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Summary Background Treatment of ventilated pneumonia is often unsuccessful, even when patients are treated according to established guidelines. Therefore, we aimed to investigate the efficacy of the combination drug device Amikacin Inhale as an adjunctive therapy to intravenous standard-of-care antibiotics for pneumonia caused by Gram-negative pathogens in intubated and mechanically ventilated patients. Methods INHALE was a prospective, double-blind, randomised, placebo-controlled, phase 3 study comprising two trials (INHALE 1 and INHALE 2) done in 153 hospital intensive-care units in 25 countries. Eligible patients were aged 18 years or older; had pneumonia that had been diagnosed by chest radiography and that was documented as being caused by or showing two risk factors for a Gram-negative, multidrug-resistant pathogen; were intubated and mechanically ventilated; had impaired oxygenation within 48 h before screening; and had a modified Clinical Pulmonary Infection Score of at least 6. Patients were stratified by region and disease severity (according to their Acute Physiology and Chronic Health Evaluation [APACHE] II score) and randomly assigned (1:1) via an interactive voice-recognition system to receive 400 mg amikacin (Amikacin Inhale) or saline placebo, both of which were aerosolised, administered every 12 h for 10 days via the same synchronised inhalation system, and given alongside standard-of-care intravenous antibiotics. All patients and all staff involved in administering devices and monitoring outcomes were masked to treatment assignment. The primary endpoint, survival at days 28–32, was analysed in all patients who received at least one dose of study drug, were infected with a Gram-negative pathogen, and had an APACHE II score of at least 10 at diagnosis. Safety analyses were done in all patients who received at least one dose of study drug. This study is registered with ClinicalTrials.gov , numbers NCT01799993 and NCT00805168 . Findings Between April 13, 2013, and April 7, 2017, 807 patients were assessed for eligibility and 725 were randomly assigned to Amikacin Inhale (362 patients) or aerosolised placebo (363 patients). 712 patients received at least one dose of study drug (354 in the Amikacin Inhale group and 358 in the placebo group), although one patient assigned to Amikacin Inhale received placebo in error and was included in the placebo group for safety analyses. 508 patients (255 in the Amikacin Inhale group and 253 in the placebo group) were assessed for the primary endpoint. We found no between-group difference in survival: 191 (75%) patients in the Amikacin Inhale group versus 196 (77%) patients in the placebo group survived until days 28–32 (odds ratio 0·841, 95% CI 0·554–1·277; p=0·43). Similar proportions of patients in the two treatment groups had a treatment-emergent adverse event (295 [84%] of 353 patients in the Amikacin Inhale group vs 303 [84%] of 359 patients in the placebo group) or a serious treatment-emergent adverse event (101 [29%] patients vs 97 [27%] patients). Interpretation Our findings do not support use of inhaled amikacin adjunctive to standard-of-care intravenous therapy in mechanically ventilated patients with Gram-negative pneumonia. Funding Bayer AG.

Background Two million non-emergency surgeries are being cancelled globally every week due to the COVID-19 pandemic, which will have a major impact on patients and healthcare systems. Methods During the peak of the pandemic in the United Kingdom, we set up a multicentre cancer network amongst 14 National Health Service institutions, performing urological, thoracic, gynaecological and general surgical urgent and cancer operations at a central COVID-19 cold site. This is a cohort study of 500 consecutive patients undergoing surgery in this network. The primary outcome was 30-day mortality from COVID-19. Secondary outcomes included all-cause mortality and post-operative complications at 30-days. Results 500 patients underwent surgery with median age 62.5 (IQR 51–71). 65% were male, 60% had a known diagnosis of cancer and 61% of surgeries were considered complex or major. No patient died from COVID-19 at 30-days. 30-day all-cause mortality was 3/500 (1%). 10 (2%) patients were diagnosed with COVID-19, 4 (1%) with confirmed laboratory diagnosis and 6 (1%) with probable COVID-19. 33/500 (7%) of patients developed Clavien-Dindo grade 3 or higher complications, with 1/33 (3%) occurring in a patient with COVID-19. Conclusion It is safe to continue cancer and urgent surgery during the COVID-19 pandemic with appropriate service reconfiguration., Highlights • Priority surgeries are being cancelled every week due to the COVID-19 pandemic. • A multicentre surgical referral network was set up as part of an NHS England approach to continuing safe surgery • The referral network consisted of 14 NHS trusts and surgery was performed at a single COVID-19 ‘cold site’. • After 500 surgeries performed, there was a 0% 30-day mortality from COVID-19. • It is safe to continue cancer and priority surgery during the COVID-19 pandemic with appropriate service reconfiguration.

Achromobacter sp are nonfermenting Gram-negative bacilli (NFGNB) that rarely cause severe infections, including ventilator-associated pneumonia (VAP). Data on the treatment of Achromobacter pneumonia are very limited, and the organism has been associated with a high mortality rate. Thus, more data are needed on treating this organism.To evaluate the treatment of Achromobacter VAP in critically ill trauma patients.This retrospective, observational study evaluated critically ill trauma patients who developed Achromobacter VAP. A previously published pathway for the diagnosis and management of VAP was used according to routine patient care. This included the use of quantitative bronchoscopic bronchoalveolar lavage cultures to definitively diagnose VAP.A total of 37 episodes of Achromobacter VAP occurred in 34 trauma intensive care unit patients over a 15-year period. The most commonly used definitive antibiotics were imipenem/cilastatin, cefepime, or trimethoprim/sulfamethoxazole. The primary outcome of clinical success was achieved in 32 of 37 episodes (87%). This is similar to previous studies of other NFGNB VAP (eg, Pseudomonas, Acinetobacter) from the study center. Microbiological success was seen in 21 of 28 episodes (75%), and VAP-related mortality was 9% (3 of 34 patients).Achromobacter is a rare but potentially serious cause of VAP in critically ill patients. In this study, there was an acceptable success rate compared with other causes of NFGNB VAP in this patient population.

tudy objective High-dose continuous venovenous hemofiltration (CVVH) is a continuous renal replacement therapy (CRRT) used frequently in patients with burns. However, antibiotic dosing is based on inference from studies assessing substantially different methods of CRRT. To address this knowledge gap for imipenem/cilastatin (I/C), we evaluated the systemic and extracorporeal clearances (CLs) of I/C in patients with burns undergoing high-dose CVVH. Design Prospective clinical pharmacokinetic study. Patients Ten adult patients with burns receiving I/C for a documented infection and requiring high-dose CVVH were studied. Methods Blood and effluent samples for analysis of I/C concentrations were collected for up to 6 hours after the I/C infusion for calculation of I/C total CL (CLTotal), CL by CVVH (CLHF), half-life during CVVH, volume of distribution at steady state (Vdss), and the percentage of drug eliminated by CVVH. Results In this patient sample, the mean age was 50 ± 17 years, total body surface area burns was 23 ± 27%, and 80% were male. Nine patients were treated with high-dose CVVH for acute kidney injury and one patient for sepsis. The mean delivered CVVH dose was 52 ± 14 ml/kg/hour (range 32–74 ml/kg/hr). The imipenem CLHF was 3.27 ± 0.48 L/hour, which accounted for 23 ± 4% of the CLTotal (14.74 ± 4.75 L/hr). Cilastatin CLHF was 1.98 ± 0.56 L/hour, which accounted for 45 ± 19% of the CLTotal (5.16 + 2.44 L/hr). The imipenem and cilastatin half-lives were 1.77 ± 0.38 hours and 4.21 ± 2.31 hours, respectively. Imipenem and cilastatin Vdss were 35.1 ± 10.3 and 32.8 ± 13.8 L, respectively. Conclusion Efficient removal of I/C by high-dose CVVH, a high overall clearance, and a high volume of distribution in burn intensive care unit patients undergoing this CRRT method warrant aggressive dosing to treat serious infections effectively depending on the infection site and/or pathogen.

