Predictors of short-term mortality in critically ill patients with solid malignancies

Admission of cancer patients with serious medical complications to the ICU remains controversial primarily because of the high short-term mortality rates in these patients. However, the cancer patient population is heterogeneous regarding age, underlying conditions, and curability of their disease, suggesting that large variations may occur in the effectiveness of intensive care within this subgroup of critically ill patients.

OBJECTIVES

To identify factors predicting 30-day mortality in patients with solid tumors admitted to a medical ICU.

PATIENTS AND METHODS

We conducted a retrospective study in 120 consecutive cancer patients (excluding patients with hematological malignancies) admitted to the medical ICU of a 650-bed university hospital between January 1990 and July 1997. Medical history, physical and laboratory test findings at admission, and therapeutic interventions within the first 24 h in the ICU were recorded. The study endpoint was vital status 30 days after ICU admission. Stepwise logistic regression was used to identify independent prognostic factors.

RESULTS

The observed 30-day mortality rate was 58.7 % (n = 68), with most deaths (92 %) occurring in the ICU. Univariate predictors of 30-day mortality were either protective [prior surgery for the cancer (p = 0.01) and complete remission (p = 0.01)] or associated with higher mortality [Knaus scale C or D (p = 0.02), shock (p = 0.04), need for vasopressors (p = 0.0006) or for mechanical ventilation (p = 0.0001), SAPS II score greater than 36 (p = 0.0001), LOD score greater than 6 (p = 0.0001), and ODIN score > 2 (p = 0.0001)]. Three variables were independent predictors: previous surgery for the cancer (OR 0.20, 95 % CI 0.07-0.58), LOD score > 6 (OR 1.26, 95 % CI 1.09-1.44), and need for mechanical ventilation (OR 3.55, 95 % CI; 1.26-6.7). Variables previously thought to be indicative of a poor prognosis (i. e., advanced age, metastatic or progressive disease, neutropenia or bone marrow transplantation) were not predictive of outcome.

CONCLUSION

When transfer to an ICU is considered an option by patients and physicians, 30-day mortality is better estimated by an evaluation of acute organ dysfunction than by the characteristics of the underlying malignancy.

Differential carbon dioxide sensitivity in childhood anxiety disorders and nonill comparison group

BACKGROUND

To examine the relationship between respiratory regulation and childhood anxiety disorders, this study considered the relationship between anxiety disorders and symptoms during carbon dioxide (CO(2)) exposure, CO(2) sensitivity in specific childhood anxiety disorders, and the relationship between symptomatic and physiological responses to CO(2).

METHODS

Following procedures established in adults, 104 children (aged 9-17 years), including 25 from a previous study, underwent 5% CO(2) inhalation. The sample included 57 probands with an anxiety disorder (social phobia, generalized anxiety disorder, separation anxiety disorder, and panic disorder) and 47 nonill comparison subjects. Symptoms of anxiety were assessed before, during, and after CO(2) inhalation.

RESULTS

All children tolerated the procedure well, experiencing transient or no increases in anxiety symptoms. Children with an anxiety disorder, particularly separation anxiety disorder, exhibited greater changes in somatic symptoms during inhalation of CO(2)-enriched air, relative to the comparison group. During CO(2) inhalation, symptom ratings were positively correlated with respiratory rate increases, as well as with levels of tidal volume, minute ventilation, end-tidal CO(2), and irregularity in respiratory rate during room-air breathing.

CONCLUSIONS

Childhood anxiety disorders, particularly separation anxiety disorder, are associated with CO(2) hypersensitivity, as defined by symptom reports. Carbon dioxide hypersensitivity is associated with physiological changes similar to those found in panic disorder. These and other data suggest that certain childhood anxiety disorders may share pathophysiological features with adult panic disorder.

Could heart rate variability analysis become an early predictor of imminent brain death? A pilot study

Physiology of brain death is characterized by major disturbances of autonomic nervous system (ANS) activity which can lead to graft dysfunction. These findings exhibit the importance of early diagnosis of brain death to improve transplantation outcome. The aim of this prospective study was to assess whether heart rate variability (HRV) analysis, a noninvasive method to investigate ANS activity in comatose patients, could achieve this goal. A total of 14 brain-injured patients were included in the study as soon as they exhibited the clinical signs of imminent brain death. The electrocardiogram was then recorded from two leads with a Holter digital monitor. The clinical diagnosis of brain death was considered after an autonomic storm had occurred. HRV was assessed from 6 h before to 6 h after brain death in both time domain and spectral analysis, estimating either global ANS activity (index of variability, total power), parasympathetic activity (percentage of delta of R-R interval >50 ms, root mean square for successive interval differences, LnHF) or sympathetic activity (LnLF). Hourly averages of these variables were compared by using one-way analysis of variance. To assess whether HRV could per se diagnose brain death, receiver operating characteristic curves were generated for total power, root mean square for successive interval differences, and LnHF. We observed, for 6 h before brain death, a progressive extinction of the influence of the ANS on cardiovascular regulation. There was no activity in the two components of the ANS as soon as brain death occurred. HRV analysis appeared to be a very sensitive but a less specific method of diagnosing brain death.

