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Query: UMLS:C0032285 (pneumonia)
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Very significant morbidity and mortality continue to accompany lower extremity amputations. In this study 90 patients underwent 110 amputations over a 4 year period. The overall complication rate was 40 per cent and the overall mortality rate 12.2 per cent. The patients at greatest risk were the above knee amputees greater than 60 years of age with peripheral vascular disease. Amputation of the lower extremity must be recognized as a major, life-threatening procedure. Careful preoperative evaluation of cardiac, pulmonary, and nutritional status along with efforts to prevent sepsis, pneumonia, pulmonary embolism, gastrointestinal ulceration, and renal failure are necessary if the mortality accompanying these procedures is to be reduced.
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PMID:Lower extremity amputation: review of 110 cases. 50 12

A case of metastatic Serratia marcescens (SM) endophthalmitis is described in a 57-year-old diabetic woman, after amputation of her leg above the knee because of peripheral vascular disease. SM cultured from the infected surgical stump was the source of septic emboli to her right eye and lungs, causing endophthalmitis and pneumonia. The ocular infection did not respond to appropriate antibiotic therapy and evisceration was required. SM infection can cause endophthalmitis refractory to antibiotics, and it should be aggressively treated when SM is cultured from any infected site.
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PMID:[Metastatic Serratia marcescens endophthalmitis]. 222 73

Irradiation has been shown experimentally to cause accelerated development of atherosclerosis in exposed large arteries. However, occurrence of such an entity in carotid arteries of patients after treatment for head and neck carcinoma is unknown. Therefore, we reviewed 179 patient charts who had undergone head and neck operations with or without irradiation between 1979-1987. Of these 179 patients, 107 (59.8%) were dead at time of follow-up. Cause of death was unknown in 42 (40%) patients; in the remainder included: respiratory arrest--33; carcinoma-related--18; cardiac--6;pneumonia--7; and trauma--1. Average interval from treatment to death was 23.5 months. Of the 72 patients known to be alive, follow-up was obtained in 52 patients. Their average age was 64.9 years. Risk factors for atherosclerosis included: male gender--43; smoking--50; hypertension--9; diabetes--4; coronary artery disease--12; and peripheral vascular disease--4. Seventy-five per cent of these patients received postoperative irradiation. Average follow-up was 64.5 months. Duplex scans were performed on 34 patients. Three patients had common or internal carotid stenoses greater than 75 per cent. All of these patients had received irradiation and none of them were symptomatic. Seven patients had carotid stenoses between 50 to 75 per cent; five of these had received irradiation. Of these five patients, one had a stroke 60 months postoperatively, and one had a TIA 36 months postoperatively. The remaining 58 patients (of which 48 had irradiation) had carotid stenoses less than 50 per cent and none were symptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Carotid artery disease in patients with head and neck carcinoma. 226 6

Group B streptococcal bacteremia outside the perinatal setting is not commonly emphasized. This report reviews all episodes of group B streptococcal bacteremia during a four and a half year period in a large community teaching hospital. Fourteen episodes occurred in neonates, four in parturient women, and 28 in other adults. Bacteremic adults were usually elderly with an average age of 68 years. Group B streptococcal bacteremia occurred in adults with various underlying diseases, including diabetes mellitus, liver disease, peripheral vascular disease, and hematologic disease, and in those receiving long-term steroid therapy. Infections causing group B streptococcal bacteremia in adults included decubitus ulcers, pneumonia, endocarditis, cellulitis, arthritis, osteomyelitis, and meningitis. Thirteen of 28 episodes of group B streptococcal bacteremia in adults were hospital-acquired. Overall mortality in adults was 70 percent. Group B streptococcal bacteremia in adults outside of the perinatal setting is associated with significant underlying diseases and has a high mortality.
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PMID:Group B streptococcal bacteremia in a community teaching hospital. 388 11

During the past five years 75 patients aged 90 years or more had 85 major surgical procedures at the Metropolitan Nashville General and Vanderbilt University hospitals. The most common operation was exploratory laparotomy. The second was lower extremity amputation for peripheral vascular disease and/or gangrene. Fifty-seven percent had general endotracheal anesthesia. Associated medical problems were common, and included congestive heart failure (24%), hypertension (21%), diabetes mellitus (13%), chronic arrhythmias (9%), history of myocardial infarction (8%), and history of cerebrovascular accident (5%). Eleven patients (13.4%), six of whom had general anesthesia, died after operation. Of these, two had postoperative pneumonia, two did not recover from bowel perforation and peritonitis, one had a postoperative myocardial infarction, another had a cerebrovascular accident, and one had sepsis. One patient's sudden death was likely due to myocardial infarction or pulmonary embolus. The other three deaths occurred in patients with extensive carcinomas (gallbladder carcinoma in one and widely metastatic carcinoma of unknown origin in two). These three patients died of the disease for which they were operated upon when the operation failed to alter its course. When surgical procedures are necessary to prolong and/or improve the quality of life in elderly patients, these procedures may be done in most cases with acceptable results.
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PMID:Surgical procedures in patients aged 90 years and older. 649 54

