Treatment of Chronic Granulomatous Disease-Related Pulmonary Aspergillus Infection in Late Pregnancy

Chronic granulomatous disease (CGD) is a primary immunodeficiency syndrome that results in increased risk for bacterial and fungal infections, as well as inflammatory/autoimmune complications. While CGD historically has been associated with early death in childhood, the life expectancy and morbidity of patients with CGD have greatly improved. Many patients with CGD now survive well into adulthood, and data on adult cohorts of patients with CGD have been published. However, reports of pregnancy management, complications, and outcomes for patients with CGD are sparse. In addition, management of invasive fungal infections, including use of newer triazole antifungals, during pregnancy has not been well described. We report a case of fungal lung infection in a pregnant woman with CGD, diagnosed during her second trimester, which was treated with multiple antifungal agents, including more than 12 weeks of isavuconazole therapy, resulting in resolution of infection and delivery of a healthy newborn at term.

Recent evolution in demographic and clinical characteristics and in-hospital morbidity in patients undergoing coronary surgery

BACKGROUND

Over the last 12 years, the demographic and clinical characteristics of patients undergoing myocardial revascularization surgery have evolved rapidly. The goal of our study was to analyze the evolution of these trends and the results of these surgical interventions.

METHODS

We identified patients who underwent a first or second myocardial revascularization between 1993 and 2004, and we arbitrarily divided them into 2 groups: 1 cohort of patients who underwent surgery between 1993 and 1998 and 1 cohort of patients who underwent surgery between 1999 and 2004. We compared demographic and clinical characteristics between the 2 cohorts and determined which variables were significant predictors of morbidity and mortality.

RESULTS

From 1993 to 2004, 12 202 patients underwent a first (95.5%) or second (4.5%) myocardial revascularization. Patients in the later cohort presented with a high-risk profile. They were older and had metabolic syndrome or diabetes and peripheral vascular disease. On the other hand, there were fewer active smokers in this group. Whereas the rate of postoperative infarction and renal insufficiency was higher in the second cohort, this group had a lower incidence of stroke and prolonged mechanical ventilation and shorter hospital stays. Overall, observed mortality decreased in spite of a steady increase in predicted mortality. Identified predictors of mortality were age, stroke, female sex, nonelective surgery, renal insufficiency, peripheral vascular disease, chronic obstructive pulmonary disease, ventricular dysfunction and stenosis of the left main trunk.

CONCLUSION

Our study confirmed current trends that show an increase in the at-risk population with dysmetabolic syndrome in cardiac surgery, as well as constant improvements in tertiary care in anesthesia and coronary surgery.

Pleural effusions following cardiac surgery: prevalence, risk factors, and clinical features

BACKGROUND

Pleural effusion is a common complication of cardiac surgery, but its characteristics and predisposing factors should be documented further. Our objective was to determine the prevalence, characteristics, and determinants of clinically significant pleural effusions, defined as those requiring therapeutic pleural drainage according to clinical assessment.

METHODS

The prevalence and characteristics of patients who had a pleural effusion within 30 days of undergoing coronary artery bypass graft, valve replacement, or both were analyzed retrospectively at our institution over a 2-year period.

RESULTS

Among the 2,892 patients included in the study (mean age, 66 years; men, 2,139), 192 patients (6.6%) had experienced a clinically significant pleural effusion in the 30 days postsurgery. These effusions occurred after a mean (+/- SD) duration of 6.6 +/- 5.9 days following interventions. Pleural fluid analysis was obtained in 114 patients (59.4%); all met the criteria for an exudate. Pleural fluid was hemorrhagic in 50% of cases. Age, body weight, baseline pulmonary function, and smoking status were similar between patients with and without effusion; however, the proportion of women; the number of patients with previous conditions of heart failure, atrial fibrillation, or peripheral vascular disease; and the number of patients receiving therapy with an anticoagulant or antiarrhythmic agent was higher in the pleural effusion group. Patients with pleural effusion had an increased prevalence of postoperative complications.

CONCLUSIONS

Pleural effusion is a common complication of heart surgery, is associated with other postoperative complications, and is more frequent in women and in patients with associated cardiac or vascular comorbidities and medications used to treat those conditions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00665015.

[Abdominal complications associated with cardiac surgery. Review of a contemporary surgical experience and of a series done without extracorporeal circulation]

INTRODUCTION

To evaluate the prevalence, risk factors and morbidity associated with gastrointestinal (GI) complications after cardiac surgery, with and without cardiopulmonary bypass, we carried out a retrospective cohort study at a university teaching hospital.

METHODS

We divided the 11,405 eligible adult patients into 2 groups: group A (operated on between January 1992 and June 1996) (4657 patients) and group B (operated on between July 1996 and December 2000) (6748 patients).

RESULTS

We found 147 GI complications in 134 (1.2%) patients. The incidence of GI morbidity was similar for the 2 groups of patients (group A, n = 59/4657 [1.2%]; group B, n = 75/6748 [1.1%]. Patients from group B were older, obese, diabetic and presented with more peripheral and cerebrovascular disease. Bleeding, gastritis and ulcer with perforation, the most common of these GI events, were associated with the esophagus and stomach (67/147 [45.5%]). Other events that we documented included cholecystitis 10 (6.8%), pancreatitis 13 (8.8%), episodes of small and large bowel ischemia 17 (11.6%), pseudomembranous colitis 12 (8.3%) and diverticulitis 5 (3.4%). Mesenteric ischemia was responsible for 11 (37.9%) of the 29 deaths. Two hundred and ninety-three patients were revascularized without extracorporeal circulation during this study. In this group, we were able to pinpoint 5 (1.7%) GI complications with 3 cases of mesenteric ischemia. Multivariate analysis identified renal insufficiency, prolonged intubation and sepsis as significant, predictive variables of GI complications for the 2 groups of patients whereas the Parsonnet score and stroke were predictive for the second group.

CONCLUSIONS

Although cardiac surgery is now being performed on older patients with significant comorbidity, we could not demonstrate a significant increase of GI complications after cardiac surgery. Off-pump coronary artery bypass does not seem to protect patients from these complications.

Measurement of respiratory mechanics using the Puritan-Bennett 7200a ventilator

This study was designed in order to validate the respiratory mechanical variables measured by the Puritan-Bennett 7200a ventilator equipped with the 30/40 module. Two ventilators were connected to a lung model and submitted to several breathing patterns by modifying the respiratory rate, the tidal volume, the inspiratory flow-rate and the model resistance. The inspiratory flow-rate (V), tidal volume (VT), peak inspiratory pressure (Pmax), plateau pressure (Pplat) and PEEP measured by the ventilators were compared with the same variables measured at the connection between the breathing circuit and the lung model. The compliance (C30/40) and the resistance (R30/40) calculated by the 30/40 module were compared with those calculated by using the variables measured by the reference equipment. Both ventilators made a constant underestimation of V by 2.8 and 3.7 L.min-1, respectively. The VT was measured with a mean error of less than 10 ml but did not reflect the preselected values in the presence of an intrinsic PEEP. The Pplat was overestimated by 7 and 10%, respectively. The same calibration error was observed with Pmax which was also affected by a pressure gradient due to the resistance of the breathing circuit. Even in the absence of intrinsic PEEP, C30/40 presented an error due to the combination of the measurement errors on VT, Pplat and PEEP. Finally, R30/40 presented a high percentage of error due to the combination of the measurement errors on V, Pmax, and Pplat, and to a sporadic aberrant selection of V. Due to these numerous sources of error, the two ventilators studied did not give reliable estimates of resistance and compliance.(ABSTRACT TRUNCATED AT 250 WORDS)