IMPLICATIONS

A total of 14 brain-injured patients with the clinical criteria of imminent brain death were enrolled for electrocardiogram recording and heart rate variability analysis (a noninvasive method to investigate autonomic nervous system activity). For 6 h before brain death, we observed a progressive extinction of autonomic nervous system activity which was not present as soon as brain death was clinically evoked.

Prevalence and severity of asthma in adolescents in France. Cross-sectional and retrospective analyses of a large population-based sample

SETTING

Asthma is the most common chronic respiratory disease among adolescents; however, very little is known about asthma in this age group.

OBJECTIVE

To explore asthma in adolescence using cross-sectional and retrospective representative data.

DESIGN

A population-based sample of adolescents was selected from 578 classes in 186 schools of eight metropolitan educational districts in France and invited to complete a self-administered questionnaire (National Adolescent Health Survey [NAHS]).

RESULTS

Of 14,278 adolescents selected, 12,466 (87%) participated in the survey. Prevalence of 'ever asthma' was higher among boys, among those in the south and west, among those from French overseas departments, in active smokers, and in those with other allergies, including food allergy. It was lower in adolescents whose mother was a housewife. Puberty was not associated with 'ever asthma'; however, asthmatic boys without signs of puberty usually had more attacks than those with. Severe asthma was associated with early onset and female sex. Asthma medications and consultations did not depend on socio-economic status. Asthmatic adolescents were found to need more health care in terms of medication use, consultations and hospitalisations other than for asthma than other adolescents; this relationship was strongest among severe asthmatics.

[Follow-up of patients suffering from age-related macular degeneration, supplied with visual aids]

BACKGROUND

Age-related macular degeneration (AMD) is at present the major cause of legal blindness in industrialized countries. The results of various treatments are often not satisfactory and follow-up by Low-Vision services is then the only solution for this population. Few studies have been published on this subject. The purpose of this study is to present the use of magnifying systems and the degree of satisfaction obtained for this series of patients 6 months after prescription.

PATIENTS AND METHODS

Forty-four patients were examined, 42 of whom were eligible for the study. Lenses, magnifying glasses, visual systems for intermediate distance, and electronic systems were proposed. A low-vision training was given to every patient.

RESULTS

The highest degree of use and satisfaction was achieved with the electronic systems. In some cases, however, the other systems were well accepted by the patients.

CONCLUSION

The follow-up of patients with age-related macular degeneration is of great social importance. The independence of elderly people can be safeguarded thanks to the help of Low-Vision services with a good equipment and a well-trained team. Sometimes, unsophisticated systems such as magnifying glasses can be proposed, but the best results are mostly obtained through electronic systems (TV).

[Health promotion and communication strategy]

This article presents a brief overview of the evolution of knowledge in health communication. Theorists suggest interesting solutions to improve messages related to health, but practitioners are asking for the means to put them to use. In health communication, then, efforts must be made to apply theory to practice. Nurses, working with other professionals, should be encouraged to engage in research aimed at improving communication strategies in health promotion. Interdisciplinary co-operation is key.

[Postoperative antero-external tibial compartment syndrome: co-responsibility of the operating table]

A 26-year-old, ASA1 patient underwent maxillofacial surgery under general anaesthesia, of 12-hour duration in the supine position. Postoperatively he developed rhabdomyolysis and acute renal failure. In the subsequent days, a bilateral leg compartment syndrome occurred with anterior tibial motor nerve injury requiring fasciotomies and excision of necrotic muscles. Several aetiological factors may have contributed to this accident: a long-lasting procedure, controlled hypotension and inappropriate position of the lower limbs. A laboratory study showed that the hardness of some new operating tables could be responsible for this complication. Some prophylactic measures are therefore required before the use of such devices.

