Markus Wehler

Thrombocytopenia in patients in the medical intensive care unit: Bleeding prevalence, transfusion requirements, and outcome*

ObjectiveTo determine prevalence, risk factors, and outcome of thrombocytopenia in medical intensive care patients. DesignProspective observational study. SettingThe 12-bed medical intensive care unit of a university hospital. PatientsAll consecutively admitted patients with normal platelet count at admission and an intensive care unit stay of >48 hrs during a 13-month period (n = 145). Measurements and Main ResultsThe prevalence of intensive care unit-acquired thrombocytopenia (platelet count, <150.0/nL) was 64 of 145 patients (44%). Intensive care unit mortality was 31% in thrombocytopenic patients and 16% in nonthrombocytopenic patients (p = .03). Mortality was higher in patients with a nadir platelet count of <100.0/nL (p < .001) and in patients with a drop in platelet count of ≥30% (p < .001). In nonsurvivors, the decrease in platelet count was greater (p < .001), the nadir platelet count lower (p < .001), and the duration of thrombocytopenia longer (p = .008) than in survivors. A logistic regression analysis identified septic shock (odds ratio [OR], 3.65; 95% confidence interval [CI], 1.40–9.52), a higher Acute Physiology and Chronic Health Evaluation II Score at admission (OR, 1.06 for 1 point; 95% CI, 1.01–1.12), and a drop in platelet count exceeding 30% (OR, 3.73; 95% CI, 1.24–11.21), but not thrombocytopenia, as independent risk factors for intensive care unit death. Correction of thrombocytopenia was associated with reduced mortality (OR, 0.002; 95% CI, 0–0.08). Major bleeding prevalence and transfusion requirements were significantly higher with thrombocytopenia. Nadir platelet count was the only independent risk factor for bleeding (OR, 4.1 for every 100.0/nL; 95% CI, 1.9–8.8). Independently associated with thrombocytopenia were disseminated intravascular coagulation (OR, 14.94; 95% CI, 3.92–57.00), cardiopulmonary resuscitation as an admission category (OR, 5.17; 95% CI, 1.42–18.85), and a higher Sequential Organ Failure Assessment score (OR, 1.20 for a 1 point change; 95% CI, 1.02–1.40). ConclusionsThrombocytopenia is common in medical intensive care unit patients. Thrombocytopenic patients have a higher prevalence of bleeding and greater transfusion requirements. A drop in platelet counts of ≥30%, but not thrombocytopenia per se, is independently associated with intensive care unit death. Serial measurements of platelet counts are important and readily available markers for monitoring the patient’s condition. Any drop in platelet count requires urgent clarification. Disseminated intravascular coagulation, signs of organ failure at admission, and cardiopulmonary resuscitation are predictors of intensive care unit-acquired thrombocytopenia.

Health-related quality of life of patients with multiple organ dysfunction: Individual changes and comparison with normative population

ObjectiveTo determine health-related quality of life in medical intensive care patients with multiple organ dysfunction. DesignProspective, observational study. SettingA 12-bed, noncoronary, medical intensive care unit of a university hospital. PatientsBetween June 1998 and May 1999, 318 consecutively admitted adult patients with an intensive care unit stay of >24 hrs were studied. Measurements and Main ResultsHealth-related quality of life was assessed using a generic instrument, the Medical Outcomes Study Short Form-36 Health Survey, at admission and at 6-month follow-up. Patients who developed multiple organ dysfunction (n = 170) consumed 85% of the therapeutic activity provided in the intensive care unit. Compared with age- and sex-adjusted general population controls, multiple organ dysfunction patients had a worse preadmission health-related quality of life than other intensive care unit patients, predominantly due to a higher burden of comorbid disease. In a multivariate analysis, multiple organ dysfunction was the only variable independently associated with deteriorated physical health domains at follow-up (odds ratio, 4.4; 95% confidence interval, 1.3–14.6;p = .015), but it had no impact on dimensions of mental health. Analyzing the impact of different organ system failures, respiratory failure (odds ratio, 4.1; 95% confidence interval, 1.6–10.3;p = .002) and acute renal failure (odds ratio, 3.3; 95% confidence interval, 1.0–11.5;p = .05) increased the risk of deteriorated physical health at follow-up. No impact of the various organ system failures on mental health was noted. At 6-month follow-up, 83–90% of survivors had regained their previous health-related quality of life, and 94% were living at home with their families. ConclusionsThis study has shown that preadmission health-related quality of life of our medical, noncoronary patients was substantially reduced compared with a matched general population. This demonstrates the need to take prehospitalization health-related quality of life into account when examining the outcomes of intensive care unit survivors. Multiple organ dysfunction was the major determinant of poor physical health at follow-up, but it had no impact on mental health domains.

