Early discharge of patients hospitalized with acute asthma: a controlled study.

There is no consensus on the optimal length of stay and timing of release from hospital in patients admitted with acute asthma. We hypothesize that it might be safe to discharge patients from hospital once they have responded clinically to intensive anti-asthma treatment. In a non-randomized prospective controlled study, we compared two discharge protocols in consecutive patients admitted for acute severe exacerbations of bronchial asthma. Patients in group A were discharged after remission of signs and symptoms and those in group B after improvement but before complete remission of signs and symptoms. Peak expiratory flow rates (PEFR) were monitored but were not used as discharge criteria for either group. Patients with complicating disease and who were likely to be non-compliant were excluded. The length of hospital stay (LOS) and best PEFR at discharge were significantly lower in group B (87 admissions) than group A (80 admissions). The mean (+/-SD) LOS was 1.8(+/- 1) days vs. 3.5(+/- 1.4) days and best PEFR was 58(+/- 17)% predicted versus 71(+/- 15)% predicted respectively (P < 0.001 for both variables). No patient in either group relapsed within 4 weeks of discharge from hospital. We concluded that the release of asthmatics who respond promptly to intensive treatment and are compliant with medication despite incomplete resolution of symptoms, signs and PEFR at the time of discharge from hospital may not be associated with increased risk of early relapse.

Hospital acquired pneumonia in the medical intensive care unit--a prospective study.

AIM OF STUDY: The aim of the study was to define the prevalence, risk factors, spectrum of organisms and sensitivity patterns, and the outcome in patients with severe hospital acquired pneumonia (HAP) in the Medical Intensive Care Unit (SCU) in a hospital in Singapore. METHOD: Consecutive patients admitted to the MICU over a 6-month period were studied and assessed daily to determine whether patients had developed HAP based on defined clinical criteria. Sputum or endotracheal aspirate was obtained and results recorded from each patient on admission and every subsequent three days throughout the stay in the MICU. Mortality during hospital stay was the main outcome measure recorded. RESULTS: A total of 136 patients (150 admissions) were studied; 24 patients were identified as having HAP. The prevalence of HAP was 17% [both ventilator-associated pneumonia (VAP) and pneumonia acquired from the ward (WAP)]. Cerebral disease was the main risk factor for VAP (OR 4.94, 95% CI 1.33-18.4). The spectrum of organisms which caused HAP were polymicrobial, Klebsiella pneumoniae, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus and coagulase negative Staphylococcus. The mortality of patients with VAP and WAP were 72.7% and 76.9% respectively. CONCLUSION: This study concludes that HAP in the MICU is common with a high mortality. The spectrum of organisms was comparable to previous studies.

Cause, treatment and outcome of patients with life-threatening haemoptysis.

BACKGROUND: Massive haemoptysis is a life-threatening situation which requires immediate medical attention and intervention. We reviewed 23 patients with life-threatening haemoptysis to document the cause, describe the treatment of these patients and to determine which form of treatment had a better outcome. DESIGN: Retrospective case study. METHODS: Consecutive patients were reviewed and data collected for the underlying cause, treatment and outcome of patients with life-threatening haemoptysis. RESULTS: Out of 23 patients, nine patients had active pulmonary tuberculosis and nine patients had post-tuberculous lung disease. Fifteen patients underwent bronchial embolisation, one patient had surgical resection and seven patients had received medical treatment. Five patients required intubation. Bronchial embolisation was significantly better than medical treatment at immediate cessation of haemoptysis (p < 0.05). Three (13%) patients died from haemoptysis. Follow-up duration averaged 16 months. CONCLUSIONS: The most common causes of haemoptysis were pulmonary tuberculosis and post-tuberculous bronchiectasis. Urgent bronchial artery embolisation was better at immediate cessation of haemoptysis than medical treatment.

Fulminant necrotising fasciitis caused by Vibrio parahaemolyticus.

We report a patient with septicaemia and fulminant necrotising fasciitis caused by Vibrio parahaemolyticus. This organism is strongly associated with seawater exposure and seafood ingestion. The patient recovered due to expedient management, prompt recognition of the organism, appropriate antimicrobial cover and surgical debridement. The lesson to be learned is that this organism should be clinically suspected and recognised from its typical history of injury and fulminant clinical progress as a delay in diagnosis and treatment may result in an increased risk of mortality.

Necrotizing fasciitis--an unusual presentation of miliary mycobacterium tuberculosis.

We report an immunocompromised patient who presented with necrotizing fasciitis as the initial presentation of miliary tuberculosis. The diagnosis of miliary tuberculosis was delayed resulting in prolonged morbidity and hospital stay. The lesson from this report is that tuberculosis should be recognised as an uncommon cause of necrotizing fasciitis in an immunocompromised patient, especially if the response to prompt and standard initial treatment is unsatisfactory.