[A scientific reading method]

To provide high quality services, nursing professionals must be prepared to update their knowledge constantly. To achieve this, various methods are available such as courses, conferences and research projects. All of these methods share one essential intellectual activity, scientific reading. Scientific reading is a complex and demanding activity that requires more than basic reading skills. Many nurses find it boring and arduous, probably because it gives them no pleasure, but especially because they lack a method. In this article, the author proposes a scientific reading method consisting of three stages: an overview approach to the text, a superficial reading, and an in-depth reading of the text. This method is simple, easy to use, and entirely appropriate for scientific reading. The author hopes that this method will give more nurses the desire to read and use scientific literature in the practice of their profession.

Efficacy of interpersonal psychotherapy for depressed adolescents

BACKGROUND

Psychotherapy is widely used for depressed adolescents, but evidence supporting its efficacy is sparse.

METHODS

In a controlled, 12-week, clinical trial of Interpersonal Psychotherapy for Depressed Adolescents (IPT-A), 48 clinic-referred adolescents (aged 12-18 years) who met the criteria for DSM-III-R major depressive disorder were randomly assigned to either weekly IPT-A or clinical monitoring. Patients were seen biweekly by a "blind" independent evaluator to assess their symptoms, social functioning, and social problem-solving skills. Thirty-two of the 48 patients completed the protocol (21 IPT-A-assigned patients and 11 patients in the control group).

RESULTS

Patients who received IPT-A reported a notably greater decrease in depressive symptoms and greater improvement in overall social functioning, functioning with friends, and specific problem-solving skills. In the intent-to-treat sample, 18 (75%) of 24 patients who received IPT-A compared with 11 patients (46%) in the control condition met recovery criterion (Hamilton Rating Scale for Depression score < or =6) at week 12.

CONCLUSIONS

These preliminary findings support the feasibility, acceptability, and efficacy of 12 weeks of IPT-A in acutely depressed adolescents in reducing depressive symptoms and improving social functioning and interpersonal problem-solving skills. Because it is a small sample consisting largely of Latino, low socioeconomic status adolescents, further studies must be conducted with other adolescent populations to confirm the generalizability of the findings.

Depressed adolescents grown up

CONTEXT

Major depressive disorder (MDD) that arises in adolescence impairs functioning and is associated with suicide risk, but little is known about its continuity into adulthood.

OBJECTIVE

To describe the clinical course of adolescent-onset MDD into adulthood.

DESIGN AND PARTICIPANTS

Prospective case-control study. Seventy-three subjects had onset of MDD based on systematic clinical assessment during adolescence (Tanner stage III-V) and 37 controls had no evidence of past or current psychiatric disorders, and also were assessed in adolescence (assessment years: 1977-1985). Follow-up was conducted 10 to 15 years after the initial assessment by an independent team without knowledge of initial diagnosis (follow-up years: 1992-1996).

SETTING

Cases were identified at Columbia Presbyterian Hospital, New York City, NY; controls were recruited from the community.

MAIN OUTCOME MEASURES

Suicide and suicide attempts, psychiatric diagnoses, treatment utilization, and social functioning.

RESULTS

Clinical outcomes of adolescent-onset MDD into adulthood compared with control subjects without psychiatric illness include a high rate of suicide (7.7%); a 5-fold increased risk for first suicide attempt; a 2-fold increased risk of MDD, but not other psychiatric disorders; an increased occurrence of psychiatric and medical hospitalization; and impaired functioning in work, social, and family life. Thirty-seven percent of those with adolescent MDD survived without an episode of MDD in adulthood vs 69% of the control participants (relative risk, 2.2 [95% confidence interval, 1.0-4.7; P<.05]).

CONCLUSION

There is substantial continuity, specificity, morbidity, and potential mortality from suicide into adulthood in adolescent-onset MDD patients. Now that empirically based guides to their treatment are becoming available, early identification and treatment seems warranted.

Effects of amiodarone on cardiac function and mitochondrial oxidative phosphorylation during ischemia and reperfusion

