Superior renal allograft survival and decreased rejection with early high-dose and sequential multi-species antilymphocyte globulin therapy.
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Animals↗
Biomedical subjects
F Thomas
Publications and source records attributed to F Thomas.
Paramedic use of advanced life support procedures: experience and attitude survey.
To gather information about paramedic use of 11 advanced life-support (ALS) procedures, 74 emergency physicians and 171 paramedics practicing in Utah were surveyed. Response was 66% and 65%, respectively. Performance difficulty, frequency of use, and success rate were evaluated. The willingness of physicians to order, and paramedics to perform each procedure were compared. Physicians' and paramedics' difficulty ratings were significantly different (P less than .001) for only 3 of the 11 procedures. During the study period, paramedics successfully performed 455 procedures; 229 were performed by 15 (13%) of the responding paramedics. The reported success rate for all attempted procedures was 82% (455/557). The number of attempts and the success rate was significantly higher (P less than .05) for paramedics with secondary medically affiliated employment. Paramedics were significantly more willing to perform 7 of the 11 procedures (P less than .001) than physicians were willing to order. We conclude that paramedic and physician difficulty ratings were generally similar, that many types of ALS procedures are rarely performed, that a small percentage of paramedics perform the largest number of ALS procedures, that secondary employment increases paramedics' procedural attempts and improves success rates, and that they are more willing to perform ALS procedures than physicians are to order them.
Allied Health Personnel↗
Risk factors associated with AIDS in Haiti.
A total of 121 acquired immunodeficiency syndrome (AIDS) patients diagnosed in Haiti were studied between June 1979 and December 1983. Risk factors were identified in 65% of 34 patients evaluated in a standardized manner since July 1983 and included: bisexuality, 38%; blood transfusion, 21%; and intravenous drug abuse or a spouse with AIDS, 6%. These risk factors were reported by only 20% of the 85 patients studied between June 1979 and June 1983. AIDS patients also reported more frequent parenteral injections prior to the onset of their illness than control subjects (e.g., siblings, friends, sexual partners). Heterosexual activity among female AIDS patients was also greater than in their female controls. It was concluded that, in contrast to the experience reported among Haitians with AIDS in the USA, risk factors are present among most patients with AIDS in Haiti.
Acquired Immunodeficiency Syndrome↗
Impact of prospective payments on a tertiary care center receiving large numbers of critically ill patients by aeromedical transport.
To determine the economic impact of federal prospective payments and the potential effect if private insurance payers were to implement similar prospective payments, we examined payments under Medicare diagnosis-related grouping (DRG) reimbursement policies for 105 Medicare and 357 non-Medicare patients admitted to a tertiary care center via air transport. Among the 105 Medicare patients, the average length of stay was 11.4 days and the mortality rate was 24%. Hospital charges exceeded DRG reimbursement for 74% of Medicare patients. A comparison of previous Medicare payment policies to current federal DRG reimbursement resulted in a revenue loss to the hospital of $667,229 ($6335 per patient). For the 357 non-Medicare patients, the average length of stay was 10.8 days, the mortality rate was 10%, and hospital charges exceeded Medicare DRG reimbursement for 78% of the patients. Implementation of DRG-like payments by non-Medicare insurers would create a hospital revenue loss of $2,493,048 ($6983 per patient). We conclude that unless current and planned prospective payment policies are modified, the use of aeromedical transport services to recruit large numbers of critically ill patients to tertiary care centers is economically prohibitive.
Aircraft↗
Reversible segmental myocardial dysfunction in septic shock.
We report two septic-shock patients who had ECG and echocardiographic changes consistent with myocardial infarction but no evidence of coronary artery disease or myocardial injury at autopsy. The segmental myocardial dysfunction completely resolved in one patient. Because septic shock can cause segmental myocardial dyskinesis, ECG and echocardiographic data may be misleading and should be interpreted cautiously.
Aged↗
Successful haematopoietic reconstitution using autologous peripheral blood mononucleated cells in a patient with acute promyelocytic leukaemia.
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Adult↗
Studies on the mechanism of insulin resistance in the liver from humans with noninsulin-dependent diabetes. Insulin action and binding in isolated hepatocytes, insulin receptor structure, and kinase activity.
