Letters to the Editor Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, 1Department Critical Care Medicine, Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Sciences, Tehran, Iran Address for correspondence: Dr. Seyed Mohammadreza Hashemian, Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. E‑mail: [email protected]
3. 4.
the fundamental critical care support course in critical care education in Japan: A survey of Japanese fundamental critical care support course experience. J Intensive Care 2013;1:5. Mohajerani SA, Hashemian SM. A comparison of anesthesiology modules between developed and developing countries; what is the role of journals. Anesthesia, Pain, and Intensive care. 2012 Aug. Iraqi anesthesiologists get FCCS training in Iran. Tehran Times, 29 November 2011, Vol 11309. Available from: http://www.tehrantimes. com/health/519‑iraqi‑anesthesiologists‑get‑fccs‑training‑in‑iran. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.147543
REFERENCES 1. 2.
Available from: http://www.sccm.org/Fundamentals/FCCS/Pages/ SponsoredCourse.aspx. Atagi K, Nishi S, Fujitani S, Kodama T, Ishikawa J, Shimaoka H. Evaluating
A rare case of isolated pauci-immune pulmonary capillaritis Sir, A 66‑year‑old male presented with complaints of dry cough and dyspnea with bilateral crackles on examination. Chest imaging showed bilateral opacification of the lungs [Figures 1 and 2]. Due to progressive respiratory failure, mechanical ventilation and antibiotics were started. Bronchoalveolar lavage was consistent with alveolar hemorrhage. Perinuclear antineutrophil cytoplasmic antibodies (P‑ANCAs) returned as positive, but other autoimmune markers were negative. Methylprednisolone and later on cyclophosphamide was started, which initially improved oxygen requirements, but patient developed multiorgan failure and subsequently expired. Autopsy confirmed diffuse alveolar hemorrhage associated with isolated pauci‑immune pulmonary capillaritis (IPIPC).
In the absence of identifiable systemic disease, pulmonary vasculitis is recognized as IPIPC. [1] Corticosteroids and cyclophosphamide remains the conventional therapy. Jennings et al., reported eight cases of IPIPC without any associated illness. [2] We present a rare case of IPIPC, who initially responded well to cyclophosphamide, but subsequently failed the treatment.
Figure 1: Chest radiography showing diffuse white opaque bilateral pulmonary infiltrates
Figure 2: Non-contrast computed tomography of the chest showing extensive patchy ground-glass lung infiltrates with bilateral pleural effusions
Raghav Gupta, Wisam Naji, Aditi Jindal1, Bhavin Sureshbhai Patel2, Garima Mittal3, Andrew Labelle
Department of Internal Medicine, Pulmonary and Critical Care Medicine, St. Luke’s Hospital, Chesterfield, Missouri, 1 Department of Pediatric Dentistry, Tufts University School of Dental Medicine, Boston, Massachusetts, USA, 2Department of Internal Medicine, Odessa State Medical University, 3Department of Medicine, Government Medical College, Patiala, Punjab, India
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 4 | Oct-Dec 2014
319
Letters to the Editor Address for correspondence: Dr. Raghav Gupta, St. Luke’s Hospital, Chesterfield, Missouri, 63017, USA. E‑mail: [email protected]
alveolar hemorrhage with underlying isolated, pauciimmune pulmonary capillaritis. Am J Respir Crit Care Med 1997;155:1101‑9. Access this article online Website: www.ijciis.org
REFERENCES 1. 2.
