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Malignant catatonia (MC) is a life-threatening manifestation which can occur in the setting of an underlying neuropsychiatric syndrome or general medical illness and shares clinical and pathophysiological features and medical comorbidities with the Neuroleptic Malignant Syndrome (NMS). The subsequent diagnosis and definitive therapy of MC are typically delayed, which increases morbidity and mortality. We present two cases of MC and review recent literature of MC and NMS, illustrating factors which delay diagnosis and management. When clinical features suggest MC or NMS, we propose early critical care consultation and stabilization with collaborative psychiatric management.

Ketoacidotic syndromes are frequently encountered in acute care medicine. This article focuses on ketosis and ketoacidotic syndromes associated with intoxications, alcohol abuse, starvation, and certain dietary supplements as well as inborn errors of metabolism. Although all of these various processes are characterized by the accumulation of ketone bodies and metabolic acidosis, there are differences in the mechanisms, clinical presentations, and principles of therapy for these heterogeneous disorders. Pathophysiologic mechanisms that account for these disorders are presented, as well as guidance regarding identification and management.

In susceptible patients, alcohol withdrawal syndrome (AWS) is often precipitated by other medical or surgical disorders, and AWS can adversely affect the course of these underlying conditions. Although the mortality rate of AWS has decreased over the past few decades, significant risk for morbidity and death remain if management is complicated by a variety of conditions. This review of AWS focuses on the scope of the clinical problem, historical features, pathophysiology, clinical presentation, and approaches to therapy, with particular emphasis on severe AWS that requires management in the intensive care unit.

The year 2015 marked the 200th anniversary of the birth of Ignaz Semmelweis, the Hungarian physician who identified unhygienic practices of physicians as a major cause of childbed fever or puerperal sepsis. Although such practices have largely disappeared as a factor in the development of chorioamnionitis and postpartum or puerperal endometritis, it is appropriate that this article on sepsis in pregnancy acknowledges his contributions to maternal health. This review describes the incidence and mortality of sepsis in pregnancy, methods to identify and define sepsis in this population, including scoring systems, causes, and sites of infection during pregnancy and parturition and management guidelines.

OBJECTIVES/SPECIFIC AIMS: Background: Delirium is a well described form of acute brain organ dysfunction characterized by decreased or increased movement, changes in attention and concentration as well as perceptual disturbances (i.e., hallucinations) and delusions. Catatonia, a neuropsychiatric syndrome traditionally described in patients with severe psychiatric illness, can present as phenotypically similar to delirium and is characterized by increased, decreased and/or abnormal movements, staring, rigidity, and mutism. Delirium and catatonia can co-occur in the setting of medical illness, but no studies have explored this relationship by age. Our objective was to assess whether advancing age and the presence of catatonia are associated with delirium. METHODS/STUDY POPULATION: Methods: We prospectively enrolled critically ill patients at a single institution who were on a ventilator or in shock and evaluated them daily for delirium using the Confusion Assessment for the ICU and for catatonia using the Bush Francis Catatonia Rating Scale. Measures of association (OR) were assessed with a simple logistic regression model with catatonia as the independent variable and delirium as the dependent variable. Effect measure modification by age was assessed using a Likelihood ratio test. RESULTS/ANTICIPATED RESULTS: Results: We enrolled 136 medical and surgical critically ill patients with 452 matched (concomitant) delirium and catatonia assessments. Median age was 59 years (IQR: 52–68). In our cohort of 136 patients, 58 patients (43%) had delirium only, 4 (3%) had catatonia only, 42 (31%) had both delirium and catatonia, and 32 (24%) had neither. Age was significantly associated with prevalent delirium (i.e., increasing age associated with decreased risk for delirium) (p=0.04) after adjusting for catatonia severity. Catatonia was significantly associated with prevalent delirium (p

