A 20-year-old woman with rapidly progressive dyspnea and diffuse pulmonary infiltrates.

Silicone is a liquid polymer previously considered to be immunologically inert and favored in cosmetic procedures. Increasing evidence shows a multisystemic inflammatory reaction to its administration constituting the silicone embolism syndrome (SES). The majority of adverse effects are seen in the pulmonary system resulting in extensive diffuse alveolar damage and ultimately ARDS. Neurologic involvement occurs frequently and is uniformly fatal. Large volume injections, high pressure infiltrations and prior exposure to silicone have been implicated, with an IgG polydimethylsiloxane antibody described. Most patients meet Schonfield criteria for fat embolism syndrome and treatment is largely supportive. As the illicit use of injectable silicone rises worldwide, so does the incidence of related morbidities and fatalities, necessitating a high index of suspicion for SES in patients with neurologic or pulmonary symptoms and recent exposure to liquid silicone. We report an unusual case of multi-organ dysfunction following silicone injection.

Predicting mortality after intracerebral hemorrhage: comparison of scoring systems and influence of withdrawal of care.

OBJECTIVE: The Broderick system and the intracerebral hemorrhage (ICH) score are two systems for predicting 30-day mortality in patients with spontaneous ICH. No previous study has compared two ICH scoring systems in an independent patient cohort. Our purpose was to externally validate and directly compare these two systems and evaluate the effect of withdrawal of care on system performance. METHODS: In all, 307 consecutive patients admitted with ICH between 1998 and 2002 were evaluated. Broderick exclusion criteria were used, resulting in a cohort of 241 patients. Admission Glasgow Coma Scale score, ICH volume, 30-day mortality, and day-30 location were collected. The sensitivity, specificity, receiver operator characteristic curves, and model explained variance (R2) of the two systems were directly compared. The statistical performances of both systems were then compared in subsets that included or excluded patients from whom care was withdrawn. RESULTS: Overall mortality was 76 of 241 (31.5%). The ICH score had significantly higher sensitivity (66% v 45%, P = .001) and higher receiver operator characteristic curves (0.814 v 0.773, P < .001) for predicting 30-day mortality. The model R2 and specificity were not significantly different between systems. Both systems were significantly associated with 30-day location stratified as home, acute rehabilitation, skilled nursing facility, or death (ICH score Chi square = 79.28, P < .001; Broderick Chi square = 60.63, P < .001). Inclusion or exclusion of patients who had supportive care withdrawn did not significantly affect overall statistical performance. CONCLUSIONS: The ICH score performed significantly better than the Broderick system. Overall statistical performance of both systems was not influenced by withdrawal of care.

The effect of body mass index on patient outcomes in a medical ICU.

STUDY OBJECTIVES: To examine the effect of patient body mass index (BMI) on outcome in intensive care. DESIGN: In a prospective study, the patients were classified into groups based on the calculated BMI, as follows: BMI < 19.0 (n = 350), > or = 19.0 and < 25.0 (n = 663), > or = 25.0 and < 29.9 (n = 585), > or = 30.0 and < 40.0 (n = 396), and > or = 40.0 (n = 154). Groups were compared by age, APACHE (acute physiology and chronic health evaluation) II score, mortality, ICU length of stay (LOS), hospital LOS, number receiving ventilation, and ventilator-days. Adverse events including nosocomial pneumonia, ventilator-days per patient, failed extubations, and line-related complications were recorded. SETTING: The study was conducted in a 9-bed medical ICU of a 650-bed tertiary care hospital. MEASUREMENTS: Height and weight were prospectively recorded for the first ICU admission during a hospital stay. RESULTS: Between January 1, 1997, and August 1, 2001, 2,148 of 2,806 patients admitted to the ICU had height and weight recorded. There were no differences in APACHE II score, mortality, ICU LOS, hospital LOS, number receiving ventilation, ventilator-days, average total cost, or average variable cost among the five groups. However, the severely obese patients were more frequently female and younger than those who were overweight and obese (p < 0.001). Adverse events were infrequent, but there were no differences between the obese/very obese compared with others. CONCLUSION: BMI has minimal effects on ICU outcome after patients are admitted to a critical care unit.