We have developed a method to isolate insulin-responsive human hepatocytes from an intraoperative liver biopsy to study insulin action and resistance in man. Hepatocytes from obese patients with noninsulin-dependent diabetes were resistant to maximal insulin concentration, and those from obese controls to submaximal insulin concentration in comparison to nonobese controls. Insulin binding per cell number was similar in all groups. However, insulin binding per surface area was decreased in the two obese groups because their hepatocytes were larger. In addition, the pool of detergent-extractable receptor was further decreased in diabetics. Insulin receptors in all groups were unaltered as determined by affinity-labeling methods. However, insulin-stimulated insulin receptor kinase activity was decreased in diabetics. Thus, in obesity, decreased surface binding could explain resistance to submaximal insulin concentrations. In diabetes, diminished insulin-stimulated protein kinase activity and decreased intracellular pool of receptors could provide an explanation for postinsulin-binding defect(s) of insulin action in human liver.
Biopsy↗
Cryptococcal pneumonia in a patient with sickle cell disease.
We present the findings in a patient having sickle cell disease who developed multilobar pneumonia. Cultures of bronchial aspirates and histologic specimens grew Cryptococcus neoformans. There was neither spontaneous clearing of the infection nor a response to bactericidal antibiotics. The patient had no underlying malignant neoplasm or immunodeficiency as indicated by history, physical examination, and specialized tests of humoral and cell-mediated immunity.
Adult↗
Air ambulance regulations: a model.
Prior attempts at establishing minimal federal air ambulance regulations and standards have been unsuccessful. However, reports of poor patient medical care during transport by some air ambulance services is now forcing many states to initiate air ambulance regulations. In 1984, the State of Utah Emergency Medical Services convened a special subcommittee to develop aeromedical regulations for the State of Utah. Using a three-level approach based upon the patient's requirements for basic, advanced, or specialized medical care and the urgency of transport, the subcommittee was able to derive medical categories necessary for the selection and utilization of air ambulance services. Minimum air ambulance regulations were then established for aircraft configuration, flight crew requirements, minimal equipment and medications, and the responsibilities of the medical director or designee for each of the three levels of medical care. We conclude that the application of a levels approach based upon the patient's medical requirements may be useful in assisting other states attempting to establish flexible but specific regulations directed at the safe transport of patients by aeromedical evacuation.
Aircraft↗
Cutaneous sporotrichosis presenting as soft tissue sarcoma.
Sporotrichosis is not an uncommon disease. Lymphocutaneous involvement is the common characteristic but systemic dissemination from the primary skin lesion has been observed. The disease is progressive but spontaneous resolution, in rare instances, has been observed. Multiple, fungating, ulcerated, tumorous cutaneous lesions, fixed to the underlying tissue, often pose a difficult diagnostic problem, as in this case. The disease has been frequently related to occupational exposure to plant life, but handling of infected animals may be a source of infection in rare instances.
Aged↗
Prospective evaluation of the CRAMS scale for triaging major trauma.
In order to effectively implement a community-wide trauma system, a mechanism of field triage is required. This process of triage should be simple to use and should accurately identify patients who are in need of level I trauma facility care. It should also allow the less critically injured to be cared for at the local hospital of their choice or at the nearest community hospital. The CRAMS (Circulation, Respiration, Abdomen, Motor, Speech) scale was prospectively studied as a potential triage tool by using it to score patients in the field and then comparing their scores to their emergency room dispositions and final outcomes. The CRAMS scale was easy to apply and accurately identified both the critically injured who should be triaged to a Level I center and the less critically injured who can be adequately cared for by Level II and III centers.
Critical Care↗
The acquired immunodeficiency syndrome in Haiti.
Two hundred twenty-nine patients in Haiti with the acquired immunodeficiency syndrome were studied between 1979 and 1984. The clinical spectrum of the syndrome in Haitians was similar in most aspects to that in patients with the disease in the United States. However, in contrast to findings in the United States, accepted risk factors (bisexuality, blood transfusions, intravenous drug abuse) were identified in only 43% of Haitian patients. Patients in Haiti with and without these risk factors were similar to each other but differed from age- and sex-matched siblings and friends in the number of heterosexual contacts and receipt of intramuscular injections. These latter activities were commoner in patients than in their siblings and friends, and represent potential modes of transmission of infection with the human T-lymphotropic virus type III.
Acquired Immunodeficiency Syndrome↗
Securing the landing zone. Operations in EMS helicopter.
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Accident Prevention↗
A nationwide survey of civilian air ambulance services.
To identify and characterize civilian air ambulance services, a questionnaire was mailed nationwide to 583 prospective air ambulance services, with 154 responding. Our survey identified differences between hospital, hospital-affiliated, and private air ambulance services as to aircraft ownership, availability, types of aircraft, types of patients being transported, types of medical personnel and equipment, aircraft retrofit, and their feelings regarding air ambulance regulations. We found that hospital air ambulances are better suited for transporting critically ill patients while many private air ambulances appear better suited to transport nonemergency patients. Hospital-affiliated air ambulance services, although not as consistent in providing the specialized care of hospital air ambulances, appear better able to provide critical care than private air ambulance services. Based upon this data, we recommend that air ambulance regulations be directed at levels of patient care. Such regulations and guidelines will assist patient safety during aeromedical transports without jeopardizing currently operating air ambulance services.
