Heart & Lung - The Journal of Critical Care

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2010-01-01

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2010-01-01

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2010-01-01

Transitions in care

Kismet Rasmusson — 2010-01-01

In the most recent issue of Heart & Lung, Annema et al described a disconnect between healthcare professionals and patients and their caregivers in the perceived reasons for heart failure (HF) hospital readmissions. Patients and their caregivers were more likely to report nonadherence and insufficient access to professional help as contributing causes. Conversely, clinicians reported comorbid conditions and knowledge deficits as issues. Although nonadherence to HF treatments played a significant role in hospital readmissions, patients' difficulties with recognizing problematic symptoms were also reported. Annema et al concluded that both patient and caregiver perceptions are as important as those of care providers when targeted interventions to reduce HF readmissions are formulated. The implications of that study provide a remarkable segue into the present focus on ways to improve outpatient care for HF, especially as it relates to hospital readmissions. The many reasons for this focus on care may be seen as a continuum: HF is the leading diagnosis of hospitalizations for persons over age 65 years, hospitalization rates have tripled from 1979 to 2004, and readmission rates have improved little over the last decade. Readmissions remain at 20% during the first 30 days after discharge, and at 50% as of 6 months after a hospitalization. With hospitalizations accounting for the majority of $37 billion in HF costs, this issue imposes a tremendous burden on healthcare delivery. Yet the HF literature is sparse and inconsistent with regard to assessing the risks for readmission, or in defining clear strategies to improve outcomes.

Gender and racial differences in psychosocial factors of low-income patients with heart failure

2009-07-14

Background: Heart failure (HF) is a debilitating chronic disease with incidence and prevalence continuing to increase, particularly in low-income, minority groups. Psychosocial variables have recently emerged as important predictors of cardiovascular risk and health outcomes in HF. However few data exist in this group. Thus, the purpose of this study is to examine the sociodemographic and psychosocial variables in low-income patients with HF.Methods: This is a descriptive, cross-sectional study using 1-time interviews. Subjects with HF were recruited from 3 cardiology clinics and 1 community hospital.Results: Fifty-five percent of the sample (n=65) were women with a mean (standard deviation) age of 59 years (14); 35% were non-white, 86% were unemployed, 56% had an annual income < $10,000, and 52% were uninsured. Most reported having high social support (83%), poor health perception (82%), and severe depressive symptoms (70%). Non-white men seemed to have worse health perceptions and more depressive symptoms.Conclusion: Low-income patients with HF, particularly non-white men, have poor health perception and more depressive symptoms. This is important because HF has been associated with increased morbidity and mortality in patients. Future research is necessary to explore ways in designing effective interventions to improve health outcomes.

Patient perception of symptoms and quality of life following ablation in patients with supraventricular tachycardia

2009-10-01

Objectives: It remains unclear which symptom experiences and aspects of quality of life (QOL) change after ablation in patients with supraventricular tachycardia (SVT). To determine how patient perceptions of symptoms and QOL change after ablation, we used a single group pretest–posttest design.Methods: Patients with SVT (n=52; mean age 41±17 years; 65% female) completed generic and disease-specific measures at baseline and 1 month after ablation.Results: Significant improvement after ablation was noted on virtually all measures (P <.05). Patients reported decreases from baseline regarding frequency and duration of episodes, number of symptoms, and impact of SVT on routine activities. All symptoms decreased in prevalence; however, no symptoms were completely eliminated at 1-month follow-up. Women, more so than men, reported larger changes in symptom and QOL scores after ablation.Conclusions: Despite the small sample, statistically significant improvement was found after ablation in a variety of patients with different symptoms and QOL indices.

Thrombocytopenia and outcome in critically ill patients with bloodstream infection

2009-10-16

Objective: Thrombocytopenia is common in intensive care units (ICUs), and is associated with a poor prognosis. An acute decrease in total platelet count is frequently observed in severe sepsis, followed by a relative increase indicating organ-failure recovery. However, few data are available describing this effect and its relationship with outcomes in specific subgroups of ICU patients.Methods: A retrospective, observational cohort study was conducted to investigate the incidence and prognosis of thrombocytopenia in a cohort of critically ill patients (n=155) with a microbiologically documented nosocomial bloodstream infection.Results: Thrombocytopenia occurred more frequently in nonsurvivors. The ICU mortality rates increased according to severity of thrombocytopenia. Thrombocytopenia was independently associated with worse outcomes in ICU patients with nosocomial bloodstream infection.Conclusion: Determining trends in platelet counts is of additional prognostic value, compared with single measurements.

