Primary Sjogren's Syndrome Presenting As Pleuritis and Pleural Effusion.

Sjogren's syndrome is an autoimmune condition characterized by infiltration of exocrine glands but, in rare cases, can have extraglandular involvement with pleural effusion being an exceedingly rare form. Here we present a case of Sjogren's pleuritis resulting in pleural effusion, a rare initial presentation for Sjogren's syndrome. A woman in her 20s presented to the emergency department after a recent hospitalization for pneumonia, pleural effusion, and pulmonary embolism.

Utility of Bedside Ultrasound in Percutaneous Tracheostomy.

Percutaneous tracheostomy placement is a common procedure performed in the intensive care unit. The use of an anterior neck ultrasound exam is routinely performed preprocedure, allowing for vessel visualization in determining the safety and feasibility of performing the procedure bedside. This prospective observational cohort study was conducted to determine whether vasculature in the anterior neck, seen on bedside ultrasound exam, contributes to bleeding complications during or after percutaneous tracheostomy (PCT) placement.

Algorithmic Approach to the Diagnosis of Organizing Pneumonia: A Correlation of Clinical, Radiologic, and Pathologic Features.

Organizing pneumonia (OP), characterized histopathologically by patchy filling of alveoli and bronchioles by loose plugs of connective tissue, may be seen in a variety of conditions. These include but are not limited to after an infection, drug reactions, radiation therapy, and collagen vascular diseases. When a specific cause is responsible for this entity, it is referred to as "secondary OP.

Association Between Inhaled Corticosteroids and Tracheobronchomalacia.

Objective: The aim of this study was to assess any association between use of inhaled corticosteroids (ICS) and tracheobronchomalacia (TBM).

Methods: This study was a retrospective analysis of patients with asthma and COPD, with and without TBM. Patients were diagnosed with TBM on the basis of CT imaging, flexible bronchoscopy, or both.

Feasibility, Safety, and Utility of Advanced Critical Care Transesophageal Echocardiography Performed by Pulmonary/Critical Care Fellows in a Medical ICU.

Background: Competence in advanced critical care transesophageal echocardiography allows the intensivist to diagnose and manage cardiopulmonary failure when transthoracic echocardiography is not sufficient to answer the clinical question. This report describes the feasibility, safety, and utility of transesophageal echocardiography performed by pulmonary and critical care fellows in a medical ICU in critically ill patients who were mechanically ventilated.

Methods: This longitudinal descriptive study of advanced transesophageal echocardiography was performed in patients who were mechanically ventilated.

Safety of Propofol as an Induction Agent for Urgent Endotracheal Intubation in the Medical Intensive Care Unit.

Purpose: Propofol is known to provide excellent intubation conditions without the use of neuromuscular blocking agents. However, propofol has adverse effects that may limit its use in the critically ill patients, particularly in the hemodynamically unstable patient. We report on the safety and efficacy of propofol for use as an agent for urgent endotracheal intubation (UEI) in the critically ill patients.

Critical care nurses' perception of time spent at rapid responses.

Rationale: Critical care nurses are an integral part of rapid response (RR) teams. The length of time they spend away from an intensive care unit (ICU) to attend RRs and how ICU nurses perceive the time away from the ICU has not been previously evaluated.

Objectives: To determine: (1) the time an ICU nurse spends at RRs; (2) ICU nurses' view of nursing absence; and (3) RR characteristics associated with longer nursing time.

Video laryngoscopy is associated with increased first pass success and decreased rate of esophageal intubations during urgent endotracheal intubation in a medical intensive care unit when compared to direct laryngoscopy.

Background: To compare the complication rates of urgent endotracheal intubation (UEI) performed by pulmonary critical care medicine (PCCM) fellows and attending intensivists using a direct laryngoscope (DL) versus a video laryngoscope (VL) in a medical intensive care unit (MICU).

Methods: We studied all UEIs performed from November 2008 through July 2012 in an 18-bed MICU in a university-affiliated hospital. All UEIs were performed by 15 PCCM fellows or attending intensivists using only the DL from November 2008 through February 2010 and the VL from March 2010 to July 2012.

