Ronald J. Markert

Survival factors in rhino-orbital-cerebral mucormycosis.

Mucormycosis is a highly aggressive fungal infection affecting diabetic, immunocompromised, and, occasionally, healthy patients. This infection is associated with significant mortality. We have reviewed 208 cases in the literature since 1970, 139 of which were presented in sufficient detail to assess prognostic factors, and added data from six of our patients. The histories of these 145 patients were analyzed for the following variables: 1) underlying conditions associated with mucormycotic infections; 2) incidence of ocular and orbital signs and symptoms; 3) incidence of nonocular signs and symptoms; 4) interval from symptom onset to treatment; and 5) the pattern of sinus involvement seen on imaging studies and noted at the time of surgery. Factors related to a lower survival rate include: 1) delayed diagnosis and treatment; 2) hemiparesis or hemiplegia; 3) bilateral sinus involvement; 4) leukemia; 5) renal disease; and 6) treatment with deferoxamine. The association of facial necrosis with a poor prognosis fell just short of statistical significance, but appears clinically important. This is the first review that documents the heretofore intuitive claim that early diagnosis is necessary to cure this disease. Standard treatment with amphotericin B and aggressive surgery are reviewed and adjunctive therapeutic modalities are discussed, including local amphotericin B irrigation, hyperbaric oxygen, and optimizing the immunosuppressive regimen in transplant patients. Hyperbaric oxygen was found to have a favorable effect on prognosis. In addition, possible treatment options for patients with declining renal function are reviewed.

In-hospital cardiopulmonary resuscitation. Survival in 1 hospital and literature review.

Cardiopulmonary resuscitation (CPR) has been used extensively in the hospital setting since its introduction over 3 decades ago. We reviewed the CPR records at 1 hospital during a 2-year period and the results from 113 published reports of inpatient CPR with a total patient population of 26,095. We compared the survival rates of patients following CPR and the pre-arrest and intra-arrest factors related to survival. At the hospital where CPR records were reviewed, 44% of patients initially survived following CPR, and the 1-year survival rate was 5%. Patients with shorter durations of CPR and those administered fewer procedures and medications during CPR survived longer than patients with prolonged CPR. Patients with witnessed cardiac arrests were more likely to survive than those with unwitnessed arrests. Also, patients with respiratory arrests had much better survival than patients with cardiopulmonary arrests. Worldwide, 113 studies showed a survival to discharge rate of 15.2% (United States = 15%, Canada = 16%, United Kingdom = 17%, other European countries = 14%). Patients were more likely to survive to discharge if they were treated in a community hospital (versus a teaching or Veterans Affairs hospital) or were younger. Patients with ventricular tachycardia or fibrillation were more likely to survive than those with asystole or electromechanical dissociation. Patients location was related to outcome, with emergency room and coronary care unit patients more likely to survive than intensive care unit and general ward patients. Other factors related to better survival rates were respiratory arrest, witnessed arrest, absence of comorbidity, and short duration of CPR. Knowledge of the likelihood of survival following CPR for subgroups of the hospital population based on pre-arrest and intra-arrest factors can help patients, their families, and their physicians decide, with compassion and conviction, in what situations CPR should be administered.

Stress, Negative Social Exchange, and Health Symptoms in University Students

Abstract Although social support has been studied extensively in terms of its role in the relationship between stress and health, less attention has been devoted to the impact of negative social interactions. In this investigation, the authors examined the unique contributions of positive social support and negative social exchange in the relationship between stress and health symptoms, using data from 206 undergraduates at a large state university. Negative social exchange accounted for more variance in physical health symptoms than did life-event stress, daily hassles, or social support. The relationship between negative social interaction and physical symptoms was not the result of variance shared with psychological well-being. The importance of attending to negative aspects of social interaction among university students in terms of their health and well-being is discussed.

