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Biomedical subjects

J K Stoller

Publications and source records attributed to J K Stoller.

At least 73 records · Page 4Linked to original sources
PubMed1994

Travel for the technology-dependent individual.

In summary, recreational travel for the technology-dependent individual is common and includes travel via ground, water, and air, with oxygen and with mechanical ventilators. However, successful travel requires substantial advance preparation that involves fact-finding and communication with physicians, carriers, and vendors of equipment and oxygen. An increasing number of resource documents, both in the trade and in the scholarly literature are available for relevant information and assistance.

Aircraft↗
PubMed1994

Diagnosis and management of upper airway obstruction.

Upper airway obstruction is a potentially fatal condition that requires prompt diagnosis and treatment. Common causes include foreign body aspiration, infections (even in the adult population) and sequelae of intubation, tracheostomy, and transtracheal oxygen catheters. Spirometry is an insensitive test for diagnosing upper airway obstruction and reflects the functional, rather than anatomic, severity of an obstruction. Although simple tomography still plays an important role, CT and magnetic resonance imaging scans are useful additions to our diagnostic armamentarium. Advances in laser technology, surgery, and bronchoscopy have broadened treatment options but require further evaluation.

Airway Obstruction↗
PubMed1993

Diclofenac (Voltaren)-induced eosinophilic pneumonitis. Case report and review of the literature.

This report describes dyspnea, cough, erythema multiforme, and a diffuse pulmonary interstitial infiltrate associated with eosinophilic alveolitis in a 67-year-old man taking diclofenac sodium (Voltaren). Onset of these pulmonary abnormalities after beginning diclofenac therapy implicates this drug, which, to our knowledge, has not been described previously to cause eosinophilic pneumonitis. The current report expands the spectrum of nonsteroidal anti-inflammatory drug-induced eosinophilic pneumonitis and reviews available experience with other implicated non-steroidal anti-inflammatory drugs.

Aged↗
PubMed1993

Hypoplastic trachea in Down's syndrome.

Our study sought to determine whether tracheal dimensions were reduced in patients with Down's syndrome and whether such a narrowing, if present, was related to the presence of congenital heart disease or to body habitus (height or weight). The inner diameter of the tracheal air column was measured at 2 cm above the aortic arch in 14 adult patients with Down's syndrome, and the results compared with previously established norms. Two-way analysis of variance showed no significant difference in z-scores between sexes or between those with or without congenital heart disease. Z-scores were significantly different from zero for both coronal diameters (p = 0.0010) and sagittal diameters (p = 0.0003). The negative limits on the 95% confidence interval for coronal z-scores (-2.5 to -0.8) and sagittal z-scores (-2.6 to -1.0) indicate that our patients have tracheal diameters significantly smaller than normal. Linear regression analysis showed no significant correlation between tracheal diameters and patients' height or weight. We conclude that tracheal diameters in adult patients with Down's syndrome are reduced and that the narrowing cannot be ascribed to associated congenital heart disease or to body habitus.

Abnormalities, Multiple↗
PubMed1993

Trial of standard versus modified expiration to achieve end-of-test spirometry criteria.

To assess whether satisfying American Thoracic Society (ATS) end-of-test spirometry criteria can be enhanced by modifying the patient's expiratory technique, we conducted a cross-over trial of two expiratory techniques in 48 patients with a range of pulmonary functions (Group 1, n = 12: FEV1/FVC < 0.45; Group 2, n = 11: FEV1/FVC, 0.45 to 0.60; Group 3, n = 16: FEV1/FVC, 0.61 to 0.74; Group 4, n = 9: FEV1/FVC > or = 0.75). After randomizing the order of testing, each patient performed three exhalations using a "standard" forced expiratory maneuver and a modified expiratory technique consisting of an initial maximal expiratory effort followed by a "relaxed expiration" for as long as possible. Patients initiated "relaxed expiration" when instructed by the supervising technician, who issued the instruction to relax when expiratory airflow fell to < or = 200 ml/s (as determined by flow-volume loop analysis). ATS end-of-test criteria were satisfied significantly more often using the modified expiratory technique (58.3% of testing sessions) than using the standard technique (18.7% of sessions, p = 0.001) because of prolongation of the forced expiratory time (FET) with the modified technique in all patient groups. In the 38 patients with FEV1/FVC < or = 0.75, the largest FVC and FET rose significantly using the modified expiratory technique, without compromising the largest FEV1 in any group. In patients with FEV1/FVC > or = 0.75, FET increased without concomitant changes in FVC or FEV1.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Reduction of blood loss from diagnostic sampling in critically ill patients using a blood-conserving arterial line system.

