The Outcome of Cardiac Dysfunction in Critically Ill Trauma Patients: Myocardial Contusion Complicated by Refractory Hypotension

Abstract Background:  This work attempted to define the care and course of those most severely affected patients in the setting of blunt chest trauma, who had hypotension refractory to routine fluid resuscitation. Methods:  Twenty-three critically ill blunt trauma ICU patients were resuscitated and enrolled with ongoing hypotension required placement of a pulmonary artery catheter. The REF^?Explorer (Baxter, Edwards, Anaheim, CA) catheter was placed in the right heart measuring pressure, volume and oxygen utilization information, as well as recording Injury Severity Score, EKG, CXR, CPK/MB and echocardiography over the initial 72-h time period. Results:  There were an approximately 2,300 Level I trauma patients admitted annually over a 4-year period with an overall mortality rate of 4.3% (100) patients with 3.4% (79) patients “ruling in” with elevated cardiac enzymes, associated with an increased mortality rate of 6.7% (p < 0.05). The 23 patients were male (17, 74%), mean age 41.2 years, with no past medical history (19, 83%), in a motor vehicle accident (21, 91%), with pulmonary injury (9, 39%), undergoing celiotomy in (10, 44%). They presented with moderate to severe trauma acuity defined as mean GCS of 8.6, TS of 11.3, and ISS of 34 with an increased mean hospital stay of 15 days versus 6 days in the ICU; and a 26 days versus 10 days overall stay for those with myocardial contusion (p < 0.05). Analysis of diagnostic variables found an abnormal EKG in (21, 91%), CXR in (20, 87%) and echocardiogram in (8, 37%). The total CPK was found to be elevated, mean 2,219 (204–8,278 U/l), while the MB fraction was normal 2.3 ± 1.3%. Invasive cardiac monitoring found an increase in CO of 1.6 l/min from 5.9 to 7.8 l/min during the first 24 h of recovery. Survival was worsened with increased ISS (29 vs. 43) p < 0.02, but improved with longer ICU (17 vs. 8) p < 0.03 and hospital (39 vs. 7) p < 0.05 stay in days. The analysis of commonly used diagnostic modalities – EKG, CXR, ECHO, or CO, did not correlate with survival, but the total CPK was increased in survivors (2,715 vs. 1,432 U/l) p < 0.009. Conclusion:  There is worsened morbidity with a 2-fold increase in ICU LOS and hospital stay, and a 1.5-fold increase in mortality in the severe myocardial contusion group. The diagnostic dilemma posed by lack of definitive testing continues unresolved after analysis of routinemodalities – EKG, CXR, ECHO, CPK or CO – failing to yield a “best test”.     

Cyclospora: Review of an Emerging Parasite

Cyclospora is a parasite traditionally associated with diarrhea in travelers to endemic countries. Recently, several cases of cyclosporiasis were reported in nontravelers in the United States and Canada, implicating various fruits and vegetables as vehicles of infection. The life cycle of cyclospora is not fully known, but is believed to involve both asexual and sexual stages of proliferation. Food- and water-borne transmission of infection have been implicated. Patients infected with Cyclospora cayetanensis have protracted watery diarrhea. Various generalized symptoms are also present, making cyclosporiasis indistinguishable from infectious diarrhea caused by other microorganisms. Diagnosis depends on identifying the organism by microbiologic examination of stool samples. Treatment consists of supportive care, maintenance of fluid and electrolyte status, symptomatic relief, and antibiotic therapy. Trimethoprim-sulfamethoxazole is the only antibiotic available that is effective in eradicating the organism.     

Effect of Plasma TNF-α on Filgrastim-Stimulated Hematopoiesis in Mice and Humans

Study Objective . To delineate possible explanations for a nonmonotone hematopoiesis, dose-response curve with filgrastim therapy after high-dose chemotherapy. Design . Sequential two-phase study. Settings . University teaching hospital and basic pharmaceutical sciences laboratory. Subjects . Thirty-nine patients with breast cancer or melanoma and 15 normal CF-1 male mice. Interventions . Serial blood samples were obtained from patients after high-dose chemotherapy to evaluate hematopoiesis and tumor necrosis factor-α (TNF-α) concentrations. Murine hematopoiesis was induced by filgrastim with or without coadministration of lipopolysaccharide. Measurements and Main Results . Detection of plasma TNF-α in patients corresponded to substantially slower recovery of granulocytes, erythrocytes, and platelets, and was directly proportional to the prescribed dosage of filgrastim. Lipopolysaccharide stimulated the secretion of TNF-α in mice and totally aberrated filgrastim-induced granulopoiesis. Conclusions . This in vivo evidence suggests that regulatory pathways involving endogenous cytokines may override the effect of recombinant cytokines.     

Hypertension and Left Ventricular Hypertrophy: Is Drug Therapy Beneficial?

Left ventricular hypertrophy (LVH) is a consequence of long-standing hypertension and is considered to be an independent risk factor for cardiovascular morbidity and mortality. Several antihypertensive agents are capable of inducing regression of LVH, but it is not known which class of drugs is most effective. The impact of drug-induced reversal of hypertrophy on ventricular function remains a controversial issue. Furthermore, the long-term clinical benefits of LVH regression have yet to be documented. Controversies also exist regarding the clinical outcomes associated with drug-induced LVH regression.