W. N. K. A. van Mook

Endotracheal Aspirate and Bronchoalveolar Lavage Fluid Analysis: Interchangeable Diagnostic Modalities in Suspected Ventilator-Associated Pneumonia?

ABSTRACT Authoritative guidelines state that the diagnosis of ventilator-associated pneumonia (VAP) can be established using either endotracheal aspirate (ETA) or bronchoalveolar lavage fluid (BALF) analysis, thereby suggesting that their results are considered to be in accordance. Therefore, the results of ETA Gram staining and semiquantitative cultures were compared to the results from a paired ETA-BALF analysis. Different thresholds for the positivity of ETAs were assessed. This was a prospective study of all patients who underwent bronchoalveolar lavage for suspected VAP in a 27-bed university intensive care unit during an 8-year period. VAP was diagnosed when ≥2% of the BALF cells contained intracellular organisms and/or when BALF quantitative culture revealed ≥104 CFU/ml of potentially pathogenic microorganisms. ETA Gram staining and semiquantitative cultures were compared to the results from paired BALF analysis by Cohens kappa coefficients. VAP was suspected in 311 patients and diagnosed in 122 (39%) patients. In 288 (93%) patients, the results from the ETA analysis were available for comparison. Depending on the threshold used and the diagnostic modality, VAP incidences varied from 15% to 68%. For the diagnosis of VAP, the most accurate threshold for positivity of ETA semiquantitative cultures was moderate or heavy growth, whereas the optimal threshold for BALF Gram staining was ≥1 microorganisms per high power field. The Cohens kappa coefficients were 0.22, 0.31, and 0.60 for ETA and paired BALF Gram stains, cultures, and BALF Gram stains, respectively. Since the ETA and BALF Gram stains and cultures agreed only fairly, they are probably not interchangeable for diagnosing VAP.

Mimivirus is not a frequent cause of ventilator-associated pneumonia in critically ill patients.

Acanthamoeba polyphaga mimivirus (APMV) belongs to the amoebae‐associated microorganisms. Antibodies to APMV have been found in patients with pneumonia suggesting a potential role as a respiratory pathogen. In addition, positive serology for APMV was associated with an increased duration of mechanical ventilation and intensive care unit stay in patients with ventilator‐associated pneumonia. The aim of the present study was to assess the presence of APMV in bronchoalveolar lavage fluid samples of critically ill patients suspected of ventilator‐associated pneumonia. The study was conducted in the intensive care unit of the Maastricht University Medical Centre. All consecutive bronchoalveolar lavage fluid samples obtained between January 2005 and October 2009 from patients suspected of ventilator‐associated pneumonia were eligible for inclusion. All samples were analyzed by real‐time PCR targeting the APMV. A total of 260 bronchoalveolar lavage fluid samples from 214 patients (139 male, 75 female) were included. Bacterial ventilator‐associated pneumonia was confirmed microbiologically in 105 out of 260 (40%) suspected episodes of ventilator‐associated pneumonia (86 patients). The presence of APMV DNA could not be demonstrated in the bacterial ventilator‐associated pneumonia positive or in the bacterial ventilator‐associated pneumonia negative bronchoalveolar lavage fluid samples. Although suspected, APMV appeared not to be present in critically ill patients suspected of ventilator‐associated pneumonia, and APMV does not seem to be a frequent cause of ventilator‐associated pneumonia. J Med. Virol. 85:1836–1841, 2013.

Clara cell protein in bronchoalveolar lavage fluid: a predictor of ventilator-associated pneumonia?

IntroductionClara cell protein 10 (CC-10) has been associated with inflammatory and infectious pulmonary diseases. This study evaluates CC-10 concentrations in bronchoalveolar lavage (BAL) fluid as a potential marker of ventilator-associated pneumonia (VAP).MethodsBetween January 2003 and December 2007, BAL fluid samples obtained from critically ill patients at the intensive care unit of the Maastricht University Medical Centre clinically suspected of having VAP were included. Patients were divided into two groups: (1) microbiologically confirmed VAP (the VAP group) and (2) microbiologically unconfirmed VAP (the non-VAP group). The concentration of CC-10 was measured by means of a commercially available enzyme-linked immunosorbent assay kit, and retrospective analysis was performed. Areas under the curve of receiver operating characteristic curves were calculated for CC-10 concentrations.ResultsA total of 196 patients (122 men, 74 women) were included. A total of 79 (40%) of 196 cases of suspected VAP were microbiologically confirmed. The median CC-10 concentration in the VAP group was 3,019 ng/mL (range, 282 to 65,546 ng/mL) versus 2,504 ng/mL (range, 62 to 30,240 ng/mL) in the non-VAP group (P = 0.03). There was no significant difference in CC-10 concentrations between patients treated with or without corticosteroids (P = 0.26) or antibiotic therapy (P = 0.9). The CC-10 concentration did not differ significantly between patients with Gram-positive versus Gram-negative bacteria that caused the VAP (P = 0.06). However, CC-10 concentrations did differ significantly between the late-onset VAP group and the non-VAP group.ConclusionsThe CC-10 concentration in BAL fluid yielded low diagnostic accuracy in confirming the presence of VAP.

