Patients In Poor Clinical Condition Research Articles

Therapeutic management of grade IV aneurysm patients

The timing of surgery in patients suffering from subarachnoid hemorrhage grade IV and V according to Hunt and Hess, is still controversial. Several authors advocate early surgery for patients in poor clinical condition. Improved outcome and decreased mortality rates were reported. Others exclude patients in poor condition from early aneurysm surgery. Forty grade IV aneurysm patients were admitted to our department. After ventriculostomy and cerebral angiography, 28 of them were operated on within 72 hours. The postoperative treatment included hypertensive, hypervolemic, hemodilutional therapy (triple-H therapy) and intensive monitoring (intracerebral pressure, blood pressure, hemodynamic parameters). The mean follow-up time was 6 months. Out of the 28 patients who underwent early surgery, 64% were in good health, 11% in poor health, 25% died; there were no survivors in a vegetative state. Twelve patients were treated conservatively; 50% died from infarction and rebleeding, before the operation was performed. Six underwent delayed aneurysm surgery after clinical improvement. In this group, 25% had good clinical outcome. Our results favor an aggressive treatment of grade IV aneurysm patients by means of ventricular drainage, early surgery and triple-H therapy.

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Surgical Considerations in Cerebral Amyloid Angiopathy

Abstract In cerebral amyloid angiopathy, the contractile elements of the leptomeningeal and cortical arteries are replaced by noncontractile amyloid beta protein. The incidence of amyloid angiopathy increases with advancing age. It is associated with Alzheimer's disease and spontaneous cerebral hemorrhage. The latter can have the characteristic acute computed tomographic appearance of a hematoma at the cortex-white matter junction with extension of blood into the subarachnoid, subdural, and intraventricular spaces. Multiple hemorrhages are frequent. Additional bleeding can occur after evacuation of the hematoma, and postoperative hemorrhage can occur after cortical biopsy. To elucidate the role of surgery in this condition, we have reviewed 20 consecutive operated cases of cerebral amyloid angiopathy. A first group of 8 patients with senila dementia underwent cortical biopsy without resultant hemorrhage. A second group of 6 patients in good clinical condition had delayed evacuation of a spontaneous cerebral hematoma from cerebral amyloid angiopathy because of the radiological misdiagnosis of a hemorrhage within a tumor. One patient died of a pulmonary embolism, and another had subsequent multiple hemorrhages that were ultimately fatal. A third group of 6 patients in poor neurological condition had the acute evacuation of a spontaneous cerebral hematoma to relieve intracranial hypertension. All died or were severely disabled. One had repeated hemorrhages which added a progressively more severe organic dementia onto an initial hemiplegia. We conclude that acute evacuation of a spontaneous cerebral hematoma from amyloid angiopathy patients in poor clinical condition results in a high mortality and morbidity, that delayed surgery in patients in good condition is better tolerated, and that cortical surgery in the absence of a cerebral hemorrhage can be accomplished relatively safely with meticulous attention to hemostasis. The outcome of surgery is a function of both the severity of the cerebral amyloid angiopathy and the extent of the hemorrhage that it produces, especially as it involves multiple lobes and extends into the ventricles or subdural space. Survivors remain at risk for hemorrhages that are progressively more disabling.

Pseudomonas aeruginosa variants isolated from patients with cystic fibrosis are killed by a bactericidal protein from human polymorphonuclear leukocytes

The susceptibility of paired mucoid and nonmucoid variants of Pseudomonas aeruginosa isolated from 13 patients with cystic fibrosis (CF) to killing by a 55,000-Da bactericidal protein (BP55) from human polymorphonuclear leukocytes was studied. Mucoid and nonmucoid variants were equally sensitive to killing by BP55 at both pH 5.6 and pH 7.2. Eleven of the isolates were resistant to the bactericidal activity of 10% normal human serum but were as sensitive as the serum-sensitive isolates to BP55. Similarly, the 15 isolates with lipopolysaccharides (LPS) containing O-polysaccharide side chains (smooth LPS) were as sensitive to BP55 as those isolates with rough LPS.P. aeruginosa isolates from patients in poor clinical condition were more likely to have LPS of the smooth type and to be resistant to killing by 10% human serum than the isolates from patients in good clinical condition. We have concluded that the susceptibility of the P. aeruginosa isolates from patients with CF to killing by BP55 does not correlate with mucoid or nonmucoid variations, with the presence or absence of smooth LPS, or with the sensitivity or resistance to killing by normal human serum.

Intensive cytoreductive therapy followed by autologous bone marrow transplantation for patients with hematologic malignancies or solid tumors.

