Beneficial effects of chest tube drainage of pleural effusion in acute respiratory failure refractory to positive end-expiratory pressure ventilation.

BACKGROUND: As part of an ongoing prospective evaluation of the response of acute respiratory failure (ARF) to ventilation with titrated amounts of positive end-expiratory pressure (PEEP), a subset of patients with a poor response to the initial application of PEEP and radiographic evidence of pleural effusion was identified. The effusion(s) were treated by tube thoracostomy (TT) to test the hypothesis that drainage would have a favorable effect on oxygenation and compliance in critically ill patients with substantial pulmonary dysfunction. METHODS: Consecutive patients with ARF underwent a titrated progressive application of PEEP if arterial oxygen saturation was less than 90% on fraction of inspired oxygen less than 0.5. One or two thoracostomy tubes (TT) were placed afterward in patients with radiologic evidence of effusion who had a poor response to PEEP therapy. The lung injury score (LIS), PaO2:FiO2 (P:F), peak airway pressure, dynamic compliance, and TT output were recorded. Changes over time were analyzed by one-way analysis of variance with repeated measures. RESULTS: Nineteen of 199 patients needed TT. LIS was 3.0 +/- 0.1. Maximum PEEP was 16.6 +/ 1.0 cm H2O. TT drainage was 863 +/- 164 ml in the first 8 hours. Mortality was 63% (12 of 19) but only 41% (74 of 180) in the patients who did not require TT (p = 0.11). TT improved oxygenation and compliance immediately after insertion in 17 of 19 patients, and P:F remained statistically higher (245 +/- 29 versus 151 +/- 13, p < 0.01) 24 hours after TT drainage. There was no correlation between the volume of fluid removed and P:F either immediately (R2, 0.16) or 24 hours after TT (R2, 0.07). CONCLUSIONS: Drainage of pleural fluid resulted in a significant improvement in oxygenation in ARF patients with pleural effusions who were refractory to treatment with mechanical ventilation and PEEP. TT represents a simple and safe alternative for aggressive management of selected patients, obviating the inherent risk of pneumothorax with thoracentesis and possibly avoiding the need for more complex forms of support in this critically ill patient population.

Relationship of systemic inflammatory response syndrome to organ dysfunction, length of stay, and mortality in critical surgical illness: effect of intensive care unit resuscitation.

BACKGROUND: A systemic proinflammatory response has been implicated in the pathogenesis of organ dysfunction. The effects of surgery, surgical stress, anesthesia, and subsequent intensive care unit (ICU) resuscitation may affect the components of the systemic inflammatory response syndrome (SIRS) score (temperature, heart rate, respiratory rate, and white blood cell count). Any SIRS scores calculated within 24 hours after surgery or at the onset of nonoperative resuscitation may overestimate the proinflammatory response itself, making quantitation of SIRS at that time potentially too sensitive. We hypothesized that SIRS attributable to ICU resuscitation can be quantitated, and that SIRS after the first day of therapy in the ICU correlates with several outcomes. METHODS: Prospective analysis of 2300 surgical ICU admissions during a 49-month period. Acute Physiology and Chronic Health Evaluation III (APACHE III) scores were recorded after 24 hours. Daily and cumulative multiple organ dysfunction scores (0-4 points for each of 6 organs, 24 points total) and SIRS scores (1 point for each parameter, 4 points total) were recorded. Defined end points were hospital mortality, days in the ICU, and organ dysfunction. RESULTS: On day 1, 49.4% of patients had SIRS (score > or =2), whereas 34.5% of patients who remained in the ICU had SIRS (score > or =2) on day 2 (P<.001). The SIRS score decreased by a mean of 0.8 points from day 1 to day 2, regardless of the type of admission. A SIRS score that decreased on day 2, in comparison with the score on day 1, resulted in less mortality than a unchanged or higher score on day 2 (11% vs. 18% vs. 22%, P<.001). Systemic inflammatory response scores were higher for nonsurvivors than survivors on each of the first 7 days in the ICU. The day 2 SIRS score correlated well with the admission APACHE III score (P<.001) and all defined end points (all P<.001). The day 2 SIRS score also correlated with the day 2 multiple organ dysfunction score (P<.001). By multiple logistic regression, APACHE III (P<.001), day 2 SIRS score (P<.01) (but not day 1 SIRS score, P = .99), and day 2 multiple organ dysfunction score (P<.001) (but not day 1 multiple organ dysfunction score, P = .81) predicted mortality. CONCLUSIONS: Systemic inflammatory response syndrome attributable to surgery or surgical stress can be quantitated. Twenty-four hours of ICU resuscitation results in a decline in the SIRS score. The magnitude of the proinflammatory response on the second ICU day may be a useful predictor of outcome in critical surgical illness.