This study was carried out in order to determine if the efficiency of amiodarone, a class III antiarrhythmic agent, is associated with changes in mitochondrial oxidative phosphorylation. A population of 30 rats were treated with amiodarone (100 mg/kg/day) for 5 days. A second population receiving only vehicle was used as control. The hearts were perfused according to the working mode. After 15 min of normoxic perfusion, the left main coronary artery was ligated and the ligation was maintained for 20 min. The ligation was removed and reperfusion continued for a further 30 min. The electrocardiogram was monitored continuously. At the end of perfusion, the ischemic and non ischemic areas were visually separated and mitochondria were harvested from each area. Their oxidative and energy metabolism were assessed with palmitoylcarnitine as substrate in 2 respiration media differing in their free calcium concentration (0 or 0.34 microm). In normoxic conditions, amiodarone treatment increased the cardiac metabolic efficiency (mechanical work to oxygen consumption ratio). The local ischemia decreased the aortic and coronary flows without modifying the cardiac metabolic efficiency. Amiodarone treatment maintained the aortic flow at a significantly higher value; the duration of severe arrhythmias was significantly decreased by the drug. The reperfusion of the ischemic area allowed the partial recovery of fluid dynamics. The coronary flow was restored to 89% of the pre ischemic value. Conversely, the aortic flow never exceeded that measured at the end of ischemia, partly due to the important development of severe arrhythmias. The recovery of aortic flow and metabolic efficiency during reperfusion was improved by amiodarone treatment; ventricular tachycardia and fibrillation duration were reduced. In the mitochondria issued from the normoxic area, the energy metabolism was not altered by the amiodarone treatment, but the presence of calcium in the respiration medium modified the oxidative phosphorylation. The divalent cation slightly decreased the state III respiration rate and increased noticeably the state IV respiration rate. This was associated with an important mitochondrial AMP production and maintenance of ADP in the respiration medium. This energy wasting was reported to decrease the mitochondrial metabolic efficiency. After an ischemia-reperfusion sequence, mitochondrial oxidation phosphorylation was reduced and amiodarone treatment amplified this decrease. This was presumably due to an increased mitochondrial calcium accumulation. Thus, the beneficial properties of amiodarone during reperfusion are supposed to be due to a protection against the deleterious effect of excess matrix calcium on mitochondrial energy metabolism.

Ventilatory physiology of children and adolescents with anxiety disorders

BACKGROUND

Abnormalities in ventilatory physiology have been noted in adults with panic disorder. We tested the hypothesis that abnormalities in ventilatory physiology differentiate children and adolescents with anxiety disorders from psychiatrically healthy children.

METHODS

Ventilatory physiology was monitored with a canopy apparatus during room-air breathing and 15 minutes of carbon dioxide exposure in 33 children and adolescents comprising 18 probands with an anxiety disorder and 15 psychiatrically healthy children.

RESULTS

During room-air breathing, probands had significantly larger minute ventilation, larger tidal volumes, and more variable breathing patterns than healthy comparisons, but the groups did not differ in end-tidal carbon dioxide or respiratory rate. During carbon dioxide challenge, probands exhibited larger minute ventilation and respiratory rate responses relative to comparisons.

CONCLUSION

These findings on the association between ventilatory physiology and anxiety disorders in children and adolescents are consistent with results from studies of adults with panic disorder.

Is a dietary n-3 fatty acid supplement able to influence the cardiac effect of the psychological stress?

Epidemiological studies suggest that n-3 polyunsaturated fatty acids (PUFA) are involved in the prevention of cardiovascular disease. Stress is known to increase the incidence of CVD and the present study was realised to evaluate some physiological and biochemical effects of dietary docosahexaenoic acid (DHA) in male Wistar rats subjected to a psycho social stress. Rats were fed for 8 weeks a semi-purified diet containing 10% of either sunflower seed oil or the same oil supplemented with DHA. This food supply represented 50% of their daily requirement. The remaining 50% were supplied as 45 mg food pellets designed to induce stress in rats by an intermittent-feeding schedule process. The control group (n = 12) was fed the equivalent food ration as a single daily feeding. The physiological cardiovascular parameters were recorded by telemetry through a transmitter introduced in the abdomen. At the end of the experimentation, the heart and adrenals were withdrawn and the fatty acid composition and the catecholamine store were determined. Dietary DHA induced a pronounced alteration of the fatty acid profile of cardiac phospholipids (PL). The level of all the n-6 PUFAs was reduced while 22:6 n-3 was increased. The stress induced a significant increase in heart rate which was not observed in DHA-fed group. The time evolution of the systolic blood pressure was not affected by the stress and was roughly similar in the stressed rats of either dietary group. Conversely, the systolic blood pressure decreased in the unstressed rats fed DHA. Similar data were obtained for the diastolic blood pressure. The beneficial effect of DHA was also observed on cardiac contractility, since the dP/dt(max) increase was prevented in the DHA-fed rats. The stress-induced modifications were associated with an increase in cardiac noradrenaline level which was not observed in DHA-fed rats. The fatty acid composition of adrenals was significantly related to the fatty acid intake particularly the neutral lipid fraction (NL) which incorporated a large amount of DHA. Conversely, n-3 PUFAs were poorly incorporated in adrenal phospholipids. Moreover the NL/PL ratio was significantly increased in the DHA fed rats. The amount of adrenal catecholamines did not differ significantly between the groups. These results show that a supplementation of the diet with DHA induced cardiovascular alterations which could be detected in conscious animals within a few weeks. These alterations were elicited by a reduced heart rate and systolic and diastolic blood pressure.

