Basil Varkey

Isolation of Blastomyces dermatitidis in Soil Associated with a Large Outbreak of Blastomycosis in Wisconsin

In investigating six cases of blastomycosis in two school groups that had separately visited an environmental camp in northern Wisconsin in June 1984, we identified a large outbreak of the disease and isolated Blastomyces dermatitidis from soil at a beaver pond near the camp. Of 89 elementary-school children and 10 adults from the two groups, 48 (51 percent) of the 95 evaluated in September had blastomycosis. Of the cases, 26 (54 percent) were symptomatic (the median incubation period was 45 days; range, 21 to 106 days). No cases were identified in 10 groups that visited the camp two weeks before or after these two groups. A review of camp itineraries, a questionnaire survey, and environmental investigation showed that blastomycosis occurred in two of four groups that visited a beaver pond and in none of eight groups that did not. Walking on the beaver lodge (P = 0.008) and picking up items from its soil (P = 0.05) were associated with illness. Cultures of soil from the beaver lodge and decomposed wood near the beaver dam yielded B. dermatitidis. We conclude that B. dermatitidis in the soil can be a reservoir for human infection.

Pain Management Principles in the Critically Ill

This article addresses conventional pharmacologic and nonpharmacologic treatment of pain in patients in ICUs. For the critically ill patient, opioids have been the mainstay of pain control. The optimal choice of opioid and dosing regimen for a specific patient varies depending on factors such as the pharmacokinetics and physicochemical characteristics of an opioid and the bodys handling of the opioid, concomitant sedative regimen, potential or actual adverse drug events, and development of tolerance. The clinician must appreciate that favorable pharmacokinetic properties such as a short-elimination half-life do not necessarily translate into clinical advantages in the ICU setting. A variety of medications have been proposed as alternatives or adjuncts to the opioids for pain control that have unique considerations when contemplated for use in the critically ill patient. Most have been relatively unstudied in the ICU setting, and many have limitations with respect to availability of the GI route of administration in patients with questionable GI absorptive function. Nonpharmacologic, complementary therapies are low cost, easy to provide, and safe, and many clinicians can implement them with little difficulty or resources. However, the evidence base for their effectiveness is limited. At present, insufficient research evidence is available to support a broad implementation of nonpharmacologic therapies in ICUs.

Viral infections in patients with chronic obstructive pulmonary disease

Purpose of review Chronic obstructive pulmonary disease is a major cause of morbidity and mortality worldwide. There is increasing evidence that implicates viral infections as a major risk factor for exacerbations of chronic obstructive pulmonary disease. Recent studies have attempted to better characterize the epidemiology of viral infections in chronic obstructive pulmonary disease, identify unique clinical manifestations of virus-associated exacerbations, and develop new diagnostic tools and treatments. Recent findings Rhinovirus, the organism most often responsible for causing the common cold, is also the most common infectious cause of chronic obstructive pulmonary disease exacerbations. Coronavirus, influenza, respiratory syncytial virus, parainfluenza, adenovirus, and metapneumovirus are other important viral causes of chronic obstructive pulmonary disease exacerbations. These exacerbations can be severe with prolonged recovery times. Although PCR technology has dramatically increased the detection rate of viruses in patients with chronic obstructive pulmonary disease, it does not differentiate infection from colonization. The use of biomarkers represents an exciting new potential diagnostic tool that may lend new insights into the pathogenesis of viral infections in patients with chronic obstructive pulmonary disease. Summary Despite strong epidemiologic evidence linking respiratory virus infection to exacerbations of chronic obstructive pulmonary disease, many of the cellular and molecular mechanisms by which viruses cause exacerbations remain undetermined. Future research efforts to understand these mechanisms would aid the development of novel therapeutics to reduce the morbidity and mortality of this disease.

Structured Approaches to Pain Management in the ICU

Pain in patients who are critically ill remains undertreated despite decades of research, guideline development and distribution, and intense educational efforts. By nature of their complex medical conditions, these patients present unique challenges to the delivery of optimal pain treatment. Outdated clinical practices and faulty systems, such as a formulary that allows dangerous prescriptions, present additional obstacles. A multidisciplinary and patient-centered continuous quality improvement process is essential to identifying barriers and implementing evidence-based solutions to the problem of undertreated pain in hospital ICUs. This article addresses barriers common to the ICU setting and presents a number of structured approaches that have been shown to be successful in improving pain treatment in patients who are critically ill.

Epidural abscess, vertebral destruction, and paraplegia caused by extending infection from an aspergilloma

An aspergilloma developed in a lung cyst in a 53-year-old man. Aspergillus infection then contiguously spread to the epidural space, causing an abscess, vertebral destruction, and paraplegia at the level of T4. Chronic alcoholism, liver cirrhosis, and corticosteroid treatment may have been predisposing factors in this patient. Although Aspergillus epidural abscess has been described infrequently, this complication has not been described in association with an aspergilloma. Symptoms, signs, or roentgenographic or laboratory findings suggestive of vertebral or meningeal pathologic lesions in patients with aspergilloma should alert the physician to the possibility of contiguous spread of infection.

