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Query: UMLS:C0243026 (sepsis)
 52,417 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Marked deterioration of neurologic function accompanies organ dysfunction in systemic sepsis. Although previous hypotheses have suggested that cerebral hypoperfusion, anoxia or progressive edema of the brain may be causative, the pathogenesis remains unknown. Patients with sepsis with stable or supported hemodynamics and adequate oxygenation may manifest confusion, stupor or coma. Recent evidence has demonstrated that the brain is the source of many classical mediators of inflammation after various forms of injury. These mediators, including the leukotrienes, have pronounced effect on cerebrovascular function. Endotoxin is known to stimulate the release of arachidonate from cell membranes, the rate limiting step in leukotriene synthesis. The current studies were performed to test the hypothesis that neurologic dysfunction associated with endotoxemia is characterized by alterations in cerebrovascular permeability or vasomotor function manifested by intracranial hypertension, or both. We studied the response of miniature swine to experimental endotoxemic shock and compared this response with hemorrhagic hypotension. We observed a dramatic elevation of intracranial pressure in swine subjected to endotoxemic shock, despite arterial hypotension. Moreover, estimation of cerebral blood volume (CBV) by reflectance infrared photoplethysmography demonstrated a dramatic increase in CBV, which corresponded to this elevation in intracranial pressure. However, cerebral cortical oxygen saturation was significantly reduced despite this net increase in CBV, indicative of an increase in the venous volume of the brain, while arterial volume remained the same or decreased from baseline levels. Oxygen extraction across the brain decreased during this same period compared with baseline and control values. These results demonstrate that endotoxemia is associated with the development of intracranial hypertension and an increase in CBV secondary to elevation of cerebrovascular venous volume coupled with reduced oxygen extraction across the brain. This evidence of cerebrovascular dysfunction probably represents blood flow maldistribution, similar to that seen in other organs with sepsis, suggesting a cause for altered neurologic function in systemic sepsis.
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PMID:Alterations in intracranial pressure and cerebral blood volume in endotoxemia. 842 4

Previous studies found that seizures in orthotopic liver transplantation (OLT) herald a catastrophic neurologic event, but the studies were done of patients who later died and came to autopsy. We studied 630 OLT patients. Laboratory values, electroencephalography, neuroimaging, and levels of cyclosporine or FK506 were reviewed. Neurotoxicity from immunosuppression was considered a trigger for seizures when toxic blood level or increases > or = to 100% were documented, or when white matter lesions or confusional state or tremors were present. Generalized tonic-clonic seizures occurred in 28 of 630 patients (4%). In 7 patients seizures were part of an agonal event (central nervous system infection [n = 3], anoxic encephalopathy [n = 1], cerebral edema with fulminant hepatic failure [n = 1], intracranial hemorrhage [n = 1], and sepsis [n = 1]. In 17 patients cyclosporine (n = 11) or FK506 (n = 6) could be implicated. Remaining causes were acute uremia (n = 1), meningioma (n = 1), and unknown (n = 2). All patients were initially treated with anticonvulsants. Median follow-up of 2 years did not reveal seizure recurrence after discontinuation of anticonvulsants. We conclude that the majority of new-onset seizures after OLT are not indicative of a poor prognosis. Immunosuppression neurotoxicity is the most frequent cause. Anticonvulsant therapy is not necessary for favorable long-term outcome.
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PMID:Causes and outcome of seizures in liver transplant recipients. 896 Jul 38

Significant variations and inconsistency in both the physician's and nurse's approach to the treatment of neonates with a "rule-out sepsis" (R/O sepsis) diagnosis is seen as both high cost and low quality. Because R/O sepsis is seen as a diagnostic dilemma for practicing clinicians, there has been a widespread tendency to readily initiate antibiotic treatment, without adequate consideration of the high financial and morbidity costs associated with the complications of treating the noninfected infant. This study demonstrates that the use of an agreed upon risk profile facilitated the collaborative standardization of diagnosis and treatment of the R/O sepsis patient, improved quality, and reduced costs (by minimizing over treatment) without increasing risk. This collaborative approach enhanced nurse-physician relationships, resulting in significant cost savings as well as diminished anxiety and confusion among the parents of neonates diagnosed with R/O sepsis.
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PMID:Nurse/physician collaborative practice: improving health care quality while decreasing cost. 914 58

