The role of chronic alcohol abuse in the development of acute respiratory distress syndrome in adults

OBJECTIVE

To determine the effect of a history of chronic alcohol abuse on the incidence of acute respiratory distress syndrome (ARDS) and in-hospital mortality.

DESIGN

Prospective cohort study.

PATIENTS

A total of 351 medical and surgical intensive care unit patients with one of seven at-risk diagnoses for the development of ARDS.

MAIN OUTCOME MEASURES

The development of ARDS and in-hospital mortality.

RESULTS

Of the 351 patients enrolled in the study, the incidence of ARDS in patients with a history of alcohol abuse was significantly higher than in patients without a history of alcohol abuse (43% vs 22%) (P < .001; relative risk [RR], 1.98; 95% confidence interval [Cl], 1.32 to 2.85). In patients with sepsis, ARDS developed in 52% of the patients with a prior history of alcohol abuse compared with only 20% in patients without a history of alcohol abuse (P < .001; RR, 2.59; 95% Cl, 1.29 to 5.12). Fifty-one percent (52/102) of the patients who developed ARDS died compared with only 14% (36/249) of patients who did not develop ARDS (P < .001). In the subset of patients who developed ARDS, the in-hospital mortality rate was 65% in patients with a prior history of alcohol abuse. This mortality rate was significantly higher (P = .003) than the mortality rate in patients without a history of alcohol abuse (36%).

CONCLUSIONS

A prior history of chronic alcohol abuse significantly increases the risk of developing ARDS in critically ill patients with an identified at-risk diagnosis. Our results may be useful in the earlier and more accurate identification of patients at high risk for developing ARDS.

Establishing the relative accuracy of three new definitions of the adult respiratory distress syndrome

OBJECTIVES

Over the last few years, new definitions of the adult respiratory distress syndrome (ARDS) have been introduced that potentially identify patients earlier in their course of acute lung injury. However, these definitions have never been compared with any of the older and potentially stricter definitions of ARDS to determine if similar patients are eventually identified. We compared new definitions of ARDS--as represented by the Lung Injury Score, a modified Lung Injury Score, and the American-European Consensus Conference definition--against a stricter definition of ARDS to determine their accuracy.

DESIGN

Prospective.

SETTING

Intensive care unit (ICU) patients in a tertiary, university-affiliated city hospital.

PATIENTS

ICU patients with clearly defined at-risk diagnoses for ARDS (group 1, n = 111) and general medical ICU patients without clearly defined at-risk diagnoses for ARDS (group 2, n = 125).

MEASUREMENTS AND MAIN RESULTS

Measurements of hypoxemia, static respiratory system compliance, positive end-expiratory pressure, radiographic changes, and general demographic information were collected. The sensitivity, specificity, positive-predictive value, negative-predictive value, and accuracy of all three new definitions were determined. Accuracy was defined as the true-positive plus the true-negative results divided by the total number of patients. When compared with a stricter definition of ARDS, all three definitions maintained a high degree of accuracy in those patients with a clearly defined at-risk diagnosis (group 1): Lung Injury Score 90.0% (95% confidence interval 84-96); modified Lung Injury Score 97.3% (95% confidence interval 94-100), and the American-European Consensus Conference definition 97.3% (95% confidence interval 94-100). For these at-risk patients, the accuracy of the modified Lung Injury Score and the American-European Consensus Conference definition was significantly better than the Lung Injury Score when compared with the strict definition (p = .027 for both comparisons). Although all three definitions maintained an accuracy of > 90% for general medical ICU patients (group 2), the low frequency of ARDS in these patients (3.4%) produced a low positive-predictive value for all three definitions.

CONCLUSIONS

We conclude that the Lung Injury Score, the modified Lung Injury Score, and the American-European Consensus Conference definition identify similar patients, provided that these methods are applied to patients with clearly defined at-risk diagnoses for ARDS.

Long-term followup of anterior cruciate ligament reconstruction using freeze-dried fascia lata allografts

We identified 79 patients who underwent arthroscopically assisted intraarticular anterior cruciate ligament reconstruction with freeze-dried fascia lata allografts and an additional lateral extraarticular reconstruction. We were able to contact 62 patients (79%) for follow-up evaluation at an average of 134.5 months. Forty patients (51%) returned for objective evaluation. Lysholm scores at followup averaged 92.3 and Tegner activity scores averaged 5.1. Only four (6%) of the 62 patients contacted reported episodes of full giving way. Thirty (75%) of the 40 patients examined demonstrated 3 mm or less side-to-side difference on KT-1000 arthrometer manual maximum evaluation. Forty-eight (77%) of the 62 patients were participating in sporting activities at final followup. No patient had evidence of graft rejection.