Internal mammary artery is a safe conduit for repeat coronary revascularization.

The safety of repeat coronary revascularization using the internal mammary artery (IMA) as a conduit was examined in patients undergoing repeat revascularization between January 1988 and June 1991. The 71 patients in whom the IMA was used as one of the conduits were compared with 57 patients in whom only vein grafts were used. Patients undergoing IMA grafts were likely to have more vessels revascularized. Nevertheless, there were no significant differences in outcome between the two groups as measured by complications or period of hospitalization. In a multivariate analysis, the only independent predictor of poor outcome was emergency surgical treatment. The current study would indicate that IMA grafts are safe in the setting of repeat coronary revascularization.

Large-volume liposuction complicated by retroperitoneal hemorrhage: management principles and implications for the quality improvement process.

Large-volume liposuction can be associated rarely with major medical complications and death. The case of exsanguinating retroperitoneal hemorrhage that led to cardiopulmonary arrest in an obese 47-year-old woman who underwent large-volume liposuction is described. Extensive liposuction is not a minor procedure. Performance in an ambulatory setting should be monitored carefully, if it is performed at all. Reporting of adverse events associated with outpatient procedures performed by plastic surgeons should be mandated. Hemodynamic instability in the early postoperative period in an otherwise healthy patient may be due to fluid overload, lidocaine toxicity, or to hemorrhagic shock and must be recognized and treated aggressively. Guidelines for the safe practice of large-volume liposuction need to be established.

Laser tissue welding: a biotechnological advance for the future.

Laser tissue welding as well as other alternative methods of closure will play a more important role in surgical specialties as laparoscopic, endoscopic, and microsurgical techniques continue to develop. Laser tissue welding uses laser energy to anastomose tissues and is ideally suited for applications in which suturing and stapling is difficult. Recent advances have led to a better understanding of the mechanisms of tissue welding. Additionally, technical achievements including the introduction of protein solders and temperature-controlled feedback systems have led to the acceptance of laser tissue welding in clinical medicine. In this article, we describe the history and development of laser tissue welding and review the current and potential applications of this technology.

Acquired trichomegaly of the eyelashes: a cutaneous marker of acquired immunodeficiency syndrome.

Acquired trichomegaly of the eyelashes was found in seven patients infected with human immunodeficiency virus type 1. These patients had advanced infection with severe T-helper cell depletion, high levels of p24 antigenemia, and inability to tolerate zidovudine therapy. Control of infection with other antiretroviral agents caused the trichomegaly to regress. Acquired trichomegaly may be a useful clinical marker for assessment of severity of infection.

Intestinal perforation after suction lipoplasty: a case report and review of the literature.

Intrabdominal penetration with intestinal perforation is a relatively uncommon complication after liposuction. Seven cases have been reported in the literature, with a mortality rate > 50%. Here we present a case of a perforated viscus after suction lipoplasty of the abdomen using the tumescent technique. Multiple small-bowel enterotomies were made with the suction cannula. It is our hope that a heightened awareness of this potentially life-threatening complication will promote early and aggressive diagnosis and treatment of liposuction patients who present with gastrointestinal complaints in the early postoperative period.

Acute paranasal sinusitis in critically ill patients: guidelines for prevention, diagnosis, and treatment.