Offspring of depressed parents. 10 Years later

BACKGROUND

There have been numerous studies that have shown that offspring of depressed parents are at a high risk for major depressive disorder (MDD) and impairment. None have followed up the offspring into adulthood to obtain more precise estimates of risk.

METHOD

One hundred eighty-two offspring from 91 families, in which 1 or more parents had MDD (high risk) or in which neither parent was depressed (low risk), were blindly reassessed in the third follow-up, using a structured diagnostic instrument 10 years after their initial identification.

RESULTS

Compared with the offspring for whom neither parent was depressed, the offspring of depressed parents had increased rates of MDD, particularly before puberty, and phobias (both at approximately a 3-fold risk), panic disorder, alcohol dependence (at a 5-fold risk), and greater social impairment. The peak age at onset for MDD in both high- and low-risk offspring ranged from 15 to 20 years. The peak age at onset for anxiety disorder was considerably earlier, especially in female offspring in the high-risk group. The onset of alcohol dependence in the offspring in the high-risk group peaked in adolescence and then after the age of 25 years. The depressed offspring of depressed parents, compared with nondepressed parents, had more serious and impairing depressions during the follow-up period but were less likely to go for treatment.

CONCLUSIONS

The offspring of depressed parents are a high-risk group for onset of anxiety disorder and MDD in childhood, MDD in adolescence, and alcohol dependence in adolescence and early adulthood. The findings support the potential value of early detection in the offspring of depressed parents.

A conceptual framework for managing clinical processes

Reengineering of the health care delivery system is underway, as is the transformation of the processes and methods used for recording information describing patient care (i.e., the development of a computer-based record). This report describes the use of object-oriented analysis and design to develop and implement clinical process reengineering as well as the organization of clinical data. In addition, the facility of the proposed framework for implementing workflow computing is discussed.

Building a virtual reality temporal bone dissection simulator

The temporal bone is one of seven bones that comprise the human skull, and has an intimate relationship with many vital structures. Anatomically, its three-dimensional relationships make it one of the most challenging areas for surgeons to understand and master. In addition, the temporal bone contains minute structures that are among the most sophisticated and delicate in the human body. These structures include the cochlea and vestibular organs, which are responsible for hearing and balance; the middle ear, including the ossicles, which conduct acoustic energy to the cochlea; and the facial nerve, which is responsible for controlling the muscles of facial expression, and contributes to the sensation of taste. Additionally, the temporal bone forms a major portion of the skull base, and has intimate relationships to vital structures including the carotid artery, jugular vein, cerebral cortex, brainstem, and cranial nerves. Surgical procedures performed on the temporal bone include: procedures to eradicate chronic and acute infections; procedures to remove malignant and benign tumors within the temporal bone, from the skull base, or from the posterior cranial fossa; procedures to restore the hearing mechanism; procedures to eliminate balance disorders; and procedures to correct congenital anomalies. For surgeons-in-training, and even surgeons-in-practice, mastery of the anatomy of the temporal bone and the many complex approaches necessary to treat patients takes years of focused endeavor. This is typically accomplished through the dissection of human cadaver temporal bones, which are scarce, and require a dedicated laboratory facility. Efforts are currently underway to develop a realistic simulator for temporal bone procedures. Users immersed in the simulator will interact with a three-dimensional temporal bone, derived from patient-specific data, using a haptic interface to simulate traditional surgical procedures. Feedback from experts in otologic surgery will be built into the system for additional instruction. This presentation will include an overview of the application being developed, a report of its current state of development, and plans for the future.

Unusual presentation of a tuberculous peritonitis in a patient with concomitant AIDS and liver cirrhosis

We report a case of tuberculous peritonitis in a patient with concomitant HIV infection and liver cirrhosis. A 50-year-old man with viral B and delta liver cirrhosis and AIDS was diagnosed with spontaneous Escherichia coli peritonitis and successfully treated with beta-lactamins. Three months later, ascites reappeared and Mycobacterium tuberculosis was identified in peritoneal fluid cultures. The triple antituberculosis regimen was adjusted to his level of liver failure but the patient died of hepatic encephalopathy. Concomitant HIV infection and liver cirrhosis favour tuberculous peritonitis but they also make its diagnosis extremely difficult. Considering the poor prognosis of this infection when untreated, tuberculous peritonitis should be systematically suspected in such patients.