Managing the cost of care: a predictive study to identify critical care patients at risk for nosocomial pneumonia

Nosocomial infections represent a major health problem and can have a significant impact on the cost of treating a patient. Hospital-acquired pneumonia (HAP) is the second most common nosocomial infection in the United States and the leading cause of death due to a nosocomial infection. The high prevalence of HAP and its significant impact on increased length of stay and incremental treatment costs identify nosocomial pneumonia (NP) as a key component in managing the total cost of care. The study's objective was to develop a predictive tool for identifying those adult patients in critical care (CC) who are at greatest risk of developing NP to better manage the costs of care. The authors also expected to determine the expected probability of a patient developing NP in CC. A prospective study of longer stay critical care unit (CCU) patients was performed in nine U.S. CCUs. There were no interventions in the study. Development was based on variables common to CC and specific patient profile risk factors. Twelve statistically significant and clinically meaningful risk factors were identified and placed in a sequential cascade fashion. The positive predictive value of the sequential decision process and corresponding tool was 87.03 percent.

Surgical management of the thyroid nodule: patient selection based on the results of fine-needle aspiration cytology

To determine whether the routine use of fine-needle aspiration (FNA) cytology reduces the rate of unnecessary surgery, the surgical pathology of 54 thyroidectomy patients who had preoperative FNA was compared to the results obtained with 24 thyroidectomy patients who did not have preoperative FNA. Twenty-nine (85.3%) of the 34 patients who had a positive FNA were confirmed by histology to have a thyroid neoplasm; in 24 patients, the neoplasm was malignant. Two of the 17 patients who had a negative FNA but underwent thyroidectomy based on other factors were found to have thyroid cancer. Only 8 (33.3%) of the 24 surgical specimens of patients who did not have an FNA were found to be malignant. FNA had a sensitivity of 93.5% and a specificity of 75.0%. The results indicate that the routine use of FNA for patients with thyroid nodules reduces the incidence of unnecessary surgery. Furthermore, FNA alone is sufficient to identify most patients at risk and is, therefore, cost-effective. However, the presence of other findings suspicious of malignancy should preclude clinical decision making based on FNA alone.

The rhinologic evaluation of Alzheimer's disease

Olfactory dysfunction is currently not listed among the NINCDS-ADRDA clinical criteria for the diagnosis of Alzheimer's disease. There is a large amount of psychophysical and neuropathologic evidence to suggest that patients with Alzheimer's type dementia have olfactory system abnormalities. The rhinologic status of this group has not been characterized. The authors examined 21 Alzheimer's patients and 21 age-matched controls to determine whether 1. the Alzheimer's group, in fact, had a diminished sense of smell, and whether 2. rhinologic factors were responsible for this nasal dysfunction. The findings support a neurologically mediated phenomenon as the cause for significant impairment in olfactory function in patients with probable Alzheimer's disease.

Actinomycosis in obstructive tonsillar hypertrophy and recurrent tonsillitis

A quantitative analysis of adenoid and tonsillar specimens from 460 patients was performed. The patients underwent tonsillectomy or adenotonsillectomy for either recurrent tonsillitis or obstructive tonsillar hypertrophy. Histologic preparations revealed Actinomycetes as statistically more prevalent in the obstructive population. The presence of Actinomycetes in the adenotonsillar core of this diagnostic group may indicate an etiologic role for this organism in tonsillar and adenoidal hypertrophy.

Catheterization of branchial sinus tracts. A new method

The complete surgical extirpation of branchial cleft abnormalities is essential in avoiding recurrent disease. The most technically difficult maneuver is often the localization and excision of associated sinus tracts and fistulae. The authors communicate a simple yet effective technique for dealing with this difficulty utilizing the Fogarty embolectomy catheter.

The otolaryngologic manifestations of Pelizaeus-Merzbacher disease

Pelizaeus-Merzbacher disease is a condition of central nervous system dysmyelination. We describe a familial series in which both otologic and laryngologic abnormalities were present. The diagnosis of this invariably fatal disorder can be made on a clinical and/or pathologic basis. As the otolaryngologic manifestations are often the first to appear, the consulting head and neck surgeon may be essential in the initial diagnosis of this hereditary disease.

Rhinocerebral mucormycosis: results of aggressive surgical debridement and amphotericin B

Rhinocerebral mucormycosis is a fulminant, devastating fungal disease. The use of amphotericin B, combined with aggressive surgical debridement, has increased survival rates from approximately 20% to 70%. Eleven patients with this rare disease have been treated over the past 6 years. Therapy with amphotericin B was begun in all patients as soon as the diagnosis of mucormycosis was suspected. Seven patients underwent aggressive surgical debridement; all seven had disease involving the sphenoethmoidal complex, requiring external ethmoidectomy with or without sphenoidotomy. Six patients had maxillary sinus disease, requiring Caldwell-Luc antrostomy or maxillectomy. Three patients required orbital exenteration. Surgery was performed within 24 hours of diagnosis on all but two of our patients. Despite prompt diagnosis, aggressive surgical debridement, therapy with amphotericin B, and correction of metabolic acidosis, our mortality rate was 82%. Rhinocerebral mucormycosis remains a rapidly progressive, frequently fatal disease.

The initial evaluation of dysosmia

Patients with disturbances in their sense of smell often represent a bewildering array of alternative diagnoses. The existing knowledge of olfactory disorders has been schematized into a systematic history approach toward the development of a differential diagnosis for dysosmic patients. Its components should elicit essential elements of the history which, according to the literature, have been associated with dysosmia. The ability to update the details of specific components permits it to be adapted to the needs of the individual practitioner.