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Pneumonia acquired during hospitalization (nosocomial) is the leading cause of death from hospital-acquired infection. This condition is usually caused by aspiration of gram-negative bacilli, often in patients with decreased immune defenses. A prospective study was undertaken of 300 patients with intra-abdominal abscess to compare the outcomes of patients with nosocomial pneumonia with the outcomes of patients without pneumonia but with recurrence of intra-abdominal abscess. There were 34 patients who were admitted to the hospital with pneumonia; these had a mortality of 44 percent and were excluded from the study. The mortality of 171 patients with no nosocomial pneumonia and no recurrent intra-abdominal abscess was 20 percent (34 patients). The 36 patients with recurrent abdominal abscess had a 17 percent mortality; 47 patients with nosocomial pneumonia had a 53 percent mortality. There were and additional 12 patients who had both nosocomial pneumonia and recurrent intra-abdominal abscess; mortality in this group was 75 percent. Several risk factors were identified: APACHE II score (Acute Physiology and Chronic Health Evaluation), the need for assistance with respiration, steroids, generalized peritonitis, and need for surgery. It is concluded that nosocomial pneumonia is an independent risk factor associated with significant mortality, compared with recurrence of intra-abdominal abscess. (Consumer Summary produced by Reliance Medical Information, Inc.)

Wetenschappelijk onderzoek laat zien dat omstandigheden rondom de conceptie, zwangerschap en de eerste levensjaren van invloed kunnen zijn op de gezondheid op korte en lange termijn. Metabole programmering is beschreven als een van de processen die hieraan ten grondslag zou kunnen liggen. Dit heeft geleid tot de hypothese dat de periode van conceptie tot ongeveer het tweede levensjaar een kritieke periode is, die mede bepaalt of een kind gezond oud zal worden. Deze cruciale periode van 1000 dagen kan worden gezien als een window of opportunityvoor preventie en gezondheidsbevordering, met een blijvende positieve invloed op de latere gezondheid. In dit referaat worden onderzoeken besproken waaruit het belang van het proces van metabole programmering blijkt. Dit proces start mogelijk al tijdens de conceptie en wellicht zelfs eerder.

OBJECTIVE: To compare the outcome of abdominal infection in patients with or without previous systemic glucocorticoid therapy and to determine the effect of steroid administration on the relationship between APACHE II (Acute Physiology and Chronic Health Evaluation) scores and mortality. HYPOTHESIS: Steroid therapy leads to greater mortality and relatively lower APACHE II scores. DESIGN: Prospective cohort study. SETTING: University hospital. PATIENTS: Two hundred ninety-seven consecutive adult patients with abdominal infection treated by surgical or percutaneous drainage. Treatment was at the clinician's discretion. Seventy-one patients received systemic steroid therapy. OUTCOME MEASURES: APACHE II score, clinical course, and death in hospital; relationship between APACHE II score and mortality in the steroid and no steroid groups. RESULTS: Thirty-three patients receiving steroid therapy (46%) died vs 55 (24%) of 226 patients not receiving steroid therapy. The APACHE II score (P<.0001) and steroid administration (P=.04) were each independently associated with death. Steroid-treated patients had the same probability of dying as "nonsteroid" patients with an APACHE II score a mean of 3.7 points higher (95% confidence limits, 0.03 and 7.7). The confidence that 2, 3, or 4 extra APACHE II points is the appropriate correction for steroid-treated patients is 80%, 60%, or 40%, respectively. CONCLUSIONS: Patients receiving steroid therapy appear to be at higher risk of dying of abdominal infection than predicted by APACHE 11 scores. The number of patients receiving cancer chemotherapy was too small to determine whether this was an additional risk factor. In the design of clinical trials stratified by APACHE II scores, steroid-treated patients should either be excluded or assigned two extra APACHE II points.(Arch Surg. 1994;129:33-38)

To compare the profiles of those patients selected by general practitioners for measurement of serum cholesterol with the recommended profiles for opportunistic cholesterol testing described in the national practice guidelines published by the Dutch College of General Practitioners.

• Therapeutic trials for intra-abdominal sepsis require pretreatment stratification; physiologic scoring has been recently proposed for this purpose. We have prospectively tested the validity of one such scoring system, namely, the Acute Physiology and Chronic Health Evaluation (APACHE II). As part of a larger database, we correlated APACHE II scores with mortality in 100 patients hospitalized for generalized peritonitis or abdominal abscess. Use of steroids was recorded because of our suspicion that steroids increase mortality but blunt the physiologic response to sepsis. Thirty-one patients died, including 12 of 19 patients receiving steroids. Stepwise discriminant analysis revealed that the APACHE II score and steroid use were each independently associated with the rate of mortality. We report a prospective validation of pretreatment APACHE II scoring in abdominal sepsis. Steroid use is an independent risk factor.(Arch Surg 1988;123:225-229)

Multiple organ system failure may result from tissue damage caused by activated neutrophils or endotoxin. A significant part of this tissue damage is due to peroxidation induced by oxygen-free radicals and requires iron as a co-factor. Iron chelation has been shown to prevent tissue damage in some models. This experiment was carried out to determine whether iron chelation with deferoxamine (DFO) would prevent lung damage in a swine model of Gram-negative septicemia. Fifteen animals were randomized to control, Pseudomonas aeruginosainfusion at a rate of 2 ± 107colony forming units/20 kg/min (septic group), or Pseudomonasinfusion combined with DFO pretreatment at a dose of 80 mg/kg/h (septic-treated group). Three of six septic-treated animals became severely hypotensive and died during the course of the experiment as opposed to none of six septic animals. Surviving septic-treated animals were significantly hypotensive (60 ± 24 mmHg mean arterial pressure) compared to septic (122 ± 9 mmHg) and control (109 ± 8 mmHg) animals. DFO did not improve respiratory function (e.g., pO2) or morphology in septic animals. We conclude that iron-chelation therapy with DFO at the above dosage results in a significant deterioration in cardiovascular function in septic swine. Lung damage was not prevented.

The trend toward outpatient surgery led to this study to determine the safety of elective outpatient laparoscopic surgery for the higher risk patient. One hundred consecutive higher risk patients from all patients scheduled for elective outpatient laparoscopic surgery were studied prospectively in a 256-bed community hospital. Seventeen percent of patients required admission. In each instance the need was readily evident in the perioperative observation period. Eighty-three percent of patients were stable and were successfully treated as outpatients. No patient who remained stable decompensated later, and none required readmission to treat complications resulting from outpatient status. The 2 % readmission rate (for unrelated reasons) was comparable to the 2 % readmission rate for low-risk patients. It was concluded that routine outpatient laparoscopic surgery is safe for elective higher risk patients. Problems requiring admission are readily evident during the period of observation and no patient who remains stable decompensates later.