Lack of antibodies to Legionella pneumophila and Legionella micdadei in hemodialysis patients

In 231 adult hemodialysis patients and 134 healthy adults, we measured antibodies to Legionella pneumophila (serogroups 1-6) and Legionella micdadei by indirect immunofluorescent antibody tests to assess the risk of Legionnaires' disease. One of the patients had a titer of 1:512 to Legionella pneumophila but he had no history of Legionnaires' disease. Two had a titer of 1:64 to Legionella pneumophila, and none had a titer of greater than or equal to 1:64 to Legionella micdadei. By contrast, none of the control group had a titer greater than or equal to 1:64 to Legionella pneumophila and two had a titer of 1:64 to Legionella micdadei. Thus, our population of maintenance hemodialysis patients did not display increased prevalence of antibodies of Legionella pneumophila and Legionella micdadei, but prospective studies of pneumonia in hemodialysis patients might further evaluate possible risk of Legionnaires' disease.     

Pulmonary injury in burned patients

Inhalation injury has emerged as the number one cause of fatality in the burn patient. Fiberoptic bronchoscopy and 133Xe scanning complement traditional clinical signs of inhalation injury and have led to discovery of a higher incidence of these injuries among patients with burns. Patients with inhalation injury typically demonstrate three stages: acute pulmonary insufficiency, pulmonary edema, and bronchopneumonia, all of which carry at least 50 per cent mortality rates. The major early pathophysiologic changes in the lungs of burned patients are related to upper-airway obstruction and lower-airway permeability edema. Treatment consists of intubation for signs of respiratory distress, pulmonary toilet, humidification of inspired air, and antibiotics for documented infection.     

Pulmonary emboli in burned patients

The incidence of and prophylaxis against clinically important pulmonary emboli (PE) in burned patients is an often discussed problem. To study its magnitude, all patients admitted with acute burns were followed for clinical evidence of thromboembolism: 2,106 patients were evaluated (1,439 adults). No children had evidence of PE. Six adults (0.4%) sustained a PE: none died. Mean burn size was 26.8%; mean age, 35.1 years; and mean weight, 90.8 kg. Mean PBD of the PE was 16.5 days. None with PE were ICU patients and none had lower-extremity IV lines. Two patients had embolic events after discharge from the hospital. No ICU patients who died unexpectedly had a PE. Only two patients had significant risk factors; they were obese with leg burns. Three had no risk factors; normal weight and upper body burns without prolonged bed rest. The incidence of pulmonary emboli and resulting morbidity do not justify routine prophylactic heparinization of all burned patients.     

Circulating fibronectin in burned patients

Plasma and serum fibronectin levels were determined in a serial study of 24 non-septic burned patients by means of the passive haemagglutination test and electroimmunoassay. The results showed a consistent pattern of observed changes: a decrease of circulating fibronectin in the initial (first 72 hours post-burn), and during post-operative period (usually by the end of the first week and during the second week post-injury). Fibronectin level decreases were more remarkable than total serum protein concentration changes following injury, as reflected by decrease of fibronectin/protein ratio.     

Fluid replacement in burned patients

The selection of the fluid replacement for the burned patients is based on a sound understanding of the pathophysiology of the burn injury as well as a similar understanding of the properties of the various fluids available. The appropriate matching of these properties with the specific goals and necessary monitoring techniques for each patient will result in success. Those caring for the burned patient must remain both flexible and knowledgeable in order to optimize results.     

Cyanide toxicity in burned patients

The role of cyanide (CN) in smoke inhalation injury has been the subject of investigation for many years. Prospective evaluation of serum CN, thiocyanate (the primary metabolic product of CN), and carboxyhemoglobin (COHb) in patients suspected by history of having smoke inhalation injury was performed in 144 patients. Eight of 12 patients with "lethal" CN levels (greater than 1.0 mg/L) died. All had sublethal levels of COHb. A separate group of patients who were DOA following fatal burn injuries were also studied. Lethal CN levels were found in 12 of 14 victims with lethal COHb levels and in 14 of 20 victims with sublethal COHb levels. The results show that elevated CN levels are frequent in patients with smoke inhalation and suggest that cyanide toxicity is a contributor to severe inhalation injuries. In some cases, CN was the primary measured toxicant.     

Leucocyte aggregation in burned patients

Leucocyte aggregation describes one type of biophysical behaviour of white cells. To test whether this parameter is changed in burned patients, 15 burn victims were investigated immediately after admission into hospital. Cell counts and aggregation were measured and related to the prognosis of the injury. Compared with normal controls, burning injury is associated with higher white cell counts and enhanced leucocyte aggregation. Fatal injuries showed a (non-significant) tendency for higher aggregation values than survivors. There are significant positive correlations between white cell counts, maximal aggregation values and the burned body surface area. The results suggest that leucocyte aggregation is pathologically enhanced in response to burns. Possibly this alteration is of prognostic importance.     

Neutrophil chemiluminescence in burned patients

Phagocytic and bactericidal assays showed that a close correlation was present between bactericidal activity and neutrophil chemiluminescence (PMN-CL) (r = 0.81; p less than 0.01). This suggested that the microbicidal action of the neutrophil depends metabolically on the generation of oxygenating agents. PMN-CL and opsonic index (OI) were measured in 36 burned patients. The levels of serum transferrin (Tf) were examined simultaneously by nephelometric method in order to determine the correlation between humoral-phagocyte axis of immune system and nutritional status. It was found that PMN-CL and OI were generally lower in the greater than 35% TBSA burn group (PMN-CL, 1.85 +/- 0.21 cpm X 10(3), OI, 0.69 +/- 0.06) compared with control subjects (PMN-CL, 3.55 +/- 0.15 cpm X 10(3), OI, 1.05 +/- 0.04). It suggested that both neutrophil oxygenation activity and opsonic activity were impaired following severe burns. PMN-CL was higher in the smaller than 30% TBSA burn group during infection phase as compared with control subjects (5.61 +/- 0.26 cpm X 10(3) vs. 3.55 +/- 01.5 cpm X 10(3); p less than 0.01). It remained high in patients with persistent infection, but fell to normal if appropriate therapy was instituted. This result indicated that the neutrophils of the majority of patients with minor burns during acute infection were in an activated state both metabolically and functionally. The occurrence of sepsis was associated with a marked lowering of PMN-CL and OI values, but no difference was noted before and after the development of sepsis. The incidence of sepsis was 85.7% when PMN-CL was lower than 2 cpm X 10(3).(ABSTRACT TRUNCATED AT 250 WORDS)     

Acalculous cholecystitis in burned patients

Ten cases of acalculous cholecystitis in burned patients are reviewed. The disorder appears to be associated with overwhelming bacterial invasion or other postburn complications leading to dehydration or necessitating surgery. Recommendations regarding prophylaxis and therapy are made.