of endobronchial pulmonary actinomycosis in a patient with AIDS.

The role of Aspergillus species as a pathogen in acquired immunodeficiency syndrome (AIDS) has not been clearly defined. From 1984 to 1989, more than 2,000 AIDS patients were seen at Beth Israel Medical Center, New York. Aspergillus was isolated in ten patients; seven had invasive disease and three had noninvasive disease. Invasive pulmonary aspergillosis (IPA) was diagnosed in six patients and invasive renal aspergillosis was found in one patient. Five were homosexual men and two were intravenous drug users. At presentation, all ten had fever, seven had cough, eight had dyspnea, and five had pleuritic chest pain. Chest roentgenograms revealed focal infiltrates in six patients, bilateral interstitial infiltrates in two patients, and bilateral pneumothoraces in one patient. Predisposing conditions included corticosteroid therapy in four, granulocytopenia (less than 1,000/cu m) in two, and broad-spectrum antibiotic therapy in five. Three of the four patients receiving corticosteroids received them as adjuvant therapy for Pneumocystis carinii pneumonia (PCP). Aspergillus was identified antemortem in eight patients, in bronchoalveolar lavage (BAL) fluid in six, in transbronchial biopsy specimen in three, in open lung biopsy specimen in one, and postmortem in one patient. Six of seven patients had at least one concomitant pulmonary process. Six underwent necropsy and findings showed IPA in three, disseminated aspergillosis in two, and PCP in one. Invasive aspergillosis, although significant, is uncommon in AIDS. When Aspergillus is isolated in the setting of corticosteroid therapy, antibiotics, or granulocytopenia, one must suspect invasive disease.

UNLABELLED:We compared flow-by ventilation (FB) via the Puritan-Bennett 7200a ventilator with T-piece ventilation (TP) during weaning from mechanical ventilation (MV). METHODS:We placed 22 consecutive postsurgical patients being weaned from MV on FB at base flows of 10 L/min and 20 L/min and then on TP. Blood pressure, pulse rate, respiratory rate, blood gases, tidal volume, and peak inspiratory flow were measured after at least 20 min in each mode. Statistical analysis of clinical status used a three-level, one-way analysis of variance with technique as a within-subjects factor. Setup costs of the three ventilatory modes were evaluated using relative value units for labor plus actual costs of added equipment and supplies. RESULTS:Although there was a statistically significant difference in PaCO2 among the ventilatory modes, this was not clinically important. No other differences were found. Each FB mode cost $2.55 to set up, whereas TP cost $11.90. CONCLUSIONS:FB and TP were clinically equivalent. However, the alarm and monitoring capabilities during FB are useful and may be worth the one-time cost ($1,000) of adding the optional flow-by software to the 7200a ventilator.

Pulmonary actinomycosis is a rare clinical entity. It may arise primarily from aspiration of infected oropharyngeal material or secondarily from contiguous spread of cervicofacial or abdominal infection. We report the case of an HIV-seropositive patient with a two-week history of fever, a productive cough, and pleuritic chest pain. Chest x-ray revealed bilateral patchy alveolar infiltrates. Histological examination of transbronchial biopsy specimens revealed acute inflammation and granules with radiating gram-positive filaments with clubbed ends consistent with actinomycosis. The patient responded to intravenous penicillin and is currently well on long-term enteral antibiotic therapy.