Coccidioides immitis is a fungus endemic to the southwestern United States. Susceptible hosts, including blacks, Hispanics, Filipinos, Native Americans, and those with compromised immunity, may develop disseminated disease, including fungemia. We retrospectively reviewed the records of all patients (n = 33) with Coccidioides immitis fungemia (CIF) at a 550-bed public hospital in Phoenix, Arizona, from 1990 to 2002. This is the largest reported series of CIF. The purpose of the study was to review the incidence, signs, symptoms, and outcomes of CIF. Twenty-nine patients had human immunodeficiency virus infection. CIF was associated with sepsis, end-stage alcoholic liver disease, and diabetes in four patients. Survival was poor; 24 of the 33 patients died within 28 days. CIF manifested as a systemic inflammatory response syndrome with progressive cardiorespiratory failure. Despite fluid loading, infusion of vasoactive agents, and mechanical ventilation with positive end-expiratory pressure, patients typically experienced a rapidly progressive course and death. CIF portends an ominous prognosis and typically occurs in the setting of advanced human immunodeficiency virus or medical or surgical crises.

Acute arthritis in critically ill patients may be caused by local or systemic infection, by a flare of chronic joint disease such as rheumatoid or crystal-associated arthritis, or by less common entities such as hemarthrosis. Diagnosis requires analysis of synovial fluid, and appropriate treatment is based on its findings. Prompt diagnosis and treatment are usually necessary to prevent the significant morbidity associated with these conditions.

Tetanus is a rare disease in the United States. From 1995-1997, the average annual incidence of tetanus was 0.15/1,000,000 population. Injecting-drug users, particularly those who use heroin, are among the highest risk population for acquiring tetanus. We present a case of an injecting-drug user who was seen in the emergency department with worsening diffuse midthoracic back pain and spasms. He subsequently developed acute respiratory failure and central nervous system hypoxic injury. Serum obtained before administration of tetanus immune globulin showed a tetanus antibody titer greater than 16 times the level considered protective. Because of limited human data on the minimum protective level of neutralizing antibody, as well as reports of tetanus among individuals with "protective" antibody titers, the diagnosis of tetanus should not be excluded solely on the basis of antitetanus titers.

Because of the critical role of neutrophils in host defenses, it was hypothesized that stimulation of neutrophil production and function with Filgrastim would improve the outcome of hospitalized patients with community-acquired pneumonia. To test this hypothesis, a randomized, placebo-controlled, multicenter trial of Filgrastim (300 micrograms/day up to 10 days) as an adjunct to antibiotics was conducted for these patients. Outcome measures included time to resolution of morbidity (TRM, a composite measure of temperature, respiratory rate, blood oxygenation, and chest radiograph), 28-day mortality, length of stay, and adverse events. Filgrastim increased blood neutrophils 3-fold, but TRM, mortality, and length of hospitalization were not affected. Treatment, however, accelerated radiologic improvement and appeared to reduce serious complications (e.g., empyema, adult respiratory distress syndrome, and disseminated intravascular coagulation). Filgrastim administration was safe and well tolerated in these patients. Additional trials are needed to establish the value of this approach to treatment of infectious diseases.

The incidence of coccidioidomycosis in the southwestern United States has sharply increased over the last decade as a result of environmental and demographic changes. It is important to review the epidemiology, diagnostic indicators, and therapeutic options for both immunocompetent and immunocompromised patients who have a particularly high risk of infection.

Simultaneous electrophysiological and behavioral studies were performed on 21–32 day old juvenile medaka (Oryzias latipes) exposed at sublethal concentrations to organic chemicals representing various modes of action. Non-invasive recordings were made of the electrical impulses generated within giant neuronal Mauthner cells, associated interneurons and motoneurons, and axial musculature, all of which initiate the startle or `escape' response in fish. Timing in ms between these electrical sequelae was measured for each fish before and after 24 and 48 h exposure to a chemical. Carbaryl and phenol affected Mauthner cell to motoneuron transmission while chlorpyrifos, carbaryl, phenol and 2,4-dinitrophenol (DNP) showed neuromuscular effects. The variety of neurological effects detected at various concentrations of chemicals tested here suggest that different mechanisms may be responsible. Also noted was the number of startle responses to number of stimuli ratio (R/S); this ratio was affected by most chemicals. Medaka generally appeared to be more susceptible to predation after exposure to chlorpyrifos, carbaryl, fenvalerate, endosulfan, phenol, 1-octanol and DNP. The effects threshold for many of the test compounds was found to be consistent for both the neurophysiological and behavioral endpoints. Consequently, electrophysiological responses of Mauthner cell-initiated startle responses provided a measure of neurological injury that is also directly correlated to a definitive and ecologically relevant behavioral endpoint.