Ventilator-associated pneumonia (VAP) is associated with significant morbidity (ventilator days, ICU days, and cost) and mortality increase in trauma patients. Multidrug-resistant strains of causative VAP pathogens are becoming increasingly common. Aerosolized antibiotics achieve high alveolar concentrations and provide valuable adjuncts in the treatment of VAP. This study examined the impact of aerosolized antibiotics in the treatment of VAP in trauma patients. Patients with either

An integral part of ventilator-associated pneumonia (VAP) therapy is the appropriate choice of empiric antibiotics. Our previous experience demonstrated adherence to an empiric therapy pathway was associated with only modest changes in organisms causing VAP. The purpose of the current study was to evaluate the impact of a restrictive antibiotic policy for VAP in trauma patients on the incidence and sensitivities of causative pathogens since the previous study.Patients with VAP diagnosed on bronchoalveolar lavage since the previous study were stratified by age, gender, mechanism of injury, and injury severity. All patients received empiric antibiotics based on duration of intensive care unit (ICU) stay using a unit-specific pathway. The incidence and sensitivities of causative pathogens in the current study were documented. The adequacy of the VAP pathway was evaluated for all VAP episodes. The current study was then compared with the previous study.Over a 10-year period, 1,474 episodes of VAP were diagnosed with 2,387 causative pathogens isolated. Overall incidence of gram-positive and gram-negative VAP pathogens was unchanged between the study periods. The current study experienced an increase in the incidence of Staphylococcus aureus (23% vs. 17%, p = 0.001) and methicillin-resistant Staphylococcus aureus (10% vs. 6%, p = 0.002) compared with the previous study. The pathway for empiric antibiotics resulted in adequate empiric coverage in 85% of VAP episodes, which was improved compared with the previous study (76%, p = 0.024). Furthermore, despite the increased incidence of early methicillin-resistant Staphylococcus aureus (MRSA) VAP, adequacy of the pathway improved for both the early period (91% vs. 86%, p = 0.001) as well as the late period (86% vs. 63%, p 0.001) in the current study compared with the previous study.A comprehensive protocol for the diagnosis and management of VAP, along with antibiotic stewardship, can prevent the development of bacterial resistance to empiric therapy.

Anxiety and stress are everyday issues for many people with high-functioning autism, and while cognitive-behavioural therapy is the treatment of choice for the management of anxiety, there are challenges in using it with people with high-functioning autism. This study used modified experience sampling techniques to examine everyday anxiety and stress in adults with high-functioning autism and to explore the feasibility of delivering real-time stress management techniques using a mobile platform. High levels of anxiety were found to be characterised by worry, confusing thoughts and being alone but was not associated with internal focus, imagery or rumination. Participants reported improved mood and less worry and anxious thinking in the active phase of the study. These results support previous studies indicating that people with high-functioning autism differ in their experience of anxiety and provided preliminary data on the feasibility of real-time stress management. The limitations of this approach are discussed together with considerations for future work in the area of developing clinical interventions on mobile platforms.

Background Ventilator-associated pneumonia (VAP) represents one of the driving forces behind antibiotic use in the ICU. In a previous study, we established a defined algorithm for treatment of hospital-acquired VAP dictated by the causative pathogen. The purpose of the current study was to evaluate the impact of this algorithm for hospital-acquired VAP on recurrence and charges in trauma patients. Study Design Patients with VAP secondary to MRSA, Acinetobacter baumannii , Pseudomonas aeruginosa , Stenotrophomonas maltophilia , or Enterobacteriaceae during 5 years subsequent to the previous study were evaluated. All VAP were diagnosed using quantitative cultures of the bronchoalveolar lavage effluent. Duration of antimicrobial therapy was dictated by the causative pathogen. If microbiologic resolution, defined as 3 colony-forming units/mL, was achieved, therapy was stopped by day 10. The remainder received 14 days of therapy. Recurrence was defined as >10 5 colony-forming units/mL on subsequent bronchoalveolar lavage performed within 2 weeks after completion of appropriate therapy. Results Five hundred and twenty-nine VAP episodes were identified in 381 patients. Overall recurrence was unchanged compared with the previous study (1.5% vs 2%; p = 0.3). There was a decrease in the number of bronchoalveolar lavages performed per patient compared with the previous study (1.6 vs 2.3; p = 0.24) and a reduction of 4.8 antibiotic days per VAP episode compared with the previous study. Both changes resulted in a cumulative reduction of $3,535.04 per patient, for a savings of $1.35 million during the study period. Conclusions Hospital-acquired VAP can be managed effectively by a defined course of therapy dictated by the causative pathogen. Adherence to an established algorithm simplified the management of VAP and contributed to a cumulative reduction in patient charges without impacting recurrence.

Background The diagnosis of ventilator-associated pneumonia (VAP) in our institution has followed an established diagnostic threshold (DT) of equal to or greater than 10 colony-forming units (CFU) per milliliter on bronchoalveolar lavage (BAL) based on our previous study (PS). Because mortality from VAP is related to treatment delay, some have advocated a lower DT. The purpose of the current study (CS) was to evaluate the impact of adherence to this DT for VAP on false-negative (FN) rates and mortality in trauma patients. Methods Consecutive patients over 9 years with VAP (defined as ≥10 CFU/mL in the BAL effluent) subsequent to the PS were identified. Data regarding each BAL performed and the colony counts of each organism identified were recorded. An FN BAL result was defined as any patient who had less than 10 CFU/mL and developed VAP with the same organism up to 7 days after the previous culture. The CS was then compared with the PS. Results Over 9 years, 1,679 patients underwent 3,202 BALs. Of these, 79% were male, 88% experienced blunt injury, mean age and Injury Severity Score (ISS) were 44 years and 31, respectively. Overall, there were 73 FN BAL results (2.3%) in the CS compared with 3% in the PS (p = 0.092). In those patients with 10 organisms, the FN rate was reduced (7.5% vs. 11%, p = 0.045), and mortality was unchanged (5.4% vs. 8.3%, p = 0.361) in the CS compared with the PS. The use of the threshold equal to or greater than 10 resulted in a cumulative reduction in antibiotic charges of $1.57 million. Conclusion Continued adherence to the diagnostic threshold of equal to or greater than 10 for quantitative BAL in trauma patients has maintained a low incidence of FN BALs and reduced patient charges without impacting mortality. The purported benefit of a lower threshold is not supported. In addition, the potential sequelae of increased resistant organisms, antibiotic-related complications, and costs associated with prolonged unnecessary antibiotic exposure are minimized. Level of evidence Prognostic study, level III.