Aircraft↗
A survey of advanced trauma life support procedures being performed by physicians and nurses used on hospital aeromedical evacuation services.
Traumatized patients may be transported by a variety of aeromedical transport teams. Frequently, the skills of physicians, nurses, and paramedical personnel overlap. This study was undertaken to determine if nurses used on hospital aeromedical evaluation services perform advanced trauma life support (ATLS) procedures usually reserved for physicians. Forty-seven hospital programs responded to our questionnaire. Flight nurses on programs (26) in which physicians were frequently used were significantly (p less than 0.05) less likely to perform cricothyreotomy, esophageal obturator airway placement, oral intubations, and pericardiocentesis than flight nurses of programs (21) not using flight physicians. Except for cervical tong placement (p less than 0.05), central line placement (p less than 0.05), and the performance of saphenous vein cutdown (p less than 0.05), no differences were found in procedures performed by flight nurses of programs not using physicians and those performed by flight physicians. We conclude that flight nurse abilities are expanding into areas traditionally set aside for physicians in providing advanced trauma life support procedures on hospital aeromedical services. Future studies need to be performed to determine their success and complication rates.
Aerospace Medicine↗
Physician decision-making--evaluation of data used in a computerized ICU.
New instrumentation, techniques and computers have made such large amounts of information rapidly available to ICU clinicians that there is now a danger of information overload. To help with this problem at LDS Hospital, a computerized system was implemented in the Shock-Trauma ICU. This ICU is almost totally computerized with each patient's physiologic, laboratory, drug, demographic, fluid input/output and nutritional data integrated into the patient's computer record. In the ICU, physician decision-making takes place in two situations: during rounds and on-site. For this study, data usage in decision-making was evaluated in both of these environments. The items of data used in decision-making were tabulated into six categories: bedside monitor, laboratory, drugs, input/output and IV, blood gas laboratory, observations and other. Comparisons were made between the portion of the computerized database occupied by a category and its use in decision-making. Combined laboratory data (clinical, microbiology and blood gas) made up 38 to 41% of total patient data reviewed and occupied 16.3% of the database. Observations made up 21-22% of the data reviewed and occupied 6.8% of the database. Drugs, input/output and IV data usage ranged from 13% to 23%, but occupied 36% of the database. Bedside monitor data usage was 12.5% to 22% and occupied 32.5% of the database. The 'other' category, used 2.5% to 5% of the time, made up 8.4% of the database. These results indicate that patient data collection and storage must be evaluated and optimized. This evaluation, along with implementation of the computerized ICU Rounds Report developed for optimal data presentation, will help physicians to evaluate patient status and should facilitate effective decisions.
Diagnosis, Computer-Assisted↗
A prospective comparison of arterial catheter blood and catheter-tip cultures in critically ill patients.
To determine if a culture of blood obtained through an arterial catheter reflects culture of the catheter's tip, we studied 68 arterial catheters removed from 65 patients with and without suspected catheter infections. Cultures of blood obtained before catheter removal were compared to catheter-tip cultures. The arterial catheter blood culture was neither sensitive nor highly predictive of positive catheter-tip cultures. Suspicion of catheter infection was not associated with a significantly higher rate of positive catheter-tip or blood cultures.
Adult↗
Effect of volume of blood cultured on detection of Streptococcus viridans bacteraemia.
Fifty eight patients undergoing dental extraction each had 45 ml blood collected. This was divided into 30 ml and 15 ml blood samples for culture. The 30 ml sample was inoculated into 120 ml nutrient broth with 0.05% liquoid and the 15 ml sample into 60 ml of identical broth so that the final dilution of blood in broth was always 1/5. Bacteraemia due to viridans streptococci was found in 27 and 15 patients by culturing the 30 ml and 15 ml blood samples respectively. Only one further case of streptococcal bacteraemia was detected by culture of the total volume of blood collected (45 ml) rather than culture of the 30 ml blood sample alone. These findings suggest that the culture of 30 ml blood results in the detection of up to 80% more blood cultures yielding Streptococcus viridans than the culture of only 15 ml blood. The collection of more than 30 ml blood for each culture is unlikely to prove worthwhile. It is suggested that 30 ml rather than 15 ml blood is probably the optimal volume of blood for each culture of S viridans when patients with suspected infective endocarditis are investigated.
Adult↗