The production of hyperlactatemia in the critically ill patient has previously been thought to be primarily related to anaerobic conditions. Newer data suggests that lactate accumulates under aerobic conditions in clinical settings that were previously thought to solely represent anaerobic processes. This review summarizes the present understanding of lactate metabolism and reviews the data supporting use of lactate determinations in the critical care setting. The use of lactate as a marker of inadequate tissue perfusion as well as its role as a prognostic indicator are discussed. The utility of managing lactic acidosis with various buffers is also reviewed.

The advent of crack cocaine has changed the face of acute cocaine intoxication. Repeated doses of highly concentrated, rapidly delivered drug can give rise to an array of potentially fatal cardiovascular, neurologic, and respiratory complications.

Although concentrated infusions of potassium chloride commonly are used to treat hypokalemia in intensive care unit patients, few studies have examined their effects on plasma potassium levels. Forty patients with hypokalemia were given infusions of 20 mmol of potassium chloride in 100 mL of normal saline over 1 hour; 26 patients received the infusions through the central vein and 14 patients through the peripheral vein. Plasma potassium ([K]p) was measured at 15-minute intervals during and after the infusion in 31 patients. delta K was defined as the difference between each potassium determination and baseline plasma potassium concentration. Continuous electrocardiographic recording was carried out during the infusion and during the 1-hour period immediately preceding the infusion. Mean baseline [K]p was 2.9 mmol/L and all subsequent plasma concentrations significantly increased from baseline. Mean peak [K]p was 3.5 mmol/L, [K]p (1 hour postinfusion) was 3.2 mmol/L, and mean postinfusion delta K was 0.48 mmol/L (range -0.1-1.7 mmol/L). Arrhythmias, changes in cardiac conduction intervals, and other complications did not occur. The frequency of premature ventricular beats decreased significantly during the infusion compared with that of the control period. The high concentration (200 mmol/L) and rate of delivery (20 mmol/hr) of the potassium chloride infusions were well tolerated, decreased the frequency of ventricular arrhythmias, and did not cause transient hyperkalemia.

This article reviews the ongoing controversy surrounding the selection of crystalloid or colloid therapy in various states of circulatory shock. Shock conditions associated with increased microvascular permeability are specifically described. Appropriate monitoring techniques are discussed as well as complications of fluid resuscitation.

OBJECTIVE To test the hypothesis that the mortality rate of acutely ill patients admitted to a medical ward or medical ICU is higher for those patients who present with hypomagnesemia than for those patients who do not present with hypomagnesemia. DESIGN Prospective, observational study. SETTING Emergency Department admissions to the medical ward and medical ICU of a tertiary care teaching hospital serving an inner city patient population. SUBJECTS A total of 381 consecutive acutely ill patients. MEASUREMENTS Serum magnesium concentrations and other metabolic variables were measured on admission from the Emergency Department. Acute Physiology and Chronic Health Evaluation (APACHE II) scores were computed for all patients, and mortality rates were determined for hypomagnesemic and normomagnesemic groups. MAIN RESULTS Hypomagnesemic and normomagnesemic groups had comparable APACHE II scores and other variables. However, the mortality rates of the hypomagnesemic ward and medical ICU groups were approximately twice (p < .01) the rate of the normomagnesemic groups. Additionally, the duration of hospital survival in those patients who died was approximately 8 days less for hypomagnesemia than normomagnesemia, but not for ward admissions. Other associated metabolic abnormalities were frequently observed in both hypomagnesemic and normomagnesemic groups, including hypokalemia and hypocalcemia. CONCLUSIONS Hypomagnesemia detected at the time of admission of acutely ill medical patients is associated with an increased mortality rate for both ward and medical ICU patients.

