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Purpose: To determine the long-term outcome of ventilator-associated pneumonia (VAP) and identify factors associated with increased mortality., Methods: We retrospectively studied 671 patients with VAP admitted to an intensive care unit between 1994 and 2000. We determined long-term and out-of-hospital mortality for these patients., Results: The in-hospital mortality was 42.3%; 19.8% of patients had concomitant bacteremia, the mortality was 59.7% versus 38.0% for those without bacteremia (P <.001). The factors associated with increased hospital mortality by univariable analysis were: diagnosis on admission, the need of vasopressors during the stay in the intensive care unit, not undergoing a tracheostomy, the absence of fever, the presence of concomitant bacteremia, and renal failure or the need for dialysis. Patients transferred from an outside hospital and patients with normal serum bicarbonate, serum total bilirubin <2 mg/dL, and platelets >120x4> 10(3)/microL had a lower in-hospital mortality. All of these factors except bilirubin level, platelet count, transfer from outside hospital, and serum bicarbonate remained significant on multivariable analysis. The estimated mortality at 1, 3 and 5 years is 25.9% (95% confidence interval [CI], 20.2-30.1%), 33.6% (95% CI, 27.4-39.2%) and 44.7% (95% CI, 38.1-50.6%), respectively., Conclusions: VAP is associated with a high rate of hospital and long-term mortality. The presence of bacteremia is associated with a high mortality. The 5-year estimated mortality of the survivors is less than 50%.

Lung resection provides the best chance of cure for individuals with early stage non-small cell lung cancer. Naturally, lung resection will lead to a decrease in lung function. The population that develops lung cancer often has concomitant lung disease and a reduced ability to tolerate further losses in lung function. The goal of the preoperative pulmonary assessment of individuals with resectable lung cancer is to identify those individuals whose short- and long-term morbidity and mortality would be unacceptably high if surgical resection were to occur. Pulmonary function measures such as the forced expiratory volume in 1 second and the diffusing capacity for carbon monoxide are useful predictors of postoperative outcome. In situations in which lung function is not normal, the prediction of postoperative lung function from preoperative results and the assessment of exercise capacity can be performed to further clarify risks. Published guidelines help to direct the order of testing, permitting us to offer resection to as many patients as possible.

Purpose: Because the correlation between ammonia levels and the severity of hepatic encephalopathy remains controversial, we prospectively evaluated the correlation in 121 consecutive patients with cirrhosis., Methods: The diagnosis of hepatic encephalopathy was based on clinical criteria, and the severity of hepatic encephalopathy was based on the West Haven Criteria for grading of mental status. Arterial and venous blood samples were obtained from each patient. Four types of ammonia measurements were analyzed: arterial and venous total ammonia, and arterial and venous partial pressure of ammonia. Spearman rank correlations (r(s)) were calculated., Results: Of the 121 patients, 30 (25%) had grade 0 encephalopathy (no signs or symptoms), 27 (22%) had grade 1, 23 (19%) had grade 2, 28 (23%) had grade 3, and 13 (11%) had grade 4 (the most severe signs and symptoms). Each of the four measures of ammonia increased with the severity of hepatic encephalopathy: arterial total ammonia (r(s) = 0.61, P < or = 0.001), venous total ammonia (r(s) = 0.56, P < or = 0.001), arterial partial pressure of ammonia (r(s) = 0.55, P < or = 0.001), and venous partial pressure of ammonia (r(s) = 0.52, P < or = 0.001)., Conclusion: Ammonia levels correlate with the severity of hepatic encephalopathy. Venous sampling is adequate for ammonia measurement. There appears to be no additional advantage of measuring the partial pressure of ammonia compared with total ammonia levels.