Guillain-Barré syndrome: rehabilitation outcome and recent developments.

Guillain-Barré syndrome is the most common polyneuropathy causing major disability and respiratory failure. Respiratory complications are the main cause of death. Improved respiratory care and new treatment strategies such as plasmaphoresis and immunoglobulin have been shown to improve outcome. We studied the course and outcome of 37 patients with Guillain-Barré syndrome who were admitted to a rehabilitation and respiratory care facility over a 10-year period. There were 21 males and 16 females with a mean age of 62+/-3 years. Fourteen patients developed respiratory failure requiring endotracheal intubation and mechanical ventilation. The mean duration of mechanical ventilation was 38+/-10 days. All patients were successfully liberated from the ventilator. However, 83 percent of the patients were moderately to severely disabled at the time of discharge. Thirteen out of 37 (35 percent) developed long-term disability. None of the patients died over the period of follow-up. These results indicate that early recognition and treatment of respiratory complications in Guillain-Barré syndrome could reduce the morbidity and mortality of this condition.     

Respiratory function of people with amyotrophic lateral sclerosis and caregiver distress level: a correlational study

ABSTRACT: BACKGROUND: Amyotrophic Lateral Sclerosis (ALS) is a rare, fatal neurodegenerative disorder with no curative treatment characterized by degeneration of motor neurons involving a progressive impairment of motor and respiratory functions. Most patients die of ventilator respiratory failure. Caregivers have a great influence on the patient"s quality of life as well as on the quality of care. Home influence of the caregiver on patient care is notable. To date, no study has investigated how psychological issues of caregivers would influence respiratory variables of ALS patients. The study aimed at finding out if there is a relationship between the respiratory function of ALS patients and the level of distress of their caregivers. METHODS: A cross-sectional study was conducted to investigate respiratory issues (PCF and FVC) and the perception of social support of ALS patients. Caregivers filled questionnaires about trait anxiety, depression, and burden of care. Forty ALS patients and their caregivers were recruited. RESULTS: FVC and PCF were positively related to patient perception of social support and negatively related to caregiver anxiety, depression, and burden. DISCUSSION: The distress of ALS caregivers is related to patient respiratory issues. The first and more intuitive explanation emphasizes the impact that the patient's clinical condition has with respect to the caregiver. However, it is possible to hypothesize that if caregivers feel psychologically better, their patient's quality of life improves and that a condition of greater well-being and relaxation could also increase ventilatory capacity. Furthermore, care management could be carried out more easily by caregivers who pay more attention to the patient's respiratory needs. CONCLUSION: Patient perception of social support and caregiver distress are related to respiratory issues in ALS.     

Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS): multicentre observational cohort study

Objective To determine whether clinicians'' prognoses in patients with severe acute exacerbations of obstructive lung disease admitted to intensive care match observed outcomes in terms of survival.Design Prospective cohort study.Setting 92 intensive care units and three respiratory high dependency units in the United Kingdom.Participants 832 patients aged 45 years and older with breathlessness, respiratory failure, or change in mental status because of an exacerbation of COPD, asthma, or a combination of the two.Main outcome measures Outcome predicted by clinicians. Observed survival at 180 days. Results 517 patients (62%) survived to 180 days. Clinicians'' prognoses were pessimistic, with a mean predicted survival of 49% at 180 days. For the fifth of patients with the poorest prognosis according to the clinician, the predicted survival rate was 10% and the actual rate was 40%. Information from a database covering 74% of intensive care units in the UK suggested no material difference between units that participated and those that did not. Patients recruited were similar to those not recruited in the same units.Conclusions Because decisions on whether to admit patients with COPD or asthma to intensive care for intubation depend on clinicians'' prognoses, some patients who might otherwise survive are probably being denied admission because of unwarranted prognostic pessimism.     

Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports.

