Heart & Lung - The Journal of Critical Care - Articles in Press

Management of recurrent pleural effusions with a tunneled catheter - Corrected Proof

Elizabeth McConnell Baker, Sheila Melander — 2009-12-11

Recurrent pulmonary effusions are commonly seen in patients with end-stage diseases. Traditional treatment modalities have required several days of hospitalization or frequent invasive procedures. Drainage with a tunneled pulmonary catheter can provide symptom palliation and resolution of the effusion without activity restriction or hospitalization.

Acquired noncompaction associated with coronary heart disease and myopathy - Corrected Proof

Josef Finsterer, Claudia Stöllberger, Elisabeth Bonner — 2009-12-11

In a 77-year-old man with a history of arterial hypertension, coronary heart disease, dilative cardiomyopathy, mitral and tricuspid insufficiency, arteriovenous block III, implantation of a pacemaker, atrial fibrillation, and heart failure, left ventricular hypertrabeculation (LVHT) was detected on transthoracic echocardiography during hospitalization for worsening heart failure. Revision of previous echocardiography did not show LVHT in any of the previous investigations why LVHT was interpreted as acquired. The additional presentation with bilateral ptosis, madarosis (absent eyelashes), bilateral hypoacusis, sore neck muscles, absent tendon reflexes, weakness for foot extension, ataxic stance, and recurrently elevated creatine kinase with normal troponin-T suggested a metabolic myopathy. Autopsy after death resulting from intractable heart failure, 17 months later, confirmed severe coronary heart disease and LVHT in the apex. The case confirms that LVHT may be acquired in single cases with neuromuscular disease and may represent an adaptive mechanism of an impaired myocardium.

Risk factors for late extubation after coronary artery bypass grafting - Corrected Proof

2009-12-11

Objective: To evaluate the independent risk factors for late extubation after coronary artery bypass grafting (CABG).Methods: Preoperative, intraoperative, and postoperative characteristics of patients undergoing isolated CABG between June 2005 and June 2008 at the Tongji Hospital were retrospectively analyzed. Elapsed time between CABG and extubation of more than 8hours was defined as late extubation.Results: The incidence of late extubation after CABG was 69.23% (288/416). Through univariate and logistic regression analysis, the independent risk factors for late extubation after CABG were older age (odds ratio [OR]=4.804), duration of cardiopulmonary bypass (OR=2.426), perioperative use of intra-aortic balloon pump (OR=1.451), preoperative arterial oxygen partial pressure (OR=.204), and postoperative hemoglobin level (OR=.793).Conclusion: Older age, prolonged cardiopulmonary bypass time, perioperative intra-aortic balloon pump requirement, low preoperative arterial oxygen partial pressure, and low postoperative hemoglobin level were identified as the 5 independent risk factors for late extubation after CABG.

Severe encephalopathy after ingestion of star fruit juice in a patient with chronic renal failure admitted to the intensive care unit - Corrected Proof

2009-12-11

Star fruit (Averrhoa carambola) is a popular tropical fruit that is usually consumed as fresh fruit or fruit juice. Consumption of star fruit by patients with chronic renal failure can lead to neurologic symptoms. The present report describes the clinical course, management, and outcome of a patient with chronic renal failure admitted to an intensive care unit after ingestion of star fruit juice 2 days before hospital admission. A case of nausea, vomiting, intractable hiccups, and severe encephalopathy along with mental confusion, disorientation, agitation, and seizures in a 53-year-old woman is presented. The patient's ventilatory pattern worsened, with development of dyspnea and tachypnea, which resulted in her transfer to an intensive care unit. Although hemodialysis was performed and the septic shock was adequately treated, the patient died on the fifth day after hospital admission. The susceptibility of patients with chronic renal failure to star fruit and the severity of intoxication are poorly known by intensivists. This case demonstrates that star fruit consumption should be considered as a cause of rapid deterioration in the renal function of patients with underlying chronic renal failure, potentially resulting in a fatal outcome.

