Diagnosing ventilator-associated pneumonia (VAP) in UK NHS ICUs: the perceived value and role of a novel optical technology.

BACKGROUND: Diagnosing ventilator-associated pneumonia (VAP) in an intensive care unit (ICU) is a complex process. Our aim was to collect, evaluate and represent the information relating to current clinical practice for the diagnosis of VAP in UK NHS ICUs, and to explore the potential value and role of a novel diagnostic for VAP, which uses optical molecular alveoscopy to visualise the alveolar space. METHODS: Qualitative study performing semi-structured interviews with clinical experts. Interviews were recorded, transcribed, and thematically analysed. A flow diagram of the VAP patient pathway was elicited and validated with the expert interviewees. Fourteen clinicians were interviewed from a range of UK NHS hospitals: 12 ICU consultants, 1 professor of respiratory medicine and 1 professor of critical care. RESULTS: Five themes were identified, relating to [1] current practice for the diagnosis of VAP, [2] current clinical need in VAP diagnostics, [3] the potential value and role of the technology, [4] the barriers to adoption and [5] the evidence requirements for the technology, to help facilitate a successful adoption. These themes indicated that diagnosis of VAP is extremely difficult, as is the decision to stop antibiotic treatment. The analysis revealed that there is a clinical need for a diagnostic that provides an accurate and timely diagnosis of the causative pathogen, without the long delays associated with return of culture results, and which is not dangerous to the patient. It was determined that the technology would satisfy important aspects of this clinical need for diagnosing VAP (and pneumonia, more generally), but would require further evidence on safety and efficacy in the patient population to facilitate adoption. CONCLUSIONS: Care pathway analysis performed in this study was deemed accurate and representative of current practice for diagnosing VAP in a UK ICU as determined by relevant clinical experts, and explored the value and role of a novel diagnostic, which uses optical technology, and could streamline the diagnostic pathway for VAP and other pneumonias.

Cost implications for the NHS of using the Alere™ i Influenza A & B near patient test with nasal swabs.

BACKGROUND: Influenza is an acute viral infection of the respiratory tract. A rapid confirmatory diagnosis of influenza is important, since it is highly transmissible and outbreaks of influenza within the hospital setting increase morbidity and mortality. The objective of this study was to evaluate the cost implications, from the perspective of the UK NHS, of using on-label nasal swabs with the Alere™ i Influenza A & B test in a near patient setting. METHODS: A cost consequence model was developed. The time horizon of the model was from hospital admission on suspicion of influenza until the end of treatment (following a diagnosis of influenza or discharge from hospital). Data on the prevalence of influenza and the sensitivity and specificity of the Alere™ i Influenza A & B test came from two prospective observational diagnostic accuracy studies. Costs were obtained from published resources. Uncertainties in the model data were investigated using deterministic, one-way sensitivity analyses. RESULTS: Using the Alere™ i Influenza A & B point of care test with nasal swabs (on label) in NHS medical assessment units and emergency departments could save approximately £242,730 per 1000 adults presenting with influenza-like symptoms. The main cause for this was reduced times to availability of the result compared with the laboratory RT-PCR test. Other key drivers of savings were the cost of isolation, the prevalence of influenza, the specificity of the test, and the availability of isolation resources. CONCLUSIONS: The Alere™ i Influenza A & B point of care test would have greatest impact in hospitals that have extensive delays in the time to receive a result. Sensitivity analyses identified the model parameters which would have greatest effect on the result and confirmed that assumptions were conservative, i.e. did not change key results.

Management of cardiogenic shock in the setting of ST-elevation myocardial infarction: controversies and future directions.

The treatment of patients with ST-segment elevation myocardial infarction (STEMI) has changed dramatically since reperfusion therapy has been adopted more commonly, yet 5-10% of patients still develop cardiogenic shock and remain a therapeutic challenge in the setting of STEMI. In this review, we outline the available evidence from randomized controlled trials and registries, including risk factors, diagnostic tools, and various treatments. The main focus of this report is on the currently available treatment options (revascularization, intra-aortic balloon counterpulsation), emerging treatment options (percutaneous hemodynamic support, extracorporeal membrane oxygenation), and ongoing efforts to design systems of care to more efficiently care for these patients.

Lack of effect of cold water prawns on plasma cholesterol and lipoproteins in normo-lipidaemic men.