Skin temperature and core-peripheral temperature gradient as markers of hemodynamic status in critically ill patients: A review

Bernadette M. Schey, David Y. Williams, Tracey Bucknall — 2010-01-01

Objective: To examine the evidential basis underpinning the monitoring of skin temperature and core-peripheral temperature gradient as elements of hemodynamic assessment in critically ill and adult cardiac surgical patients.Methods: Twenty-six studies examining the efficacy of skin temperature or temperature gradient as markers of hemodynamic status were selected as part of an integrative review.Results: Evidence pertaining to the efficacy of these parameters as markers of cardiac function is equivocal and has not been well appraised in the adult cardiac surgical population. Skin temperature and systemic vascular resistance are also affected by factors other than cardiac output.Conclusions: Skin temperature and core-peripheral temperature gradient should not be considered in isolation from other hemodynamic parameters when assessing cardiac status until they are validated by further large-scale prospective studies.

Determinants of perceived health in older adults with hypertension

Lisa M. Lewis, Barbara J. Riegel — 2009-08-13

Objective: To describe perceived health and assess the factors that contribute to perceived health in community-dwelling older adults diagnosed with hypertension.Methods: The study was a secondary analysis of data from a cross-sectional study that examined community-dwelling adults’ health status, use of health services, and access to care. Hierarchical regression identified factors that contributed to perceived health in 1485 adults aged 60 years and older who were diagnosed with hypertension.Results: A model of nonmodifiable factors, support resources, and lifestyle factors explained a significant proportion of the variance in perceived health, most of which was captured by nonmodifiable factors.Conclusion: Attention to nonmodifiable factors is needed in both clinical practice and research to identify a subset of older adults diagnosed with hypertension who are at risk for poor perceived health.

Combining community participatory research with a randomized clinical trial: The protecting the hood against tobacco (PHAT) smoking cessation study

2009-07-23

Background: This article describes the process and results of a smoking cessation intervention randomized clinical trial (RCT) that was conducted as a community-based participatory research project. This RCT tested whether outcomes are improved by adding social justice and tobacco industry targeting messages to a smoking cessation program conducted among African American adults within a low-income community in San Francisco, California. This study provides lessons for future similar research projects that focus on urban low-income populations.Methods: Participants were randomly allocated to receive a smoking-cessation program (control group [CG]) or CG care plus tobacco industry and media (IAM) messages. Primary interventions were behavioral. At intake, participants reporting severe withdrawal or smoking≥25 cigarettes daily were offered free nicotine replacement therapy. Baseline data were from an in-person interview. Outcome measures included self-reported smoking status; validation of quitting was by salivary cotinine assays.Results: Of 87 participants providing baseline data, 31% (27) did not join the RCT. Proportions quitting in the CG and IAM group were 11.5% and 13.6% at 6 months and 5.3% and 15.8% at 12 months, respectively.Conclusion: African Americans in underserved inner-city neighborhoods can be recruited into RCTs with community participatory approaches. Differences between the CG and IAM in proportions who quit were 2.1% and 10.5% at 6 and 12 months, respectively. More than 3 years with adequate funding, high staffing ratios, and intense outreach and follow-up schedules are needed to achieve recruitment and study goals.

Viridans streptococcal (Streptococcus intermedius) mitral valve subacute bacterial endocarditis (SBE) in a patient with mitral valve prolapse after a dental procedure: The importance of antibiotic prophylaxis

