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Chest 02/2001; 119(1 Suppl):176S-193S. · 5.25 Impact Factor
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ABSTRACT: Pneumonia is the second most common type of nosocomial infection and is most prevalent in patients who are mechanically ventilated. Nosocomial pneumonia (NP) is the leading contributor to mortality in patients, accounting for approximately 50% of deaths in patients with hospital-acquired infections. Several factors place patients at risk for developing NP, including prolonged length of hospital stay and local epidemiology. Gram-positive pathogens such as Streptococcus pneumoniae and, more recently, Staphylococcus aureus, as well as atypical organisms such as Legionella spp are increasingly associated with NP. Emerging antimicrobial resistance among these organisms confounds treatment interventions. Lack of local definitive information and patient comorbidities further complicate the physician's treatment decisions. The role of invasive pulmonary diagnostic techniques remains problematic and controversial. Studies, however, have shown that early initiation of appropriate empiric therapy is essential to improving patient outcome and reducing mortality. This article will review therapeutic options and appropriate antimicrobial agents for use in the treatment of nosocomial pneumonia in the era of emerging drug resistances.
Diagnostic Microbiology and Infectious Disease 03/1999; 33(2):131-9. · 2.53 Impact Factor
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Chest 12/1998; 114(5 Suppl):561S-578S. · 5.25 Impact Factor
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ABSTRACT: Mycoplasma hominis is a commensal of humans. The organism has been predominantly associated with infections of the genitourinary tract. Extragenital infections have been described in neonates, in women during the postpartum period, and in immunocompromised patients. Pneumonia caused by M. hominis is very rare. This report describes the development of M. hominis pneumonia in a lung transplantation recipient and underscores the difficulty in establishing the correct diagnosis and the need for early and aggressive treatment with appropriate antimicrobial agents to insure a good outcome.
Chest 12/1997; 112(5):1428-32. · 5.25 Impact Factor
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ABSTRACT: There is controversy over whether colonization with drug-resistant organisms is a contraindication to lung transplantation.
We undertook a retrospective review of the results of lung transplantation for patients with cystic fibrosis (CF) at Duke University Medical Center.
As of May 1996, 21 patients with CF underwent bilateral lung transplantation. The first patient died within 24 h of transplantation from sepsis due to Stenotrophomonas maltophilia. Of the remaining 20 patients, 17 (85%) are alive and in stable condition. The three deaths were related primarily to bronchiolitis obliterans at 4 and 18 months in two patients and to cytomegalovirus pneumonitis at 5 months in the other patient. The 17 surviving patients have been followed up for a mean of 13 months (range, 0.5 to 34 months). Most of them were colonized and infected with multidrug-resistant organisms before transplantation. Following transplantation, 11 patients had complications from infections. One patient had bacteremia due to a panresistant Burkholderia cepacia and was treated successfully. Two patients had bacteremia and wound infection due to Burkholderia gladioli, previously thought to be pathogenic only in plants. Both patients were treated successfully. Of the six patients with Aspergillus fumigatus isolated from cultures before transplantation, only one had invasive disease following transplantation and responded to treatment.
The organisms present before transplantation were not the primary cause of mortality in our patient population. Our findings suggest that lung transplantation should be considered in CF patients infected with multidrug-resistant organisms.
Chest 11/1997; 112(4):924-30. · 5.25 Impact Factor
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L B Marks,
M T Munley,
G C Bentel,
S M Zhou,
D Hollis,
C Scarfone,
G S Sibley,
F M Kong,
R Jirtle,
R Jaszczak,
R E Coleman, V Tapson,
M Anscher
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ABSTRACT: To develop methods of predicting the pulmonary consequences of thoracic irradiation (RT) by prospectively studying changes in pulmonary function following RT.
