Should fever in ICU patients be treated routinely? No, according to the results of a prospective study from Switzerland.

Gozzoli and colleagues randomized 18 surgical ICU patients with temperatures of 38.5°C or higher to external cooling with blankets, ice packs, and cloths, and 20 similar patients to no antipyretic therapy. Excluded from the study were patients who were receiving parallel antipyretic drug treatment. The primary outcome measure was a reduction in fever in 24 hours.

At 24 hours, the mean temperature fell from 38.9°C to 37.6°C in the treated patients, and from 38.8°C to 37.7°C in the controls. The discomfort level was similar in both groups. After 24 hours, fever recurred in four (22%) and two (10%) patients, respectively. Both groups had similar ICU stays (median, six days each), hospital stays (median, 22 vs 23 days, respectively), and mortality (two [11%] vs three [15%], respectively).

The authors estimate that at their institution the annual cost (in US dollars) of antipyretic therapy for about 18 febrile ICU patients per month would be $10,000 when acetaminophen is used, $10,500 when cooling is done with blankets, and $29,000 for ice packs. They note that while treatment of fever may not be worthwhile in all ICU patients, they do recommend it for patients with temperatures above 40.5°C, especially in the presence of neurotrauma or other acute neurologic diseases, severe hypoxemia, malignant hyperthermia, or heat shock.

Gozzoli V, Schöttker P, Suter PM, Ricou B. Is it worth treating fever in intensive care unit patients? Preliminary results from a randomized trial of the effect of external cooling. Arch Intern Med. 2001;161:121-123.

A six-item questionnaire is a valid, easily administered instrument for comparing health-related quality-of-life changes over time in children with obstructive sleep disorders (OSDs). The instrument (OSD-6) may provide useful information when used before and after surgery, as well as in the absence of any intervention, according to the authors of a prospective, multicenter study.

The investigators recruited 100 caregivers of children with OSDs (age range, 2.1 to 12.9 years) to administer the instrument to the children in their care. The questionnaire covers six domains, with scores ranging from 0 (no problem) to 6 (it couldn't be worse); the types of problems covered in the questionnaire are listed in Table 1. Forty-five caregivers completed another survey within three weeks of the first to determine test-retest reliability, and 62 completed another survey after their children had undergone adenotonsillectomy to evaluate the questionnaire's responsiveness to clinical change. An additional 12 caregivers whose children did not undergo surgery filled out another survey more than three weeks after the first.

Test-retest reliability was good for all domains except activity limitations. Among the 62 children who underwent adenotonsillectomy, postsurgical OSD scores were found to have decreased substantially in 55 of them (88.7%); the mean change among these children was 3.0. Among the other 12 children for whom surveys were filled out more than three weeks later, the mean change was 0.35.

The authors suggest that a caregiver who completes the OSD-6 may be more attuned to a child's quality of life than a physician who has only brief contact with the child.

de Serres LM, Derkay C, Astley S, et al. Measuring quality of life in children with obstructive sleep disorders. Arch Otolaryngol Head Neck Surg. 2000; 126:1423-1429.

A community-based outreach program to encourage use of the pneumococcal and influenza vaccines by persons age 65 years and older is reasonably cost-effective, and more cost-effective than promoting either vaccine alone, according to the authors of a controlled study.

Weaver et al randomized 622 members of a Seattle senior center, ages 65 and older, to a high-intensity intervention designed to encourage pneumococcal and inf luenza vaccine use, and 623 similar subjects to a low-intensity intervention (control group); 530 and 553, respectively, completed a follow-up survey seven months later. The primary outcome measure was the proportion of participants who reported receiving either or both vaccines. The determination of cost effectiveness was based on the known relationships between use of the two vaccines and the illnesses and outcomes they are designed to prevent.

The cost per quality-adjusted life-year (QALY) was $35,486 for the combined outreach initiative, $53,547 for the pneumococcal vaccine, and $130,908 for the influenza vaccine. Among higher-risk subjects (those who had never received the pneumococcal vaccine or had not received the influenza vaccine during the previous year), the costs (per QALY) were $11,771, $38,030, and $22,431, respectively.

The authors estimate that cost effectiveness would improve even further if the combined outreach initiative were replicated for one or more additional years. In this scenario, the cost (per QALY) would be $26,512 for the initiative as originally implemented. If the combined initiative was repeated but targeted only at those at higher risk, the cost (per QALY) would be $7,843.