Impact of a disease-management program on symptom burden and health-related quality of life in patients with idiopathic pulmonary fibrosis and their care partners - Corrected Proof

2009-11-23

Background: Patients were recruited from the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, located within the University of Pittsburgh Medical Center. Idiopathic pulmonary fibrosis results in scarring of the lung and respiratory failure, and has a median survival of 3 to 5 years from the time of diagnosis. The purpose of this study was to determine whether patients with idiopathic pulmonary fibrosis and their care partners could be more optimally managed by a disease-management intervention entitled “Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management,” which nurses delivered using the format of a support group. We hypothesized that participation would improve perceptions of health-related quality of life (HRQoL) and decrease symptom burden.Methods: Subjects were 42 participants randomized to an experimental (10 patient/care partner dyads) or control (11 patient/care partner dyads) group. Experimental group participants attended the 6-week program, and controls received usual care. Before and after the program, all participants completed questionnaires designed to assess symptom burden and HRQoL. Patients and care partners in the intervention group were also interviewed in their home to elicit information on their experience after participating in the Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management.Results: After the intervention, experimental group patients rated their HRQoL less positively (P = .038) and tended to report more anxiety (P = .077) compared with controls. Care partners rated their stress at a lower level (P = .018) compared with controls. Course evaluations were uniformly positive. Post-study qualitative interviews with experimental group participants suggested benefits not exemplified by these scores. Patient participants felt less isolated, were able to put their disease into perspective, and valued participating in research and helping others.Conclusion: Further exploration of the impact of disease-management interventions in patients with advanced lung disease and their care partners is needed using both qualitative and quantitative methodology. Disease-management interventions have the potential to positively affect patients with advanced lung disease and their care partners.

The feasibility and utility of the aid to cardiac triage intervention to improve nurses' cardiac triage decisions - Corrected Proof

Cynthia Arslanian-Engoren, Bonnie Hagerty, Cathy L. Antonakos, Kim A. Eagle — 2009-11-23

Background: Despite the benefits of prompt treatment of myocardial infarction, gender disparities exist in emergency department (ED) nurses' cardiac triage decisions.Objective: To determine the feasibility and utility of the aid to cardiac triage (ACT) intervention designed to improve ED nurses' cardiac triage decisions for women with myocardial infarction.Methods: A prospective, exploratory design was used. To determine feasibility, we evaluated the 1-hour time allocated for the intervention and ED nurses' participation rates. Twenty-three participants completed a utility questionnaire at the completion of the 1-hour intervention, and 18 participants completed the questionnaire 3 months post-intervention.Results: The ACT intervention was delivered within 30 to 40minutes, allowing 20minutes for questions and discussion. ED nurses viewed the ACT intervention as a useful, helpful, and practical tool for improving their cardiac triage decisions at both intervention completion and 3 months later.Conclusion: The evaluation supports the feasibility and utility of the ACT intervention.

Testing the psychometric properties of the Chinese version of the Heart Failure Learning Needs Inventory - Corrected Proof

Mingming Yu, Sek Ying Chair, Carmen W.H. Chan, Meili Liu — 2009-11-23

Objective: To translate the Heart Failure Learning Needs Inventory into Chinese and to evaluate its psychometric properties in the Chinese population with heart failure (HF).Methods: The study used a cross-sectional design. Instrument performance was measured on a convenience sample of 247 patients with HF recruited from the cardiac departments of 3 university-affiliated hospitals and repeated on 34 patients to examine the test–retest reliability.Results: One item of advanced directives was deleted from the Chinese version of the instrument because of its poor culture relevance. The Chinese version demonstrated acceptable internal consistency with a Cronbach's α of .96 for the total scale and .77 to .89 for the subscales. The item-to-total correlation ranging from .54 to .85 provided further evidence of the instrument's internal consistency. The content validity index was .86, indicating satisfactory content validity. The test–retest reliability was satisfactory with an intraclass correlation coefficient of .96 for the total scale and .61 to .91 for the subscales. There were no significant differences in the total scale and subscale scores over 10 days (P > .05). This finding further supported the stability of the instrument. Moreover, principle component analysis revealed 9 factors, explaining 60.89% of the variance. Means of the subscales were relatively lower than that of the western countries. Furthermore, the means of 2 subscales, general HF information and lifestyle modification, were different among patients with New York Heart Association classifications I and IV.Conclusion: The Chinese version of the Heart Failure Learning Needs Inventory is a reliable and valid instrument to measure the learning needs of patients with HF in Mainland China.

