Beyond Ortner's syndrome--unusual pulmonary complications of the giant left atrium.

INTRODUCTION: The giant left atrium (GLA) is a complication of severe mitral valve disease and causes morbidity by compressing adjacent intra-thoracic structures. CLINICAL PICTURE: We report 2 cases of unusual pulmonary complications of the GLA. Case 1 developed recurrent collapse of the left lung due to left main bronchus compression. Case 2 was diagnosed with right middle lobe compression and collapse. TREATMENT AND OUTCOME: Case 1 was successfully treated by mitral valve replacement and left atrial reduction surgery. Case 2 was treated conservatively. CONCLUSION: Pulmonary atelectasis may occur in patients with GLA due to bronchopulmonary compression. Surgical management with valve replacement and atrial reduction may be necessary to relieve airway compression.

Treatment of severe carinal stenosis with overlapping metallic endoprosthesis.

A 50-year-old man presented with respiratory distress from central airway compression secondary to malignant mediastinal adenopathy. The stenosis involved the carinal triangle and created residual luminal diameters of 6 mm, 6 mm, and pinhole in the distal trachea and right and left mainstem bronchi, respectively. Airway patency at the carina was restored successfully with a stenting method that uses two overlapping Wall stents.

Mortality patterns in a medical intensive care unit.

We studied the mortality rate and patterns in a 6-bedded Medical Intensive Care Unit in a busy general hospital. We found a high mortality rate (26% in-ICU and 42% in-hospitalization) and that mortality was strongly associated with the following factors: cardiac arrest, respirator support, duration of stay in ICU, infection and the immunocompromised state. Lack of formal patient selection and entry criteria and Critical-Care Specialists may be contributing factors.

Smoking cessation programme: the Singapore General Hospital experience.

INTRODUCTION: The National Health Survey in Singapore reported that the prevalence of smoking had decreased from 20 percent in 1984 to 15 percent in 1998. This may be due to the efforts of smoking cessation education established island-wide. In this study, we review the efficacy of the Singapore General Hospital smoking cessation programme and examine the efficacy of different treatment modalities. METHODS: We studied the immediate quit rate and point prevalence abstinence rates at six and 12 months in our telephone survey. Subjects were patients who attended our programme from June 1999 to December 2002. Pharmacotherapeutic aids utilised with counselling sessions were individualised. RESULTS: The study populations for outpatient and inpatient arms were 394 patients and 425 patients, respectively. In the outpatient programme, mean age was 46 years (range of 12 to 80 years), and the ratio between males and females was 8.6. The outpatient immediate quit rate was 33 percent, and the six and 12 month quit rates were both 36 percent. However, in the inpatient programme, mean age was 65 years (range of 15 to 93 years), and the ratio between males and females was 4.9. The six and 12 month quit rates of the inpatient arms were 30 percent and 32 percent, respectively. Although there is no statistically significant difference in the different treatment modalities, the immediate quit rates for bupropion only and counselling only were relatively higher (36 percent and 41 percent, respectively). These were sustained at more than 35 percent at six and 12 months follow-up. We achieved comparable efficacy compared to published data. Counselling, as a sole therapy, can be effective in a select patient group. One-time inpatient counselling achieved a quit rate (32 percent at 12 months) far superior to previously-reported self-quit rate (3 percent and 8 percent at 12 months). CONCLUSION: We strongly recommend that all inpatients who are smokers to be routinely referred for counselling.

Intentional overdosage with isoniazid: case report and review of literature.

Isoniazid (INH) is widely used in most prophylactic and therapeutic anti-tuberculosis regimens because of its effectiveness and low cost. Yet, INH poisoning appears to be rare. We report the first case of intentional INH overdosage in Singapore. A 26-year-old Filipino male presented with mental obtundation, recurrent seizures, metabolic acidosis and hepatic dysfunction. He was successfully treated with large doses of pyridoxine (vitamin B6). Recommendations for the management of acute INH toxicity are highlighted.