Weaver M, Krieger J, Castorina J, et al. Cost-effectiveness of combined outreach for the pneumococcal and influenza vaccines. Arch Intern Med. 2001;161:111-120.

Postdischarge survival and functional capacity are better indicators of outcome than intensive care unit (ICU) mortality and hospital discharge, say the authors of this retrospective study from the Cleveland Clinic Foundation. In addition, the investigators found that the small number of patients who require prolonged ICU stays consume a disproportionate amount of ICU and hospital direct costs.

Bashour et al evaluated postdischarge survival and functional outcomes in 2,618 patients who underwent cardiac surgery; 2,476 (94.6%) had ICU stays of fewer than 10 days, and 142 (5.4%) had ICU stays of 10 or more days. Only 37 (1.5%) of the patients in the first group, but 47 (33.1%) of the patients in the second group, died while in the hospital.

Of the 95 patients who required prolonged ICU stays but who were discharged from the hospital, 94 were followed for 16 to 37 months. Twenty-six (28%) died during the first six months postdischarge, and an additional 18 (19%) died within the next 25 months. The 50 long-term survivors had a median Duke Activity Status Index score (a reflection of vital status and functional capacity) of 26 out of a possible 58.2.

Further, the 142 patients who had stayed in the ICU for at least 10 days accounted for 48% of the total ICU costs attributed to all 2,618 patients and 23% of the total hospital direct costs. Multivariable analysis demonstrated that a prolonged ICU length of stay and poor postsurgical survival were associated with previous myocardial infarction, preoperative hypoalbuminemia, and a history of congestive heart failure.

Advanced age was associated with prolonged ICU stay but did not predict postsurgery survival.

Bashour CA, Yared J-P, Ryan TA, et al. Long-term survival and functional capacity in cardiac surgery patients after prolonged intensive care. Crit Care Med. 2000;28:3847-3853.

Asthma that remains symptomatic despite regular treatment with inhaled and/or oral corticosteroids is associated with persistent airway T-lymphocyte activation. However, there may not be concomitant eosinophil recruitment and activation in the airways, say the authors of this prospective study.

Redington and associates compared airway inflammatory changes in five patients with severe, chronic, corticosteroid-dependent, symptomatic asthma with similar changes in nine control patients with asthma that was clinically well controlled with inhaled corticosteroids. At the time of the study, the five symptomatic patients were being treated with oral prednisolone and high-dose inhaled corticosteroids.

Compared with the controls, the symptomatic patients had a significantly greater proportion of bronchoalveolar lavage (BAL) fluid T lymphocytes that were positive for the activation markers CD25 and HLA-DR. Bronchial biopsy specimens in both groups showed similar numbers of mast cells, eosinophils, and T lymphocytes. The number of subepithelial eosinophil cells did not correlate significantly with expression of either of the T-lymphocyte activation markers in the symptomatic patients but correlated significantly with expression of both markers in the controls.

Redington AE, Wilson JW, Walls AF, et al. Persistent airway T-lymphocyte activation in chronic corticosteroid-treated symptomatic asthma. Ann Allergy Asthma Immunol. 2000;85:501-507.

In patients with severe chronic obstructive pulmonary disease (COPD), noninvasive positive pressure ventilation (NPPV) provides only limited benefit, according to the authors of a prospective, controlled trial.

Casanova et al compared the effectiveness of standard treatment plus nocturnal NPPV with that of conventional standard treatment alone in 52 patients with stable, severe COPD. The 12-month study was completed by 20 patients randomized to nocturnal nasal ventilation with bi-level positive pressure ventilation and by 24 control subjects who received standard treatment.

At three months, the NPPV patients had an insignificantly lower number of hospital admissions and episodes of endotracheal intubation; however, even these small differences were not apparent at six or 12 months. Similarly, no significant changes were observed in arterial blood gas results, forced expiratory volume in one second, forced vital capacity, or lung volumes. Dyspnea improved significantly in the NPPV group by the end of the third month, but by six months the improvement was less apparent.

The authors suggest that NPPV may be of benefit in selected patients who can tolerate higher pressures and who could be closely monitored. However, the small proportion of suitable candidates for such treatment limits its clinical value.

Casanova C, Celli BR, Tost L, et al. Long-term controlled trial of nocturnal nasal positive pressure ventilation in patients with severe COPD. Chest. 2000;118:1582-1590.

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