Peak body temperature predicts mortality in critically ill patients without cerebral damage - Corrected Proof

2009-10-19

Objectives: We investigated whether mortality in intensive care unit (ICU) patients without cerebral damage is associated with fever manifestation and characteristics.Methods: Patients admitted to a medical-surgical ICU between October 2005 and July 2006 were prospectively studied. Exclusion criteria were acute brain injury, intracerebral/subarachnoid hemorrhage, ischemic stroke, and brain surgery. An ear-based or axillary thermometer was used to measure body temperature. The association between fever (ear-based temperature, >38.3°C), fever characteristics, and ICU mortality was evaluated using univariate and multivariate analysis.Results: Two hundred and thirty-nine patients were enrolled. Fever was not associated with ICU mortality after adjustment for confounding patient factors. A significant dose-response increase of ICU mortality according to 1°C increments of peak body temperature was demonstrated, whereas peak body temperature was an independent predictor of ICU mortality.Conclusion: These findings imply that, although fever is not generally associated with mortality in patients without cerebral damage, it can be harmful and should be suppressed when it becomes very high. Rigorous clinical trials are needed to help establish antipyretic therapy guidelines.

Qualitative examination of compliance in heart failure patients in The Netherlands - Corrected Proof

2009-10-19

Background: Noncompliance with pharmacological and nonpharmacological recommendations is a problem in many heart failure (HF) patients, leading to worse symptoms and readmission. Although knowledge is available regarding factors related to compliance with HF regimens, little is known about patients' perspectives. We investigated patients' reasons and motivations for compliance with HF regimens from their perspective, and we studied how patients manage these recommendations in daily life. The health belief model was used as a framework for this study.Methods: A qualitative descriptive study was used, and 15 HF patients were interviewed about reasons for compliance, barriers to compliance, interventions that helped them comply with medications, sodium restriction, fluid restriction, and daily weighing.Results: The most commonly reported reasons for compliance included fear of hospitalization and HF symptoms. Barriers to compliance were mainly related to the negative aspects of a regimen, e.g., taste of the food and thirst. Most patients tried to make their lifestyle changes part of the daily routine. Several problems and misunderstandings with the regimen were evident. Patients themselves offered many tips that helped them comply with the regimen.Conclusions: To improve compliance in HF patients, patient-tailored interventions must be targeted at specific problems and patients' beliefs regarding the regimen, and aim at implementing the regimen into daily life. Healthcare providers need to emphasize the benefits of compliance, motivate patients to comply, and focus on individual barriers to compliance, knowledge deficits, and misunderstandings regarding the regimen. More specific advice about medications and diet is needed. Group interventions, including tips patients themselves provide, might also be useful in helping patients implement the HF regimen in their daily lives.

Coronary Artery Disease in Patients With Peripheral Artery Disease - Corrected Proof

2009-10-16

Objectives: Peripheral artery disease (PAD) is an atherosclerotic disease associated with cardiovascular risk factors, and with high cardiovascular morbidity and mortality. This study sought to assess the prevalence of angiographic coronary artery disease (CAD), and to determine the predictive value of traditional cardiovascular risk factors on the presence of CAD in patients with PAD of the lower extremities.Methods: In total, 231 patients who presented at hospital complaining of intermittent claudication were included. All patients underwent simultaneous peripheral and cardiac angiography. Age, gender, hypertension, diabetes, smoking, and lipid values were recorded.Results: The coronary angiograms of 64 (28%) patients were within normal limits, and 167 (72%) patients manifested CAD. Logistic regression analysis revealed that hypertension and diabetes were independent predictors for the presence of CAD or PAD.Conclusion: Aggressive treatment of cardiovascular risk factors, especially hypertension and diabetes, in PAD is critically important in reducing mortality and morbidity.

Successful treatment of saphenous venous graft thrombus by tirofiban infusion - Corrected Proof

2009-10-16

A 60-year old man with a history of coronary-artery bypass grafting presented with symptoms of acute coronary syndrome. Coronary angiography revealed a huge intraluminal thrombus in the saphenous vein graft to the second obtuse marginal branch of the left circumflex artery. A glycoprotein IIb/IIIa inhibitor (tirofiban) was administered intravenously. Two days later, thrombus dissolution and Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow were evident on repeat coronary angiography. Glycoprotein IIb/IIIa inhibitors may be useful in a thrombus-laden saphenous-vein graft.