The current severe nursing shortage in the United States has many causes and its solution requires new strategies, Collaboration among the American Association of Critical-Care Nurses (AACN), the Society of Critical Care Medicine (SCCM) and the American College of Cardiology (ACC) has provided a model for the multidisciplinary approach needed. Narse-physician collaboration is an important strategy to address the ongoing shortage.

Fluid therapy is a uniformly accepted, logical, and highly effective therapeutic intervention for the treatment of patients with reductions in circulating intravascular volume. This article discusses fluid resuscitation of shock associated with increased vascular permeability and addresses the use of colloids and crystalloids in these disorders.

The increased prevalence of rodents resistant to warfarin led to the development of the hydroxycoumarin anticoagulant brodifacoum. A 25-year-old man attempted suicide by consuming four boxes of d-CON Mouse-Prufe II; each box contains 42 g of bait that is 0.005% brodifacoum. He presented to a hospital nine days later with syncope, hematochezia, gross hematuria, epistaxis, anemia, and a severe coagulopathy. Radiographic studies were consistent with pleural, pericardial, and mediastinal hemorrhages. Vitamin K and fresh frozen plasma were given, and he was later discharged on oral phytonadione (vitamin K1). The patient's coagulopathy recurred, necessitating multiple plasma transfusions and prolonged treatment with oral phytonadione. Fifteen weeks after hospital discharge, he presented again with a history of additional brodifacoum ingestion. Neurologic status was initially normal, but in the emergency department he suddenly became comatose soon after emesis was induced with syrup of ipecac. Computed tomography of the brain revealed a subarachnoid hemorrhage that led to brain death less than 24 hours later. This case demonstrates the severe and prolonged coagulopathy that can result from ingestion of brodifacoum, a compound that has a toxic potency about 200-fold that of warfarin and a half-life as much as 60 times longer.

To examine the hemodynamic patterns of critically ill patients with septicemia to evaluate their relationship to blood bacteriology.Retrospective study.Medical ICUs of a tertiary care medical center.Total of 59 critically ill patients with bacteremia: 33 with Gram-positive and 26 with Gram-negative bacteremia.Hemodynamic variables and mixed venous oxygen saturation (SvO2) measurements associated with the highest cardiac index measured within 72 hrs of positive blood cultures.No significant differences in cardiac index, mean arterial pressure, systemic vascular resistance, oxygen extraction ratio, or SvO2 were observed comparing the two groups.We were unable to demonstrate clinically important differences between the hemodynamic responses to Gram-positive vs. Gram-negative sepsis.

We induced severe left-sided lung fibrosis by the unilateral endobronchial instillation of paraquat (1.0 mg/kg) into the left lungs of adult Fischer 344 male rats. Growth of the contralateral lung as well as its proliferative activity were measured 6 or 14 days later. Whereas the left lung underwent severe fibrosis and shrinkage with more than 85% reduction in lung volume, the right lung more than doubled in size. In addition, there was a significant increase in total protein content, DNA content, and DNA synthesis. We conclude that unilateral lung injury resulting in ipsilateral fibrosis and loss of parenchyma is associated with compensatory growth of the contralateral lung.

The majority of industrial organic chemicals lack identifiable structural characteristics that result in specific biological activity. These nonpolar-nonelectrolytes are acutely toxic to aquatic organisms via a nonspecific mode of action termed narcosis. The toxicity of industrial chemicals eliciting nonpolar narcosis can be reliably predicted by log P (baseline toxicity models). Using single chemical and joint toxic action models, several research groups have reported classes of polar compounds (for example, esters, phenols, and anilines) that elicit a narcosis-like syndrome; however, they are more acutely toxic than what is predicted using baseline toxicity models. An assessment of rainbow trout (Salmo gairdneri) in vivo respiratory-cardiovascular responses during intoxication by polar narcotic phenol and aniline derivatives established a toxicity syndrome unique to that elicited by nonpolar narcotics. This finding further suggests a mode of action unique to polar narcotics and supports the use of structure-activity relationships specific for these compounds. The proposition that there may be multiple mechanisms or sites of narcotic action is compatible with recent studies concerning the cellular and molecular mechanisms of anesthetic action.

