Jonathan E. Kass

Intensive care unit outcome in the very elderly

ObjectivesTo determine if age, previous functional status, or acute severity of illness affect the acute and long-term mortality rates and functional status of the very elderly (≥85 yrs) after an ICU admission. DesignCohort study (retrospective entry for the first year of the study and prospective entry thereafter with prospective follow-up throughout). SettingAn ICU in a community teaching hospital with follow-up at home or at a skilled nursing facility. PatientsAll (n = 105) patients ≥85 yrs admitted to the ICU over a 2-yr period. Main Outcome MeasuresICU, 30-day post-hospital discharge, and 1-yr mortality rates, activities of daily living scores, organ system failure score at the time of ICU admission. ResultsThe ICU, 30-day posthospital discharge, and the 1-yr mortality rates were 30%, 43%, and 64%, respectively. Mortality rates significantly increased between the ICU stay or 30 days posthospital discharge and 1-yr follow-up periods. Of those patients who lived up to 6 months after hospital discharge, 86% survived to 1 yr with little change in functional status from baseline. In the patients with ≥2 organ system failures, there were 88% 30-day posthospital discharge and 100% 1-yr mortality rates. Severity of illness, as measured by the number of organ system failures, was associated with increased ICU (odds ratio 3.38; 95% confidence interval, 1.51 to 7.60; p < .005) and 1 yr (odds ratio 5.76; 95% confidence interval, 2.49 to 13.29; p < .0001) mortality rates, while age within this group and preadmission functional status were not. ConclusionsWithin the very elderly population, acute severity of illness is the most significant predictor of mortality after an ICU admission. For most very elderly patients, surviving 1 yr after an ICU admission, there is little change in functional status.

An algorithmic approach to chronic dyspnea

QUESTION The objective of the study was to prospectively evaluate an algorithmic approach to the cause(s) of chronic dyspnea. MATERIALS/PATIENTS/METHODS: Prospective observational study. The study group consisted of 123 patients with a chief complaint of dyspnea of unknown cause present for >8 weeks. Dyspnea severity scores were documented at entry and after therapy. Patients underwent an algorithmic approach to dyspnea. Therapy could be instituted at any time that data supported a treatable diagnosis. Whenever possible, accuracy of diagnosis was confirmed with an improvement in dyspnea after therapy. Tests required, spectrum and frequency of diagnoses, and the values of individual tests were determined. RESULTS Cause(s) was(were) diagnosed in 122/123 patients (99%); 97 patients had one diagnosis and 25 two diagnoses. Fifty-three percent of diagnoses were respiratory and 47% were non-respiratory. Following therapy, dyspnea improved in 63% of patients. CONCLUSIONS The prospective algorithmic approach led to diagnoses in 99% of cases. A third of patients were diagnosed with each tier of the algorithm, thus minimizing the need for invasive testing. Specific diagnoses led to improvement in dyspnea in the majority of cases. Based on the results of this study, the algorithm can be revised to further minimize unnecessary tests without loss of diagnostic accuracy.

Endobronchial ultrasound with transbronchial needle aspiration in the diagnosis of bilateral hilar and mediastinal lymphadenopathy.

Background:Bilateral hilar and/or mediastinal lymphadenopathy (BHL±ML) is an important radiographic finding. Since it was examined 38 years ago by Winterbauer and colleagues, better diagnostic techniques have been developed. The purpose of this study was to reexamine the diagnosis of BHL±ML by Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA). Methods:We carried out a retrospective analysis of data from 78 consecutive patients with BHL±ML who underwent EBUS-TBNA. Patient’s characteristics including age, sex, symptoms, radiographic abnormalities, lymph node size, procedural complications, and the final pathologic diagnosis were recorded. Results:There were 8 diagnostic categories. Sarcoidosis was the most common diagnosis (73%), followed by lymphoma (10%), and reactive lymphadenopathy (10%). Nonlymphoma malignancy was found in 1 case. Seventy-three percent of the patients with sarcoidosis had stage 1 and 27% had stage 2 disease. The diagnosis was made by EBUS-TBNA in 92.3% of the cases. The diagnostic accuracy for EBUS-TBNA was 95% for stage 1 and 93% for stage 2. Fifty one percent of the patients were asymptomatic. Fifty seven percent of sarcoidosis and 36% of the nonsarcoidosis patients were asymptomatic. There were no significant complications from EBUS-TBNA. Conclusions:EBUS-TBNA is a safe and minimally invasive procedure with a high diagnostic yield for BHL±ML. Sarcoidosis is still the most common diagnosis but the incidence seems to have decreased over the years. The increase in nonsarcoidosis patients and the evidence that lymphoma does occur in some asymptomatic patients suggests that biopsy confirmation with EBUS-TBNA is warranted.

Fever of unknown origin and pancytopenia caused by culture-proven delayed onset disseminated bacillus Calmette-Guérin (BCG) infection after intravesical instillation

A 78-year-old man was diagnosed with bladder carcinoma in situ and was successfully treated with intravesical bacillus Calmette-Guérin (BCG) instillations. At 6 months after the last dose, he developed fever, weight loss and malaise. He had an extensive negative workup at an outside hospital and was treated empirically with ciprofloxacin for 2 weeks. The fever resolved but returned months later and he was readmitted with pancytopenia, elevated alkaline phosphatase and ground glass opacities on the chest CT. Bone marrow and liver biopsies showed non-caseating granulomas and were negative for acid-fast bacillus (AFB) and fungal stains. Mycobacterium tuberculosis complex PCR of the bone marrow was negative. Owing to the high clinical suspicion of disseminated BCG infection, the patient was treated empirically. After 9 weeks of incubation, the bone marrow AFB culture grew Mycobacterium bovis. Within 2 months of treatment his symptoms resolved and his laboratory results normalised.