Fever of unknown origin (FUO) due to a solitary cavitary lung lesion: The deadly ferritin-laced doughnut - Corrected Proof

Burke A. Cunha, Francisco M. Pherez, Douglas S. Katz — 2009-10-16

Fever of unknown origin (FUO) is the clinical designation for patients who have fevers >101F that have persisted for >3 weeks that remain undiagnosed, after an intensive ambulatory/in-hospital workup. Fevers of unknown origin may be due to wide variety of infectious, neoplastic, or rheumatic/inflammatory disorders. The most common causes of FUOs in elderly patients are infectious and neoplastic diseases. With FUOs, the clinical presentation and routine laboratory tests are usually sufficient to narrow differential diagnostic possibilities. We present a case of an elderly Italian woman who presented with an FUO and a solitary, thick-walled cavitary lesion on chest x-ray (CXR). The infectious disease differential diagnosis of her FUO included lung abscess, M. tuberculosis (TB), systemic mycoses, and echinococcal-cyst (or hydatid-cyst) disease. The malignancy and neoplastic differential diagnosis included bronchogenic carcinoma, lymphoma, and metastatic carcinoma. Her nonspecific laboratory tests indicated a highly elevated erythrocyte sedimentation rate (ESR) >100 mm/hour, chronic thrombocytosis, relative lymphopenia, and highly elevated serum ferritin levels. Excluding highly elevated serum ferritin levels, the differential diagnosis of her FUO with a solitary, thick-walled cavitary lesion was lung abscess vs. tuberculosis. However, her highly elevated serum ferritin levels proved to be the critical diagnostic clue in predicting the diagnosis of squamous-cell carcinoma. We conclude that serum ferritin levels are an important part of the laboratory workup. As with other nonspecific laboratory tests, the diagnostic significance of highly elevated ferritin levels depends associated clinical features in the clinical presentation.

Qualitative study of pain of patients with chronic obstructive pulmonary disease - Corrected Proof

2009-10-16

Objective: This study evaluated the pain experiences of patients with chronic obstructive pulmonary disease (COPD).Sample: We studied 16 patients with severe COPD.Design: A semistructured interview was performed to obtain information on patients' experiences with pain and the impact of pain on quality of life (QOL). Data were analyzed using the methodology of Kvale.Results: Three main themes emerged: incomprehensible and unbearable pain; locked in my body and shut out from the world; and the vicious COPD circle. Patients reported moderate to severe pain located primarily in the shoulders, neck, upper arms, and chest. Patients reported a number of severe symptoms occurring simultaneously, and negatively affecting each other. Vicious circles of pain, breathlessness, sleep disturbance, and anxiety were described as exerting negative effects on patients' QOL.Conclusion: Unrelieved pain appears to be a significant problem in patients with COPD. Research is warranted to determine if pain is clustered with other symptoms, and how these symptoms affect the clinical management of COPD.

Clinical characteristics, ballooning pattern, and long-term prognosis of transient left ventricular ballooning syndrome - Corrected Proof

2009-10-05

Objective: Although patients with transient left ventricular ballooning syndrome (TLVBS), also known as Takotsubo cardiomyopathy, improve rapidly and recover left ventricular systolic function, the long-term prognosis is not well-known. This study investigated the clinical features of TLVBS, and its in-hospital and long-term (in-hospital plus postdischarge) mortality.Methods and Results: We evaluated 87 patients diagnosed with TLVBS. The median follow-up was 42 months (interquartile range, 19 to 72 months). During follow-up, no recurrences were reported, but 20 (23%) patients died. Two nonsurvivors (2%) were suspected of dying from sudden cardiac death. The in-hospital total mortality rate was 9%, but the in-hospital cardiac mortality rate was 0%. Most deaths were associated with underlying noncardiac diseases. Baseline characteristics were mostly similar between survivors and nonsurvivors. However, nonsurvivors were older, and more likely to be smokers compared with survivors. Underlying noncardiac diseases were the only independent predictors of long-term mortality (hazard ratio, 3.954; 95% confidence interval, 1.369 to 11.422; P=.011). There were no significant differences in long-term mortality, according to the preceding stress events or ballooning patterns.Conclusions: Although a substantial number of patients with TLVBS die, the long-term cardiac mortality is low. The severity of heart failure owing to TLVBS may influence in-hospital mortality, whereas underlying noncardiac diseases have a more significant correlation with the long-term prognosis than does TLVBS itself.

Acute transient phlebitis during eptifibatide intravenous injection: Case report - Corrected Proof

Emile Hay, Yossef Blaer, Vladimir Shlyakhover, Amos Katz, Jamal Jafari — 2009-10-05

We present a 56-year-old man who developed acute transient phlebitis of the right cephalic vein during an intravenous injection of eptifibatide (Integrilin, Schering Plough, Kenilworth, NJ). The eptifibatide injections were discontinued, and signs of phlebitis disappeared within minutes. The patient's course was uneventful, and he was discharged home after 8 days. As far as we know, this is the first report of acute transient phlebitis during intravenous eptifibatide injections in the English-language medical literature.