Respiratory effort-related arousals contribute to sympathetic modulation of heart rate variability.

Purpose: Sympathetic activation induced by sleep-disordered breathing may contribute to cardiovascular morbidity. However, the apnea-hypopnea index (AHI) excludes respiratory effort-related arousals (RERAs) associated with inspiratory flow limitation without oxygen desaturation. We sought to determine whether RERAs are associated with sympathetic activation.

Adequacy of chest compressions performed by medical housestaff.

Background: Chest compressions (CCs) are a critical part of cardiopulmonary resuscitation. We studied the presence and duration of adequate CCs performed by medical housestaff, and correlated our findings with gender and body mass index.

Methods: Fifty-eight first-postgraduate-year medical housestaff performed CCs on a computerized patient simulator equipped with a calibrated CC measurement device.

Utility of ultrasonography for detection of gastric fluid during urgent endotracheal intubation.

Purpose: Aspiration of gastric contents is a dangerous complication of urgent endotracheal intubation (UEI). Left upper quadrant (LUQ) ultrasonography may have the potential to decrease this complication by identifying patients with gastric fluid content, thereby allowing the UEI team to evacuate gastric contents prior to intubation.

Methods: This was an observational study of 80 UEIs where LUQ ultrasonography was performed in a medical intensive care unit of a tertiary care hospital.

Transferable capacity for gastrointestinal colonization in Enterococcus faecium in a mouse model.

A high level of gastrointestinal colonization frequently precedes invasive infection due to Enterococcus faecium. Factors other than antimicrobial resistance that promote gastrointestinal colonization by E. faecium have not been identified.

Antibiotic-induced enterococcal expansion in the mouse intestine occurs throughout the small bowel and correlates poorly with suppression of competing flora.

To test the hypothesis that establishing gastrointestinal colonization with multiresistant Enterococcus faecium (VRE) C68 results from expansion of the enterococcal population in the upper small bowel, we compared VRE quantities recovered from the proximal, middle, and distal segments of the small bowel from mice treated with different antimicrobial agents. Antibiotics associated with high-level VRE fecal colonization (cefotetan, ceftriaxone, clindamycin, and ticarcillin-clavulanic acid) increased VRE quantities in all small-bowel segments, whereas cefepime and piperacillin-tazobactam did not. Enterococcal expansion did not correlate with reductions in numbers of native gram-negative or anaerobic flora.

Enterococcus faecium low-affinity pbp5 is a transferable determinant.

Using 15 unrelated Enterococcus faecium isolates as donors, we demonstrated that ampicillin resistance was transferable to an E. faecium recipient containing a pbp5 deletion for all but four strains. The transfers occurred at low frequencies (generally ca.

In vitro antienterococcal activity explains associations between exposures to antimicrobial agents and risk of colonization by multiresistant enterococci.

We compared ceftriaxone and piperacillin-tazobactam at doses ranging from 0.1 to 2 times the human equivalent daily dose (HEDD), to determine their impact on gastrointestinal colonization by ampicillin- and vancomycin-resistant Enterococcus faecium C68 in a mouse model. Ceftriaxone failed to promote colonization at doses up to 0.

Beta-lactam antibiotics and gastrointestinal colonization with vancomycin-resistant enterococci.

We studied the effect of different subcutaneously administered beta-lactam antibiotics on the establishment of gastrointestinal colonization by vancomycin-resistant Enterococcus faecium C68 in a mouse model. Aztreonam, cefazolin, cefepime, and, to a lesser extent, ceftazidime, which neither have significant antienterococcal activity nor are secreted into human bile at high concentrations, did not promote significant vancomycin-resistant enterococci (VRE) colonization. Piperacillin-tazobactam, which has antienterococcal activity and is secreted in human bile at high concentrations, inhibited colonization after limited exposure to the inoculum but was associated with progressively increased VRE colony counts in stool samples after repeated exposure to the VRE inoculum.