Medical professionalism frameworks across non-Western cultures: A narrative overview

Abstract Background: Medical professionalism is context-specific, but most literature on professionalism stems from Western countries. This study is about benchmarking of different frameworks on professionalism and interpreting the commonalities and discrepancies of understanding professionalism across different cultures. We need to study the cultural underpinning of medical professionalism to graduate future “global” practitioners who are culturally sensitive enough to recognize differences (and also similarities) of expectations of patients in various contexts. Aim: This study aims at describing culture specific elements of three identified non-Western frameworks of professionalism, as well as their commonalities and differences. Method: A narrative overview was carried out of studies that address professionalism in non-Western cultures in the period 2002–2014. Results: Out of 143 articles on medical professionalism, only four studies provided three structured professionalism frameworks in non-Western contexts. Medical professionalism attributes in non-Western cultures were influenced by cultural values. Out of the 24 identified attributes of professionalism, 3 attributes were shared by the three cultures. Twelve attributes were shared by at least two cultures, and the rest of the attributes were unique to each culture. Conclusions: The three frameworks provided culture-specific elements in a unique conceptual framework of medical professionalism according to the region they originated from. There is no single framework on professionalism that can be globally acknowledged. A culture-oriented concept of professionalism is necessary to understand what the profession is dedicated to and to incorporate the concept into the medical students’ and physicians’ professional identity formation.

Alternative diagnosis in the putative ventilator-associated pneumonia patient not meeting lavage-based diagnostic criteria

Abstract Background: The clinical picture of ventilator-associated pneumonia (VAP) can be mimicked by other infectious and non-infectious diseases. The aim of this study was to determine the alternative diagnoses and to develop a diagnostic flow chart for patients suspected of having VAP not meeting the diagnostic broncho-alveolar lavage (BAL) criteria. Methods: Adult intensive care patients with a clinical suspicion of VAP and negative BAL results were included. The clinical suspicion of VAP was based on the combination of clinical, radiological, and microbiological criteria. BAL was considered positive if cell differentiation revealed ≥ 2% cells with intracellular organisms and/or quantitative culture results of ≥ 104 cfu/ml. The most likely alternative diagnosis of fever and pulmonary densities was retrospectively determined by two authors independently. Results: In all, 110 of 207 patients with suspected VAP did not meet the diagnostic BAL criteria and required further diagnostic evaluation. In 67 patients an alternative diagnosis for fever could be found. In 51 patients an alternative diagnosis of both fever and pulmonary densities could be established. In almost 40% of patients no alternative diagnosis could be provided. Non-bacterial pneumonia was diagnosed in 10 patients with Herpes simplex virus 1 (HSV-1) as the most common pathogen. In eight patients non-infectious pneumonitis was diagnosed. Conclusion: Due to the wide range of alternative diagnoses and applied tests the diagnostic work-up proved to be necessarily individualized and guided by repeated clinical assessment. The most frequently found alternative diagnoses were viral pneumonia and non-infectious pneumonitis.

Community-based education: The influence of role modeling on career choice and practice location

Abstract Introduction: Research findings in medical education support the importance of positive role models in enhancing learning and influencing the career path of medical students and graduates. The authors explored the characteristics of positive and negative role models during Community-Based Education and Service (COBES), as well as their effect on trainees’ career paths. Method: A cross-sectional survey was conducted by means of a questionnaire among medical students to explore the characteristics of positive and negative role models during COBES. Associations between gender, choice of specialty, and practice location were assessed using the chi-square test. All qualitative data analysis was performed using the principles of primary, secondary, and tertiary coding. Result: The majority of the students indicated that role modeling during COBES will affect their choice of specialty and practice location with a significant gender difference in terms of practice location (p < 0.005). Qualitative data supported the finding that positive role modeling during COBES may influence graduates willingness to work in rural area. Conclusion: The desire and willingness to work in a rural community combined with good communication and excellent interpersonal skills as well as good leadership skills are attributes of good role modeling that could influence medical students’ career choice during COBES.