Factors associated with health-related quality of life in chronic pancreatitis.

OBJECTIVES:Chronic pancreatitis may lead to considerable reduction in health-related quality of life, but factors associated with a poor perceived health status have not been investigated.METHODS:We recruited 265 patients with chronic pancreatitis from a tertiary care gastroenterology clinic. Health-related quality of life was assessed using the Short Form-36 Health Survey. Data were compared with age- and gender-adjusted values from the German general population (6964 adults). Factors associated with poor perceived health status were identified by logistic regression.RESULTS:All domains of health-related quality of life were reduced in chronic pancreatitis. Decrements were most pronounced in role limitations caused by physical (−25%) and emotional health problems (−15%), and general health perceptions (−19%). Severity of abdominal pain, chronic pancreatic diarrhea, low body weight, and loss of work independently contributed to the physical component score of the Short Form-36 (adjusted R2= 33.8%) and were the factors most closely associated with poor health status perception. The etiology and duration of the disease or changes in pancreatic morphology had no impact on health-related quality of life.CONCLUSIONS:Patients with chronic pancreatitis experience substantial impairments in health-related quality of life. The severity of chronic pancreatitis-related symptoms is directly associated with patient function and well-being. These data offer further insight into the impact of chronic pancreatitis on patient health status and may serve as the basis for the development of disease-specific instruments, which are needed to measure the effect of therapeutic interventions on patient-derived health outcomes.

Health‐related quality of life in chronic pancreatitis: a psychometric assessment

Background: Measurement properties of a generic instrument to assess health‐related quality of life in patients with chronic pancreatitis have not been described. Methods: We assessed the health‐related quality of life in 314 patients with chronic pancreatitis using the generic Medical Outcomes Study Short Form‐36 Health Survey. Data were compared with age‐ and gender‐matched general population norms and the psychometric properties of the instrument were evaluated. Results: Patients with chronic pancreatitis reported considerably worse scores on all Short Form‐36 scales compared with the general population. Decrements were most pronounced in role limitations caused by physical (−29%) and emotional health problems (−20%), and general health perceptions (−19%). Test–retest reliability coefficients were ≥0.82 for all subscales and internal consistency coefficients ranged from 0.78 to 0.92. Floor effects were negligible for all but the two role subscales, but there were substantial ceiling effects for five of the eight subscales. Construct validity was supported by the findings that the Short Form‐36 discriminated well between patients of different age, burden of chronic illness and severity of symptoms. Conclusions: Patients with chronic pancreatitis experience substantial deteriorations in health‐related quality of life compared with the general population. The Short Form‐36 proved to be a feasible, reliable and valid measure for descriptive studies of patients with chronic pancreatitis, but ceiling effects may limit its usefulness as an outcome measure in the assessment of treatment effects.

Faecal Elastase-1: Lyophilization of Stool Samples Prevents False Low Results in Diarrhoea

Background: In patients with diarrhoea, faecal elastase-1 is used to detect exocrine pancreatic insufficiency. Diarrhoea is defined as >85% stool water content. Methods: We analysed elastase-1 in 519 stool samples from 310 patients unprocessed as well as after lyophilization in a standard laboratory lyophilizator. Stool water content was calculated by weight difference before and after lyophilization. Results:

Pseudomembranous Tracheobronchitis Due to Bacillus cereus

We present a case of a rapidly progressive pseudomembranous tracheobronchitis and pneumonia in a 52-year-old woman with severe aplastic anemia. Bacillus cereus was isolated from bronchoalveolar lavage fluids, blood cultures, and pseudomembrane biopsy specimens; despite intensive antibiotic treatment, the patients condition deteriorated rapidly. To our knowledge, this is the first report of a B. cereus infection that has caused pseudomembranous tracheobronchitis, possibly because of the production of bacterial toxins.

Interventional endoscopic therapy in chronic pancreatitis including temporary stenting : A definitive treatment?

Objective. In the past 15 years there have been tremendous advances in endoscopic management of chronic pancreatitis (CP). However, the value of endoscopic pancreatic stenting is still debatable. Material and methods. In 98 patients suffering from symptomatic CP (84 M, 14 F, 49±12, age range 23–83 years) endotherapy including temporary stenting of the pancreatic duct was performed. After final stent removal, indicating the primary end-point of endotherapy, 96 patients were followed for 35±28 (8 days–111) months. All data were assessed retrospectively. Results. As well as other endoscopic procedures, a total of 358 prostheses were inserted in the pancreatic duct and left in place for 3±1 (1 day–11) months. Total stent treatment time was 10±10 (6 days–49) months. At 46±27 (4–111) months after limited endotherapy, 57 patients had no need for secondary intervention, two-thirds were even without further pain sensations. In 22 patients, surgical treatment and in 17 patients further endoscopic therapy became necessary, which was significantly correlated with continued alcohol consumption. Conclusions. Temporary stent placement as a part of interventional endoscopic therapy in CP shows a high rate of technical and long-term clinical success, with no need for secondary treatment in a remarkable number of patients. Continued cessation of alcohol consumption supports the treatment benefit significantly.