OBJECTIVE--To examine the possible contribution of sedation with propofol in the deaths of children who were intubated and required intensive care. DESIGN--Case note review. SETTING--Three intensive care units. SUBJECTS--Five children with upper respiratory tract infections aged between 4 weeks and 6 years. RESULTS--Four patients had laryngotracheo-bronchitis and one had bronchiolitis. All were sedated with propofol. The clinical course in all five cases was remarkably similar: an increasing metabolic acidosis was associated with brady-arrhythmia and progressive myocardial failure, which did not respond to resuscitative measures. All children developed lipaemic serum after starting propofol. These features are not usually associated with respiratory tract infections. No evidence was found of viral myocarditis, which was considered as a possible cause of death. CONCLUSION--Although the exact cause of death in these children could not be defined, propofol may have been a contributing factor.     

Triage: a working solution to overcrowding in the emergency department

Recently, emergency departments across the continent have become crowded with patients requiring non-urgent care. To alleviate this situation at The Hospital for Sick Children in Toronto, receptionists in the emergency department direct patients requiring urgent care to the emergency room and those requiring non-urgent care to a screening clinic (triage). During a two-month period, 13,551 patients visited the emergency department. The triage receptionist sent 8368 patients to the emergency room and 5183 to the screening clinic. About 45% of patients visiting the emergency room had suffered accidents and injuries, and 19% had respiratory illness; 15% of patient visits resulted in admission to hospital. In contrast to this, 49% of patients sent to the screening clinic had respiratory illness and 18% had infective disease; less than 1% of patients needed hospitalization.     

Noninvasive positive-pressure ventilation in acute respiratory failure

Noninvasive positive-pressure ventilation is a type of mechanical ventilation that does not require an artificial airway. Studies published in the 1990s that evaluated the efficacy of this technique for the treatment of diseases as chronic obstructive pulmonary disease, congestive heart failure and acute respiratory failure have generalized its use in recent years. Important issues include the selection of the ventilation interface and the type of ventilator. Currently available interfaces include nasal, oronasal and facial masks, mouthpieces and helmets. Comparisons of the available interfaces have not shown one to be clearly superior. Both critical care ventilators and portable ventilators can be used for noninvasive positive-pressure ventilation; however, the choice of ventilator type depends on the patient''s condition and therapeutic requirements and on the expertise of the attending staff and the location of care. The best results (decreased need for intubation and decreased mortality) have been reported among patients with exacerbations of chronic obstructive pulmonary disease and cardiogenic pulmonary edema.Noninvasive positive-pressure ventilation is the delivery of mechanical ventilation to patients with respiratory failure without the requirement of an artificial airway. The key change that led to the recent increase in the use of this technique occurred in the early 1980s with the introduction of the nasal continuous positive airway pressure mask for the treatment of obstructive sleep apnea. Studies published in the 1990s that evaluated the efficacy of noninvasive positive-pressure ventilation for treatment of diseases such as chronic obstructive pulmonary disease, congestive heart failure and acute respiratory failure have generalized its use in recent years.¹ In 1998, an international study on the use of mechanical ventilation found that 5% of patients admitted to intensive care units received noninvasive positive-pressure ventilation.²Noninvasive positive-pressure ventilation includes various techniques for augmenting alveolar ventilation without an endotracheal airway. The clinical application of noninvasive ventilation by use of continuous positive airway pressure alone is referred to as “mask CPAP,” and noninvasive ventilation by use of intermittent positive-pressure ventilation with or without continuous positive airway pressure is called noninvasive positive-pressure ventilation.     

Gender Differences in patient-provider symptom agreement in reporting respiratory complaints on a questionnaire

Background: Men and women communicate differently, but it is unclear whether this influences health care outcomes.Objective: Because women patients frequently choose women health care providers, we examined whether this preference was affected by communication styles. We focused on communication of disease-specific symptoms, hypothesizing that symptom agreement between women patients and women health care providers would be greater than between other patient-provider gender combinations.Methods: Patients attending outpatient clinics were recruited as part of a study of respiratory illness at 7 university-affiliated sites during 3 consecutive influenza seasons (2000–2003). Individuals aged ≥ 19 years were offered enrollment if they sought care for cold or flu symptoms at a participating study site. Patients were eligible to participate in the study if they reported any 1 of 6 symptoms: cough, runny nose, fever (subjective), muscle aches, sore throat, and/or exhaustion. Using separate questionnaires, patients and their health care providers recorded the patients' respiratory symptoms (as present or absent). Patients recorded their symptoms before visiting their health care provider, and providers recorded patient symptoms after the visit. Symptom agreement was compared using general estimating equations across all gender combinations.Results: A total of 327 patients (220 women, 107 men) and 84 health care providers (37 women, 47 men) participated in the study. Overall symptom agreement for all patient-provider gender combinations was 81.9% (95% CI, 79.6%–84.2%). For each symptom, the observed agreement significantly exceeded the agreement expected by chance alone (P < 0.001 for all symptoms except “no energy,” which was P = 0.023). The male-male pairing of patient and provider was more likely to agree on a symptom than were the other gender combinations, although not statistically significantly more so than the female-female pairing.Conclusions: In this survey of patients with respiratory illness, there was no significant difference in symptom agreement for most symptoms between the male-male and female-female patient-provider combinations. Based on these findings, symptom agreement alone does not explain why women patients select women health care providers.     