Prevalence and prognostic relevance of sick euthyroid syndrome in a medical intensive care unit.

The prevalence and prognostic relevance of alterations in thyroid function indices in 100 critically ill patients were evaluated prospectively on admission to our medical intensive care unit (MICU). Patients with a present or past history of thyroid disorder and those on drugs that might interfere with thyroid function indices were excluded. Eighty-four (84%) of the patients had altered thyroid function indices suggestive of sick euthyroid syndrome (SES). The overall mortality rate for patients with and without evidence of SES were 40% and 6% respectively (P < 0.01). Serum total 3,3',5-triiodothyronine (T3) and total thyroxine (T4) concentrations were reduced in 67% and 24% of the patients respectively. The low T3 state and the low T3 and T4 state accounted for 55% and 29% of the SES cases respectively. No correlation was noted between the serum T4 concentration and survival outcome while a normal serum T3 value served as a good predictor for survival (97%). However, routine study of thyroid function indices in critically ill patients for its prognostic value is not encouraged as results are often heterogenous due to various limitations which will be discussed.

Boerhaave's syndrome presenting as a right-sided pleural effusion.

INTRODUCTION: Boerhaave's syndrome is an uncommon condition where there is oesophageal rupture following forceful vomiting, subsequent mediastinitis and is associated with high mortality and morbidity in the absence of therapy. We present a case of Boerhaave's syndrome in a 79-year-old woman who developed a right-sided effusion, an unusual presentation. CLINICAL PICTURE: A 79-year-old woman developed a right-sided empyema and mediastinitis after a bout of repeated vomiting. Gastrograffin swallows and oesophago-gastroduodenoscopy confirmed oesophageal rupture. TREATMENT: The patient was treated with antibiotics and a tube thoracostomy. An open thoracotomy, oesophagostomy and thoracic window was subsequently performed. OUTCOME: The oesophageal rupture was contained but patient died from postoperative complications. CONCLUSIONS: Physicians should have a high index of suspicion of oesophageal rupture when patients present with Meckler's triad of symptoms and especially when pleural fluid cultures grow bacteria native to the gastrointestinal tract.

Impact on quality of patient care and procedure use in the medical intensive care unit (MICU) following reorganisation.

We conducted this retrospective, cohort study to evaluate the quality of patient care and procedure use in the medical care unit (MICU) following reorganisation and staffing by an intensivist. Consecutive admissions to an adult MICU in a university affiliated hospital during two 3-month periods, August to October 1993 (Period 1, n = 112) and January to March 1994 (Period 2, n = 127) were analysed. In Period 1, the MICU was run under the open system in which patient care was provided by the individual attending physicians. In Period 2, a resident MICU team led by a trained intensivist took over the medical care from the primary physicians when the patients were admitted to the MICU. The intensivist also vetted MICU admission and decided on MICU discharge. In addition, there was a resident respiratory therapist to attend to ventilatory care during office hours. After office hours, the care of the MICU was delegated to the on-call team on a rotational basis among the medical departments. This was the semi-closed ICU model. The patients in the two periods were similar with respect to age, sex, race, source of admission and APACHE II scores. There was improvement in the median ICU length of stay for survivors from 3 days in Period 1, to 2 days in Period 2 (P = 0.0114). The relative risk of ICU death in Period 1 compared to Period 2 was 1.23 (P = 0.286). There was no significant difference in the use of peritoneal dialysis (5.4% versus 6.3%) and mechanical ventilation (55.4% versus 49.6%). However, utilisation of intra-arterial lines and pulmonary artery catheters increased from 0% in both Periods 1 and 2 to 23.6% and 5.5%, respectively. Reorganisation of the MICU in Period 2 resulted in reduced length of MICU stay for survivors. Hence, we believe that coverage by a dedicated ICU team and active respiratory care by a respiratory therapist during office hours were beneficial for the care of the critically ill. There was also a noticeable increase in the use of invasive monitoring.