Several imaging-based scoring systems have been used as outcome measures in assessing the severity of cystic fibrosis (CF) lung disease. It has been shown that chest radiography performs equally to computed tomography (CT). There is the opinion that of the two most commonly used chest radiograph (CXR) systems, the Brasfield system is less sensitive and reliable than the Wisconsin system.This report assesses the reproducibility and reliability of the two systems.Thirty patients with CXRs during a 5-year period were randomly selected. One hundred eighty-two studies had data for all CXRs and pulmonary function tests (PFTs), Forced Expiratory Volume in One Second (FEV-1) and Forced Vital Capacity (FVC). PFT values closest to the date of each CXR were recorded. Four radiologists scored each image twice by both the Brasfield and Wisconsin systems. Intra- and inter-rater reliability, correlation with PFTs and direct correlation of the two systems were calculated.Intra-rater agreement: r = 0.86-0.99 Brasfield, r = 0.78-0.96 Wisconsin. Inter-rater agreement: 0.76-0.90 Brasfield, r = 0.74-0.97 Wisconsin. Brasfield vs. FEV-1: r = 0.55, vs. FVC r = 0.61. Wisconsin vs. FEV-1: r = 0.57, vs. FVC r = 0.66. Correlation of the two systems: r = 0.86 (all P 0.001).The Brasfield and Wisconsin systems performed very similarly providing equally reproducible, robust and reliable measures.

To report a case of Chryseobacterium indologenes ventilator-associated pneumonia (VAP) in a critically ill trauma patient.This report describes a 66-year-old critically ill trauma patient who developed VAP, which was caused by C indologenes. The patient was injured in a riding lawn mower accident that trapped him underwater in a pond. The patient required surgery for intra-abdominal injuries and was mechanically ventilated in the trauma intensive care unit. On hospital day 5, the patient developed signs and symptoms of VAP. A diagnosis of C indologenes VAP was confirmed based on a quantitative culture from a bronchoscopic bronchoalveolar lavage. The patient's infection was successfully treated with moxifloxacin for 2 days followed by cefepime for 7 days.Formally known as Flavobacterium indologenes, C indologenes is a Gram-negative bacillus normally found in plants, soil, foodstuffs, and fresh and marine water sources. Recently, worldwide reports of C indologenes infections in humans have been increasing, though reports from the United States are still rare. Bacteremia and pneumonia are the most commonly reported infections, and most patients are immunocompromised. The current case differs from most previous reports because this patient was in the United States and did not have any traditional immunocompromised states (eg, transplant, cancer, HIV/AIDS, or corticosteroid use).This case report demonstrates that C indologenes can cause VAP in a trauma ICU patient.

Guidelines advise that patients with ventilator-associated pneumonia (VAP) should respond clinically by Day 3 of antibiotics. White blood cell (WBC) count, maximum temperature (Tmax), and PaO2:FIO2 ratio are all said to respond significantly by Day 6. Resolution of abnormalities has not been evaluated in trauma patients.Retrospective review of trauma patients with VAP. The WBC count, Tmax, and PaO2:FIO2 were evaluated for 16 days after diagnosis. Patients were grouped into uncomplicated VAP, complicated VAP (those with inadequate empirical therapy [IEAT], VAP relapse/superinfection, or acute respiratory distress syndrome), and concurrent infection+VAP (those also infected at another site).There were 126 patients (uncomplicated VAP=29, complicated VAP=69, and concurrent infection+VAP=28). The mean Tmax in patients with uncomplicated VAP decreased significantly from diagnosis to Day 4 (Day 1: 39 ± 0.5°C vs. Day 4: 38.6 ± 0.7°C; p=0.028) but never normalized. Their WBC counts and PaO2:FIO2 did not change significantly over the 16-day follow-up and never normalized. When comparing the three groups, the probability of resolving all three abnormalities was not different (p=0.5).Clinical and laboratory abnormalities in critically injured patients with VAP do not resolve as quickly as suggested in the guidelines. Future studies should evaluate new methods to determine the response to antibiotic therapy in critically injured patients with VAP.

To determine the feasibility of obtaining intraoperative contrast-enhanced ultrasound (CEUS) imaging in patients undergoing open partial nephrectomy for renal cancer. We hypothesize that the study was feasible and the addition of CEUS would improve lesion identification and characterization.The study population consisted of 10 patients with known renal mass scheduled for intraoperative ultrasound-guided open partial nephrectomy. After dissection and exposure of the kidney by the surgeon, an intraoperative pre- and post-CEUS was performed by the radiologist. Feasibility was defined as successful imaging in 8 of 10 patients with intraoperative CEUS. Image quality, lesion conspicuity/contrast, lesion vascularity, morphology, and size were assessed and graded with pre- and post-contrast images.Intraoperative ultrasound was successfully acquired in 10 of 11 patients for renal mass detection and characterization. One study was canceled intraoperatively as a result of clinical complications related to a difficult surgery. Tumor size ranged from 1.3 to 4.2 cm. All lesions were solid. No additional lesions were found on CEUS compared with baseline imaging. Image quality post-contrast ranged from acceptable to excellent. There were no adverse events recorded for all 10 patients.In our feasibility study consisting of 10 patients, CEUS for detection and characterization of renal mass undergoing open partial nephrectomy was feasible and safe. Because intraoperative ultrasound during open partial nephrectomy can affect the extent of surgery, CEUS can be used to help detect and characterize renal mass for surgical planning/resection intraoperatively.

Background The purpose of this study was to determine the clinical cure rate of high-dose vancomycin for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) ventilator-associated pneumonia (VAP) in critically ill trauma patients. Recent trials suggest that a traditional dose of 1 g q12 hours results in unacceptable cure rates for MRSA VAP. Thus, more aggressive vancomycin dosing has the potential to improve efficacy. Based on pharmacokinetic principles, the goal initial dose at the study center has been 20 mg/kg q12 hours or q8 hours since the 1990s. Methods All patients admitted to the trauma intensive care unit from 1997 to 2008 diagnosed with MRSA VAP were retrospectively reviewed. Diagnosis required bacterial growth ≥ 100,000 colony forming units/mL from a bronchoscopic bronchoalveolar lavage, new or changing infiltrate, plus at least two of the following: fever, leukocytosis or leukopenia, or purulent sputum. Results Overall, 125 patients with 141 episodes of MRSA VAP were identified. Mean age was 47 years ± 21 years, median Injury Severity Score was 29 (22-43), 70% of patients were male, and the mean length of intensive care unit stay was 38 days ± 35 days. The mean initial vancomycin dose was 18.1 mg/kg/dose with a mean duration of therapy of 11 days. Clinical success was achieved in 88% (125 of 131) of episodes, with microbiological success in 89% (66 of 74) of episodes with a follow-up bronchoscopic bronchoalveolar lavage. Overall mortality was 20% (25 of 125), with death due to VAP in 12 of 25 deaths. Mean initial vancomycin trough concentrations were 10.6 mg/L in the clinical success group and 13.3 mg/L in the clinical failure group (p = not significant). Conclusions High-dose vancomycin provided an acceptable cure rate for MRSA VAP in critically ill trauma patients. Level of evidence Therapeutic study, level III.