Caregiving for patients requiring left ventricular assistance device support - Corrected Proof

Kathy Baker, Maureen Flattery, Jeanne Salyer, Kathryn H. Haugh, Megan Maltby — 2009-10-05

Background: The responsibility of caregiving for patients requiring left ventricular assistance device (LVAD) support may be significant. However, little is known about their experience. Data from the Interagency Registry for Mechanically Assisted Circulatory Support (2006-2009) reported that 1722 patients had received LVADs as a bridge to transplantation, recovery, or destination therapy. The use of this advanced technology in the management of endstage heart failure is expected to continue, suggesting increased involvement of family members and significant others. The purpose of this qualitative study was to describe the experiences of caregivers of patients who received LVAD therapy as a bridge to transplantation.Methods: Semistructured interviews allowed participants to describe their experiences as caregivers. Interviews were audiotape-recorded and transcribed verbatim. An analysis was conducted using Sandelowski's three-step process for the analysis of phenomenological data: data dwelling, open coding, and data reduction.Results: Participants (n=5 women and 1 man; age, 51 years; range=44 to 66 years; duration of caregiving, 183.9 days; range, 26 to 372 days; relationship to patient: spouse=3, parent=1, significant other=1, and friend=1) were designated caregivers of patients discharged home with an LVAD. Two themes emerged: sacrifice and moving beyond. Caregivers sacrificed relationships with friends and family, jobs and livelihood, health, and peace of mind in their roles as caregivers. “Moving beyond” reflected coping and adaptation to the sacrifices of being a caregiver.Conclusions: Experiences described by caregivers suggest that they successfully incorporated the role of caregiver for patients with a complex therapeutic regimen into their daily lives. The specific findings should guide healthcare professionals in their efforts to support caregivers.

Delectable deductive diagnosis: Lean children of fat parents - Corrected Proof

George Nikolić — 2009-10-05

The patient was a 75-year-old woman with chronic ischemic/hypertensive heart disease, and a permanent pacemaker had been inserted 2 years previously for a “bifascicular block.” The 12-lead electrocardiogram (ECG) shown in was performed in the emergency room (ER) after a transient ischemic attack (TIA). The patient was asymptomatic by then.

Septic shock caused by Plesiomonas shigelloides in a patient with sickle beta-zero thalassemia - Corrected Proof

2009-09-14

Abstract: Invasive infection and extraintestinal complications are rarely caused by Plesiomonas shigelloides, a waterborne bacterium belonging to the Vibrionaceae family. We report a case of a 16-year-old female patient with sickle beta-zero thalassemia who survived septic shock caused by P. shigelloides associated with secondary acute respiratory distress syndrome and disseminated intravascular coagulation. Treatment with a carbapenem was successful, and the patient recovered without any sequelae. The previous reports of P. shigelloides sepsis are cited, and possible pathogenic mechanisms are discussed.

Anemia and blood transfusion practices in the critically ill: A prospective cohort review - Corrected Proof

Jissy Thomas, Louise Jensen, Susan Nahirniak, R.T. Noel Gibney — 2009-09-14

Background: Nearly 75% of critically ill patients develop anemia in the intensive care unit (ICU). Anemia can be treated with red blood cell (RBC) transfusions, although evidence suggests that lower hemoglobin levels are tolerated in the critically ill. Despite such recommendations, variation exists in clinical practice.Methods: A prospective cohort was assessed for anemia and RBC transfusion practices in 100 consecutive adults admitted to our General Systems ICU.Results: The prevalence of anemia in this cohort was 98%. Mean blood loss via phlebotomy was 25±10.3 mL per patient per day. The RBC transfusion rate for the ICU stay was 40%, increasing to 70% in patients whose ICU stay was >7 days. The mean pretransfusion level of hemoglobin was 7.35±0.47 mg/dL for the total cohort, and 8.2±0.65 mg/dL for those with a history of cardiovascular disease.Conclusion: Anemia was common in this critically ill cohort, with hemoglobin levels continuing to drop with ICU stay. Pretransfusion hemoglobin levels were lower than reported by others, yet the RBC transfusion rate was comparable. There was no association between anemia and phlebotomy practices in our ICU.