Composition of clogging material in pancreatic endoprostheses

BACKGROUND Endoscopic management of chronic pancreatitis (CP), especially pancreatic stent placement, has made tremendous advances. However, good clinical results are hampered by rapid occlusion. The objective of this study was to understand mechanisms and materials that cause stent occlusion. METHODS The clogging material of 50 lyophilized pancreatic endoprostheses (length 8.5 cm, range 5-14 cm, diameter 7-11F) from patients with CP was completely removed and weighed. Protein solubilization was achieved at pH 8.0 by using sodium dodecyl sulfate (SDS) and 2-mercaptoethanol in the presence of proteasome inhibitors. Proteins were separated by using a SDS-polyacrylamide gel electrophoresis. Protein identification was performed by the Western blot technique, as well as by mass spectrometry. Insoluble components were examined by polarized light microscopy and after staining (periodic acid-Schiff [PAS]). RESULTS Clogging material was found in 49 prostheses, mainly at the duodenal flap (80%). More than a third of the prostheses contained visible calcium carbonate calculi. Light microscopy and PAS staining showed plant debris (80%), crystals (73.5%), and mucopolysaccharides (100%). The dry weight of clogging material (18 +/- 13 mg, range 3-72 mg) correlated significantly with the stent diameter ( p = 0.029) but not with any other stent- or patient-related criteria. Albumin, its degradation products, and lithostathine were identified as the main proteinaceous components. CONCLUSIONS Almost all pancreatic stents had clogging material, predominantly located at the duodenal flap, which contained plant material, mucopolysaccharides, and crystals, as well as visible calcium carbonate calculi. Albumin and lithostathine may play an important role in the development of stent occlusion.

Changes in hepatic perfusion after administration of hydroxyethyl starch in intensive care patients assessed using color-coded Doppler sonography

Using color-coded Doppler sonography (CCDS), changes in the resistance index of the hepatic artery (HA-RI) and in the velocities of the hepatic artery, portal and splenic vein (HA-V, PV-V, SV-V) were measured after administration of hydroxyethyl starch (HES) in 50 intensive care patients. PV-V and SV-V increased, whereas HA-V and HA-RI remained unchanged. CCDS is suitable to assess liver perfusion in intensive care patients. Since HES enhances splanchnic perfusion, its application improves hepatic perfusion in intensive care patients.

Pancreatic elastase-1 in fecal dry matter in health and disease

Background: In patients with diarrhea , fecal pancreatic elastase-I (E-!) us used to detect or rule out exocrine pancreatic insufficiency . We recently could demonstrate (Gastroenterology 1998.114. A45 7) that dilution ofE-1 does occur in diarrhea, leading to false low results. Methods: A total of 512 consecutive stool samples from clinical routine and 100 stool samples from healthy control persons (49 f. 51 m, mean age 35 yrs.) were analyzed unprocessed as well as after lyophilization in a standard laboratory IyophiIisator. E-I was determined with a commercially available test kit (ScheBo Tech. Germany). Water content was calculated by weighing the samples on precision scales before and after lyophilization. Results : 137/512 clinical stool samples had a stool water content >85%; these were regarded as diarrhea. In those, mean E-I concentration in unprocessed stools was 395 ± 152 /Lglg, but was 855 ± 408 /Lglg when measured after lyophili zation and mathematical correction to a stool water content of 75% (p= O.OOO I) . In 11/137 diarrhea sample s (8%), E-I concentrations were lower than normal «200 /Lglg) when measured unprocessed, but were normal when corrected for the elevated water content of stools. In healthy controls. E-I was 3877 ± 2203 /Lglg(range 642 9465 /Lg/g); stool water content was 69 ± 6%. Leaving off the three lowest results, a cut-off value of 800 /Lg/g fecal dry matter can be defined as the normal limit. Conclusion: More than 25% of stool samples sent in for E-I determination can be classified as diarrhea. False low E-I concentrations do occur due to elevated stool water conten. This mistake can be avoided by lyophilization of stool samples and mathematical correction. We established reference values for fecal dry matter to be used in diarrhea and in doubtful cases.