Predictors of short-term and long-term mortality in critically ill patients admitted to the intensive care unit following allogeneic stem cell transplantation

Historically, the mortality of patients admitted to the ICU after allogeneic stem cell transplantation (alloSCT) is high. Advancements in transplantation procedures, infectious monitoring and supportive care may have improved the outcome. This study aimed to determine short-term and long-term mortality after ICU admission of patients after alloSCT and to identify prognostic clinical and transplantation-related determinants present at ICU admission for long-term outcome. A multicenter cohort study was performed to determine 30-day and 1-year mortality within 2 years following alloSCT. A total of 251 patients were included. The 30-day and 1-year mortality was 55% and 80%, respectively. Platelet count <25 × 109/L (OR: 2.26, CI: 1.02–5.01) and serum bilirubin >19 μmol/L (OR: 2.47 CI: 1.08–5.65) at admission, other donor than a HLA-matched-related or HLA-matched-unrelated donor (OR: 4.59, CI: 1.49–14.1) and vasoactive medication within 24 h (OR: 2.35, CI: 1.28–4.31) were associated with increased 30-day mortality. Other donor than a HLA-matched-related or HLA-matched-unrelated donor (OR: 1.9, CI: 1.13–3.19), serum bilirubin >77 (OR: 2.05, CI: 1.28–3.30) and vasoactive medication within 24 h (OR: 1.65, CI: 1.12–2.43) were associated with increased 1-year mortality. Neutropenia was associated with decreased 30-day and 1-year mortality (OR: 0.29, CI: 0.14–0.59 and OR: 0.70, CI: 0.48–0.98). Myeloablative conditioning and T cell-depleted transplantation were not associated with increased mortality.

Working among the rural communities in Ghana - why doctors choose to engage in rural practice

BackgroundAn unequal distribution of health personnel, leading to unfavourable differences in health status between urban and rural populations, is a serious cause for concern globally. Part of the solution to this problem lies in attracting medical doctors to rural, remote communities, which presents a real challenge. The present study therefore explored the factors that influence medical doctors’ decision to practise in rural Ghana.MethodsWe conducted a cross-sectional descriptive study based on questionnaires. Participants were doctors working in health facilities in the districts and rural areas of the Northern Region, Ghana. The qualitative data analysis consisted of an iterative process of open, axial and selective coding.ResultsWe administered the questionnaires to 40 doctors, 27 of whom completed and returned the form, signalling a response rate of 67.5%. The majority of the doctors were male (88.9%) and had been trained at the University for Development Studies, School of Medicine and Health Sciences (UDS-SMHS) (63%). Although they had chosen to work in the remote areas, they identified a number of factors that could prevent future doctors from accepting rural postings, such as: a lack of social amenities, financial and material resources; limited career progression opportunities; and too little emphasis on rural practice in medical school curricula. Moreover, respondents flagged specific stakeholders who, in their opinion, had a major role to play in the attraction of doctors and in convincing them to work in remote areas.ConclusionsThe medical doctors we surveyed had gravitated to the rural areas themselves for the opportunity to acquire clinical skills and gain experience and professional independence. Nevertheless, they felt that in order to attract such cadre of health professionals to rural areas and retain them there, specific challenges needed addressing. For instance, they called for an enforceable, national policy on rural postings, demanding strong political commitment and leadership. Another recommendation flowing from the study findings is to extend the introduction of Community-Based Education and Service (COBES) or similar curriculum components to other medical schools in order to prepare students for rural practice, increasing the likelihood of them accepting rural postings.

Organ donation after euthanasia: a pure act of altruism fulfilling the patient's last wish

Euthanasia is controversial among health care professionals worldwide, but the number of countries that allow euthanasia is increasing and currently includes Belgium, the Netherlands, Luxembourg, Colombia, and the province Quebec in Canada (1). Several ethical controversies, such as whether the physician should always inform patients about the possibility of organ donation after euthanasia, which preparatory investigations are allowed, and whether the donor should be informed about matching recipients, are beyond the scope of this article (2).

Molecular epidemiology of Pneumocystis jiroveci in human immunodeficiency virus-positive and -negative immunocompromised patients in The Netherlands

Pneumocystis jiroveci infections can cause pneumocystis pneumonia (PCP) or lead to colonization without signs of PCP. Over the years, different genotypes of P. jiroveci have been discovered. Genomic typing of P. jiroveci in different subpopulations can contribute to unravelling the pathogenesis, transmission and spread of the different genotypes. In this study, we wanted to determine the distribution of P. jiroveci genotypes in immunocompetent and immunocompromised patients in The Netherlands and determine the clinical relevance of these detected mutations. A real-time PCR targeting the major surface glycoprotein gene (MSG) was used as a screening test for the presence of P. jiroveci DNA. Samples positive for MSG were genotyped based on the internal transcribed spacer (ITS) and dihydropteroate synthase (DHPS) genes. Of the 595 included bronchoalveolar lavage fluid samples, 116 revealed the presence of P. jiroveci DNA. A total of 52 of the 116 samples were ITS genotyped and 58 DHPS genotyped. The ITS genotyping revealed 17 ITS types, including two types that have not been described previously. There was no correlation between ITS genotype and underlying disease. All ITS- and DHPS-genotyped samples were found in immunocompromised patients. Of the 58 DHPS-genotyped samples, 50 were found to be WT. The other eight samples revealed a mixed genotype consisting of WT and type 1. The majority of the latter recovered on trimethoprim-sulfamethoxazole suggesting no clinical relevance for this mutation.