Persistent methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia due to a linezolid “tolerant” strain unresponsive to daptomycin - Corrected Proof

Burke A. Cunha, Sara Nausheen, Paul Schoch — 2009-09-04

Abstract: Antibiotic “tolerance” is a rare cause of antibiotic failure. Antibiotic “tolerance” is defined as an minimal bactericidal concentration (MBC) 32× the minimal inhibitory concentration (MIC) of the isolate. Although susceptibility testing based on the MIC suggests susceptibility of “tolerant” strains, bactericidal concentrations are often beyond achievable serum levels and therapeutic failure may result. We present a case of persistent methicillin-sensitive S. aureus (MSSA) bacteremia due to a linezolid tolerant strain unresponsive to daptomycin therapy. We believe this is the first report of persistent MSSA bacteremia due to a linezolid “tolerant” strain.

Adult Kawasaki's disease with myocarditis, splenomegaly, and highly elevated serum ferritin levels - Corrected Proof

2009-09-04

Abstract: Kawasaki's disease is a disease of unknown cause. The characteristic clinical features of Kawasaki's disease are fever≥102°F for≥5 days accompanied by a bilateral bulbar conjunctivitis/conjunctival suffusion, erythematous rash, cervical adenopathy, pharyngeal erythema, and swelling of the dorsum of the hands/feet. Kawasaki's disease primarily affects children and is rare in adults. In children, Kawasaki's disease is more likely to be associated with aseptic meningitis, coronary artery aneurysms, and thrombocytosis. In adult Kawasaki's disease, unilateral cervical adenopathy, arthritis, conjunctival suffusion/conjunctivitis, and elevated serum transaminases (serum glutamic oxaloacetic transaminase [SGOT]/serum glutamate pyruvate transaminase [SGPT]) are more likely. Kawasaki's disease in adults may be mimicked by other acute infections with fever and rash, that is, group A streptococcal scarlet fever, toxic shock syndrome (TSS), and Rocky Mountain Spotted Fever (RMSF). Because there are no specific tests for Kawasaki's disease, diagnosis is based on criteria and the clinical syndromic approach. In addition to rash and fever, scarlet fever is characterized by circumoral pallor, oropharyngeal edema, Pastia's lines, and peripheral eosinophilia, but not conjunctival suffusion, splenomegaly, swelling of the dorsum of the hands/feet, thrombocytosis, or an elevated SGOT/SGPT. In TSS, in addition to rash and fever, there is conjunctival suffusion, oropharyngeal erythema, and edema of the dorsum of the hands/feet, an elevated SGOT/SGPT, and thrombocytopenia. Patients with TSS do not have cervical adenopathy or splenomegaly. RMSF presents with fever and a maculopapular rash that becomes petechial, first appearing on the wrists/ankles after 3 to 5 days. RMSF is accompanied by a prominent headache, periorbital edema, conjunctival suffusion, splenomegaly, thrombocytopenia, an elevated SGOT/SGPT, swelling of the dorsum of the hands/feet, but not oropharyngeal erythema.We present a case of adult Kawasaki's disease with myocarditis and splenomegaly. The patient's myocarditis rapidly resolved, and he did not develop coronary artery aneurysms. In addition to splenomegaly, this case of adult Kawasaki's disease is remarkable because the patient had highly elevated serum ferritin levels of 944-1303 ng/mL; (normal<189 ng/mL). To the best of our knowledge, this is the first report of adult Kawasaki's disease with highly elevated serum ferritin levels. This is also the first report of splenomegaly in adult Kawasaki's disease. We conclude that Kawasaki's disease should be considered in the differential diagnosis in adult patients with rash/fever for≥5 days with conjunctival suffusion, cervical adenopathy, swelling of the dorsum of the hands/feet, thrombocytosis and otherwise unexplained highly elevated ferritin levels.