OBJECTIVE: Dietary guidelines for the prevention of coronary heart disease (CHD) have restricted the intake of foods rich in dietary cholesterol, on the grounds that the dietary cholesterol will increase blood cholesterol. In the case of shellfish, this recommendation may limit the intake of a valuable dietary source of long chain n-3 polyunsaturated fatty acids (LC n-3 PUFA). The objective of this study was to undertake a dietary intervention to determine the effects of cold water prawns on plasma lipids and lipoproteins. METHODS: 23 healthy male subjects were randomised to receive either 225 g of cold water prawns or an equivalent weight of fish ('crab') sticks as a control for 12 weeks in a cross-over design. Blood samples were taken at the beginning and end of each intervention for the determination of plasma lipids and lipoproteins by routine enzymatic assays and iodixanol density gradient centrifugation respectively. RESULTS: The diets were well matched for the intake of total energy and macronutrients, and body weight remained stable throughout the study. The prawn intervention increased the intake of dietary cholesterol to 750 mg/d against 200 mg/d on the control. The intake of LC n-3 PUFA from prawns was estimated to be between 0.5-0.7 g/d. The consumption of prawns produced no significant effects on the concentration of plasma total or LDL cholesterol, triacylglycerol, HDL cholesterol or apolipoproteins A-I and B relative to the control, or within each intervention group over time. There was also no significant effect on LDL density (particle size) relative to the control, or any difference between and within treatments in total plasma lipoprotein profiles by density gradient centrifugation. CONCLUSION: These findings provide evidence to suggest that the consumption of cold water prawns, at least in healthy, male subjects, should not be restricted on the grounds of this seafood producing an adverse effect on plasma LDL cholesterol.

Drug-eluting versus bare metal stenting in acute myocardial infarction. A clinical review.

Coronary heart disease is a leading cause of death around the world. The treatment of acute myocardial infarction has evolved with the advent of novel thrombolytic agents, anticoagulants, antiplatelets, and innovative percutaneous techniques. The development of drug-eluting stents has dramatically lowered the risk of in-stent restenosis compared to bare metal stents. Clinicians in the United States and Europe have begun utilizing DES in the setting of AMI despite the fact that no practice guidelines exist to support their use. Lingering concerns exist about the reported increased risk of early and late stent thrombosis after DES implantation. In this review, we will highlight the >7,500 patients studied in randomized controlled trials and >30,000 registry patients comparing drug-eluting and bare metal stent implantation during acute myocardial infarction. In the selected patient populations of the 13 randomized controlled trials comparing drug-eluting and bare metal stent implantation, death/re-infarction/stent thrombosis were not different between groups while target vessel revascularization was significantly lower in the drug-eluting stent patients. In the "real world" registry studies, mortality/target vessel revascularization/stent thrombosis were less frequent in the first year after drug-eluting stent implantation while re-infarction was not different between the groups. While multiple questions remain regarding long-term follow up and especially late stent thrombosis, it appears that drug-eluting stents are effective at decreasing target vessel revascularization while not being associated with an elevated risk of death/re-infarction/stent thrombosis in the first year post myocardial infarction.

The hypo-echoic cortical rim in lupus nephritis.

Hypo-echoic cortical rims are an unusual ultrasound finding in patients with renal disease. A case report is presented of a patient with lupus nephritis who demonstrated hypo-echoic cortical rims. A brief review of the pathological causes of hypo-echoic cortical rims is given.

Management of tracheobronchial disruption resulting from blunt trauma.

Delayed diagnosis of tracheobronchial disruption resulting from blunt trauma continues to cause major morbidity and death. At the University of Louisville from 1968 to 1982, 13 patients had tracheobronchial disruption resulting from blunt trauma. All injuries were caused by motor vehicle accidents. Disruptions were located in the trachea in six patients and in the right bronchus in seven patients. Physical findings included: subcutaneous emphysema (11 patients), respiratory distress (10 patients), hemoptysis (six patients), and flail chest (four patients). Four patients (30%) died, three from multiple major associated injuries and the other before therapy could be instituted. Among the nine survivors, six had immediate diagnosis and prompt surgical treatment, which consisted of suture repair in five and pneumonectomy in the other patient. Two patients had delay in diagnosis, and repair was attempted at 4 and 30 days, respectively; bronchial stricture resulted in one and pneumonectomy, empyema, and bronchopleural fistula in the other. Another patient with a bronchial mucosal tear was treated nonoperatively without complication. Tracheobronchial disruption should always be considered with massive blunt chest trauma. Repeated bronchoscopy is indicated for unexplained pleural air leaks, lobar atelectasis, or persistent pneumothorax. Prompt diagnosis and expeditious surgical therapy result in fewer complications and increased survival.

Burkitt's lymphoma in the femoral triangle of a white american male.

A teenage white male was recently evaluated for a rapidly enlarging mass in the right groin. Biopsy of the mass disclosed Burkitt's lymphoma. Aggressive therapy was instituted, including extirpative surgery, followed by chemotherapy and radiation therapy. Using these combined modalities, it was possible to eliminate the lymphoma. Unfortunately, severe pancytopenia and immunosuppression developed and the patient died of gram-negative sepsis. This disease should be considered in the differential diagnosis of any rapidly enlarging solid tumor in a young patient.