Rates Of Pneumonia In Patients Research Articles

Etiology and long-term functional swallow outcomes in pediatric unilateral vocal fold immobility

ObjectiveUnilateral vocal fold immobility (UVFI) results in deficits in phonatory, respiratory, and swallow function of the pediatric patient. Little is known about long-term functional swallow outcomes. MethodsMedical records of children diagnosed with UVFI between 2005 and 2014 at a tertiary children's hospital were retrospectively reviewed. Etiology, laryngoscopy findings, and swallow status at diagnosis and follow-up were recorded. Swallow outcomes were compared by etiology using Fisher's exact test. McNemar's test was used to identify correlations between return of mobility and swallow recovery. Rates of pneumonia were compared with initial swallow evaluation results using a two-tailed t-test. ResultsEighty-eight patients with UVFI were identified and 73 patients (47% female, mean age 14.4 months, standard deviation (SD) 26.7 months) had complete medical records. Mean follow up time was 52.7 months (SD 36.8 months). Etiologies included cardiothoracic surgery (68.5%), idiopathic (12.3%), prolonged intubation (11.0%), central nervous system (CNS) abnormality (5.5%), and non-cardiac iatrogenic injury to the recurrent laryngeal nerve (2.7%). Forty-seven patients underwent a follow up laryngoscopy, and recovery of vocal fold (VF) mobility was documented in 42.6% (20/47). At diagnosis, 31.5% fed orally, compared with 79.5% at follow-up. Direct correlation between recovery of VF mobility and swallow recovery was not demonstrated. Cardiac etiologies demonstrated higher rates of swallow recovery than CNS abnormalities (p = 0.0393). Twenty-five children aspirated on initial modified barium swallow (MBS) and 10 children developed pneumonias at some point during the follow up period. There was no significant difference in rates of pneumonia in patients with and without aspiration on MBS. ConclusionRecovery of swallow in children with UVFI does not directly parallel return of VF mobility. Long-term swallow outcome is favorable in this population. Initial MBS does not indicate ultimate swallow outcome.

Hydrocortisone prevents immunosuppression by interleukin-10+ natural killer cells after trauma-hemorrhage.

Trauma induces a state of immunosuppression, which is responsible for the development of nosocomial infections. Hydrocortisone reduces the rate of pneumonia in patients with trauma. Because alterations of dendritic cells and natural killer cells play a central role in trauma-induced immunosuppression, we investigated whether hydrocortisone modulates the dendritic cell/natural killer cell cross talk in the context of posttraumatic pneumonia. Experimental study. Research laboratory from an university hospital. Bagg Albino/cJ mice (weight, 20-24 g). First, in an a priori substudy of a multicenter, randomized, double-blind, placebo-controlled trial of hydrocortisone (200 mg/d for 7 d) in patients with severe trauma, we have measured the blood levels of five cytokines (tumor necrosis factor-α, interleukin-6, interleukin-10, interleukin-12, interleukin-17) at day 1 and day 8. In a second step, the effects of hydrocortisone on dendritic cell/natural killer cell cross talk were studied in a mouse model of posttraumatic pneumonia. Hydrocortisone (0.6 mg/mice i.p.) was administered immediately after hemorrhage. Twenty-four hours later, the mice were challenged with Staphylococcus aureus (7 × 10 colony-forming units). Using sera collected during a multicenter study in patients with trauma, we found that hydrocortisone decreased the blood level of interleukin-10, a cytokine centrally involved in the regulation of dendritic cell/natural killer cell cluster. In a mouse model of trauma-hemorrhage-induced immunosuppression, splenic natural killer cells induced an interleukin-10-dependent elimination of splenic dendritic cell. Hydrocortisone treatment reduced this suppressive function of natural killer cells and increased survival of mice with posthemorrhage pneumonia. The reduction of the interleukin-10 level in natural killer cells by hydrocortisone was partially dependent on the up-regulation of glucocorticoid-induced tumor necrosis factor receptor-ligand (TNFsf18) on dendritic cell. These data demonstrate that trauma-induced immunosuppression is characterized by an interleukin-10-dependent elimination of dendritic cell by natural killer cells and that hydrocortisone improves outcome by limiting this immunosuppressive feedback loop.