Prognostic factors in chronic obstructive pulmonary disease

Purpose of review Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Its epidemiology has changed over the years and the key changes are a rising mortality rate and a greater incidence among women. Predicting survival time of patients with COPD is difficult. Reliable prognostic markers are useful and important information for patients, their families, and for the physician. The purpose of this review is to examine traditional and newer prognostic factors of COPD. Recent findings Loss of fat free mass (FFM), need and frequency of hospitalization for acute exacerbation, and symptom score are now recognized as important parameters to supplement the traditional prognostic markers of age, forced expiratory volume in 1 second (FEV1), hypoxemia, and hypercapnia. Summary A prognostic model based on office practice data now affords a means of more reliably predicting outcome for patients with COPD.

Chronic obstructive pulmonary disease: effects beyond the lungs.

Purpose of review This article reviews the systemic effects of chronic obstructive pulmonary disease in general and the musculoskeletal effects and cachexia in particular. Recent findings Shift in muscle fiber type from I to II, reduction of capillary/mitochondria ratio, reduction of oxidative enzymes and oxidative capacity, alteration in amino acid profile, changes in respiratory muscle dynamics, activation of the ubiquitin–proteosome pathway with loss of contractile proteins are some of the factors found to cause muscle dysfunction in chronic obstructive pulmonary disease. Chemotaxis and capability to produce more reactive oxygen species and to cause extracellular proteolysis are enhanced in neutrophils of chronic obstructive pulmonary disease patients. Tumor necrosis factor-α is shown to cause loss of myosin chains in a time and dose-dependent fashion and to induce production of reactive oxygen species through activation of the cyclooxygenase pathway. Inflammation and oxidative stress caused by reactive oxygen species fuel each other. Weight loss due to muscle wasting (cachexia) in chronic obstructive pulmonary disease is not solely related to malnutrition and is an independent predictor of mortality. Causative factors for cachexia include cytokine effects, protein degradation enhanced by increased ubiquination, upregulation of mRNA for key enzymes, increased energy expenditure and neurohormonal effects such as leptin production and an imbalance in anabolic and catabolic hormone homeostasis. Summary The findings noted above may well have the common link of inflammation in and beyond the lungs.

Pain Management Within the Palliative and End-of-Life Care Experience in the ICU*

In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss.

Improving health-related quality of life in chronic obstructive pulmonary disease.

Purpose of review Most current treatments for chronic obstructive pulmonary disease (COPD) have been unable to improve survival or arrest decline in lung function. This reality highlights the importance of patient-focused outcomes that address symptom relief, functional status, and overall health-related quality ov life (HRQOL). Measures of HRQOL can complement established physiologic outcomes that have been traditionally used. Recent findings There are several generic and disease-specific instruments that can be used to measure HRQOL, each incorporating various aspects of physical, psychological, and social function. Basic concepts regarding these instruments are presented. Recent studies suggest that HRQOL is an important measure of prognosis and healthcare resource utilization in COPD patients. Summary An increasing number of studies now incorporate HRQOL as an outcome measure. Interventions that have shown a positive effect on some or all components of HRQOL, including inhaled corticosteroids, inhaled bronchodilators, opioids, oxygen therapy, pulmonary rehabilitation, implementation of a disease-specific self-management program, and lung volume reduction surgery are discussed in this review.

Prophylactic vaccinations in chronic obstructive pulmonary disease: current status

Purpose of review Acute exacerbations of chronic obstructive pulmonary disease (COPD) are a major cause of morbidity and mortality worldwide. Most acute exacerbations are triggered by community-acquired respiratory infections. Medications to treat COPD exacerbations are limited; therefore, identifying effective ways to prevent exacerbations are needed. Influenza and pneumococcal vaccines are currently recommended for all persons with COPD. However, current immunization rates are far lower than the Healthy People 2010 Goals. The reasons for nonadherence are multifactorial and strategies for overcoming these barriers are discussed. Recent findings Influenza vaccine clearly reduces the number of acute exacerbations that occur in persons with COPD. Influenza vaccine may reduce hospitalizations and mortality from COPD, but the evidence is not conclusive. Pneumococcal vaccine reduces the incidence of invasive pneumococcal disease. However, there is not enough evidence to conclude that pneumococcal vaccination in persons with COPD has a significant impact on reducing morbidity or mortality. Vaccination with both influenza and pneumococcal vaccine may produce an additive effect that reduces exacerbations more effectively than either vaccine alone. Whole genome sequencing of bacteria and genome mining may represent a powerful way to identify novel potential vaccine antigens for future vaccine development. Summary Although clinical trial data are limited, vaccinations can prevent some of the infections that cause COPD exacerbations and should be administered to all patients with COPD. Vaccines do not cause exacerbations of COPD. Patient and physician barriers to vaccination can be overcome with targeted education and system-wide interventions. Further research efforts should focus on improving current vaccines and identifying novel targets for future vaccine development.