Nosocomial sinusitis is common in critical illness. Randomized trials indicate that radiographic sinusitis (RS) occurs in 25%-75% of all critically ill patients and that 18%-32% of endotracheally intubated patients will develop sinusitis. Variability in the estimated incidence of RS stems from the many radiographic techniques used for diagnosis. Critically ill patients with suspected sinusitis should undergo computed tomographic scanning of all paranasal sinuses. If the scans are positive (opacification, mucosal thickening, air-fluid level), aspiration is performed after meticulous nasal disinfection. Infection is confirmed if a pathogen is identified along with neutrophils. Nosocomial sinusitis is usually caused by gram-negative bacilli or is polymicrobial. Pseudomonas aeruginosa, the most common causative organism, represents 15.9% of isolates. The most common gram-positive isolate is Staphylococcus aureus (10.6%); fungi represent 8.5% of isolates. Infection is treated with aspiration and systemic antibiotics. Treatment failures are common; drainage with indwelling catheters is sometimes necessary.

Accurate localization and surgical management of active lower gastrointestinal hemorrhage with technetium-labeled erythrocyte scintigraphy.

OBJECTIVE: There is disagreement over the reliability of technetium Tc 99m (99mTc)-labeled erythrocyte scintigraphy in the localization of active lower gastrointestinal hemorrhage. A previous study at The New York Hospital-Cornell Medical Center that showed a superior sensitivity for localization of scintigraphy versus angiography in surgical patients led the authors to emphasize scintigraphy as the diagnostic test of first choice in the clinical diagnostic algorithm. The authors hypothesized that tagged erythrocyte scintigraphy can be used accurately as the primary diagnostic modality in localizing acute bleeding and guiding surgical intervention. METHODS: The authors conducted a 5-year, retrospective analysis of 224 inpatients who underwent scintigraphic imaging for diagnosis and localization of active lower gastrointestinal bleeding. Using scintigraphy as the primary diagnostic test, with colonoscopy, upper endoscopy, and angiography as adjunctive studies, 99mTc-labeled erythrocyte scans were performed at the clinician's discretion and were reviewed again for study purposes by two nuclear radiologists who were blinded to clinical outcome. Adjunctive diagnostic tests also were ordered for clinical indications. RESULTS: Using delayed periodic scintigraphic imaging, results of 115 scans (51.3%) demonstrated bleeding, with 96 scans (42.9%) localizing to a specific anatomic site. Patients with positive scans were five times more likely to require surgery (p < 0.005) than patients with negative scans, and surgical patients were twice as likely to localize by scintigraphy (p < 0.0001). Fifty patients (22.3%) required surgical intervention to control hemorrhage and had a bleeding site confirmed by both clinical and pathologic examinations. Forty-eight of those patients (96%) had a bleeding site determined preoperatively. For 37 patients with bleeding sites localized preoperatively by scintigraphy, 36 (97.3%) had correct localization based on surgical pathology. Only one patient required a subtotal colectomy solely because of nonlocalized bleeding. No patient bled postoperatively, and there was no mortality in either operated or nonoperated patients. The mean volume of transfused erythrocytes was similar in both scan-localized and nonlocalized surgical patients. CONCLUSION: When performed correctly and interpreted conservatively, scintigraphy is a useful and safe means of guiding segmental resection, and should be the primary tool used in the diagnosis of patients with active lower gastrointestinal bleeding.

Squamous cell carcinoma of the breast after augmentation with liquid silicone injection.

Squamous cell carcinoma of the breast is an extremely rare neoplasm. Approximately 50 cases have been reported in the English literature since 1917. The pathogenesis of squamous cell carcinoma of the breast is puzzling because epithelial elements are not normally identified in breast tissue. It has been suggested that epithelial cells are derived from epidermoid cysts deposited during early embryological development, from metaplastic transformation of ductal cells, or after trauma or surgical manipulation. Although no evidence has been published to support a casual relationship between liquid silicone-induced mastopathy and breast carcinoma, squamous cell cancers are known to arise in the setting of prolonged inflammation often seen after liquid silicone injection. This case of primary squamous cell carcinoma of the breast, arising 25 years after augmentation with liquid silicone injections, occurred in a 70-year-old patient with silicone-induced mastopathy.

Chronic T cell lymphocytosis with large granular lymphocytes of helper (OKT4) phenotype.