Percutaneous endoscopic gastrostomy: a randomized prospective comparison of early and delayed feeding

BACKGROUND It has been customary to initiate feeding through percutaneous endoscopic gastrostomy (PEG) tubes 24 hours or more after placement of these tubes. Recent changes in practice environment and emphasis on early discharge of hospitalized patients prompted us to evaluate early PEG feeding in a randomized prospective manner. METHODS Forty-one patients were included in the study. After an informed consent, the patients were randomly assigned to two groups. Groups I (21 patients) received tube feedings 3 hours and Group II (20 patients) received feedings 24 hours after PEG placement. All patients received an Iso-osmolar formula by continuous infusion at 30 ml/hour for the first 24 hours of feeding. The rates were then increased to 70 ml/hour. Residual volumes, tube length, peristomal leakage, and vital signs were checked, and a global assessment was done every 4 hours. Evaluation by a physician was done every 24 hours for 72 hours. If the residual volume was more than 60 ml (significant residual volume), the tube feedings were held for 2 hours. Patients exited the study at 72 hours from the time of procedure. All deaths were recorded to calculate 30-day mortality. RESULTS One patient (Group 2) died during the study period. Three patients (two in Group 1 and one in Group 2) had a significant residual volume. One patient (Group 1) had local skin infection requiring treatment. None of the patients had any signs of peritonitis or systemic infection. CONCLUSION Early PEG tube feeding (3 hours after tube placement) is as safe as next day feeding in elderly patients.

A prospective controlled evaluation of endoscopic detection of angiodysplasia and its association with aortic valve disease

BACKGROUND In view of controversy about the association of aortic stenosis and angiodysplasia of the gut, we performed a prospective, controlled study to evaluate the relationship between aortic valve disease and gastrointestinal angiodysplasia. METHODS Forty patients who had endoscopy for clinical indications such as gastrointestinal bleeding, anemia, polyps, colon cancer, and dyspepsia, and who were found to have angiodysplasia of the gastrointestinal tract, underwent two-dimensional and Doppler echocardiography. Thirty-seven controls matched for age, sex, indication, and nature of endoscopic examination, but without angiodysplasia, underwent similar echocardiographic examination. RESULTS None of the patients in either group had aortic stenosis. The prevalence of aortic sclerosis, aortic insufficiency, and low left ventricular ejection fraction was similar in patients with and without angiodysplasia. CONCLUSIONS This study does not support the role of aortic valve disease as the cause of angiodysplasia of the gastrointestinal tract. A subgroup of patients with angiodysplasia with aortic sclerosis, with or without other valvular disease (but none with aortic stenosis), had increased prevalence of gastrointestinal bleeding when compared with controls. When aortic valve disease or decreased left ventricular ejection fraction were analyzed as independent predictors, none of them in and of itself appeared to be a factor in bleeding from these gastrointestinal lesions.

Predictive factors for high mortality in hypernatremic patients.

Hypernatremia (serum sodium level of > 145 mEq/L) is associated with high mortality. This study reports an analysis of mortality in 116 patients with hypernatremia from two large university-affiliated teaching hospitals. The purpose was to identify factors predictive of high mortality in hypernatremic patients. Medical records were reviewed to obtain the following data: serum sodium (Na+) levels; systolic (S) and diastolic (D) blood pressure (BP) at the time of admission and throughout the hospital course; status of cognitive function; and type of fluid administered. The patients were divided into two groups: expired and survived. Seventy-seven of 116 patients (66%) expired, while 39 patients (34%) survived and were discharged from the hospital. The mean age and gender for patients who died (70.9 +/- 15.4 years, 90% men) were not different from those who survived (66.4 +/- 17.3 years, 87% men). For the serum Na+ levels recorded at three different times (early, peak, and late), mean late serum Na+ level during hospital course was significantly higher in patients who died than in those who survived (151.2 +/- 9.2 v 143.1 +/- 8.0 mEq/L, respectively; P < .001). Mean admission serum Na+ level (154.9 +/- 5.5 v 155.1 +/- 7.7 mEq/L, respectively) and mean peak serum Na+ level (157.5 +/- 6.5 v 156.8 +/- 9.4 mEq/L, respectively) were not different between the two groups. Both SBP and DBP at the time of admission (P < .05) and throughout the hospital course (P < .001) were significantly lower in the patients who died than in those who survived. The cognitive abnormalities consisting of confusion, obtundation, and speech abnormality were significantly (P < .05) higher in the expired patients than in those who survived. Normal (isotonic) saline was used significantly more frequently (P < .00001) in patients who expired than in those who survived. Thus, this study suggests that a persistently elevated serum Na+ level (possibly caused by prolonged infusion of normal saline) in association with protracted hypotension portends a dismal prognosis in hospitalized hypernatremic patients.