100 patients receiving incidental partial-lung irradiation during treatment of tumors in or adjacent to the thorax had whole-lung function assessed via symptoms and pulmonary function tests (PFTs: FEV1-forced expiratory volume 1 s; DLCO-diffusion capacity) before and repeatedly 6-48 months following RT. All had computed tomography-based three-dimensional (3D) dose calculations with lung density heterogeneity corrections for dose-volume histogram (DVH) and normal tissue complication probability (NTCP) calculations. Functional DVHs (DVfH) based on SPECT (single photon emission computed tomography) lung perfusion scans, and serial transforming growth factor-beta (TGF-beta1) levels were available in 50 and 48 patients, respectively. The incidence and severity of changes in whole-lung function were correlated with clinical, physical, and biological factors. Exploratory statistical analyses were performed using chi-square, Pearson correlations, logistic regression, and multiple linear regression.
RT-induced symptoms developed in 21 patients. In the overall group, the single best predictor for the development of symptoms was the NTCP (p < 0.05). Pre-RT PFTs alone were less predictive (p = 0.1 for FEV1, p = 0.08 for DLCO). A multivariate model based on pre-RT DLCO and CT-based NTCP was strongly predictive for the development of symptoms (p < 0.001). NTCPs based on SPECT-derived DVf Hs and TGF-beta1 levels did not appear to provide additional predictive value. The presence or absence of pulmonary symptoms was correlated with the decline in PFT 6 months following RT (p < 0.05). In the overall group, the degree of decline in PFTs was not well correlated with any of the dose-volume variables considered. In patients with "good" pre-RT PFTs, there was a relationship between the percent reduction in PFT and dose-volume parameters such as the percent of lung volume receiving > 30 Gy (p < 0.05).
The extent of alteration in whole-lung function (symptoms or PFT changes) appears to be related to both dose-volume and pre-RT PFT parameters. The data suggest that no one variable is likely to be an adequate predictor and that multivariate predictive models will be needed. Additional studies are underway to develop better predictive models that consider physical factors such as the DVH and regional perfusion, as well as biological/clinical factors such as pre-RT PFTs and TGF-beta1.
International Journal of Radiation OncologyBiologyPhysics 10/1997; 39(3):563-70. · 4.11 Impact Factor
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ABSTRACT: The first clinically successful lung transplantation was performed in 1983. Since that time, more than 2700 transplants have been recorded by the International Lung Transplant Registry [1]. Lung transplantation is currently limited to patients with endstage lung disease and a life expectancy of less than 18 months [1]. Unilateral lung transplantation is the most commonly performed procedure. Bilateral transplantation generally is reserved for patients with pulmonary sepsis. One-year survival after transplantation is currently 80-90%, and 5-year survival is estimated at 50% [1]. Early detection and treatment of the complications of lung transplantation are critical to decrease patient morbidity and mortality [2-4]. This article reviews the radiologic findings of the most common complications of lung transplantation, using our experience with 85 patients.
American Journal of Roentgenology 07/1996; 166(6):1405-11. · 2.78 Impact Factor
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ABSTRACT: Heart and lung transplantation has gained acceptance as therapy for end-stage cardiac and pulmonary failure. The early and intermediate survival benefits of one center's 10-year experience with 177 patients undergoing thoracic transplantation were examined.
As experience in cardiac and pulmonary transplantation has increased, improvements in patient selection, organ preservation, preoperative support, and perioperative care have significantly reduced the early threats to patient survival. Graft dysfunction due to chronic rejection appears to be the main risk for longer-term survival, and data compiled by the United Network for Organ Sharing (UNOS) indicate a 70% 5-year survival for heart transplants and a 50% 5-year survival for lung transplant recipients.
The medical records of 120 heart recipients, 52 lung transplant recipients, and 5 heart-lung recipients were reviewed. Cumulative survival estimates were made using Kaplan-Meier analysis. The etiologies of operative and long-term mortality in each transplant population were identified. A comparison of long-term survival after heart transplantation versus coronary revascularization in a group of patients with ischemic cardiomyopathy was performed.