A 54-year-old asymptomatic male patient was followed for more than 7 y and presented a constant T cell lymphocytosis without skin involvement or bone marrow depression. No clinical or haematological aggravation was noted during this follow-up. Morphologically, the cells were large granular lymphocytes strongly positive for beta-D-glucuronidase, negative for acid phosphatase and with features of T cells on transmission and scanning electron microscopy. The immunological studies of the lymphocytes showed the following parameters: E rosettes+, mouse rosettes-, SmIg-, OKT3+, OKT4+, OKT8-, OKT6-, Ia-, TdT-, NK-, HTLV-, decreased PHA and PWM stimulation, no interleukin 2 production and failure to enhance Ig synthesis in a PWM driven system. The karyotype was normal. This case of chronic T cell lymphocytosis with large granular lymphocytes helper profile and defect of helper function, not reported in the literature, may correspond to a distinct entity in the heterogeneous group of chronic T cell disorders.

Rosetting index (E rosettes/mouse rosettes): a simple diagnostic and prognostic value in CLL.

The rosetting index (E rosettes/mouse rosettes) was evaluated in 34 controls, 4 chronic benign lymphocytosis and 28 CLL patients, grouped according to the Rai classification: 6 asymptomatic stage 0 patients (lymphocytosis less than 10,000/mm3) with a rosetting index of 0.35 +/- 0.2; 11 asymptomatic stage 1-2 patients (lymphocytosis 10,000-40,000/mm3) with a rosetting index of 0.19 +/- 0.11; 9 symptomatic stage 3-4 patients (lymphocytosis greater than 40,000/mm3) with a rosetting index of 0.09 +/- 0.09 and 2 T-CLL patients post splenectomy and 4 chronic benign lymphocytosis patients with a rosetting index of 25 +/- 15. The average rosetting index for the controls was 10.0 (range 3.5-54). Student's t test was p less than 0.0001 for groups 1, 2 and 3 and p less than 0.02 for group 4. These results show that the rosetting index is helpful for the characterization of B-CLL in all stages, the rosetting index decreases with the proliferative activity of the disease and could be used as a prognostic factor, and the rosetting index is significantly increased in T-CLL and chronic benign T lymphocytosis thus being useful in differentiating these conditions from the early stage of CLL, when the SmIg is not conclusive of a monoclonal proliferation.

IgM lambda globular cytoplasmic inclusions in chronic lymphocytic leukaemia resembling immunocytoma.

In a 64-year-old female with chronic lymphocytic leukaemia, nearly 50% of the lymphocytes presented one or several globular intracytoplasmic inclusions resembling Russell bodies which were characterized by immunofluorescence as IgM lambda. On electron microscopy, the inclusions looked like cisternae of the rough endoplasmic reticulum. Surface membrane Ig was not detected and the serum IgM was low. The histology of a lymph node showed a lymphocytic proliferation with evidence of Ig synthesis, compatible with immunocytoma. The aggressive course of the disease necessitated polychemotherapy. This case represents an unusual ill-defined lymphoproliferative disorder, lying between the B-CLL and a non-secretory macroglobulinaemia.

Generation or large numbers of immature and mature dendritic cells from rat bone marrow cultures.

We have defined conditions for generating large numbers of dendritic cells (DC) in marrow cultures from 10-12-week-old ACI or WF rats. The combination of granulocyte-macrophage colony-stimulating factor (GM-CSF) and TNF-alpha, known to induce DC from human CD34+ progenitors, was not effective with rat. In contrast, GM-CSF plus IL-4 generated DC in high yield, corresponding to 30-40% of the initial number of plated marrow cells. The DC proliferated in distinctive aggregates, in which most cells had an immature phenotype marked by undetectable surface B7 and high levels of MHC class II products within intracellular lysosomes. When dislodged and dispersed, the aggregates gave rise to mature stellate DC with abundant surface MHC class II and B7, sparse MHC class II- lysosomes, and strong T cell-stimulating capacity. Therefore, rat marrow progenitors can generate large numbers of immature DC, with abundant intracellular MHC class II compartments, and potent, stimulatory, mature DC.