Study Objectives. To determine clinical and microbiologic plus clinical success rates in critically ill trauma patients who received treatment for Stenotrophomonas maltophilia ventilator-associated pneumonia (VAP). Design. Retrospective medical record review. Setting. Level I trauma intensive care unit of a large academic medical center. Patients. A total of 101 patients who developed S. maltophilia VAP between January 1997 and December 2007. Measurements and Main Results. Patients' baseline demographic and clinical characteristics, as well as characteristics of their VAP, were documented. The primary study outcome was the rate of clinical success in patients with S. maltophilia VAP; a secondary outcome was microbiologic plus clinical success rate in these patients. Standard definitions were employed to determine these outcomes related to VAP treatment. The study population had higher injury severity scores and a higher rate of traumatic brain injury than is typically observed in the study's intensive care unit. The median time to diagnosis of S. maltophilia VAP was 15 days (interquartile range 11–24 days). Stenotrophomonas maltophilia was the sole organism isolated in 34% of patients; the other patients had polymicrobial VAP. Despite inadequate empiric antibiotic therapy being administered to 97% of the patients, the overall clinical success rate was 87%. The microbiologic plus clinical success rate was 82%. The most common treatments for S. maltophilia VAP were trimethoprim-sulfamethoxazole (77 patients received monotherapy, 9 received combination therapy) and ciprofloxacin (6 patients received monotherapy, 8 received combination therapy); all-cause and VAP-related mortality rates were 13% and 7%, respectively. Conclusion. Critically ill trauma patients with S. maltophilia VAP responded well to therapy despite high rates of inadequate empiric antibiotic administration. Trimethoprim-sulfamethoxazole was the most common therapy, but clinical success rates did not differ significantly based on antibiotic selection. This study adds significantly to the available S. maltophilia VAP outcomes data.

Background Recent ventilator-associated pneumonia (VAP) guidelines recommend considering abbreviated therapy in patients with non− Pseudomonas aeruginosa VAP if clinical signs resolve. However, using an arbitrary day cutoff or clinical signs can be suboptimal for some, especially multiply injured patients, resulting in relapse and/or antibiotic resistance. Previously, we showed that repeat bronchoalveolar lavage (BAL) could guide antimicrobial duration for community-acquired VAP in trauma patients. The purpose of this study was to determine the appropriate duration of antimicrobial therapy for VAP in trauma patients secondary to hospital-acquired pathogens. Study Design Patients with VAP secondary to MRSA, Pseudomonas aeruginosa (PA) , Acinetobacter baumannii (AB), Stenotrophomonas maltophilia (SM), or Enterobacteriaceae (ENB) during 6 years were evaluated. All received empiric antimicrobial therapy based on duration of ICU stay. Therapy was tailored based on culture data. Repeat BAL was performed on day 4 of appropriate therapy. Microbiological resolution was defined as ≤10 3 colony-forming units/mL. Recurrence was defined as ≥10 5 colony-forming units/mL on subsequent BAL performed within 2 weeks after completion of appropriate therapy. Results Six hundred and fifty-nine patients were identified. Seventy-seven percent of patients underwent repeat BAL: 96 with MRSA, 100 with AB, 139 with PA, 50 with SM, and 120 with ENB. The majority of patients with MRSA or PA achieved microbiological resolution after 14 days. Nearly 60% of patients with AB, SM, or ENB achieved microbiological resolution after 10 days. Overall recurrence was 2%. Conclusions Repeat BAL provides objective evidence for VAP resolution in the face of potentially confounding clinical factors. Hospital-acquired VAP can be managed effectively by a defined course of therapy with a low recurrence. Duration of antimicrobial therapy for VAP in trauma patients should be dictated by the causative pathogen.

Using an arbitrary day cutoff or clinical signs to decide the duration of antibiotic therapy for ventilator-associated pneumonia (VAP) may be suboptimal for some patients. We sought to determine whether antibiotic duration for VAP can be safely abbreviated in trauma patients using repeat bronchoalveolar lavage (BAL).This was an observational case-controlled pilot study. Fifty-two patients were treated for VAP using a repeat BAL clinical pathway. Definitive antibiotic therapy for VAP was discontinued if pathogen growth was10,000 colony forming units/mL on repeat BAL performed on day 4 of antibiotic therapy (responder), otherwise therapy was continued per managing team. A matched control group of 52 VAP patients treated before (immediately consecutive) the pathway was used for comparison.Antibiotic duration in pathway patients was shorter than control patients (9.8 days +/- 3.8 days vs. 16.7 days +/- 7.4 days; p0.001), including nonfermenting gram-negative bacilli VAP (10.7 days +/- 4.1 days vs. 14.4 days +/- 4.2 days; p0.001). There were no differences in pneumonia relapse, mechanical ventilator-free intensive care unit (ICU) days, ICU-free hospital days, or mortality. Of study group isolates, 86 (82.7%) responded on repeat BAL and were treated for 8.8 days +/- 3.3 days. Of these without concomitant infections (n = 65), antibiotic duration was 7.3 days +/- 1.2 days compared with 14.4 days +/- 2.6 days for nonresponding isolates (n = 18) (p0.001).Repeat BAL decreased the duration of antibiotic therapy for VAP in trauma patients. More adequately powered investigations are needed to appropriately determine the effects of this strategy on patient outcome.

Ventilator-associated pneumonia (VAP) is a frequent complication during recovery of severely traumatized patients. The primary objective of this study was to determine if prophylactic administration of aerosolized ceftazidime reduced the incidence of VAP in high-risk injured patients without altering the incidence of other infectious complications.This was a single-institution double-blind, randomized trial that compared a seven-day course of aerosolized ceftazidime with placebo. Intubated high-risk patients admitted to the trauma intensive care unit at a large regional trauma center between February 2003 and September 2005 were eligible for enrollment. The main outcome evaluated was the incidence of VAP at two weeks and 30 days. The incidences of multi-drug-resistant infections and other infectious complications were secondary outcomes.A total of 105 patients were randomized, resulting in 52 patients in the placebo arm and 53 patients in the ceftazidime arm. There was no statistical difference between the groups with regard to demographic data, injury severity, calculated risk of VAP, or the number of doses received. In the intention-to-treat analysis, the incidence of VAP at two weeks was 24/52 (46%) in the placebo group and 21/53 (40%) in the ceftazidime group. The number of patients with VAP at 30 days was 26/52 (50%) in the placebo group and 26/53 (49%) in the ceftazidime group. There was no statistical difference in the development of multi-drug-resistant VAP or other infectious complications in the two groups.The use of aerosolized ceftazidime did not reduce the rate of VAP in high-risk patients admitted after traumatic injury, but neither did it increase the incidence of other infectious complications. Routine use of prophylactic aerosolized ceftazidime to prevent VAP in trauma patients cannot be recommended.