The detailed mortality and morbidity statistics on smoking tend to conceal the overall impact of the habit on health. About 3 million people die each year from smoking in economically developed countries, half of them before the age of 70. Cancers of eight sites are recognized as being caused by smoking--lung cancer almost entirely and the others (upper respiratory, bladder, pancreas, oesophagus, stomach, kidney, leukaemia) to a substantial extent. Six other potentially fatal diseases are also judged to be caused by smoking: respiratory heart disease, chronic obstructive lung disease, stroke, pneumonia, aortic aneurysm and ischaemic heart disease, the most common cause of death in economically developed countries. Non-fatal diseases, such as peripheral vascular disease, cataracts, hip fracture, and periodontal disease, which cause appreciable disability, cost and inconvenience are also caused by smoking. In pregnancy, smoking increases the risk of limb reduction defects, spontaneous abortion, ectopic pregnancy, and low birth weight. While there are some diseases for which smoking shows a protective effect, the 'benefits' of these are negligible in relation to the illness and premature mortality caused by smoking. About 20% of all deaths in developed countries are caused by smoking; an enormous human cost which can be completely avoided.
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PMID:Cigarette smoking: an epidemiological overview. 874 92

Changes that occur in the pharmacology of drugs in the elderly must be considered in the use of antimicrobial agents. Although absorption of orally administered drugs is not affected in a significant way, renal function decreases, drug-drug interactions increase, compliance with regimens may be decreased, and drug toxicity is increased. The most frequent infections occurring in the elderly are pneumonia, urinary tract infection, and soft-tissue infection. CDAD is usually a complication of antibiotic therapy. Pneumonia can be categorized as community-acquired, LTCF, and hospital-acquired. Therapeutic approaches vary according to which of these sites is involved. Urinary tract infection is divided into upper tract infection, lower tract infection, and asymptomatic bacteriuria. Upper tract infection is treated for a longer period than lower tract infection; with few exceptions, asymptomatic bacteriuria is usually not treated. Soft-tissue infection is usually caused by an infected pressure ulcer or cellulitis (which may be a complication of a diabetic foot ulcer or an ulcer due to peripheral vascular disease). These infections have different microbial causes and require different therapeutic approaches.
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PMID:Antibiotic agents in the elderly. 1082 60

Newer, minimally invasive catheter-based endovascular technology utilizing stent grafts are currently being evaluated for abdominal aortic aneurysm (AAA) repair. A retrospective review of all (3 years) consecutive, non-ruptured elective AAA repairs was undertaken to document the results of AAA surgical repair in a modern cohort of patients to allow a contemporary comparison with the evolving endoluminal data. One hundred twenty-one AAAs were identified in a male veteran population. Mean age was 68.5 +/-7.7 years. Medical history review showed hypertension in 55%, heart disease in 73.5%, peripheral vascular disease in 21%, stroke and transient ischemic attacks in 22%, diabetes mellitus in 7%, renal insufficiency in 10%, and smoking history in 80%. The AAA size was documented with ultrasound (5.2 +/-1.3 cm, n=40) and computed tomography (5.6 +/-1.3 cm, n=100). Fifty-nine percent had angiography. Intraoperative end points included an operative time of 165 +/-6.3 minutes from incision to dressing placement. A Dacron tube graft was used in 78%, the remaining were Dacron bifurcated grafts. A suprarenal clamp was used in 8% for proximal aortic control with juxtarenal aneurysms. A pulmonary-artery catheter was placed in 69%. A transverse incision was used in 69% of patients and a midline incision was used in the rest. Estimated blood loss was 1505 +/-103 mL; cell saver blood returned 754 +/-53 mL; crystalloid/Hespan 4771 +/-176 mL; banked packed red blood cells 0.75 +/-0.11 U. Time to extubation was, in the operating room (78.5%), on the day of the operation (5.0%), postoperative day (POD) 1 (12.4%), POD2 (1.7%), POD3 (0.8%), and one case was performed with epidural anesthesia only. Postoperative end points included a 30-day mortality rate of 1.6% (two patients). Postoperative morbidity included wound dehiscence 0.8%; sepsis, urinary tract infection, wound infection, leg ischemia, ischemic colitis, and stroke each had an incidence of 1.6%; myocardial infarction, congestive heart failure, pneumonia, re-operation for suspected bleeding, and ileus or bowel obstruction occurred with an incidence of 3.3%. No significant increase in serum creatinine levels was noted. Time to enteral fluids/nutrition was 3.5 +/-0.08 days. Patients were out of bed to a chair or walking by 1.3 +/-0.06 days postoperatively. The length of stay in the intensive care unit (ICU) was 2.0 +/-0.12 days and postoperative hospital stay was 6.6 +/- 0.33 days. Transfusion requirement for the hospital stay was 1.6 +/-0.2 U per patient. This review highlights a cohort of male veteran patients with significant cardiac co-morbidity who have undergone repair with a conventional open technique and low mortality and morbidity rates. This group had rapid extubation, time to oral intake, and ambulation. In addition, ICU and hospital stays were relatively short.
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PMID:Abdominal aortic aneurysm repair. 1156 37

