Gabriel Izbicki

Fundamentals of lung auscultation.

Computer-assisted techniques allow detailed analysis of the acoustic and physiological aspects of lung sounds. This short review of classic lung sounds includes both audio clips and interpretations made in the light of modern pulmonary acoustics.

Effect of intravenous propacetamol on blood pressure in febrile critically ill patients.

Study Objectives. To investigate the effect of intravenous propacetamol, a parenteral bioprecursor of acetaminophen, on systemic blood pressure in critically ill patients with fever, and to establish the prevalence and clinical significance of this effect.

Accelerated Spirometric Decline in New York City Firefighters With α1-Antitrypsin Deficiency

BACKGROUND On September 11, 2001, the World Trade Center (WTC) collapse caused massive air pollution, producing variable amounts of lung function reduction in the New York City Fire Department (FDNY) rescue workforce. α₁-Antitrypsin (AAT) deficiency is a risk factor for obstructive airway disease. METHODS This prospective, longitudinal cohort study of the first 4 years post-September 11, 2001, investigated the influence of AAT deficiency on adjusted longitudinal spirometric change (FEV₁) in 90 FDNY rescue workers with WTC exposure. Workers with protease inhibitor (Pi) Z heterozygosity were considered moderately AAT deficient. PiS homozygosity or PiS heterozygosity without concomitant PiZ heterozygosity was considered mild deficiency, and PiM homozygosity was considered normal. Alternately, workers had low AAT levels if serum AAT was ≤ 20 μmol/L. RESULTS In addition to normal aging-related decline (37 mL/y), significant FEV(1) decline accelerations developed with increasing AAT deficiency severity (110 mL/y for moderate and 32 mL/y for mild) or with low AAT serum levels (49 mL/y). Spirometric rates pre-September 11, 2001, did not show accelerations with AAT deficiency. Among workers with low AAT levels, cough persisted in a significant number of participants at 4 years post-September 11, 2001. CONCLUSIONS FDNY rescue workers with AAT deficiency had significant spirometric decline accelerations and persistent airway symptoms during the first 4 years after WTC exposure, representing a novel gene-by-environment interaction. Clinically meaningful decline acceleration occurred even with the mild serum AAT level reductions associated with PiS heterozygosity (without concomitant PiZ heterozygosity).

Transfusion-related leukocytosis in critically ill patients

ObjectiveWe observed that many critically ill patients developed leukocytosis following blood transfusions. To validate this observation and to explore a possible mechanism, a prospective study was designed. DesignProspective, noninterventional study. SettingSurgical/medical intensive care unit in a university-affiliated community hospital. PatientsConsecutive patients who required packed red blood cells transfusion. InterventionsWhite blood cell count (mean ± sd) ×109/L before and 2, 4, 6, 12, and 24 hrs following transfusion of nonfiltered packed red cells was measured in 96 patients. Measurements and Main ResultsTwenty patients were septic at the time of transfusion, whereas 76 were not. The incidence of post-transfusion leukocytosis in septic vs. nonseptic patients was 15% vs. 76%, respectively (p < .001). The white blood cell count in nonseptic patients increased from 14.3 ± 4.8 before transfusion to 19.5 ± 7.0 2 hrs following transfusion (p < .001) and returned to baseline in 24 hrs. In the septic group, no significant post-transfusion leukocytosis occurred. In 11 nonseptic patients requiring more than one unit of packed red cells, a significant increase in mean white blood cell count occurred 2 hrs after transfusion with nonfiltered packed red cells, whereas transfusion with prestorage-filtered packed red cells did not result in such an increase. Interleukin-8 concentrations (pg/mL) in stored nonfiltered packed red cells were significantly higher after 4 wks of storage (745.5 ± 710, p = .02) than at weeks 1 (61.2 ± 21.6) and 2 (59.3 ± 29). In the last 16 nonseptic patients, the units of nonfiltered packed red cells were assayed for interleukin-8 immediately before transfusion. Interleukin-8 concentrations were higher in units that caused leukocytosis in the recipients compared with those that did not (408.4 ± 202 vs. 65.1 ± 49, p = .02). ConclusionsTransfusion of nonfiltered packed red cells, but not of prestorage-filtered packed red cells, may frequently cause an acute and transient leukocytosis in critically ill nonseptic patients. Interleukin-8 accumulating in stored nonfiltered packed red cells may play a role in this phenomenon. Recognition of post packed red cell transfusion leukocytosis may avoid unnecessary investigations and therapies in false suspicion of sepsis.

Predictors of mortality of mechanically ventilated patients in internal medicine wards.

PURPOSE Budget restrictions have led to shortage of intensive care unit (ICU) beds in several countries. Consequently, ventilated patients are often kept on the wards. This study examined survival likelihood among patients ventilated on the wards and the predictive value of commonly used severity-of-illness scores. METHODS This study is a prospective observation and characterization of consecutive, mechanically ventilated patients in 3 internal medicine wards of a single hospital who were denied ICU admission. Outcome measures are as follows: 28-day mortality, survival to hospital discharge, and 3 months postdischarge. RESULTS Eighty-six patients were examined. The patients were 78.9 ± 8.9 years old; 53% were independent preadmission. Respiratory insufficiency due to infection was the main reason for mechanical ventilation (58%). Charlson and acute physiology scores (APS) averaged 4 ± 2.2 and 91.8 ± 26.7, respectively. Twenty-eight-day mortality was 71%, whereas in-hospital mortality was 74% and 3 months postdischarge mortality was 79%. Survivors were significantly younger than nonsurvivors (74.4 ± 8.5 years vs 80.4 ± 8.6 years, P < .01), were more likely to be ventilated for cardiac causes (41% vs 11%, P = .04), and had significantly higher initial mean blood pressure (79.4 mm Hg vs 58.2 mm Hg, P = .02) and blood albumin levels (29.8 g/L vs 25.7 g/L, P = .05). Death rate was 10 times more likely, with an APS greater than 90 on the day of intubation as compared with an APS less than 90. CONCLUSION Mortality in patients ventilated on the ward was high, especially in the subgroup of patients with an APS score greater than 90. The early calculation of APS may assist in focusing therapeutic efforts on patients with better survival chances.