Breath-by-breath analysis of cardiorespiratory interaction for quantifying developmental maturity in premature infants

In healthy neonates, connections between the heart and lungs through brain stem chemosensory pathways and the autonomic nervous system result in cardiorespiratory synchronization. This interdependence between cardiac and respiratory dynamics can be difficult to measure because of intermittent signal quality in intensive care settings and variability of heart and breathing rates. We employed a phase-based measure suggested by Sch?fer and coworkers (Sch?fer C, Rosenblum MG, Kurths J, Abel HH. Nature 392: 239-240, 1998) to obtain a breath-by-breath analysis of cardiorespiratory interaction. This measure of cardiorespiratory interaction does not distinguish between cardiac control of respiration associated with cardioventilatory coupling and respiratory influences on the heart rate associated with respiratory sinus arrhythmia. We calculated, in sliding 4-min windows, the probability density of heartbeats as a function of the concurrent phase of the respiratory cycle. Probability density functions whose Shannon entropy had a <0.1% chance of occurring from random numbers were classified as exhibiting interaction. In this way, we analyzed 18 infant-years of data from 1,202 patients in the Neonatal Intensive Care Unit at University of Virginia. We found evidence of interaction in 3.3 patient-years of data (18%). Cardiorespiratory interaction increased several-fold with postnatal development, but, surprisingly, the rate of increase was not affected by gestational age at birth. We find evidence for moderate correspondence between this measure of cardiorespiratory interaction and cardioventilatory coupling and no evidence for respiratory sinus arrhythmia, leading to the need for further investigation of the underlying mechanism. Such continuous measures of physiological interaction may serve to gauge developmental maturity in neonatal intensive care patients and prove useful in decisions about incipient illness and about hospital discharge.     

Trends in paediatric medical admissions.

In the Oxford region from 1975 to 1985 the rate of discharge from paediatric departments, when standardised for age, rose by 88%. This increase was studied by using routinely collected data. It occurred in all age groups and was due mainly to an increase in emergency admissions for acute common childhood illnesses, particularly respiratory and gastro-intestinal diseases. There was no evidence that increasing morbidity accounted for this rise; the change was due to factors in medical care. Over the 11 years the median length of stay fell from 2.4 to 1.5 days and by 1985 40% of children were discharged within a day after admission. The increase in admissions was due to lower thresholds for admission resulting in part from the increased availability of beds because of the diminishing lengths of stay.     

2014-2015 年乌鲁木齐市院前急救老年患者疾病谱分析

目的：了解乌鲁木齐市院前急救老年患者疾病谱变化,提高老年人救治效率。方法：回顾性收集2014 年1 月1 日-2015 年 12 月31 日乌鲁木齐市120院前急救调度指挥中心数据库中40823 例老年（≥ 60 岁）患者病例信息,并进行疾病谱分析。结果： 40823 例老年患者中男性22284 例,女性18539 例,平均年龄（75.25 8.49）岁;其中汉族35018 例,维吾尔族3608 例,回族1698 例,其他民族499 例。院前急救老年患者疾病谱以心脑血管疾病、呼吸系统疾病、损伤、消化系统疾病、神经系统疾病为主,且心脑 血管疾病接诊率最高。院前急救老年患者接诊高峰月份为每年3-5 月,9-10 月,12-1 月;呼叫高峰时段为每日8:00-12:00,其次为 每日12:00-16:00;高发区域集中在新市区与沙依巴克区。结论：随着院前急救老年患者接诊数量的增多,应加强院前医护人员的 相关培训。根据院前急救老年患者的高发地区、月份及时段,合理配置院前急救资源。     

Trends in the hospital care of acute childhood asthma 1970-8: a regional study.