Funguria, fungal urinary tract infections, are most commonly caused by Candida species but may also be caused by Cryptococcus neoformans, Aspergillus species, and the endemic mycoses. Candiduria presents as an increasingly common nosocomial infection, which may involve all anatomic levels of the urinary tract, resulting in a spectrum of disease varying from asymptomatic candiduria to clinical sepsis. Although several successful systemic or local therapeutic options exist for the eradication of candiduria, knowledge of the pathogenesis and natural history of candiduria has lagged. This has resulted in confusion among practitioners as to when antifungal therapy is indicated. Treatment guidelines have recently been formulated and are described herein.
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PMID:Fungal infections of the urinary tract. 1065 72

Three patients who chronically abused alcohol were found to be hyponatraemic with normal plasma potassium. The first had been admitted with confusion and weight loss, the second with hypotension and sepsis, and the third with confusion and hypoglycaemia-induced seizures. All three patients had a subnormal cortisol response in the short synacthen test; however, the plasma cortisol after three days of tetracosactrin administration was greater than 550 nmol/L. Baseline corticotropin levels were less than 10 pg/mL in all three. No structural lesions of the hypothalamo-pituitary tract were found and there was no evidence of other endocrinopathies. Glucocorticoid replacement therapy led to the resolution of hyponatraemia and hypoglycaemia, where present, and to clinical improvement. The two surviving patients remained hypocortisolaemic in the long term, without recurrence of hyponatraemia or hypoglycaemia. The features of isolated corticotropin deficiency are easily confused with other effects of chronic alcohol abuse. In alcoholic patients with unexplained hyponatraemia, hypoglycaemia or haemodynamic instability, a short tetracosactrin test is advisable.
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PMID:Isolated corticotropin deficiency in chronic alcoholism. 1070 Aug 40

J. S. is a sixty-five-year-old man who was treated at another hospital with arthroscopic debridement of an infection at the site of a right total knee replacement and was placed on long-term intravenous antibiotics. He signed out of that hospital against medical advice. One month later, he presented at our hospital with recurrent sepsis of his knee. Knee aspiration yielded frank pus with a white blood-cell count of 80,000 cells per cubic millimeter. Gram-staining demonstrated gram-positive cocci. The patient was placed on intravenous antibiotics. The patient appeared cachectic, reporting a sixty-pound (27.2-kilogram) weight loss over the past year. A metastatic workup, including a chest radiograph, an abdominal sonogram, prostate-specific antigen, a complete blood-cell count, erythrocyte sedimentation rate, and a purified-protein-derivative skin test, was negative; however, an occult neoplasm could not be excluded. The patient displayed episodes of confusion, disorientation, and argumentative behavior. Medical and psychiatric consults did not determine whether this behavior was due to previous substance abuse or a primary psychiatric disorder. Nevertheless, psychiatrists at our institution determined that the patient lacked decisional capacity. Attempts were made to salvage the knee replacement, and the patient underwent an extensive surgical debridement of the knee with insertion of drains. He was placed on intravenous antibiotics. The plan was for the patient to be managed with long-term oral suppressive antibiotics. After treatment, the patient was transferred to a skilled-nursing facility. Psychiatrists at the nursing facility deemed the patient to have decisional capacity, and the patient was permitted to leave the facility. He was discharged without antibiotics. Several weeks later, he presented at our hospital with a grossly purulent knee. The orthopaedic options were reviewed with the patient and his brother. Removal of the components was recommended. The patient did not want to "lose" his knee replacement, and he refused surgical intervention. We did not believe that the infection could be either controlled or eradicated with the components in place.
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PMID:Paternalism. 1131 99

Between December 1996 and September 1998, 13 patients with advanced recurrent malignant brain tumors (9 with glioblastoma multiforme, 1 with gliosarcoma, and 3 with anaplastic astrocytoma) were treated with a single intratumoral injection of 2 x 10(9), 2 x 10(10), 2 x 10(11), or 2 x 10(12) vector particles (VP) of a replication-defective adenoviral vector bearing the herpes simplex virus thymidine kinase gene driven by the Rous sarcoma virus promoter (Adv.RSVtk), followed by ganciclovir (GCV) treatment. The VP to infectious unit ratio was 20:1. Our primary objective was to determine the safety of this treatment. Injection of Adv.RSVtk in doses <==2 x 10(11) VP, followed by GCV, was safely tolerated. Patients treated with the highest dose, 2 x 10(12) VP, exhibited central nervous system toxicity with confusion, hyponatremia, and seizures. One patient is living and stable 29.2 months after treatment. Two patients survived >25 months before succumbing to tumor progression. Ten patients died within 10 months of treatment, 9 from tumor progression and 1 with sepsis and endocarditis. Neuropathologic examination of postmortem tissue demonstrated cavitation at the injection site, intratumoral foci of coagulative necrosis, and variable infiltration of the residual tumor with macrophages and lymphocytes.
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PMID:Phase I study of adenoviral delivery of the HSV-tk gene and ganciclovir administration in patients with current malignant brain tumors. 1093 31