Burke A. Cunha, Alexis A. D'Elia, Neha Pawar, Paul Schoch — 2009-07-13

Background: Subacute bacterial endocarditis (SBE) is an infection of the heart involving damaged valves or endothelium. The most common organisms causing SBE are the viridans streptococci. Viridans streptococci differ in their propensity to cause SBE, which is related to the ability to adhere to damaged heart valves and endothelium, which is a function of extracellular matrix production. Streptococcus intermedius is a member of the S. anginosus group. S. intermedius is one of the many strains of viridans streptococci and a rare cause of SBE. SBE may result following a high-grade, sustained veridans streptococcal bacteremia in patients with predisposing cardiac lesions. Because viridans streptococci are relatively avirulent pathogens in normal hosts, they usually present as SBE. Some strains of viridans streptococci are inherently more virulent (eg, S. intermedius) and clinically resemble S. lugdunensis or S. aureus.Methods: We report a case of S. intermedius SBE in a patient with mitral valve prolapse (MVP). Throughout the patient's life, she received antibiotic prophylaxis for dental procedures and never developed SBE. Because of changes in endocarditis prophylaxis guidelines in 2007, recommending no prophylaxis for dental procedures in patients with MVP, she did not receive prophylaxis for a dental procedure 3 months before admission. The change in prophylaxis recommendations was based on the relatively low incidence of endocarditis with certain cardiac lesions. The recommendations were also based on concern for antibiotic resistance from widespread antibiotic use for antibiotic prophylaxis. There has been no appreciable increase in penicillin resistance, and antimicrobial resistance is not an important consideration among the viridans streptococci. The incidence of SBE is not high after dental procedures in patients with MVP, but if SBE occurs, it may result in serious consequence for the patient.Results: In this case, the patient developed S. intermedius, mitral valve SBE complicated by a cerebral vascular accident, and embolic occlusion of her leg. She was given optimal antibiotic treatment with ceftriaxone 2 g (intravenously) every 24 hours plus gentamicin 120 mg (intravenously) every 24 hours (synergy dose) but failed to respond to antimicrobial therapy. Although her S. intermedius bacteremia was rapidly cleared with antimicrobial therapy, sterilization of her vegetation was not accomplished, and during therapy, the size of her cardiac vegetation actually increased in size. Because of therapeutic failure despite optimal antibiotic therapy, the increasing size of her vegetation necessitated mitral valve replacement, which the patient underwent. Reasons for apparent/real antibiotic failure include inappropriate antimicrobial therapy, inadequately dosed antimicrobial therapy, antibiotic “tolerance,” or increased pathogen virulence. Her strain of S. intermedius was sensitive to all antibiotics and not due to a “tolerant strain”, i.e., her minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) were the same (<0.25 μg/mL).Conclusion: In this case, despite optimal antimicrobial therapy, and in the absence of resistance/tolerance, therapeutic failure was best explained on the basis of S. intermedius virulence. The take-home lesson for clinicians is that it is better to err on the side of antibiotic prophylaxis even in patients with low-risk cardiac lesions. Failure to administer antibiotic prophylaxis for dental procedures may result in SBE and have disastrous consequences for the patient, which, in this case, resulted in a cerebral vascular accident, embolic occlusion of the leg, and mitral valve replacement. In terms of virulence in patients with endocarditis, S. intermedius may resemble S. lugdenesis.

Fever of unknown origin (FUO): de Quervain's subacute thyroiditis with highly elevated ferritin levels mimicking temporal arteritis (TA)

Burke A. Cunha, Azfar Chak, Stephanie Strollo — 2009-09-04

Abstract: Fever of unknown origin (FUO) refers to prolonged fevers of ≥101°F and that persists for >3 weeks that remain undiagnosed after an intensive in-hospital/outpatient workup. The most common FUO categories of are infectious, neoplastic, rheumatic/inflammatory, and miscellaneous causes. Malignancies have supplanted infectious diseases as the most common cause of FUOs in the adult population. Rheumatic/inflammatory causes of FUO are relatively less common than previously because of the introduction over the years of sophisticated diagnostic tests for most rheumatic diseases. The rheumatic/inflammatory disorders that remain important causes of FUO today are those that cannot be readily diagnosed by readily available/noninvasive tests, for example, adult Still's disease and temporal arteritis (TA). In older patients with FUO, TA can be a difficult diagnosis when the characteristic findings (ie, scalp tenderness, jaw claudication) are not present. Patients with TA presenting as FUO often have only headaches that may be accompanied by bilateral jaw discomfort. Endocrine causes of FUOs are rare. The most common endocrine disorder rarely presenting as an FUO is de Quervain's subacute thyroiditis. As in TA, subacute thyroiditis may present with headache and pain at the angle of the jaw. Both TA and subacute thyroiditis may be accompanied by fatigue, weight loss, and night sweats. We present a case of 55-year-old woman who presented with an FUO with clinical and laboratory findings suggesting TA. However, the absence of thrombocytosis and a normal alkaline phosphatase argued against the diagnosis of TA. Also against the diagnosis of TA was weight loss without loss of appetite and a slightly increased pulse. After nonspecific laboratory test results suggested that TA was not the cause of her FUO, additional tests were ordered. Thyroid function test results suggested the possibility of de Quervain's subacute thyroiditis as the cause of her FUO. To the best of our knowledge, this is the first case of de Quervain's subacute thyroiditis presenting as an FUO with elevated ferritin levels.