Effectiveness of epidural analgesia in enhanced recovery protocols following colorectal surgery

Effectiveness of epidural analgesia in enhanced recovery protocols following colorectal surgery

Impact of Pneumococcal Vaccination on Pneumonia Rates in Patients with COPD and Asthma

BackgroundPatients with chronic obstructive pulmonary disease (COPD) are included in several national pneumococcal vaccination recommendations whereas asthma patients are not. The objective of this study was to evaluate pneumonia-related hospitalization risk in patients with COPD or asthma and vaccination impact.MethodsWe identified patients with documented pneumococcal vaccination from a cohort of veterans with either a diagnosis of asthma or COPD and their matched controls. Patients were identified between October 1, 1997 and September 30, 1998 and followed for 5 years. For each group we identified pneumococcal pneumonia hospitalizations and all pneumonia-related hospitalizations in the periods before and after vaccination. We estimated hospitalization rates and compared rates in the asthma and COPD groups to controls using negative binomial regression models.ResultsWe identified 16,074 COPD patients (average age 65.8 years), 14,028 controls for the COPD patients (average age 67.5 years), 2,746 asthma patients (average age 53.0 years), and 1,345 controls for the asthma patients (average age 59.2 years). Compared to controls, the adjusted risk of pneumococcal pneumonia hospitalizations before pneumococcal vaccination was COPD = 8.02 (95% CI, 4.44–14.48) and asthma = 0.76 (0.17–3.53). For any pneumonia-related hospitalization, the adjusted risk was COPD = 3.91 (3.40–4.50) and asthma = 1.45 (0.85–2.46). After vaccination, events decreased in all groups. The adjusted risk for pneumococcal pneumonia hospitalizations postvaccination was COPD = 3.87 (2.55–5.88) and asthma = 0.30 (0.04–1.99). For any pneumonia-related hospitalization the adjusted risk was COPD = 3.71 (3.33–4.13) and asthma = 0.79 (0.50–1.25).ConclusionsThis study supports the value of vaccinating COPD patients; however, the value of vaccination for asthma patients is less certain.

Implementing the International Liaison Committee on Resuscitation guidelines on hypothermia after cardiac arrest. The German experience: still a long way to go?