To identify groups most likely to benefit from an Expressive Writing (EW) intervention, we examined psychosocial variables as intervention moderators. We hypothesized that EW would be particularly effective for participants with high levels of depressive symptoms and social support at study entry.Patients (n = 277; 60.6% male) with kidney cancer were randomly assigned to either an expressive (EW) or neutral writing (NW) condition. Intervention outcomes included measures of depressive symptoms (CESD), cancer-related symptoms (MDASI), fatigue (BFI), and sleep disturbances (PSQI) assessed at baseline, 1, 4, and 10 months later. Moderators were measured at baseline.As hypothesized, depressive symptoms and social support moderated intervention efficacy. When examining both moderators simultaneously, EW appeared to be most effective in terms of cancer-related symptoms (p 0.05) and depressive symptoms (p 0.01) for participants with elevated depressive symptoms who received high levels of social support at baseline relative to their counterparts in the NW condition. Moreover, participants in EW with high levels of social support at baseline reported lower levels sleep disturbances (p = 0.005) than their counterparts in NW.Recognition of baseline depressive symptoms and social support as intervention moderators may lead to improved patient selection for EW interventions, as EW may be particularly beneficial regarding QOL outcomes for patients that have social support available including participants with depressive symptoms. EW may not be beneficial, or potentially even contraindicated, for participants lacking social support. Copyright © 2016 John WileySons, Ltd.

BACKGROUND The optimal treatment duration for catheter-associated urinary tract infection (CA-UTI) in critically ill patients is unclear. The Infectious Diseases Society of America recommends up to 14 days of therapy; however, short-duration therapy (SDT) for 3 days to 5 days is often used in trauma intensive care unit (ICU) patients at our center. The efficacy of SDT for CA-UTI has not been studied in this population. The objective was to evaluate the efficacy of SDT for CA-UTI in trauma ICU patients. METHODS This retrospective study of patients with CA-UTI in a trauma ICU included patients with a urine culture growing bacteria of 100,000 CFU/mL or greater and definitive antibiotic treatment. Urine cultures were collected as part of standard workups for suspected sepsis. Duration of therapy was at the discretion of the trauma team. Exclusion criteria included concomitant infection, renal replacement therapy, or pregnancy. Clinical success and microbiologic success were evaluated. RESULTS One hundred ninety-two patients were evaluated, and 77 patients with SDT were included. Mean (SD) age was 49 (22) years, median Injury Severity Score (ISS) was 27 (interquartile range, 18-34), and median ICU stay was 17 days (interquartile range, 1-33 days). Mean (SD) duration of CA-UTI therapy was 4 (1) days (range, 3-5 days) with most patients (42%) receiving 5 days. The most common organisms were Escherichia coli, Enterococcus species, and Pseudomonas species. The clinical success rate was 82% (63 of 77), and the microbiologic success rate was 75% (36 of 48). Overall mortality was 4%, but no deaths were CA-UTI related. CONCLUSION SDT provided an acceptable clinical success rate in critically ill trauma patients, which was similar to studies of CA-UTI in other populations. These results suggest that SDT could be considered an option for treating CA-UTIs in trauma ICU patients. LEVEL OF EVIDENCE Therapeutic study, level V.

Background: Limited data exist on the role of adjunctive intraventricular (IVT) antibiotics for the treatment of central nervous system (CNS) infections in traumatic brain injury (TBI) patients. Objective: To evaluate differences in CNS infection cure rates for TBI patients who received adjunctive IVT antibiotics compared with intravenous (IV) antibiotics alone. Methods: We retrospectively identified patients with TBI and bacterial CNS infections admitted to the trauma intensive care unit (ICU) from 1997 to 2013. Study patients received IV and IVT antibiotics, and control patients received IV antibiotics alone. Clinical and microbiological cure rates were determined from patient records, in addition to ICU and hospital lengths of stay (LOSs), ventilator days, and hospital mortality. Results: A total of 83 patients were enrolled (32 study and 51 control). The duration of IV antibiotics was similar in both groups (10 vs 12 days, P = 0.14), and the study group received IVT antibiotics for a median of 9 days. Microbiological cure rates were 84% and 82% in study and control groups, respectively ( P = 0.95). Clinical cure rates were similar at all time points. No significant differences were seen in days of mechanical ventilation, ICU or hospital LOS, or hospital mortality. When only patients with external ventricular drains were compared, cure rates remained similar between groups. Conclusions: TBI patients with CNS infections had similar microbiological and clinical cure rates whether they were treated with adjunctive IVT antibiotics or IV antibiotics alone. Shorter than recommended durations of antibiotic therapy still resulted in acceptable cure rates and similar clinically relevant outcomes.

The Clinical Pulmonary Infection Score (CPIS) has received much attention recently. Advocates have touted its use for the diagnosis and duration of therapy in patients with ventilator-associated pneumonia (VAP). However, little has been written about its utility in trauma patients. The clinical, physiologic, and radiologic components of the CPIS may be difficult to differentiate from the systemic effects of injury. Quantitative cultures of the lower airway have been shown to be efficacious in differentiating VAP from the systemic inflammatory response syndrome (SIRS). In this study, we evaluated the potential use of CPIS as the sole means for diagnosis of VAP in critically injured patients.Patients were identified from the VAP database maintained in our Level I trauma center. Only those who had CPIS calculated at the time of bronchoscopy with BAL were included. VAP requiredor=10 colonies/mL on quantitative BAL for diagnosis. Antibiotic therapy was based on quantitative BAL results. Patients with10 colonies/mL were diagnosed with SIRS. Sensitivity and specificity of a CPIS6 for VAP diagnosis (confirmed by BAL) were calculated.In all, 158 patients underwent 285 BALs. The overall incidence for VAP was 42%. Patients with episodes of VAP and SIRS were well matched for age, Injury Severity Score, APACHE II score, and Glasgow Coma Scale score. The average CPIS was 6.8 in patients with SIRS and 6.9 for those with VAP. Using a CPIS6 as the threshold for VAP only yielded a sensitivity of 61% and a specificity of 43%.CPIS cannot differentiate VAP from SIRS in critically injured patients. Using CPIS to initiate antibiotic therapy in trauma patients could be harmful. Whether CPIS is useful to determine duration of antibiotic therapy is unknown.

Based on limited data, Candida sp. isolates from bronchoalveolar lavage (BAL) cultures in immunocompetent patients are thought to be contaminants rather than pathogens. The objective of this study was to determine the clinical significance of Candida sp. isolated from BAL cultures in critically ill trauma patients. Retrospective study in a level 1 trauma intensive care unit. All patients with Candida sp. isolated from BAL cultures over a 3-year period; 85 Candida positive BAL cultures from 62 patients were studied. The primary outcomes were the incidence of Candida sp. in BAL, antifungal use, course of the possible infection, and mortality. Of 1077 BAL cultures 85 (8%) grew Candida sp., representing 64 episodes of possible Candida sp. ventilator-associated pneumonia. No colony counts exceeded the diagnostic threshold for bacterial VAP (≥ 105 cfu/ml). Only 2 of 64 episodes (3%) were treated with systemic antifungals. Three other episodes (5%) were treated because of concomitant therapy for Candida sp. at other sites. The majority of episodes were not treated with antifungals and were considered contaminants (59/64, 92%). No patients developed subsequent candidemia, and most follow-up BALs (74%) were negative for Candida sp. Overall mortality (17%) was similar to previous patients with similar severity of injury at the study center (18%). The results of this study suggest that isolation of Candida sp. from BAL in quantities below the diagnostic threshold for VAP in this population does not require antifungal therapy.