Pneumonia has a particularly high incidence in the elderly, the cardinal risk factors being comorbidity and malnutrition. The independent bearing of age on the aetiology of pneumonia is a matter of controversy and is probably limited. Streptococcus pneumoniae is uniformly the most frequent pathogen. Elderly patients with pneumonia are frequently oligosymptomatic. Quite often, mental confusion may be the only clinical symptom. Physical and chest radiograph examination have specific and important pitfalls. Mental confusion as a surrogate marker of severe sepsis should be added to the criteria for assessing the severity of disease. Pneumonia in the elderly is associated with a considerably increased mortality, but age does not appear to be an independent predictor of death. The disease continues to be the old man's friend: survivors of a pneumonia episode are more likely to die during follow-up as compared to controls. Antimicrobial treatment in the elderly should follow a risk-adopted approach. When selecting antimicrobial agents for the treatment of the elderly, peculiarities in pharmacokinetics, drug interactions and side effects should be considered. The rate of radiographic clearance is inversely correlated with age. All elderly individuals are candidates for vaccination against pneumococci and influenza, particularly in the presence of cardiopulmonary comorbidity and any degree of immunosuppression.
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PMID:Pneumonia in the elderly--what makes the difference? 1094 14

Previous definition of classic dengue, with or without bleeding, and of dengue hemorrhagic fever (DHF) that may evolve without bleeding and with or without dengue shock syndrome (DSS) are reviewed here. The classical approach to the diagnosis and treatment of dengue, although useful in the past, nowadays breeds confusion and adds a burden to the physician's task of decision-making regarding the treatment of patients with severe forms of the disease. The classification of dengue proposed in this paper, and summarized in a diagram, incorporates new concepts about sepsis, systemic inflammatory response syndrome (SIRS), and acute respiratory distress syndrome (ARDS). This new approach, in our view, is a useful guide to initial evaluation and treatment of the disease. It also approximates the dengue syndrome to other protocols and medical procedures routinely used in intensive care units, making it easier to be followed by the health personnel working in areas subject to epidemic bursts.
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PMID:[Dengue: a new approach]. 1106 83

Case reports and case series have identified putative risk factors for the development of bilateral massive adrenal hemorrhage (BMAH) in humans. The anatomy and physiology of the adrenal gland allow development of a model to fit the pathophysiology behind these risk factors. Until now, these risk factors were not systematically tested using analytical epidemiologic studies. A case-control study was undertaken using sources of cases and controls from multiple teaching hospitals in Ontario, Canada. The results of multivariate logistic regression indicated that thrombocytopenia (odds ratio [OR] = 14.6, 95% confidence intervals [CI] = 3.0-70.1, p < 0.001), heparin exposure of any route or type beyond 3 days (4-6 days: OR = 17.0, CI = 1.9-154.6; > 6 days: OR = 33.5, CI = 4.3-262.6; p < 0.001), and sepsis (OR = 6.3, CI = 1.2-32.2, p = 0.019) were most strongly and independently associated with development of BMAH. Another weaker positive association included invasive radiologic procedure (OR = 4.4, CI = 0.9-22.1, p = 0.055). Neither major surgery or duration of hospitalization were independent risk factors. Although coronary artery disease and possibly diabetes and hypertension appeared to be markers for lower risk of BMAH, this may be a result of bias introduced by using hospital controls ("Berkson bias"), as the effect was not explained by a protective effect of vasoactive medications. Thus, a picture of the high-risk patient should include a patient who has been treated with heparin (any route or type) beyond 3 days and has had thrombocytopenia (not necessarily induced by heparin) during the course of an illness. If the setting includes unexplained abdominal, chest, or back pain; fever; confusion; hypotension or shock; abrupt anemia; or electrolyte disorders, clinicians should not hesitate to cover empirically with lifesaving glucocorticoids while awaiting results of confirmatory tests.
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PMID:Bilateral massive adrenal hemorrhage. Assessment of putative risk factors by the case-control method. 1120 2


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