Differences in social support and illness perceptions among South Asian and Caucasian patients with coronary artery disease - Corrected Proof

Keerat Grewal, Donna E. Stewart, Sherry L. Grace — 2009-09-04

Objective: Social support and illness perceptions may affect recovery from a cardiac event or procedure. Previous research has found that patients of South Asian origin with coronary artery disease (CAD) have lower levels of social support and may perceive different causes of their condition. The purpose of this study was to quantitatively investigate differences in social support and illness perceptions between Caucasian and South Asian patients with CAD.Methods: A total of 562 inpatients with CAD (53 [9%] South Asian) were recruited from 2 hospitals. The Medical Outcomes Study social support scale and Illness Perception Questionnaire were administered to examine ethnocultural differences in total social support and subscales, and in illness perceptions subscales, including causes of illness.Results: South Asian participants had significantly lower levels of tangible (P=.001) and emotional/informational support (P < .001) compared with Caucasian participants. South Asians were less likely than Caucasians to believe they have personal control over their illness (P < .001). Trends were observed, with South Asian participants being more likely to attribute their condition to stress/worry (P=.04) and poor medical care in the past (P=.02) and less likely to attribute their illness to aging (P=.03) compared with Caucasian participants.Conclusion: Lower levels of social support among South Asians in Canada may have negative effects on recovery and prognosis. Our results support qualitative findings suggesting South Asians perceive their illness to be a result of fate or related to stress. Future studies should investigate interventions targeted at modifying illness perceptions among this group in an attempt to improve risk-reducing behavior and secondary prevention use.

Using a webcast support service: Experiences of in-person attendees of an implantable cardioverter defibrillator support group - Corrected Proof

Eva R. Serber, Nancy J. Finch, Lawrence B. Afrin, W. James Greenland — 2009-08-26

Objective: Most patients with implantable cardioverter defibrillators (ICDs) adjust well to living with the device; however, some experience difficulties. Support groups assist in coping with the psychologic effects of living with an ICD. The study's aim was to examine acceptability of the in-person attendees of an ICD support group that was cast on the Internet.Sample: A patient satisfaction survey describing the participants' experience was used as a measure of acceptability in this non-experimental, survey, pilot study.Methods: The survey assessed reactions of the in-person participants with ICDs (N=46) to the introduction of webcasting and remote participation by other individuals with ICDs. Descriptive statistics were conducted.Results: Participating in a webcasted support group was viewed as highly favorable, and responses indicated high satisfaction.Conclusion: Participants were satisfied with the webcast technology, enabling broader access to patients. Research is needed to assess the acceptability and satisfaction among remote participants and the group's effectiveness on clinical outcomes.

Severe myocardial ischemia after concentrated epinephrine use for the treatment of anaphylaxis: Kounis syndrome or epinephrine effect? - Corrected Proof

Cemil Izgi, Cihan Cevik, Kenneth Nugent — 2009-08-26

Epinephrine is the cornerstone of treatment for anaphylaxis, which is a life-threatening condition that requires rapid management. However, epinephrine administration can have complications. We report a patient in whom accidental concentrated epinephrine use for management of anaphylaxis caused severe myocardial ischemia.

Outcome of patients with cystic fibrosis admitted to the intensive care unit: Is invasive mechanical ventilation a risk factor for death in patients waiting lung transplantation? - Corrected Proof

2009-08-26

Objective: The admission of patients with cystic fibrosis (CF) to the intensive care unit (ICU) is controversial. Our aim was to study the long-term outcome of patients with CF who were admitted to the ICU and the effect of ventilation modality.Methods: The medical records of 104 admissions (1996-2006) of 48 patients with CF (age 18±9 years) were reviewed. Seventeen patients were admitted with reversible conditions (group 1). Thirty-one patients were admitted for acute on chronic respiratory failure (group 2).Results: In group 1, 16 of 17 patients survived up to 10 years from ICU admission. Conversely, in group 2, 23 of 31 patients (74%) died of respiratory failure. In group 2, 17 of 18 patients who were mechanically ventilated died within 90 days from admission, and 7 of 10 patients treated for prolonged periods with bi-level positive airway pressure are still alive up to 10 years after admission and transplantation.Conclusion: Patients requiring mechanical ventilation may have a poor prognosis. The outcome of treatment with bi-level positive airway pressure is good, even in patients who had many episodes of acute respiratory failure.

Clinical presentation and treatment of atrial fibrillation in Wolff-Parkinson-White syndrome - Corrected Proof

Joanne L. Thanavaro, Samer Thanavaro — 2009-08-26

Abstract: A case of Wolff-Parkinson-White syndrome with atrial fibrillation (AF) is reported in a patient who presented with syncope, tachycardia, and hypotension. The electrocardiogram (ECG) showed a fast irregular rhythm with wide polymorphic QRS tachycardia without the QRS twisting around the isoelectric baseline, diagnostic of AF and Wolff-Parkinson-White syndrome. The patient did not respond to intravenous amiodarone. Elective cardioversion restored sinus rhythm, and the ECG showed a wide QRS complex, short PR interval, and delta wave, indicating the presence of an accessory pathway and pre-excitation. AF was easily induced during the electrophysiologic study, requiring electrical cardioversion for severe hypotension. Successful radiofrequency ablation of the accessory pathway completely prevented further inducible AF. The patient no longer had any evidence of pre-excitation on ECG and remained symptom-free with no medications for 11 months.