von Willebrand factor antigen levels are not predictive for the adult respiratory distress syndrome

In patients with nonpulmonary sepsis, von Willebrand factor antigen (vWF:Ag or Factor VIIR:Ag) levels have been reported to be predictive for the development of the adult respiratory distress syndrome (ARDS). We addressed the ability to generalize these results by measuring serial Factor vWF:Ag levels in 96 patients at risk for the development of ARDS. Patients with sepsis, pancreatitis, hypertransfusion, witnessed aspiration of gastric contents, abdominal trauma, chest trauma, and multiple fractures were studied. Sequential measurements were obtained at enrollment into the study (T = 0), and T = 6, 12, 24, and 48 h. Subjects were grouped into sepsis and nonsepsis categories and analyzed according to the following outcome definitions: ARDS and non-ARDS. The mean values for the sepsis and nonsepsis groups were elevated above normal at all time points. A statistically significant difference occurred in the mean vWF:Ag level for the ARDS and non-ARDS patients in the nonsepsis group at T = 0 (p = 0.05). To assess the clinical utility of these results, ROC (receiver operating characteristics) curves were plotted at T = 0, and optimal cutoff values of vWF:Ag were determined. In the sepsis group, the best value for vWF:Ag above which patients would actually develop ARDS was 399%, resulting in a 70% sensitivity and a 47% specificity. For the non-sepsis patients, the optimal value was 273%, yielding a sensitivity of 64% and a specificity of 52%. We conclude that measuring vWF:Ag levels are not helpful in predicting the progression to ARDS in multiple at-risk patients.

Exploring the validity of the Affect Balance Scale with a sample of family caregivers

Open-ended responses of caregiving daughters and daughters-in-law were generated by a modified random probe technique to investigate the construct validity of the two subscales of the Affect Balance Scale (ABS), i.e., the 5-item Positive Affect Scale (PAS) and the 5-item Negative Affect Scale (NAS). A set of criteria were developed to distinguish between responses that did and did not correspond to Bradburn's assumptions concerning affect. While most responses met at least one of the criteria, very few met all. In exploring the nature of affect, we found that positive affect was based to a large extent on personal accomplishments and the recognition of others. The assessment of negative affect was a more interior, or self-focused process. For a significant subset of the sample, a negative response to a closed-ended PAS or NAS item implied disagreement or discontent with the wording or the implications of the item itself, rather than an absence of affect. Not all of the ABS items were equally valid measures of affect.

Extracellular signal-regulated kinase (MAP kinase) immunoreactivity in the rhesus monkey brain

Extracellular signal regulated kinases (ERKs) are a recently cloned family of genes that encode the MAP kinase protein kinases. They are highly expressed in brain and are believed to play an integral role in neural cellular responses to receptor activation. A role for ERKs has been postulated in Alzheimer's disease, where they have been implicated in phosphorylation of tau in neurofibrillary tangles. We explored the neuroanatomic distribution of ERK immunoreactivity in the rhesus monkey brain. The hippocampal formation, especially the mossy fiber zone and the molecular layer of the dentate gyrus are the most heavily immunostained areas. Cerebral cortex is, in general, more intensely stained in the supragranular layers. The caudate, putamen, and substantia nigra contain more immunoreactivity than the claustrum, globus pallidus, or thalamus with the exception of midline thalamic structures. These results suggest a marked regional and laminar distribution of ERKs in the primate brain.

Diffuse alveolar hemorrhage due to antibasement membrane antibody disease appearing with a polyglandular autoimmune syndrome

We describe a patient with type 3-C polyglandular autoimmune syndrome who presented with diffuse alveolar hemorrhage and normal renal function. The diagnosis of antibasement membrane antibody disease was established by immunofluorescent staining of transbronchial biopsy specimens. We suggest the incorporation of antibasement membrane antibody disease into the spectrum of diseases that define the polyglandular autoimmune syndromes.

The protein core of the NCA-related pancreatic adenocarcinoma-associated antigen (DD9-Ag) is NCA-50

Earlier studies with monoclonal antibody (mcAb) DD9E7 have identified a family of nonspecific cross-reacting antigen (NCA)-related antigens that are highly expressed in human pancreatic adenocarcinoma. To analyse the molecular nature of these glycoproteins further, a lambda gt11 expression library has been constructed from the GER pancreatic adenocarcinoma cell line and screened with an NCA sequence-specific oligonucleotide probe. Sequence analysis and restriction enzyme mapping of the clones isolated have shown that they are all homologous with the NCA-50 protein core sequence rather than other related members of the carcinoembryonic antigen/NCA gene family. With use of the same probe, a 2.5-kb mRNA transcript, characteristic of NCA-50, was found in pancreatic adenocarcinoma tumour samples. This study suggests that the 80- to 115-kDa glycoproteins, which we had previously identified in pancreatic adenocarcinomas with NCA-specific mcAb DD9E7, are the result of aberrant glycosylation of the NCA-50 protein core following cell transformation.