Fifty patients were studied. Twenty patients with non-Hodgkin's lymphomas (NHL) of high-grade malignancy and 21 patients with acute leukemia (AL) were treated with high-dose cyclophosphamide and total body irradiation, and three patients with Hodgkin's disease (HD) and six patients with solid tumors were treated with high-dose cyclophosphamide and VP16-213. Those procedures were followed by autologous bone marrow transplantation (ABMT). All patients had received conventional chemo(radio)therapy before the ABMT procedure. Although remissions were obtained in patients with cytotoxic drug-resistant diseases (lymphomas and solid tumors), none has become a long-term survivor, as occurred also in patients with solid tumors in partial remission (PR). Two of five patients with NHL in PR at the time of ABMT have become long-term disease-free survivors (28+, 56+ months). Ten patients with NHL were treated in complete remission (CR) and seven are in unmaintained CR; four with long follow-up (14+ to 59+ months). All patients with AL were treated in CR; two patients received ABMT in second CR, and both relapsed. Ten of nineteen patients in first CR relapsed; eight are alive in CR, five with long follow-up. Four deaths were therapy-related, all were patients in poor clinical condition. Intensive cytoreductive therapy followed by ABMT can produce prolonged disease-free survival (and probably cure) in a fair number of patients with poor risk NHL in CR and PR and probably also in patients with acute myeloblastic leukemia in first CR. This procedure was not successful in achieving long-term disease-free survival in patients with refractory lymphomas or solid tumors.

Avirulence and altered physiological properties of cystic fibrosis strains of Pseudomonas aeruginosa.

Twenty Pseudomonas aeruginosa strains isolated from patients with cystic fibrosis in good and poor clinical condition were typed by the American Scientific (Difco Laboratories, Detroit, Mich.) Typing Scheme. Only five strains were agglutinated with a single typing serum. Ten strains were agglutinated with more than one serum, and five were not agglutinated with any serum, suggesting some type of lipopolysaccharide alteration in the majority of these strains. Of the strains from patients in good clinical condition, 72% demonstrated proteolytic activity, while 60% of the strains from patients in poor clinical condition demonstrated no proteolytic activity. Twenty-three cystic fibrosis strains of P. aeruginosa examined demonstrated reduced bacteremic virulence when compared with a virulent burn strain with a 50% lethal dose (LD50) of 1.5 X 10(1) CFU in an invasive burned mouse model. Ninety-two percent of the strains tested were avirulent at doses of 10(3) to 10(5) CFU. The LD50s were determined for 10 selected strains which exhibited specific important morphological and physiological deficiencies. Five of the strains tested gave LD50s greater than 10(6) CFU. Reduced virulence of these strains was associated with loss of two or more physiological characteristics associated with virulence. The cystic fibrosis strains of P. aeruginosa which morphologically and physiologically resembled the virulent burn strain were the most virulent (LD50s of 10(2) to 10(4). Results suggest that some degree of virulence is associated only with classic strains prevalent in early infections. The data suggest that a selection transition occurs in the lungs of patients with cystic fibrosis that favors P. aeruginosa avirulence. The avirulent state may be caused by alterations in the cell envelope, including associated factors such as motility and chemotaxis and protease production.

Cerebrovascular reactivity in patients with ruptured intracranial aneurysms.

The cerebral vasomotor reactivity to arterial hypotension and hypocapnia was studied in 34 patients between the 3rd and 13th day after rupture of an intracranial saccular aneurysm. Using the intra-arterial xenon-133 injection method, regional cerebral blood flow (rCBF) and cerebral metabolic rate of oxygen (CMRO2) were measured. The intraventricular pressure and cerebrospinal fluid (CSF) lactate and pH levels were determined. The degree of vasospasm was measured on angiograms taken immediately following the rCBF study. The patients were graded clinically according to the system of Hunt and Hess. Cerebral autoregulation was intact in patients in good clinical condition, but was impaired in patients in poor clinical condition. There was a close correlation between the degree of vasospasm and the degree of autoregulatory impairment, which varied from focal disturbances to global impairment. Intracranial hypertension and CSF lactic acidosis were commonly found in association with vasoparalysis. Cerebrovascular response to hyperventilation was generally preserved, although often reduced. During hyperventilation, the cerebral perfusion pressure became elevated, and increases in CMRO2 were often found, even in patients with severe diffuse spasm and cerebral ischemia. The clinical significance of the results in relation to the treatment of delayed cerebral ischemia and to the use of intraoperative induced hypotension is discussed.