Living with heart disease after angioplasty: A qualitative study of patients who have been successful or unsuccessful in multiple behavior change - Corrected Proof

2009-08-26

Objective: To document values, attitudes, and beliefs that influence behavior change among a diverse group of patients post-angioplasty.Methods: Purposive and maximum-variation sampling were used to assemble a demographically diverse patient cohort (N=61) who had been successful or unsuccessful at post-angioplasty multibehavior change. Semistructured interviews and grounded theory methods were used to collect and analyze qualitative data.Results: Themes showed the following: a) Patients reported surviving a life-threatening event and feared disease recurrence and death; b) the perception of a turning point and self-determination facilitated behavior change; c) social support and spiritual beliefs promoted coping with the uncertainty of living with heart disease; and d) unsuccessful behavior change was related to physical limitations, a sense that “nothing helps,” and the belief that angioplasty “cures” heart disease.Conclusion: Lifestyle interventions should be culturally relevant and adapted to physical abilities. Fostering self-determination and social support may promote successful behavior change.

Acute Streptococcus agalactiae endocarditis: Outcomes of early surgical treatment - Corrected Proof

2009-08-26

Abstract: The incidence of Streptococcus agalactiae is widely recognized as increasing in nonpregnant adults. This report describes a retrospective case series of S. agalactiae endocarditis at the Heart Institute of Sao Paulo, Brazil, between 2000 and 2006. Early diagnosis and valve surgery seem to have contributed to improved patient outcomes.

Oxygenation equilibration time after alteration of inspired oxygen in critically ill patients - Corrected Proof

2009-08-17

Abstract: To determine the time required for arterial oxygen partial pressure (Pao2) equilibration after a change in fractional inspired oxygen (Fio2) in intensive care unit (ICU) patients, a prospective study in a 7-bed university ICU was performed. Forty adult patients were examined using sequential arterial blood gas measurements after a .3 alteration in Fio2. The Pao2 value measured at 30minutes after a step change in Fio2 in both periods was accepted as representative of the equilibrium value for Pao2. The mean equilibration time was 8.26±5.6minutes and 4.5±2.65minutes for increases and decreases in Pao2, respectively (P=.003). The constant k values were .44 ± .31minutes and .72 ± .7minutes for increases and decreases in Pao2, respectively. There was no significant difference between the increase and the decrease of 90% oxygenation times in the 2 groups (P=.150 and P=.446, respectively). The study confirms that a period of less than 10minutes is adequate for 90% of the equilibration of Pao2 to occur after an Fio2 change in ICU patients.

An evaluation of family-centered care services and organization of visiting policies in Belgian intensive care units: A multicenter survey - Corrected Proof

2009-07-23

Background: Admission in an intensive care unit (ICU) is a major cause of psychologic stress for the patient and the entire family, and liberalization of visitation has been shown to have a beneficial impact. However, despite the data available, practice has not changed much to incorporate these findings.Objective: This study aimed to evaluate the visiting policies of Belgian ICUs.Methods: A descriptive multicenter questionnaire survey was prospectively conducted.Results: Fifty-seven ICUs completed the questionnaire (75.0%). All (100%) reported restricted visiting-hour policies, and limited numbers of visitors. Mean total daily visiting time was 69±33minutes. The type of visitors was restricted to only immediate relatives in 11 ICUs (19.3%). Children were not allowed in 5 ICUs (8.8%), and 46 ICUs (80.7%) fixed an age limit for visiting. Thirty ICUs (52.6%) were providing families with information in a special room in addition to the waiting room, whereas 6 (10.5%) reported having no waiting room available, and 9 ICUs (15.8%) provided an information leaflet. A structured first family meeting at time of admission was organized in 42 ICUs (73.7%). A final family meeting at ICU discharge was planned in only 16 centers (28.1%).Conclusion: Participating ICUs homogeneously reported restricted visiting policies regarding visiting hours and type and number of visitors. According to the evidence available, providing a plea for more liberal visitation, these results may be a first step toward reorganization of visiting policies in Belgian ICUs.