Quick Response Code:
DOI: 10.4103/2229-5151.147549
Seo JB, Im JG, Chung JW, Song JW, Goo JM, Park JH, et al. Pulmonary vasculitis: The spectrum of radiological findings. Br J Radiol 2000;73:1224‑31. Jennings CA, King TE Jr, Tuder R, Cherniack RM, Schwarz MI. Diffuse
Long‑term outcome factors associated with prolonged admission to the ICU Sir, The influence of prolonged intensive care unit (ICU) stay in prognosis has been studied by several authors and some found higher mortality among patients with prolonged stay compared to those who require a shorter stay in the ICU, although some authors found in their population a substantial number of these patients survive long‑term. [1,2] Some authors define prolonged length of stay of their patients to those that exceed the 95 th percentile of the overall stay, although most of the work referred to it when >14 days and other authors refer to stays >28 days.[2‑4] The objective of this study was to analyze the factors that can influence survival a year after hospital discharge associated with prolonged admission to the ICU. We retrospectively reviewed data collected prospectively on patients admitted to the ICU from January 2004 to December 2010, with prolonged stay (>14 days), according to their survival 1 year later. During the study; 6,069 patients were admitted to the ICU. Seven hundred and seven (11.6%) stayed in ICU >14 days, and consumed a large proportion of ICU bed days (55.5%), 411 (58.13%) patients left hospital alive, and we only know their year survival to 297 patients (72.26%) Table 1. A logistic regression was performed to predict 1 year survival of patients with prolonged stay in ICU. From results shown in table, patients with prolonged ICU stay have a better prognosis after a year when they have a shorter stay in the ICU and lower Acute Physiology and Chronic Health Evaluation (APACHE) II at admission. With this regression we predict 100% survival in the group of patients who left hospital alive, but it is not possible to predict the survival of the group who died (0.0%). In statistical terms, this means that the model is able to predict correctly 92.0% of patients with prolonged stay admitted in ICU. Figure 1 shows the receiver operating characteristic curve (ROC) of 320
survival after a year, for the previous logistic regression model, for long stay patients in ICU. The area under the curve was 0.736. In conclusion, although the group of patients with prolonged stay is only a small percentage of ICU admissions, but they consume a large proportion of ICU Table 1: Results of the logistic regression of patients’ year survival with prolonged stay who left the hospital alive Factors
Stay pre-ICU Stay in ICU Stay post-ICU APACHE II at admission Age Male Surgical department Medical department Tracheostomy
B
Odds ratio
95% CI
Wald
P value
−0.010 −0.036 0.000 −0.078
0.990 0.965 1.000 0.925
0.952-1.030 0.937-0.996 0.995-1.006 0.855-0.997
0.247 5.288 0.027 3.985
0.619 0.021 0.869 0.046
−0.034 −0.970 −0.348
0.967 0.379 0.706
0.943-1.012 0.111-1.273 0.180-2.752
3.463 2.445 0.250
0.063 0.118 0.617
−0.750
0.472
0.121-1.881
1.146
0.284
−0.062
0.940
0.285-2.989
0.011
0.917
ICU: Intensive care unit, APACHE: Acute physiology and chronic health evaluation, CI: Confidence interval
Figure 1: Graph of ROC curve of survival after a year for long stay patients
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 4 | Oct-Dec 2014
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
3. 4.
the fundamental critical care support course in critical care education in Japan: A survey of Japanese fundamental critical care support course experience. J Intensive Care 2013;1:5. Mohajerani SA, Hashemian SM. A comparison of anesthesiology modules between developed and developing countries; what is the role of journals. Anesthesia, Pain, and Intensive care. 2012 Aug. Iraqi anesthesiologists get FCCS training in Iran. Tehran Times, 29 November 2011, Vol 11309. Available from: http://www.tehrantimes. com/health/519‑iraqi‑anesthesiologists‑get‑fccs‑training‑in‑iran. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.147543
REFERENCES 1. 2.
Available from: http://www.sccm.org/Fundamentals/FCCS/Pages/ SponsoredCourse.aspx. Atagi K, Nishi S, Fujitani S, Kodama T, Ishikawa J, Shimaoka H. Evaluating
A rare case of isolated pauci-immune pulmonary capillaritis Sir, A 66‑year‑old male presented with complaints of dry cough and dyspnea with bilateral crackles on examination. Chest imaging showed bilateral opacification of the lungs [Figures 1 and 2]. Due to progressive respiratory failure, mechanical ventilation and antibiotics were started. Bronchoalveolar lavage was consistent with alveolar hemorrhage. Perinuclear antineutrophil cytoplasmic antibodies (P‑ANCAs) returned as positive, but other autoimmune markers were negative. Methylprednisolone and later on cyclophosphamide was started, which initially improved oxygen requirements, but patient developed multiorgan failure and subsequently expired. Autopsy confirmed diffuse alveolar hemorrhage associated with isolated pauci‑immune pulmonary capillaritis (IPIPC).
In the absence of identifiable systemic disease, pulmonary vasculitis is recognized as IPIPC. [1] Corticosteroids and cyclophosphamide remains the conventional therapy. Jennings et al., reported eight cases of IPIPC without any associated illness. [2] We present a rare case of IPIPC, who initially responded well to cyclophosphamide, but subsequently failed the treatment.