In the South-west Thames Region over the period 1970-8 the number of admissions for asthma in children aged 5-14 years increased from 256 to 684, an increase of 167%. Factors associated with this trend were investigated by an analysis of routine hospital statistics and examination of case notes for 1970 and 1978 from every hospital in the region. The trend was caused partly by an increase in readmission rates. There was a more than fivefold increase in self-referrals; these patients had less severe asthma on admission and a higher readmission rate than patients referred by general practitioners. Drug management before and after admission changed considerably over the nine years, as did hospital investigations. Overall, there was little change in the level of severity on admission. The increase in admissions was not associated with a reduction in deaths from asthma in the region and occurred in spite of major advances in the drug control of asthma; this indicates an inadequacy of ambulatory care. The shift in the balance of care towards the hospital and the increasing adoption of a primary care function by the hospital indicate a need for hospitals and general practice to agree jointly on management policies for acute asthma.     

Observations and Comments Concerning the Isolation of Group B β-Hemolytic Streptococci from Human Sources

A marked increase in the isolation of Group B streptococci from patients in the University Hospital, Saskatoon, has been noted over the past four years, and no change in technical methods has been found to explain this increase. Group B streptococci have been isolated from 242 patients, in 53 of whom the streptococcus was considered the cause of the infection. Infections occurred predominantly in the urinary tract, female genital tract and upper respiratory tract. There was a low incidence of infections in newborn infants, and only four infections were in patients under 1 year old. Infections were more frequent in women than men and in patients over 40 years of age. No particular affinity of Group B streptococci for diabetics was demonstrated.     

ICU患者呼吸道感染病原菌的分布及耐药性监测

目的了解华中科技大学同济医学院附属同济医院ICU患者呼吸道感染病原菌的分布及细菌耐药性特征,指导临床合理、科学地使用抗菌药物,为有效控制危重患者肺部感染提供依据。方法回顾分析该院2004年1月至2008年12月ICU患者呼吸道感染的病原菌分布情况,并分析其耐药性变化。结果该院ICU患者呼吸道感染病原菌主要为鲍曼不动杆菌(aba)、铜绿假单胞菌(pae)和金葡菌(sau),其中泛耐药菌株有增多趋势。耐苯唑西林金葡菌(MRSA)的检出率在77.5%~100%。药敏数据显示,pae对常用抗菌药物耐药率均较高,在25.5%~95.3%;aba仅对头孢哌酮/舒巴坦耐药率低,为12.2%,但中敏率较高,为41.7%,对其他常用抗菌药物耐药率均较高。MRSA对所有的β-内酰胺类抗菌药物均耐药,苯唑西林敏感的金葡菌(MSSA)对青霉素和红霉素耐药率较高,分别为97.1%和47.2%,对其他常用抗菌药物较敏感。结论该院ICU患者呼吸道感染以aba、pae和sau为主,且耐药现象严重,对临床常用抗菌药物有多重耐药现象,临床医生应根据药敏结果合理使用抗菌药物。     

Current practice in transferring critically ill patients among hospitals in the west of Scotland.

OBJECTIVE--To identify the requirements of an interhospital transfer service for critically ill patients. DESIGN--Retrospective survey of the current functions of a specialist interhospital transfer team from data collected at the time of transfer and from records of intensive care unit. SETTING--Mobile intensive care unit based at a tertiary referral centre, which serves the west of Scotland. PATIENTS--All critically ill patients (378) transferred between hospitals by the unit from 1986 to 1988. RESULTS--365 Patients were transferred by road and 13 by air. There was a wide variation in age (range 6 weeks to 87 years), diagnosis, reason for transfer, support required, and distance travelled. Most patients (232) were transferred for respiratory or cardiovascular support; 100 were trauma cases. 300 Patients (79%) were mechanically ventilated during transfer. No patient died in transit, although the eventual mortality was 28% (105 patients). Mortality was significantly higher in patients transferred from hospitals with intensive care units than from those without (38% (125 patients) v 23% (253); p less than 0.005). IMPLICATIONS--Safe interhospital transfer of critically ill patients is feasible; the high eventual mortality in some patient groups emphasises the need for accurate prediction of outcome if inappropriate transfer is to be avoided. The findings may help in organising secondary transfer services in future.     