Critical Thinking: Change During Medical School and Relationship to Performance in Clinical Clerkships

The development of critical thinking, the ability to solve problems by assessing evidence using valid inferences, abstractions, and generalizations, is one of the global goals advocated by most medical schools. This study determined changes in critical thinking skills between entry and near the end of the third year of medical school, assessed the predictive ability of a test of critical thinking skills, and assessed the concurrent validity of clerkship components and final grade. The Watson–Glaser Critical Thinking Assessment (WGCTA) was administered to one class of students at entry to medical school and near the end of year 3. Performance data for those students who completed their clinical clerkships on schedule were also recorded. Critical thinking improved modestly but significantly from entry to medical school to near the end of year 3. The ability of a critical thinking test to predict clerkship performance was limited; the correlation between WGCTA total score at entry and the components and final grade of five major clerkships ranged from near 0 to 0·34. The concurrent validity of clerkship components and final grade was also limited; correlations with WGCTA total score near the end of year 3 ranged between 0·08 and 0·49. The correlation between WGCTA total score and United States Medical Licensing Examination Step 2 was higher at year 3 than at medical school entry. Critical thinking skills improve moderately during medical school. Used alone, tests of critical thinking may be of limited value in predicting which students will be successful in clinical clerkships. Clerkship evaluation components and final grade have limited concurrent validity when a test of critical thinking is the criterion.

APACHE II and ISS scores as predictors of nosocomial infections in trauma patients.

BACKGROUND Nosocomial infections affect more than 2 million patients annually in the United States at a cost of

Incidence and Risk Factors for Deep Venous Thrombosis After Moderate and Severe Brain Injury

4.5 billion. The aim of this study is to identify the role of the APACHE II score and the Injury Severity Scale (ISS) as independent predictors of nosocomial infections in trauma patients admitted to the intensive care unit (ICU). METHODS A retrospective chart review of 113 trauma patients admitted to the ICU was conducted by an infectious disease physician. Demographic data and incidence of nosocomial infections were recorded. Multivariate logistic regression analysis was used to determine variables that are predictive of the occurrence of nosocomial infections. RESULTS Presence or absence of intubation, ICU length of stay, APACHE II score, and ISS were related to the presence of infections; however, only the ICU length of stay was an independent predictor of a nosocomial infection, with an odds ratio of 1.81. By linear regression, 17% of the variance in the ICU duration of stay was a result of the APACHE II score in patients with a score >/=5. CONCLUSION APACHE II score and ISS score were not good predictors of the incidence of nosocomial infections in trauma patients admitted to the ICU, but the APACHE II score has a modest correlation with the duration of stay in the ICU. A stratified cohort study could identify the subset of patients for which the APACHE II score predicts a prolonged stay in the ICU, thus an increased risk of infection.

Relationship between Critical Thinking Skills and Success in Preclinical Courses.

BACKGROUND Patients with traumatic injuries possess a high risk of developing deep venous thrombosis (DVT), thus the need for appropriate prophylaxis. Patients with head injuries pose a unique challenge due to contraindication to the use of anticoagulation. We sought to determine the incidence of DVT and identify specific risk factors for its development in patients with head injuries. METHODS All head injury admissions between January 1, 2000, and July 31, 2006, with a length of stay >or=7 days were identified. Patient data including age, sex, injuries, Glasgow Coma Scale, Injury Severity Score (ISS), and venous duplex scan results were collected. Mechanical methods were routinely used for prophylaxis; heparin was not used in this population. Weekly duplex screening was commenced at 7 days to 10 days after admission. RESULTS There were 939 patients who met criteria for review, however, duplex scans were performed in only 677, which was the population studied. Overall, DVT was present in 31.6%. There were fewer DVTs in patients with isolated head injuries (25.8%) compared with patients with those with head and extracranial injuries (34.3%)--p = 0.026. Independent predictors for DVT identified included male gender (p = 0.04), age >or=55 (p < 0.001), ISS >or=15 (p = 0.014), subarachnoid hemorrhage (p = 0.006), and lower extremity injury (p = 0.001). CONCLUSIONS DVT occurs in one third of moderately to severely brain injured patients. Isolated head injuries have a lower incidence. Older age, male gender, higher ISS, and the presence of a lower extremity injury are strong predictors for developing DVT. Regular screening and the use of prophylactic inferior vena cava filters in patients with risk factors should be strongly considered.