In this retrospective study we present our experience with chronic peritoneal dialysis in nine patients with ESRD in their 10th decade of life (> or =90 years) at the Toronto Western Hospital. A family member or a private nurse assisted all patients in dialysis procedure. The co-morbid illnesses, survival, hospitalizations and complications related or unrelated to peritoneal dialysis were reviewed. Four patients started dialysis before and five after their 90th birthday, their mean age was 90.61+/-4.04 years. All patients had three or more co-morbid illnesses at the start of dialysis. Total duration of PD treatment was 210 patient months with a median duration of 25 months (range 4-68 months). Of the nine patients, four died after a mean follow up of 38.5 months on dialysis. Of the remaining five, one was transferred to hemodialysis after remaining for 10 months on peritoneal dialysis and the other four are continuing on PD for a mean duration of 9.25 months. Peritonitis (1/13.4 patient months) and exit site infection (1/100.5 patient months) responded to treatment. Hospitalization rate was one admission per 2.5 patient years. Most often, the cause of hospitalization was unrelated to PD, e.g., cardiovascular events, pneumonia and peripheral vascular disease etc. Patient survival at 1, 3 and 5 years was 88%, 58% and 24% respectively. The technique survival was 69%, 47% and 23% at 1, 3 and 5 years respectively. We conclude that continuous peritoneal dialysis is a safe and suitable treatment even in nonagenarians (> or =90 years) ESRD patients.
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PMID:Chronic peritoneal dialysis in the tenth decade of life. 1578 46

Cirrhosis is a significant marker of adverse postoperative outcome. A large national database was analyzed for abdominal wall hernia repair outcomes in cirrhotic vs. non-cirrhotic patients. Data from cirrhotics and non-cirrhotics undergoing inpatient repair of abdominal wall hernias (excluding inguinal) from 1999 to 2004 were obtained from the University HealthSystem Consortium (UHC) database. Differences (P < 0.05) were determined using standard statistical methods. Inpatient hernia repair was performed in 30,836 non-cirrhotic (41.5% male) and 1,197 cirrhotic patients (62.7% male; P < 0.0001). Cirrhotics had a higher age distribution (P < 0.0001), no race differences (P = 0.64), underwent ICU admission more commonly (15.9% vs. 6%; P < 0.0001), had a longer LOS (5.4 vs. 3.7 days), and higher morbidity (16.5% vs. 13.8%; P = 0.008), and mortality (2.5% vs. 0.2%; P < 0.0001) compared to non-cirrhotics. Several comorbidities had a higher associated mortality in cirrhosis: functional impairment, congestive heart failure, renal failure, nutritional deficiencies, and peripheral vascular disease. The complications with the highest associated mortality in cirrhotics were aspiration pneumonia, pulmonary compromise, myocardial infarction, pneumonia, and metabolic derangements. Cirrhotics underwent emergent surgery more commonly than non-cirrhotics (58.9% vs. 29.5%; P < 0.0001), with longer LOS regardless of elective or emergent surgery. Although elective surgical morbidity in cirrhotics was no different from non-cirrhotics (15.6% vs. 13.5%; P = 0.18), emergent surgery morbidity was (17.3% vs. 14.5%; P = 0.04). While differences in elective surgical mortality in cirrhotics approached significance (0.6% vs. 0.1%; P = 0.06), mortality was 7-fold higher in emergencies (3.8% vs. 0.5%; P < 0.0001). Patients with cirrhosis carry a significant risk of adverse outcome after abdominal wall hernia repair compared to non-cirrhotics, particularly with emergent surgery. It may, however, be safer than previously thought. Ideally, patients with cirrhosis should undergo elective hernia repair after medical optimization.
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PMID:Poor outcomes in cirrhosis-associated hernia repair: a nationwide cohort study of 32,033 patients. 1613 87


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