Environmental exposures to Florida red tides: Effects on emergency room respiratory diagnoses admissions

Human exposure to Florida red tides formed by Karenia brevis, occurs from eating contaminated shellfish and inhaling aerosolized brevetoxins. Recent studies have documented acute symptom changes and pulmonary function responses after inhalation of the toxic aerosols, particularly among asthmatics. These findings suggest that there are increases in medical care facility visits for respiratory complaints and for exacerbations of underlying respiratory diseases associated with the occurrence of Florida red tides.This study examined whether the presence of a Florida red tide affected the rates of admission with a respiratory diagnosis to a hospital emergency room in Sarasota, FL. The rate of respiratory diagnoses admissions were compared for a 3-month time period when there was an onshore red tide in 2001 (red tide period) and during the same 3-month period in 2002 when no red tide bloom occurred (non-red tide period). There was no significant increase in the total number of respiratory admissions between the two time periods. However, there was a 19% increase in the rate of pneumonia cases diagnosed during the red tide period compared with the non-red tide period. We categorized home residence zip codes as coastal (within 1.6 km from the shore) or inland (>1.6 km from shore). Compared with the non-red tide period, the coastal residents had a significantly higher (54%) rate of respiratory diagnoses admissions than during the red tide period. We then divided the diagnoses into subcategories (i.e. pneumonia, bronchitis, asthma, and upper airway disease). When compared with the non-red tide period, the coastal zip codes had increases in the rates of admission of each of the subcategories during the red tide period (i.e. 31, 56, 44, and 64%, respectively). This increase was not observed seen in the inland zip codes.These results suggest that the healthcare community has a significant burden from patients, particularly those who live along the coast, needing emergency medical care for both acute and potentially chronic respiratory illnesses during red tide blooms.     

Seroepidemiological study of coronavirus infection in children and adults in St. Petersburg

As the result of prolonged (17 years) observations of patients with acute respiratory infections hospitalized in basic departments of clinics of the Research Institute of Influenza, coronavirus infection was found to be the cause of respiratory diseases, on the average, in 12% of cases (in some years in 6.8% to 28.6% of cases). The analysis of extensive morbidity rates among different age groups of the population showed that children were affected by coronavirus infection 5-7 times more often than adults. Three year cycles of this infection were established. The periods of coronaviruses activation were accompanied by their detection in patient material by electron-microscopy, a sharp increase of immune response of patients as well as in the number of nosocomial infections and the proportion of the monoinfection of the coronavirus nature. Coronaviruses played the leading role among other viruses in the etiology of hospital respiratory infections. Mucosal antibodies to coronaviruses in the secretions of the nasal cavity proved to be more important than serum antibodies not only in protection from infection, but also in the pattern of clinical manifestations of the disease.     

Invasive pulmonary aspergillosis in AIDS.

Aspergillosis is a fungal infection rarely observed in Cuba during the first years of the AIDS epidemic. However, the increase in aspergillosis cases diagnosed by autopsy in recent years, led us to study the epidemiological, clinical, radiological and anatomopathological characteristics of this disease among the Cuban AIDS patients. A total of 307 autopsies were reviewed, seven of them had invasive pulmonary aspergillosis (2.2%). The disease was predominant in men and in the white race. Neutropenia and drugs use were the risk factor more frequently observed. Clinical manifestations were those unspecific and common to other opportunistic infection of the respiratory system. The more common radiological picture were bilateral nodular infiltrates and cavitary lesions in the upper lobes (two cases). The anatomopathological diagnosis was based on the morphological characteristics of the agent and in the angioinvasive features of the pulmonary lesions. We suggest that aspergillosis should be considered in the differential diagnosis of opportunistic respiratory events of AIDS patients in advanced stages.