Operative mortality in both the cardiac and pulmonary transplant recipients was 8%. From 1990 to 1995, 70 consecutive adult cardiac transplant procedures were performed without an operative mortality. Three of five patients survived heart-lung transplantation. The extended actuarial survival rate at 5 years was 80% for the cardiac transplant recipients. The 2-year actuarial survival rate for the lung transplant recipients was 88%. Graft dysfunction was the most common cause of operative mortality in the heart transplant group whereas infection was responsible for most of the operative mortality after lung transplantation.
Cardiac and pulmonary transplantation can be applied to morbidly ill patients with excellent operative and intermediate-term survival.
Annals of Surgery 06/1996; 223(5):576-84. · 7.49 Impact Factor
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ABSTRACT: We reviewed the pattern and incidence of fungal infections in patients undergoing lung and heart-lung transplantation at Duke University Medical Center from September 1992 until August 1995, and present here 9 illustrative cases. Of the 73 lung and heart-lung transplant recipients studied, 59 (81%) had positive fungal cultures at some point after transplantation. The cases presented here illustrate that lung transplant recipients are predisposed to a wide variety of fungal infections. The clinical pattern of these infections ranges from asymptomatic to rapidly progressive fatal disease. In addition to the reactivation of previous fungal infections and recent exposure to new environmental sources, the donor lung itself can be the source of fungal infection, as we showed by using molecular epidemiology techniques. Because of the associated morbidity and mortality, efforts should be directed at investigating prophylactic antifungal regimens in lung transplant recipients. Preliminary reports on the use of itraconazole and aerosolized amphotericin B have been encouraging. Prospective randomized studies are needed to assess the safety and cost effectiveness of different regimens. Fungal infections in patients after lung transplantation can significantly impede recovery and lead to substantial mortality.
Medicine 06/1996; 75(3):142-56. · 4.35 Impact Factor
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ABSTRACT: Three-dimensional single photon emission computed tomography lung perfusion scans (SPECT) provide a unique quantitative 3-dimensional map of the distribution of functioning pulmonary vascular/alveolar subunits, information not provided by other imaging modalities. This report describes our initial experience utilizing these scans to assist in the design of radiation treatment beams and to assess changes in regional lung function following irradiation.
Patients were immobilized and scanned in the treatment position with appropriate fiducial markers. Four millicuries of technetium 99M microaggregated albumin were injected and SPECT images of the lung were generated. Pre-treatment SPECT images were used to help design radiation beams to minimize irradiation of functioning lung. Pre- and post-treatment scans were compared to assess changes in regional function. These changes in function were then correlated with the regional radiation dose.
Pre-radiotherapy SPECT scans were obtained in 18 patients (11 with lung cancer). Marked variations in regional function were frequently noted. In patients with primary lung tumors, these variations were not necessarily immediately adjacent to the tumor volume. In general, patients with poor pulmonary function pre-treatment, in whom one would like to spare as much normal lung as possible, had the most non-uniform distribution throughout the lung of functioning vascular/alveolar subunits. In these cases, pre-treatment scans were most useful in designing radiation portals to minimize irradiation of functioning lung. SPECT scans were also used to detect changes in regional lung function secondary to radiotherapy in four patients. With doses in excess of 40 Gy, reductions in regional function were noted 1-6 months following completion of radiotherapy. These reductions were not necessarily accompanied by reductions in conventional pulmonary function tests, which are assessments of whole lung function and may not reflect regional lung injury if the volume affected is small.
SPECT lung scans provide an excellent means of assessing regional lung function, superior to that obtainable with planar images. The functional data provided by the SPECT images is useful in designing "optimal" radiation treatment beams and in assessing the effect of radiotherapy on regional lung functions. Efforts are continuing in our laboratory to develop a dose response curve for regional lung damage using the tools of SPECT scanning and 3-dimensional dose calculations.
International Journal of Radiation OncologyBiologyPhysics 08/1993; 26(4):659-68. · 4.11 Impact Factor