The role of the thymus in long-term immune reconstitution has not been addressed in HIV patients who were severely immunodeficient prior to successful treatment with combination antiretroviral therapy (ART). Adult HIV-1 patients (n = 78) with nadir CD4+ T cell counts

BackgroundSuicide reduction is government strategy in many countries. We need to quantify the connection between non-fatal self-poisoning and eventual suicide.AimsTo determine mortality after an episode of self-poisoning and to identify predictors of death by any cause or by suicide.MethodA retrospective single-group cohort study was undertaken with 976 consecutive patients attending a large accident and emergency unit in 1985–1986 after non-fatal self-poisoning. Information about deaths was determined from the Office for National Statistics.ResultsOf the original patients, 94% were traced 16 years later; 17% had died, 3.5% by probable suicide. Subsequent suicide was related to numerous factors evident at the time of the episode of self-poisoning but, when examined for their independent effects, only the severity of the self-poisoning episode and relevant previous history seemed important.ConclusionsPatients attending a general hospital after self-poisoning all require good basic assessment and care responsive to their needs. Attempts to reduce the huge excess of suicide subsequent to self-harm are not likely to achieve much if they are based on the identification of subgroups through ‘risk assessment’

Study Objectives. To evaluate the safety and efficacy of aerosolized ceftazidime for prevention of ventilator-associated pneumonia (VAP) and to evaluate the effects of the drug on the proinflammatory response. Design. Prospective, randomized, double-blind, placebo-controlled clinical trial. Setting. University teaching hospital. Patients. Forty critically ill trauma patients at high risk for VAP. Intervention. Within 48 hours of admission to the intensive care unit (ICU), patients were randomly assigned to receive aerosolized ceftazidime 250 mg every 12 hours or placebo (normal saline) for up to 7 days. Bronchoalveolar concentrations of tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, IL-6, and IL-8 were determined at baseline and the end of therapy (days 4–7). Measurements and Main Results. The frequency of VAP in patients receiving aerosolized ceftazidime was 73% lower than that in patients receiving placebo at ICU day 14 (15% vs 55%, p=0.021), and 54% lower for the entire ICU stay (30% vs 65%, p=0.022). No clinically significant changes in bacterial culture and sensitivity patterns were observed. No adverse events from aerosolized ceftazidime were reported. Pulmonary TNF-α, IL-1β, and IL-8 concentrations were attenuated in the ceftazidime group compared with those in the placebo group (p

Anxiety is a major problem for many people with Asperger’s syndrome who may have qualitatively different fears from a non-Asperger’s syndrome population. Research has relied on measures developed for non-Asperger’s syndrome populations that require reporting past experiences of anxiety, which may confound assessment in people with Asperger’s syndrome due to problems with autobiographical memory as are often reported in this group. Experience sampling methodology was used to record real-time everyday experiences in 20 adults with Asperger’s syndrome and 20 neurotypical adults. Within-subject analysis was used to explore the phenomenology of thoughts occurring in people with Asperger’s syndrome when they were anxious. Comparisons were made with the group that did not have Asperger’s syndrome. The Asperger’s syndrome group were significantly more anxious than the comparison group. Factors associated with feelings of anxiety in the Asperger’s syndrome group were high levels of self-focus, worries about everyday events and periods of rumination lasting over 10 min. People in the Asperger’s syndrome group also had a tendency to think in the image form, but this was not associated with feelings of anxiety. The results are discussed with reference to psychological models of Asperger’s syndrome, cognitive models of anxiety and implications for psychological therapy for this group.

Background: The adequacy of intermittent and continuous infusion ceftazidime for the treatment of nosocomial pneumonia in critically ill trauma patients was assessed by analyzing ceftazidime pharmacokinetics in relation to the minimum inhibitory concentration (MIC) and treatment outcome. Methods: Serial blood samples were obtained during ceftazidime therapy in 31 trauma patients. Ceftazidime pharmacokinetics were compared with that of previously studied healthy volunteers. Ceftazidime pharmacokinetics were analyzed according to the time above the MIC and treatment outcome. Results: Critically ill trauma patients had a significantly increased volume of distribution and clearance (0.32 ± 0.14 L/kg and 2.35 ± 0.89 mL · min −1 · kg −1 , respectively) compared with healthy volunteers (0.21 ± 0.03 and 1.58 ± 0.23 mL · min −1 · kg −1 ). The time above the MIC was ≥92% of the dosing interval for all patients and treatment outcomes were similar between the two treatment groups. Conclusions: Ceftazidime pharmacokinetics are significantly altered in critically ill trauma patients. Both intermittent and continuous ceftazidime regimens were equally effective for the treatment of nosocomial pneumonia caused by less virulent bacteria.

Background Ventilator-associated pneumonia (VAP) carries significant mortality and morbidity. Predicting which patients will become infected could lead to measures to reduce the incidence of VAP. Methodology/Principal Findings The goal was to begin constructing a model for VAP prediction in critically-injured trauma patients, and to identify differentially expressed genes in patients who go on to develop VAP compared to similar patients who do not. Gene expression profiles of lipopolysaccharide stimulated blood cells in critically injured trauma patients that went on to develop ventilator-associated pneumonia (n = 10) was compared to those that never developed the infection (n = 10). Eight hundred and ten genes were differentially expressed between the two groups (ANOVA, P

To report a case of recurrent Stenotrophomonas maltophilia ventilator-associated pneumonia (VAP) that was successfully treated with doxycycline and aerosolized colistin.A 28-year-old male was admitted with a severe head injury and required mechanical ventilation. The patient developed S. maltophilia VAP on hospital day 17, which was cured after 7 days of treatment with high-dose intravenous trimethoprim/sulfamethoxazole (TMP/SMX). However, on day 34, the patient developed recurrent S. maltophilia VAP that did not respond clinically or demonstrate eradication on follow-up culture after 10 days of TMP/SMX. At that time, TMP/SMX was discontinued and treatment was initiated with intravenous doxycycline and aerosolized colistin. The VAP episode was cured after 14 days of treatment with doxycycline/aerosolized colistin.S. maltophilia is an emerging cause of VAP in some centers. This organism is associated with high mortality rates and has few treatment options because it is intrinsically resistant to most drug classes. Recent data suggest that doxycycline and aerosolized colistin each are effective in treatment of other multidrug-resistant organisms, such as Pseudomonas aeruginosa and Acinetobacter baumannii. However, this is the first report describing the use of this antibiotic regimen for S. maltophilia. High-dose TMP/SMX is considered to be the drug of choice primarily based on excellent in vitro activity. Few data exist on how to treat patients who fail therapy with TMP/SMX or cannot receive that drug because of resistance, allergy, or adverse events. Thus, it is important to report alternative methods for treating this infection.The positive clinical response to doxycycline and aerosolized colistin seen in the patient described here suggests that this combination may be an alternative treatment in patients who fail initial treatment or cannot receive standard therapies.