Two prospective randomised landmark trials were recently published comparing mild hypothermia for 12–24 hours with normothermia in comatose patients who had survived out-of-hospital cardiac arrest [1,2]. In 2003 the International Liaison Committee on Resuscitation ALS Task Force published the following recommendations [3] on the basis of the aforementioned evidence: unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32–34°C for 12–24 hours when the initial rhythm was ventricular fibrillation; and such cooling may also be beneficial for other rhythms or inhospital cardiac arrest. Recent evidence, however, suggests that the implementation of guidelines and scientific evidence in clinical routine is very difficult. This fact is circumstantiated by a recently published study reporting a wide variation in the management of acute respiratory distress syndrome that appears to be related to limited awareness of relevant research and adherence to local practice patterns [4]. We therefore conducted a telephone survey to address the implementation of the International Liaison Committee on Resuscitation guidelines in anesthesiological intensive care units in Germany in spring 2005. We either called the head of the department or the head of the intensive care unit of all 39 university hospital departments of anesthesiology and intensive care medicine in Germany. Twenty-eight out of these 39 (71.8%) departments provided information on their management of hypothermia after cardiac arrest in this telephone survey. We asked three simple questions: Do you treat patients after cardiac arrest in your intensive care unit? Do you use therapeutic hypothermia in patients after cardiac arrest? Do you have written standard operating procedures for therapeutic hypothermia after cardiac arrest? In the intensive care units of those departments responding to our survey, a median of 1900 patients (interquartile range, 1000–2500) were treated per year. The median proportion of ventilated patients was 73% (interquartile range, 60–83). Twenty-six out of 28 (92.9%) intensive care units treated patients after cardiac arrest. Sixteen of these 26 (61.5%) departments were not using therapeutic hypothermia. Only 10 departments out of 26 treating patients after cardiac arrest (38.5%) were using therapeutic hypothermia. Eight out of 26 (30.8%) departments had written standard operating procedures (SOP) for therapeutic hypothermia, eight out of 26 (61.5%) had no written SOP and two out of 26 (7.7%) did not provide information on this topic. The low proportion of university intensive care units adhering to published recommendations may be due to several reasons. There might be deep-rooted concern that prolonged mild hypothermia has adverse effects on the immune system, on enzyme function and on the coagulation system. Hypothermia may directly or indirectly impair neutrophil function [5]. Leukocytopenia has been described significantly more frequently in patients with induced mild hypothermia [5]. Some studies reported higher rates of pneumonia in patients treated with mild hypothermia [6]. This was, however, not reported in patients treated with therapeutic hypothermia after out-of-hospital cardiac arrest [1,2]. The widespread belief that therapeutic hypothermia with exact temperature control can be only achieved with special equipment might also result in the fact that less intensive care units use this therapy. However, adequate management of therapeutic hypothermia can be achieved with basic equipment (e.g. an ice-cube maker and a refrigerator to store cold intravenous fluids). Another reason might be that the increased work load imposed on doctors in Germany – with increased nonmedical documentation tasks and the drastically increased clinical work caused by cost-cutting reforms such as the introduction of the Diagnosis Related Group – might slow down the implementation of published guidelines due to shortcomings in medical continuing education [7]. The prompt implementation of guidelines in routine patient care might possibly be difficult as generation and implementation of SOP is a time-consuming process. Unless these SOP are generated in individual department routines, care seems to be influenced by adherence to – sometimes outdated – local practice patterns. Given the low rate of complication with short-term therapeutic hypothermia and the published beneficial effects [1,2,5], therapeutic hypothermia should be a standard treatment within the indications recommended by published guidelines and each hospital should generate or adopt written SOP for the indication and clinical use of therapeutic hypothermia [3]. Even if the optimal duration and temperature of therapeutic hypothermia as well as different cooling techniques still remain a subject of investigation, the implementation of current recommendations by international organisations based on the published evidence should be promoted and adhered to in order to guarantee optimal state-of-the-art treatment for our patients.

Clinical features of culture-proven Mycoplasma pneumoniae infections at King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

ObjectiveThis retrospective chart review describes the epidemiology and clinical features of 40 patients with culture-proven Mycoplasma pneumoniae infections at King Abdulaziz University Hospital, Jeddah, Saudi Arabia.MethodsPatients with positive M. pneumoniae cultures from respiratory specimens from January 1997 through December 1998 were identified through the Microbiology records. Charts of patients were reviewed.Results40 patients were identified, 33 (82.5%) of whom required admission. Most infections (92.5%) were community-acquired. The infection affected all age groups but was most common in infants (32.5%) and pre-school children (22.5%). It occurred year-round but was most common in the fall (35%) and spring (30%). More than three-quarters of patients (77.5%) had comorbidities. Twenty-four isolates (60%) were associated with pneumonia, 14 (35%) with upper respiratory tract infections, and 2 (5%) with bronchiolitis. Cough (82.5%), fever (75%), and malaise (58.8%) were the most common symptoms, and crepitations (60%), and wheezes (40%) were the most common signs. Most patients with pneumonia had crepitations (79.2%) but only 25% had bronchial breathing. Immunocompromised patients were more likely than non-immunocompromised patients to present with pneumonia (8/9 versus 16/31, P = 0.05). Of the 24 patients with pneumonia, 14 (58.3%) had uneventful recovery, 4 (16.7%) recovered following some complications, 3 (12.5%) died because of M pneumoniae infection, and 3 (12.5%) died due to underlying comorbidities. The 3 patients who died of M pneumoniae pneumonia had other comorbidities.Conclusionour results were similar to published data except for the finding that infections were more common in infants and preschool children and that the mortality rate of pneumonia in patients with comorbidities was high.