STUDY OBJECTIVE: To demonstrate the utility of a new blood-conserving arterial line system in reducing blood loss associated with blood drawing in the critical care setting. DESIGN: Prospective, randomized, crossover comparison between two arterial line systems. SETTING: Medical intensive care unit (ICU); tertiary care teaching institution. PATIENTS: Thirty-one patients who required invasive arterial blood pressure monitoring throughout their ICU course. INTERVENTIONS: For ICU days 1 to 2, patients were randomized to receive either a conventional arterial line system or a new blood-conserving arterial line system. On ICU days 3 to 7, patients with a conventional arterial line were crossed over to the blood-conserving arterial line, and vice versa. Laboratory blood volumes, mixed discard volumes, and blood discard volumes were then recorded to document how much blood loss is associated with each aspect of the blood sampling process. RESULTS: The mean total volume of blood sent to the laboratory for testing was 257.4 ml. As a result of "clearing the line" over the 7-day period, patients with the conventional arterial line system lost a mean volume of 340.2 ml of blood mixed with heparinized saline solution more than patients with the blood-conserving arterial line. In terms of the blood component of the blood-heparinized saline solution mixture, use of the conventional arterial line was associated with an average of 156.8 ml more blood discarded than with the blood-conserving arterial line. CONCLUSION: The new blood-conserving arterial line system provides a simple and effective method for reducing blood loss related to diagnostic sampling in the critical care setting.

Blood Specimen Collection↗
PubMed1993

Misallocation of respiratory care services: time for a change.

In summary, with increasing scrutiny given to the effectiveness and costs of health care, innovative programs that allocate respiratory care ordering to practitioners based on rigorous, specified appropriateness criteria and/or branching-logic algorithms are a promising solution to respiratory care misallocation. Widespread acceptance and implementation will require staunch medical directors' input and advocacy, therapists' support for new programs and for leaving the comforts of 'traditional' practice, and confirmation of the benefits of Respiratory Therapy Consult Services by more extensive, 'hard-nosed' evaluation.

Health Services Misuse↗
PubMed1993

Physician-ordered respiratory care vs physician-ordered use of a respiratory therapy consult service: early experience at The Cleveland Clinic Foundation.

BACKGROUND: Accumulative evidence suggests that respiratory care is frequently misallocated. We report the results of a pilot study of a delivery system aimed at correcting such misallocation. METHODS: The delivery system (Respiratory Therapy Consult Service, or RTCS) allows respiratory therapists (when requested by the case-managing physician) to determine respiratory care, with decisions guided by algorithm (ie, Consult patients). In the pilot study, Therapist Evaluators responded to requests for Consults on two study wards. All staff therapists participated in implementing Evaluator-determined treatment. STUDY DESIGN: We evaluated 38 patients (20 of whom were Consult patients) randomly selected from a total of 82 patients undergoing abdominal surgery during the study period. RESULTS: Consult patients were significantly older than non-Consult patients, more likely to be heavy smokers (67 vs 43%), and sicker as suggested by a higher Triage Score. Consult patients received more types and more total respiratory care services, demonstrated a trend toward longer stay, and had significantly higher respiratory therapy charges. CONCLUSION: Our experience shows that a consult program can be successfully implemented in a large, tertiary care institution with widespread physician and nursing support. Whether the RTCS fulfills its goal of ameliorating misallocation of respiratory care has yet to be proven and awaits the completion of other studies currently under way.

Abdomen↗
PubMed1992

Selective decontamination of the digestive tract in the intensive care unit: current status and future prospects.

OBJECTIVE: To evaluate the available data on selective decontamination of the digestive tract. This therapy aims to prevent infection in critically ill patients admitted to ICUs. Microbial carriage in the oropharynx, stomach, and gut; infection; mortality rate; and antibiotic resistance are the outcome events that are being reviewed. DATA SOURCES: Published indices, abstract booklets, and conference proceedings up to the end of 1990. STUDY SELECTION: Sixteen controlled trials of selective decontamination were identified. None of these trials was conducted as a randomized, placebo-controlled, double-blind trial. DATA EXTRACTION: Each of the three authors independently conducted a meta-analysis (thorough review) of the data from the 16 studies. DATA SYNTHESIS: Of the 16 trials, 15 show significant reduction of acquired infection among patients who received selective decontamination. Of the 14 studies that consider carriage of disease-causing microorganisms as an outcome event, 13 demonstrate a reduction in carriage of Gram-negative bacilli. Only ten studies consider mortality as an end-point, of which four demonstrate that the administration of selective decontamination is associated with decreased mortality rates in certain subgroups but not in the overall mortality rate. Of 11 studies that provide data about antibiotic resistance during selective decontamination, ten reported no increase in resistant microorganisms. Selective decontamination has been reported to be effective in controlling an outbreak of multi-resistant microorganisms. CONCLUSIONS: There is a general consensus about the efficacy of selective decontamination in diminishing microbial carriage and acquired infection rates, although conclusions about benefits related to mortality rates vary. Differences in mortality rate are found in the selective decontamination studies of patients with curable diseases, including multitrauma and cardiovascular patients. More data on resistance, collected over a longer period of time, are needed. Practical problems of blinding and the major ecological effect of selective decontamination may explain the lack of a randomized, placebo-controlled, double-blind trial.