A major unanswered question in ventilator-associated pneumonia (VAP) management relates to patient response to therapy. We investigated the use of pulmonary cytokines as biomarkers for response to antibiotic therapy for VAP.Prospective, observational pilot study of 12 critically ill trauma patients with VAP using a bronchoscopic bronchoalveolar lavage (BAL) (or =100,000 colony-forming units [cfu]/mL). All patients underwent repeat BAL after three days of adequate antibiotic therapy. Changes in pulmonary effluent interleukin (IL)-8 and tumor necrosis factor (TNF)-alpha concentrations measured on diagnostic and repeat BAL were evaluated on the basis of the presence of a microbiologic response (10,000 cfu/mL on repeat BAL).Six post-therapy BAL samples showed a microbiologic response. In responders, IL-8 and TNF-alpha concentrations decreased significantly (1,303 +/- 1,150 ng/mL in diagnostic BAL sample vs. 309 +/- 448 ng/mL after response; p = 0.08 and 9.9 +/- 18.4 ng/mL in diagnostic vs. 0.1 +/- 0.1 ng/mL in post-treatment sample; p = 0.06, respectively). In non-responders, IL-8 (449 +/- 426 ng/mL vs. 326 +/- 319 ng/mL; p = 0.59) and TNF-alpha (1.2 +/- 1.9 ng/mL vs. 0.3 +/- 0.3 ng/mL; p = 0.31) did not change significantly. Clinical response measures did not change or increased in responders, whereas these parameters did not change or decreased paradoxically in non-responders.This pilot study indicates pulmonary concentrations of IL-8 and TNF-alpha decrease in microbiologic responders with VAP. Conversely, clinical response parameters were discordant with the microbiologic response. The utility of pulmonary cytokine behavior in evaluating the effectiveness of antibiotic therapy for VAP should be studied further.

Study Objective. To determine clinical and microbiologic success in patients receiving adjunctive aerosolized antibiotics for the treatment of ventilator-associated pneumonia (VAP). Design. Retrospective medical record review. Setting. Level I trauma intensive care unit of a large academic medical center. Patients. Forty-nine patients (mean ± SD age 42 ± 19 yrs) who received aerosolized antibiotics for the treatment of a total of 60 episodes of VAP caused by Pseudomonas aeruginosaand/or Acinetobacter baumanniibetween January 2001 and July 2007. Measurements and Main Results. Patients were identified by using an existing database of patients with documented VAP at the study center. To receive a diagnosis of VAP, patients had to have bacterial growth of 105 or more colony-forming units/ml from a bronchoscopic bronchoalveolar lavage and new or changing infiltrate on chest radiograph, plus at least two of the following: abnormal body temperature (> 38°C or 10 or 10% immature bands), or macroscopically purulent sputum. By reviewing patient data, we evaluated clinical and microbiologic success using standard definitions. The median (interquartile range) Injury Severity Score and admission Acute Physiology and Chronic Health Evaluation II score were 40 (29–45) and 17 (9–21), respectively. Pseudomonas aeruginosa, A. baumannii, or both were isolated in 45, 14, and 1 episode(s), respectively. Eighteen VAP episodes included additional bacteria. Aerosolized tobramycin, amikacin, and colistimethate were used in 44, 9, and 9 episodes, respectively. Systemic antibiotics were used in 59 (98%) of the 60 episodes. Clinical success was achieved in 36 (73%) of the 49 first episodes of VAP, 8 (73%) of 11 subsequent episodes, 17 (85%) of 20 episodes that were failing intravenous monotherapy, and 30 (79%) of 38 episodes with multidrug-resistant P. aeruginosaor A. baumannii.Microbiologic success was achieved in 29 (71%) of 41 evaluable episodes. Six patients died from VAP Conclusion. Treatment with adjunctive aerosolized antibiotics was associated with a good response rate in critically ill trauma patients with VAP due to nonfermenting gram-negative bacilli. It is noteworthy that episodes of VAP that followed intravenous therapy failure and/or that were due to multidrug-resistant organisms responded well.

Background: More than one half of lower respiratory cultures are negative for ventilator-associated pneumonia (VAP) and final reporting requires 72 hours to 96 hours. A previous retrospective study concluded that preliminary bronchoalveolar lavage (BAL) culture results (pBAL), reported at approximately 24 hours, accurately predicted final BAL culture results (fBAL). Our objective was to verify the predictive value of pBALs for fBALs, and evaluate the use of insignificant (1-99,999 cfu/mL) pBALs for rapid discontinuation of empirical antibiotics. Methods: All BALs performed in the intensive care unit (ICU) of the Presley Regional Trauma Center were used to compare pBALs with fBALs. Trauma intensive care unit patients whose antibiotics were discontinued using pBALs (study group), were compared with a historical control group who had their antibiotics discontinued using fBALs. Results: Preliminary and final results of 474 prospectively collected BALs were compared. Significant pBALs had a positive predictive value of 100%, whereas the negative predictive values of "no growth to date" and insignificant pBALs were 99% and 95%, respectively. Study patients (n = 176) were similar to control patients (n = 112) except for a higher median injury severity score (34 vs. 29; p < 0.001). The median (interquartile range) duration of empirical antibiotic therapy in patients without VAP was shorter for study patients [1.5 (1.25, 2) vs. 3 (3, 4) days, p < 0.001]. Empirical antibiotics were temporarily interrupted in four patients with VAP because of falsely negative pBALs without adverse clinical sequelae. Conclusions: Preliminary BALs were highly predictive for final results. Using insignificant pBALs appears to be a safe strategy for promptly discontinuing empirical antibiotics in trauma patients with suspected VAP.

Background: Empiric antibiotic therapy is routinely initiated for patients with presumed ventilator-associated pneumonia (VAP). The impact of inadequate empiric antibiotic therapy (IEAT) may vary among critically ill populations. The purpose of this retrospective study was to determine the effect of IEAT on the outcome for adult trauma patients with VAP. Methods: This study enrolled 82 patients with multiple VAP episodes (200 VAP episodes; mean, 2.4 ± 0.65 per patient; range, 2-5 episodes). An episode of IEAT was a VAP episode with empiric therapy having no in vitro activity against causative bacteria. Overall, there were 78 (39%) IEAT episodes involving 54 patients. Most often, IEAT was attributable to the presence of Acinetobacter spp, Stenotrophomonas maltophilia, or Alcaligenes xylosoxidans. All the patients received appropriate definitive therapy according to the final culture. The patients were classified by number of IEAT episodes: 0 (n = 28), 1 (n = 34), and more than 1 (n = 20). Results: Demographics and injury severity were similar among the groups. The mortality rate was 3.6% for no episodes, 8.8% for one episode, and 45% for more than one episode (p < 0.001). On the basis of multiple logistic regression, experiencing multiple IEAT episodes was independently associated with the risk of death (odds ratio, 4.28; 95% confidence interval, 1.44-12.71). Additionally, experiencing multiple IEAT episodes was associated with prolonged intensive care unit stay (p = 0.007) and prolonged mechanical ventilation (p = 0.005). Conclusions: Critically ill trauma patients experiencing multiple episodes of IEAT for VAP have increased morbidity and mortality. These findings reinforce the importance of developing and refining a unit-specific pathway for the empiric management of VAP.