Rapid clinical diagnosis in fatal swine influenza (H1N1) pneumonia in an adult with negative rapid influenza diagnostic tests (RIDTs): Diagnostic swine influenza triad

Burke A. Cunha, Uzma Syed, Nardeen Mickail, Stephanie Strollo — 2010-01-01

Background: The “herald wave” of the H1N1 pandemic spread from Mexico to the United States in spring 2009. Initially, the epicenter of H1N1 in the United States was in the New York area. Our hospital, like others, was inundated with large numbers of patients who presented at the Emergency Department (ED) with influenza-like illnesses (ILIs) for swine influenza testing and evaluation.Methods: The Winthrop-University Hospital ED used rapid influenza (QuickVue A/B) tests to screen for H1N1 infection. Patients who were rapid influenza A test-positive were also reverse transcription-polymerase chain reaction (RT-PCR) positive for H1N1. In our ED, 30% of patients with ILIs and possible H1N1 pneumonia had negative rapid influenza A screening tests. Because H1N1 RT-PCR testing was restricted, there was no laboratory test to confirm or rule out H1N1. Other rapid influenza diagnostic tests (RIDTs), e.g., the respiratory fluorescent antibody (FA) viral panel test, were used to identify H1N1 patients with negative RIDTs.Results: Unfortunately, there was not a good correlation between RIDT results and RT-PCR results. There was a critical need to develop a clinical syndromic approach for diagnosing hospitalized adults with probable H1N1 pneumonia with negative RIDTs. Early in the pandemic, the Winthrop-University Hospital Infectious Disease Division developed a diagnostic weighted point score system to diagnose H1N1 pneumonia clinically in RIDT-negative adults. The point score system worked well, but was time-consuming. As the “herald wave” of the pandemic progressed, our ED staff needed a rapid, simplified method to diagnose probable H1N1 pneumonia in hospitalized adults with negative RIDTs. A rapid and simplified diagnosis was based on the diagnostic weighted point score system, which we simplified into a triad of key, nonspecific laboratory indicators. In adults hospitalized with an ILI, a fever >102°F with severe myalgias, and a chest x-ray without focal segmental/lobar infiltrates, the presence of three indicators, i.e., otherwise unexplained relative lymphopenia, elevated serum transaminases, and an elevated creatinine phosphokinase, constituted the diagnostic swine influenza triad. The Infectious Disease Division's diagnostic swine flu triad was used effectively as the pandemic progressed, and was not only useful in correctly diagnosing probable H1N1 pneumonia in hospitalized adults with negative RIDTs, but was also in ruling out mimics of swine influenza, e.g., exacerbations of chronic bronchitis, asthma, or congestive heart failure, as well as bacterial community-acquired pneumonias (CAPs), e.g., legionnaire's disease.Conclusion: Clinicians can use the Winthrop-University Hospital Infectious Disease Division's Diagnostic swine influenza triad to make a rapid clinical diagnosis of probable H1N1 pneumonia in hospitalized adult patients with negative RIDTs.

The “damp shadow” sign: Another clinical indicator of miliary tuberculosis

René Agustín Flores-Franco, Luis Armando Ríos-Ortiz — 2009-08-10

To the Editor: In relation to a previous case report about a temperature pattern observed in a patient with miliary tuberculosis, we described an objective sign related to night sweats observed in another patient with the same disease.

Erratum

2010-01-01

In “Winthrop-University Hospital Infectious Disease Division's swine influenza (H1N1) pneumonia diagnostic weighted point score system for hospitalized adults with influenza-like illnesses (ILIs) and negative rapid influenza diagnostic tests (RIDTs)” (Cunha et al., Heart Lung 2009;38:534–538) the following table has corrected data:

Heart and Lung's 2009 Reviewer List

2010-01-01

The Editors express their gratitude to the following individuals who provided their scientific expertise and constructive advice in the review of manuscript for the Journal in 2009:

2010-01-01

Editorial Board

2010-01-01

Information for Readers

2010-01-01

Heart & Lung - The Journal of Critical Care

Information for Authors

Reviewer Application

Reader Communication

Transitions in care

Gender and racial differences in psychosocial factors of low-income patients with heart failure

Patient perception of symptoms and quality of life following ablation in patients with supraventricular tachycardia

Thrombocytopenia and outcome in critically ill patients with bloodstream infection

Skin temperature and core-peripheral temperature gradient as markers of hemodynamic status in critically ill patients: A review

Determinants of perceived health in older adults with hypertension

Combining community participatory research with a randomized clinical trial: The protecting the hood against tobacco (PHAT) smoking cessation study

Viridans streptococcal (Streptococcus intermedius) mitral valve subacute bacterial endocarditis (SBE) in a patient with mitral valve prolapse after a dental procedure: The importance of antibiotic prophylaxis

Fever of unknown origin (FUO): de Quervain's subacute thyroiditis with highly elevated ferritin levels mimicking temporal arteritis (TA)

Rapid clinical diagnosis in fatal swine influenza (H1N1) pneumonia in an adult with negative rapid influenza diagnostic tests (RIDTs): Diagnostic swine influenza triad

The “damp shadow” sign: Another clinical indicator of miliary tuberculosis

Erratum

Heart and Lung's 2009 Reviewer List

Table of Contents

Editorial Board

Information for Readers