Anti-Bacterial Agents↗
PubMed1992

Pleural effusion resulting from metastatic papillary carcinoma of the thyroid.

We present a patient with a symptomatic pleural effusion resulting from papillary carcinoma of the thyroid metastatic to the pleura. Distinctive features include clinically evident pleural metastasis and the presence of psammoma bodies in the pleural fluid, which are characteristic (albeit not pathognomonic) of papillary carcinoma of the thyroid.

Carcinoma, Papillary↗
PubMed1991

Columnar papilloma of the bronchus. Case report and literature review.

Solitary papillomas are rare endobronchial neoplasms that are most commonly lined by a squamous epithelium (i.e., squamous papillomas). Papillomas exhibiting nonsquamous epithelium are even more unusual; only seven solitary papillomas lined by columnar epithelium (i.e., columnar papillomas) have been previously described. The current report presents the eighth patient with a columnar papilloma and demonstrates some features common to solitary papillomas (i.e., central location in the airways, associated atelectasis), but distinctive from squamous papillomas (i.e., absence of malignant potential).

Aged↗
PubMed1991

Cost impact of metered dose inhalers vs small volume nebulizers in hospitalized patients: the Cleveland Clinic experience.

To assess the cost impact of using metered dose inhalers (MDIs) versus small volume nebulizers (SVNs) for hospitalized adult patients not being managed in ICUs, we analyzed the labor, equipment, and medication costs associated with using MDIs at The Cleveland Clinic Foundation. Over the study interval (January 1988-December 1989), a policy was implemented to enhance MDI use, resulting in increased use of MDIs (18% of all bronchodilator treatments in 1989 vs 5% in 1988). Based on a volume of approximately 70,000 bronchodilator treatments/year in our hospital, increased MDI use with this policy reduced direct costs by $26,510, with associated savings in respiratory-therapist time. To extend this analysis of costs to other institutional settings, we present an analysis of projected changes in institutional costs when the volume of bronchodilator therapies and the percentage administered by MDI varies.

Adult↗
PubMed1990

Reduction of intrapulmonary shunt and resolution of digital clubbing associated with primary biliary cirrhosis after liver transplantation.

This report describes a patient with marked hypoxemia caused by intrapulmonary shunt associated with primary biliary cirrhosis. Liver transplantation resulted in resolution of digital clubbing and reduction of intrapulmonary shunt as demonstrated by normalization of room air arterial blood gases, reduction in shunt fraction and normalization of the indocyanine-enhanced echocardiogram and perfusion lung scan. This patient's course challenges the conventional notion that intrapulmonary shunting associated with chronic liver disease does not reverse after liver transplantation.

Adult↗
PubMed1990

Intrathoracic lymph node evaluation by CT and MRI with histopathologic correlation in non-small cell bronchogenic carcinoma.

Twenty patients with non-small cell bronchogenic carcinoma were prospectively studied for intrathoracic lymphadenopathy using computed tomography (CT) and magnetic resonance imaging (MRI). The CT and MRI results were correlated with the surgical histopathology results of 103 harvested lymph nodes. Based on node dimension (utilizing a 1-cm cutoff value), neither imaging modality was accurate in predicting the histopathology of the nodes. CT had a sensitivity of 21%, specificity of 95%, and an overall accuracy of 85%; MRI had a sensitivity of 14%, specificity of 97%, and an overall accuracy of 85%. Moreover, CT and MRI detected preoperatively only 17% and 14%, respectively, of the harvested nodes. In summary, lymph node sizes measured by CT and MRI are inaccurate in predicting the benignity or malignancy of lymph nodes. Lymphadenopathy can be present even with a "negative" CT or MRI scan of the thorax.

Carcinoma, Bronchogenic↗