Background: The use of quantitative cultures of the bronchoalveolar lavage (BAL) effluent to distinguish between posttraumatic inflammatory response and ventilator-associated pneumonia (VAP) is becoming more common. However, the diagnostic threshold of either 10 4 or 10 5 colonies/mL remains debatable. Because mortality from VAP is related to treatment delay, some have chosen a lower diagnostic threshold (≥10 4 colonies/mL). This may result in unnecessary antibiotic use with its sequelae: increased resistant organisms, antibiotic-related complications, and increased costs. The purpose of this study is to determine the optimal diagnostic threshold for VAP diagnosis using quantitative cultures of the BAL effluent. Methods: Data on patients with fiberoptic bronchoscopy with BAL are maintained in a prospectively collected database at our Level I trauma center. This database was reviewed for timing and frequency of BAL and the colony counts of each organism identified. Indication for bronchoscopy was clinical evidence of VAP. VAP was defined as ≥10 5 colonies/mL in the BAL effluent. A false-negative BAL was defined as any patient who had < 105 colonies/mL and developed VAP with the same organism up to 7 days after the previous culture. Results: Over a 46-month period, 526 patients underwent 1,372 fiberoptic bronchoscopy procedures with BAL. Of these, 72% were male patients, 91% followed blunt injury, and mean age and Injury Severity Score were 43 years and 30, respectively. Overall mortality was 14%. There were 1,898 organisms identified (42% were gram-positive and 58% were gram-negative). VAP was diagnosed in 38% of BAL. Overall, there were 43 episodes in 38 patients defined as false-negative (3%). The false-negative rate was 9% in patients with 10 4 organisms. The most common false-negative organisms were Pseudomonas and Acinetobacter species. Conclusion: The VAP diagnostic threshold for quantitative BAL in trauma patients should be ≥10 5 colonies/mL. One may consider a threshold of ≥10 4 colonies/mL in severely injured patients with Pseudomonas or Acinetobacter species.

A common strategy for the diagnosis of ventilator-associated pneumonia (VAP) includes quantitative cultures from bronchoalveolar lavage (BAL). Often, empiric antibiotic therapy is initiated and continued until the final culture report. However, approximately 60 per cent of BAL cultures rule out VAP. Preliminary BAL results, obtained earlier, may identify these patients and allow early discontinuation of empiric antibiotics. This is desirable because unnecessary antibiotic therapy results in increased bacterial resistance, adverse drug events, and increased costs. The purpose of this study was to determine the value of preliminary BAL results for predicting final BAL results. A total of 1579 isolates from 868 BAL cultures over a 3-year period were analyzed. Preliminary and final colony counts for each isolate were categorized as either no growth (NG), insignificant (1-99,999 cfu/mL), or significant (or = 100,000 cfu/mL). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of preliminary results were calculated based on individual isolates and individual BAL samples. The presence of concurrent antibiotic therapy was collected for all false-negative isolates. On preliminary report, there were 367 isolates with NG, 820 isolates with insignificant growth, and 392 isolates with significant growth. Overall preliminary culture results had a sensitivity of approximately 90 per cent and specificity of90 per cent for the presence of VAP. Preliminary culture results accurately predicted the presence or absence of VAP in 838 (96.5%) of the BALs performed. Individual isolates and BAL samples with insignificant preliminary growth had greater reliability in predicting the absence of VAP than those with NG. There was no difference in the number of false-negative isolates that were taken while concurrent antibiotic therapy was present between insignificant and NG groups. Preliminary culture results yielding either insignificant or significant growth are highly predictive for final colony counts of similar magnitude. BALs with preliminary results demonstrating no growth are not as reliable. Isolates with significant preliminary growth should be considered clinically important, and antibiotic therapy should be changed, if necessary, to target such organisms. Isolates with insignificant preliminary growth have a low rate of false negatives; therefore, empiric antibiotic therapy specific for such organisms could be discontinued before obtaining final results. Empiric antibiotics should be continued until the final results are available in those patients with NG BALs.

An 18 year old male ingested Hawaiian Baby Woodrose seeds (containing the hallucinogen lysergic acid) and required hospitalization for psychotic behavior. This is the second documented case of an acute psychosis ascribed to ingestion of this plant, and it is suggested that Hawaiian Baby Woodrose ingestion should be present in the differential diagnosis when dealing with the acutely psychotic young adult patient.

Acinetobacter organisms, which are a common cause of ventilator-associated pneumonia (VAP) in some health care centers, are becoming more resistant to such first-line agents as imipenem-cilastatin (Imi-Cil). Sulbactam has good in vitro activity against Acinetobacter organisms; thus, ampicillin-sulbactam (Amp-Sulb) may be a viable treatment alternative. The outcomes for critically ill trauma patients with Acinetobacter VAP treated with either Amp-Sulb or Imi-Cil were compared retrospectively. A total of 77 episodes in 75 patients were studied. Fourteen patients were treated with Amp-Sulb, and 63 patients were treated with Imi-Cil. Treatment efficacy was similar in the Amp-Sulb and Imi-Cil groups (93% vs. 83%, respectively; P>.05). No statistically significant differences between groups were noted with regard to associated mortality, duration of mechanical ventilation, or length of stay in the intensive care unit or hospital. However, adjunctive aminoglycoside therapy was used more often in the Amp-Sulb group. Patients generally received Amp-Sulb because of imipenem resistance. Amp-Sulb was effective in treating a small number of patients with Acinetobacter VAP; however, more data are needed.

Purpose To assess whether improvements in measurable health-related quality-of-life (HR-QoL) functions parallel the rapid visual recovery after phacoemulsification. Setting The Cataract Treatment Center, Sunderland Eye Infirmary, Sunderland, England. Methods This study comprised 144 patients having first-eye phacoemulsification cataract extraction. They were assessed using a standard EuroQoL generic (non-disease specific) multidimensional HR-QoL instrument to evaluate preoperative and 1 month postoperative health profile measures in social, psychological, and general health aspects. Results Within 1 month of phacoemulsification, change in vision was accompanied by significant changes in HR-QoL functions such as home activities, social activities, self-care, mobility, and psychological well-being. Conclusion The speed of visual rehabilitation after phacoemulsification was paralleled by improvement across HR-QoL functions, resulting in the rapid recovery of functional independence and health status.

Between 1973 and 1981 1000 successful studies involving ambulatory monitoring of intra-arterial blood pressure were performed using percutaneous cannulation of the brachial artery. We have reviewed the clinical effects of these studies and 35 other cases where attempted cannulation was unsuccessful. One major complication occurred, when an infected haematoma arising at the cannulation site led to the formation of a false aneurysm. In only one other case was distal pulsation diminished following the study. There were 157 reported "minor" complications in 122 studies, including haematoma, haemorrhage, transient paraesthesiae in median nerve territory, and evidence of micro-emboli. A limited study using pulsed wave Doppler ultrasound revealed no significant alteration in arterial lumen size or flow in 20 subjects. The procedure was therefore associated with a much smaller incidence of clinical problems than has been reported with other investigations involving cannulation of the brachial artery.