Ectopic pancreatic pseudocyst and cyst presenting as a cervical and mediastinal mass - case report and review of the literature

Ectopic pancreas in the mediastinum is extremely rare. We are reporting on a case of a twenty two year old woman who presented to our clinic with a large cervical mass. The CT scan revealed a cystic lesion in the anterior mediastinum. The patient underwent surgical resection by cervical approach. A Cystic mass with pseudocysts, cysts and complete pancreatic tissue were found in pathology. There were no signs of pancreatitis or malignancy. No recurrence was observed after a follow up of four years. We reviewed the case reports describing this rare condition in the medical literature.We conclude that the possibility of ectopic pancreatic tissue should be included in the differential diagnosis of anterior mediastinal cystic mass, though as a remote possibility. Surgery is probably needed for the diagnosis and treatment. Posterior mediastinal pseudocyst is a different entity associated with acute pancreatitis. In those cases surgery is not recommended. Our third conclusion is that pancreatic tissue should be actively sought, if a structure resembling a pseudocyst is found in an unexpected location.Virtual slidesThe virtual slide(s) for this article can be found here:http://www.diagnosticpathology.diagnomx.eu/vs/1849369005957671

Does sweat volume influence the sweat test result

Objective Low volume sweat samples are considered unreliable for the diagnosis of cystic fibrosis, based on the assertion that sweat conductivity and chloride are reduced at lower sweating rates. We aimed to re-evaluate the relationship between sweat volume and test results. Design We reviewed all sweat tests performed in our institution to assess the relationship between sweat volume and conductivity, and between sweat volume and sweat chloride. We also compared results between pairs of sweat tests taken simultaneously from a single patient, one with sweat volume below and the other above the currently accepted minimum volume (15 µl). Results A weak inverse relationship between sweat volume and sweat conductivity was found (n=1500, R2=0.105, p<0.001). There was no correlation between sweat volume and sweat chloride (n=463, R2=0.002, p>0.05). In discordant pairs (one below and one exceeding the accepted minimum volume), the mean test result in the low volume sample was slightly higher than its counterpart. In 76 such pairs, mean conductivity was 41.1±14.6 mmol/l in the lower volume sample, compared with 36.8±16.0 mmol/l in the higher volume sample (p<0.001). Similarly, in 33 of the pairs, mean sweat chloride was 28.4±15.7 mmol/l in the lower volume sample compared with 25.1±15.2 mmol/l in the higher volume sample (p=0.004). Conclusion A normal sweat conductivity and/or chloride value from a sweat volume <15 µl in a patient whose clinical symptoms are not very suggestive of cystic fibrosis, renders this diagnosis unlikely. In contrast, elevated sweat chloride or conductivity measured from a sample whose volume is <15 µl may represent an artefact related to the low volume.

Trial of prophylactic inhaled steroids to prevent or reduce pulmonary function decline, pulmonary symptoms, and airway hyperreactivity in firefighters at the world trade center site

BACKGROUND Inhaled corticosteroids (ICS) are the most effective anti-inflammatory treatment for asthmatics. This trial evaluated the effects of prophylactic ICS in firefighters exposed to the World Trade Center disaster. METHODS Inhaled budesonide via a dry powder inhaler (Pulmicort Turbuhaler, AstraZeneca, Wilmington, DE) was offered on-site to New York City firefighters between September 18 and 25, 2001. One to 2 years later, firefighters (n = 64) who completed 4 weeks of daily ICS treatment were evaluated and compared with an age- and exposure-matched comparison group (n = 72) who did not use ICS. RESULTS When spirometry results at the final visit were compared with those from the weeks following the 9/11 disaster, the treatment group had a greater increase in forced vital capacity (P = .009) and possibly a slower decline in forced expiratory volume at 1 second (P = .11), as well as a greater improvement in perceived well-being as assessed by the St Georges Respiratory Questionnaire (P < .01). There was no difference in airway hyperreactivity and no evidence of adverse effects from ICS. CONCLUSIONS Because the potential for hazardous exposures is great at many disasters, disease prevention programs based on environmental controls and respiratory protection are warranted immediately. Our results suggest that, pending further study with a larger sample, prophylactic ICS should be considered, along with respiratory protection, to minimize possible lung insult.

National asthma observational survey of severe asthmatics in Israel: the no-air study

BackgroundAsthma is considered a global public health issue requiring a significant medical expenditure as a result of its high prevalence and the low rate of disease control.ObjectiveThis is the first nationwide survey of severe asthma patients carried out in Israel. In this study we aimed to assess health resources utilization, compliance with treatment and disease-control in a subgroup of patients with severe asthma in Israel.Material and methodOne hundred and twenty-three patients with a diagnosis of asthma for more then one year, as well as a hospitalization during the last 12 months due to asthma exacerbation or maintenance systemic steroids therapy, were included in this non-interventional observational study.ResultsAsthma was uncontrolled in 43.9%, partly controlled in 50.4% and well controlled in only 5.7%. The majority of the patients (83%) were compliant with drug treatment.ConclusionThe fact that 83% of the asthma patients included in this study were compliant with their asthma therapy was not manifested in asthma control. Therefore concrete tools are required for achieving and maintaining asthma control, especially in the treatment of the most severe asthmatic patients.