Extracorporeal membrane oxygenation for cardiac failure after congenital heart operation

Despite continuing improvement in myocardial protection and surgical technique, the repair of complex congenital heart lesions can result in cardiopulmonary compromise refractory to conventional therapy. In a 29-month period, 24 patients (aged 14 hours to 6 years) were treated with extracorporeal membrane oxygenation (ECMO) 28 times for profound cardiopulmonary failure. Four patients required ECMO after each of two cardiopulmonary bypass procedures. Seventeen patients required ECMO to be initiated in the operating room: 12 (71%) were weaned successfully from ECMO, and 8 (47%) survived. Seven patients had ECMO initiated in the intensive care unit: 6 (86%) were weaned, and 5 (71%) survived. Serial echocardiograms demonstrated substantial recovery of cardiac function in 18 of 21 instances (86%) of ventricular failure from myocardial dysfunction. Overall, 18 of 24 patients (75%) were successfully weaned from ECMO including all 4 who underwent 2 ECMO treatments. We conclude that ECMO can successfully salvage children who have serious cardiopulmonary failure immediately after a congenital heart operation and that long-term survival is possible after two ECMO treatments.

A two-factor model of caregiving appraisal and psychological well-being

Groups of spouse (N = 285) and adult child (N = 244) caregivers of elderly parents suffering from Alzheimer's disease were interviewed regarding their caregiving behaviors, evaluations of caregiving, and general psychological well-being. A model of caregiving dynamics where the objective stressor, caregiver resources, and subjective appraisal of caregiving (operationalized as caregiving satisfaction and burden) were studied as they affected both positive affect and depression was tested. For spouses, caregiving satisfaction was not related to aspects of the stressor, but was a significant determinant of positive affect. Among adult children, high levels of caregiving behavior resulted in both greater caregiving satisfaction and burden. Burden, in turn, was related to depression in both groups but, among adult child caregivers, positive affect was not affected by caregiving satisfaction. Limited support was found for the hypothesis that the positive and negative aspects of caregiving contributed to analogous aspects of generalized psychological well-being but not to the opposite-valence outcomes.

The effects of marital status and partner support on rape trauma

Psychological functioning within the first four weeks after rape was compared for married and single victims. Marital status did not significantly affect psychological symptoms following the assault. For married women, lack of support by the partner--particularly when it was unexpected--was significantly related to poor psychological functioning after the rape.

Molecular biology of Crohn's disease mycobacteria

A Glasgow surgeon, T.K. Dalziel, published a detailed description of chronic enteritis in humans in 1913. He proposed that the disease was caused by the same organisms as those responsible for chronic enteritis, Johne's disease, in animals described a few years earlier (1895). Dalziel's dilemma was that he could see acid-fast bacilli in the diseased animal tissues but not in the diseased human tissues. Little real progress in the medical understanding of the causes of chronic enteritis in humans occurred over the next half a century or more. From 1978, a decade of research in many laboratories using improved methods for the culture of environmental mycobacteria showed that these could be grown in bacillary form from about one in five cases of Crohn's disease, from the same proportion of cases of ulcerative colitis, and from about one in ten control tissues. Spheroplasts were grown from two in five cases of Crohn's disease, one in five cases of ulcerative colitis, and rarely from control tissues. The nature of these agents was often uncertain. We describe work which began in 1985 and led rapidly to the identification of IS900, a DNA repetitive element in an uncharacterized Crohn's disease mycobacterial isolate. With other isolates, these were then shown by DNA fingerprinting to be indistinguishable from Mycobacterium paratuberculosis, Johne's bacillus. Similar techniques also demonstrated the wood-pigeon strain of M. avium in some Crohn's disease cultures. This bacillus can also cause chronic enteritis in calves. IS900 is the first of a family of unusual DNA insertion sequences which extend widely throughout environmental mycobacteria. Use of assays based on PCR amplification of highly specific DNA sequences from these insertional elements, and recombinant and synthetic peptides from their predicted proteins, will revolutionize the detection and characterization of these agents. These methods, applied to animal, human and environmental samples, will indicate new ways for the prevention and treatment of chronic enteritis, as well as other disorders associated with infections by environmental mycobacteria.