Primary gastrointestinal (GI) lymphomas constitute 5%-10% of all gastrointestinal tumors. Involvement of the entire GI tract as multiple polypoid lesions is very rare. Multiple lymphomatous polyposis is a distinctive and rare type of malignant GI lymphoma. Multiple lymphomatous polyposis is thought to represent mantle cell lymphoma of the GI tract. Approximately 60 cases of MLP have been reported so far. We report the first case of diffuse large B-cell lymphoma presenting as multiple lymphomatous polyposis of the GI tract in a 49-year-old patient with HIV and describe the clinicopathologic features. The patient was treated with a combination therapy of highly active antiretroviral therapy and CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) and exhibited complete remission.

We reviewed the changes in Do2 and Vo2 in 58 patients with ARDS after interventions which included fluid loading, blood transfusion, and PEEP. After a significant change in Do2, patients with lactic acidosis (lactate level greater than 2.4 mmol/L) exhibited significant corresponding changes in Vo2 (p less than 0.001); however, no change in Vo2 was observed in patients without lactic acidosis (1-beta greater than 0.8). We conclude that a biphasic pattern of oxygen utilization in patients with ARDS emerges when subsets of patients with and without lactic acidosis are compared. Lactic acidosis, a marker of anaerobic metabolism, may be a characteristic of patients with ARDS who exhibit changes in Vo2 that are dependent on changes in Do2.

Coccidioidomycosis, a disease endemic to the southwestern United States, is caused by the dimorphic fungus Coccidioides immitis. This organism, initially categorized as a protozoan, has been known to cause morbidity and mortality for more than 100 years. Coccidioidomycosis is usually a benign, self-limiting respiratory disorder, but may lead to progressive pulmonary disease and dissemination. Manifestations are protean, and coccidioidomycosis is often confused with other disorders. Management of advanced infection is unsatisfactory. When fungemia is identified, prognosis is poor. 1-5 A patient presented with a lesion initially identified as a related fungus, Rhinosporidiosis seeberi. The patient rapidly deteriorated with acute respiratory failure, obtundation, coma, shock, and death. Blood cultures ultimately grew coccidioidomycosis. The clinical features of severe coccidioidomycosis including fungemia, together with a comparison of the key clinical and microbiologic features of coccidioidomycosis and rhinosporidiosis, are discussed.

We evaluated the feasibility of utilizing physician assistants as providers of primary care in a medical ICU. After a three-month period of rigorous training, two PAs were assigned to the ICU. Their performance as well as the operation of the ICU over a two-year period was evaluated and compared to two preceding years when it was operated by house officers. There were no changes in occupancy, mortality or the rate of complications. Evidence for more careful evaluation of patients prior to admission and discharge, manifesting as slightly fewer admissions and slightly longer duration of hospitalization, was also documented. We conclude that properly trained PAs may have a role in providing health care in intensive care settings. (Chest 1991; 99:89–91)

This article reviews the hypothesis that staffing with full-time intensive care physicians leads to improvements in the management of ICUs and in the outcome for ICU patients. Variations in the professional organization of critical care units in the United States are discussed. The advantages and disadvantages of open, closed, and transitional (comanagement) ICU organizational structures are presented.

Variations in the strontium isotope ratio ( 87 Sr/ 86 Sr) of tooth enamel are used to examine the migration patterns of late Pleistocene mammoths and mastodons from Florida. An animal’s 87 Sr/ 86 Sr ratio tracks the ratios of its environment, which vary with differences in bedrock and soil. Consequently, the environmentally controlled differences in 87 Sr/ 86 Sr ratio recorded in mineralized tissue, such as tooth enamel, may be used to reconstruct the movement patterns of an individual. We map variations in local 87 Sr/ 86 Sr ratios across modern Florida and Georgia through analysis of rodent teeth, plants, and surface water, then use this map to interpret the movement patterns of extinct mammals. Mastodons from northern and central Florida have higher 87 Sr/ 86 Sr ratios than both modern environmental samples from Florida and fossils from nonmigratory species, suggesting that mastodons migrated north into Georgia. Mammoths display ratios similar to those of environmental samples and resident species, suggesting that they did not migrate outside Florida.