Figure 1: Chest radiography showing diffuse white opaque bilateral pulmonary infiltrates
Figure 2: Non-contrast computed tomography of the chest showing extensive patchy ground-glass lung infiltrates with bilateral pleural effusions
Raghav Gupta, Wisam Naji, Aditi Jindal1, Bhavin Sureshbhai Patel2, Garima Mittal3, Andrew Labelle
Department of Internal Medicine, Pulmonary and Critical Care Medicine, St. Luke’s Hospital, Chesterfield, Missouri, 1 Department of Pediatric Dentistry, Tufts University School of Dental Medicine, Boston, Massachusetts, USA, 2Department of Internal Medicine, Odessa State Medical University, 3Department of Medicine, Government Medical College, Patiala, Punjab, India
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 4 | Oct-Dec 2014
319
Letters to the Editor Address for correspondence: Dr. Raghav Gupta, St. Luke’s Hospital, Chesterfield, Missouri, 63017, USA. E‑mail: [email protected]
alveolar hemorrhage with underlying isolated, pauciimmune pulmonary capillaritis. Am J Respir Crit Care Med 1997;155:1101‑9. Access this article online Website: www.ijciis.org
REFERENCES 1. 2.
Quick Response Code:
DOI: 10.4103/2229-5151.147549
Seo JB, Im JG, Chung JW, Song JW, Goo JM, Park JH, et al. Pulmonary vasculitis: The spectrum of radiological findings. Br J Radiol 2000;73:1224‑31. Jennings CA, King TE Jr, Tuder R, Cherniack RM, Schwarz MI. Diffuse
Long‑term outcome factors associated with prolonged admission to the ICU Sir, The influence of prolonged intensive care unit (ICU) stay in prognosis has been studied by several authors and some found higher mortality among patients with prolonged stay compared to those who require a shorter stay in the ICU, although some authors found in their population a substantial number of these patients survive long‑term. [1,2] Some authors define prolonged length of stay of their patients to those that exceed the 95 th percentile of the overall stay, although most of the work referred to it when >14 days and other authors refer to stays >28 days.[2‑4] The objective of this study was to analyze the factors that can influence survival a year after hospital discharge associated with prolonged admission to the ICU. We retrospectively reviewed data collected prospectively on patients admitted to the ICU from January 2004 to December 2010, with prolonged stay (>14 days), according to their survival 1 year later. During the study; 6,069 patients were admitted to the ICU. Seven hundred and seven (11.6%) stayed in ICU >14 days, and consumed a large proportion of ICU bed days (55.5%), 411 (58.13%) patients left hospital alive, and we only know their year survival to 297 patients (72.26%) Table 1. A logistic regression was performed to predict 1 year survival of patients with prolonged stay in ICU. From results shown in table, patients with prolonged ICU stay have a better prognosis after a year when they have a shorter stay in the ICU and lower Acute Physiology and Chronic Health Evaluation (APACHE) II at admission. With this regression we predict 100% survival in the group of patients who left hospital alive, but it is not possible to predict the survival of the group who died (0.0%). In statistical terms, this means that the model is able to predict correctly 92.0% of patients with prolonged stay admitted in ICU. Figure 1 shows the receiver operating characteristic curve (ROC) of 320
survival after a year, for the previous logistic regression model, for long stay patients in ICU. The area under the curve was 0.736. In conclusion, although the group of patients with prolonged stay is only a small percentage of ICU admissions, but they consume a large proportion of ICU Table 1: Results of the logistic regression of patients’ year survival with prolonged stay who left the hospital alive Factors
Stay pre-ICU Stay in ICU Stay post-ICU APACHE II at admission Age Male Surgical department Medical department Tracheostomy
B
Odds ratio
95% CI
Wald
P value
−0.010 −0.036 0.000 −0.078
0.990 0.965 1.000 0.925
0.952-1.030 0.937-0.996 0.995-1.006 0.855-0.997
0.247 5.288 0.027 3.985
0.619 0.021 0.869 0.046
−0.034 −0.970 −0.348
0.967 0.379 0.706
0.943-1.012 0.111-1.273 0.180-2.752
3.463 2.445 0.250
0.063 0.118 0.617
−0.750
0.472
0.121-1.881
1.146
0.284
−0.062
0.940
0.285-2.989
0.011
0.917
ICU: Intensive care unit, APACHE: Acute physiology and chronic health evaluation, CI: Confidence interval
Figure 1: Graph of ROC curve of survival after a year for long stay patients
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 4 | Oct-Dec 2014
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