Craniofacial injuries resulting from taxicab accidents in New York City.

Taxicab accidents are a common occurrence in New York City. This review was undertaken to characterize the nature of craniofacial injuries that result from taxicab accidents. Data were collected on 16 patients who required admission to trauma or plastic and reconstructive surgery services, after sustaining craniofacial injury as a result of a taxicab accident. Front-end deceleration collisions were the most common mechanism of injury. Fifty-six percent of the patients were thrown against the bulletproof, Plexiglas driver safety divider and sustained an injury most commonly to the anterior midface. Both bony and soft-tissue injuries were common in the entire group. Complex facial fractures were sustained by 56% of patients, with nasal-septal fractures most common, followed by naso-ethmoid-orbital, anterior frontal, anterior maxillary, and Le Fort I and II fractures. Only 1 patient in the group was wearing a seat belt and that patient was a driver. Given the high incidence of craniofacial injury, appropriate safety standards for taxicabs must be initiated, including the reevaluation of the utility of the safety divider and mandatory seat belt use for rear-seat passengers.

Acquired ichthyosis in concomitant HIV-1 and HTLV-II infection: a new association with intravenous drug abuse.

BACKGROUND: Papulosquamous eruptions are common in HIV-1-infected patients. Acquired ichthyosis may occur after profound T-cell depletion. Intravenous drug users infected with HIV-1 can be coinfected with human lymphotropic virus II (HTLV-II). OBJECTIVE: We examined the relation between acquired ichthyosis and concomitant infection with HIV-1 and HTLV-II in intravenous drug users. METHODS: We examined 184 male and female HIV-1-positive intravenous drug users for acquired ichthyosis. Enzyme-linked immunosorbent assay was used to screen these patients for antibody to HTLV-I/II. Western blot, viral isolation, and the polymerase chain reaction were used to confirm that serologic responses were from HTLV-II and not HTLV-I. RESULTS: Acquired ichthyosis occurred in 6.3% of white, 16.4% of Hispanic, and 21.7% of black patients. It occurred only after profound helper T-cell depletion, in association with increasing age, and with concomitant infection with HTLV-II (22.2% vs. 6.8% in HIV-1 singly infected patients [p < 0.038]). CONCLUSION: Acquired ichthyosis may be a marker of concomitant infection with HIV-1 and HTLV-II in intravenous drug users and occurs after profound helper T-cell depletion.

Clinical features and outcome of patients admitted to the intensive care unit after plastic surgical procedures: implications for cost reduction and quality of care.

Recent interest in cutting cost and improving utilization and delivery of perioperative services has prompted surgeons to identify patient populations that would benefit from care in an intensive care unit as opposed to intermediate or standard care. The purpose of this study was to evaluate patients admitted to the surgical intensive care unit (SICU) after major plastic/reconstructive surgical procedures in order to determine appropriate perioperative management strategies for these patients. We reviewed retrospectively the data from 2,805 consecutive admissions to the SICU between 1990 and 1996. Forty-two patients (1.5%) who had undergone major plastic/reconstructive procedures were identified. Outcomes (mortality, length of stay in the SICU and hospital, and the degree of organ dysfunction) were compared between this population, an illness severity-matched (Acute Physiology and Chronic Health Evaluation [APACHE]-II and APACHE III) population of patients recovering from vascular surgical procedures, and a similarly matched population of SICU patients who were randomly assigned to serve as a second control group. The hospital mortality of the plastic surgical patient population (9.5%) was significantly higher than the zero mortality of the random cohort (p < 0.05). A second analysis compared the SICU plastics group to a case-controlled group of patients who were admitted to the postanesthesia care unit (PACU) for at least 24 hours of perioperative monitoring. SICU patients had significantly higher APACHE II scores (10.9) when compared to PACU patients (7.2; p < 0.01). Based on severity of illness scoring and eventual mortality, patients admitted to our SICU after major reconstructive surgery were selected appropriately for that setting. In contrast, the patients who stayed in the PACU for perioperative monitoring did not require life-supporting therapy and, therefore, were overmonitored. Care could be provided in a specialized unit with dedicated nursing specifically trained for that purpose.