Biomedical subjects

J Lopez

Publications and source records attributed to J Lopez.

At least 55 records · Page 3Linked to original sources

PubMed1999

Prospective analysis of complications 30 days after outpatient upper endoscopy.

OBJECTIVE: The aim of this study was to compare complication rates reported by patients 30 days after outpatient upper endoscopy with those discussed at our monthly morbidity and mortality conference. We also intended to establish which complications were reported most frequently 30 days after upper endoscopy, and which patients or procedures involved the highest risk. METHODS: Trained interviewers performed standardized telephone interviews on consecutive outpatients undergoing upper endoscopy over a 1-yr period. Patients were queried regarding potential events related to their upper endoscopy in the 30 days subsequent, including symptoms, emergency room (ER) and/or physician visits, and hospitalizations. The indications, findings, and therapies were reviewed from endoscopic reports. RESULTS: A total of 473 patients were contacted 30 days after outpatient upper endoscopy and agreed to participate in our study. The most common complications reported by patients at 30 days were sore throat (9.5%) and abdominal discomfort (5.3%). Twelve patients (2.5%) required an ER/physician visit and five patients (1.1%) required hospitalization. The minority of both ER/physician visits (16.7%) and hospitalizations (40%) were discussed at our monthly morbidity and mortality conferences. CONCLUSIONS: More complications were reported by patients 30 days after outpatient upper endoscopy than were discussed at our monthly morbidity and mortality conferences. The most frequent complications reported by patients were sore throat and abdominal pain. The minority of ER/physician visits and hospitalizations were discussed at our morbidity and mortality conferences.

Abdominal Pain↗

PubMed1999

The impact of delaying gastric emptying by either meal substrate or drug on the [13C]-urea breath test.

OBJECTIVE: Optimal [13C]-urea breath test (UBT) conditions for diagnosis of Helicobacter pylori infection are still being fine-tuned. In the present study we investigated the impact of delaying gastric emptying by different meal substrates or L-DOPA, a drug known to induce gastric stasis, on the performance of the [13C]-UBT. METHODS: A total of 115 patients participated in the study. On two consecutive days, participants ingested [13C]-urea (100 mg) 10 min after either 270 ml of a mixed formula meal (1 Kcal/ml) or an equivalent amount of tap water. In 11 participants two additional tests were performed with or without oral 500 mg L-DOPA given 30 min before [13C]-urea load. The 13C/12C ratio in a basal breath sample was compared with ratios in samples collected 30 and 60 min after [13C]-urea. Histological assessment of H. pylori presence in antral biopsy served as reference standard. RESULTS: Formula UBT showed excellent specificity (100% at 30 and 60 min) and good sensitivity (97% at both time intervals), whereas water UBT had the same specificity but slightly lower sensitivity (94% at 30 min and 73% at 60 min). In formula UBT, 13C/12C ratios were higher at 60 min than at 30 min (21.7+/-2 vs 17.7+/-1.8 per thousand respectively, p < 0.01, whereas in water UBT 13C/12C ratios were higher at 30 min than at 60 min (13.9+/-1.5 vs 8.4+/-0.09 per thousand respectively, p < 0.01). Pretreatment with L-DOPA did not modify either the sensitivity or the specificity of the UBT. CONCLUSIONS: The performance of the [13C]-urea with a formula meal may not be improved by pharmacologically delaying gastric emptying. A short, water-based test may be a sensible approach to worldwide standardization of the [13C]-UBT for H. pylori infection.

Adult↗

PubMed1999

Safety and efficacy of metformin in a restricted formulary.

OBJECTIVE: To assess the efficacy and safety of metformin (MET) in the Veterans' Administration Northern California Health Care System during the period from June 1995 through April 1996 when its use required approval by Endocrinology. STUDY DESIGN: A retrospective review of patient charts and computerized pharmacy and laboratory records. Patients served as their own historical controls. PATIENTS AND METHODS: Patients receiving MET (n = 251) were identified from the pharmacy database. On-line laboratory data, including the intermediate outcome variable HbA1c, were retrieved by computer for the interval 4 months prior to the initial prescription to May 1996. Clinical data including weight and blood pressure were obtained from chart review. RESULTS: Of 228 patients whose charts were available for review, 29 reported side effects, and 12 discontinued use due to these side effects. No patients were identified with lactic acidosis. Both baseline and treatment data on HbA1c were available on 164 patients. Mean HbA1c (%) data (unpaired), expressed as mean +/- SE, were as follows: between 4 months pretreatment and 1 month pretreatment, 9.41 +/- 0.19 (n = 103 tests); between 1 month pretreatment and baseline, 9.41 +/- 0.19 (n = 110 tests); 3 months of treatment, 8.79 +/- 0.16 (n = 157 tests, P < 0.05); 6 months of treatment, 8.30 +/- 0.17 (n = 79 tests, P < 0.0001); 9 months of treatment, 8.72 +/- 0.24 (n = 70 tests, P < 0.05), compared to pretreatment values. Similar analysis of unpaired weight and blood pressure data in 152 patients did not reveal any reduction in these clinical parameters over this treatment period. Serum lipids were unchanged on treatment (by paired analysis), but the number of tests was limited. CONCLUSION: In this setting, MET provided sustained beneficial effects on glycemic control and was well tolerated. Any effects on weight, blood pressure, and serum lipids were not demonstrable in this analysis. We conclude that MET can substantially improve outcome of diabetes care.

Blood Pressure↗

PubMed1999

The superior colliculus, a neuronal network resistant to the Gaba withdrawal syndrome.

Chronic intracortical perfusion of GABA (Gamma Amino Butyric Acid) and its subsequent withdrawal generates the GABA withdrawal syndrome (GWS). This particular epileptic model has been observed in the motor cortex of monkeys and rats. Our purpose was to study the GWS in the motor cortex (MC), dorsal hippocampus (DH), and superior colliculus (SC). Thirty chronically-implanted adult Wistar rats were separated into 3 groups of 10 (8 experimental and 2 controls). The first group received GABA in MC, the second in the DH and the third in the SC. GABA was released in doses of 10 to 60 micrograms/microliter/h for 6 days employing osmotic mini-pumps. Two control rats per group received saline solution in the above-mentioned structures. Rats perfused in the MC showed GWS after interruption of the GABA flow. The group perfused in the DH showed paroxysmal discharges and epileptic seizures during perfusion. They also later showed GWS. No epileptic effects were observed in the SC-perfused group during either the GABA perfusion or during withdrawal. None of the six control animals showed epileptic effects. Our results show that the SC offers a strong resistance to GWS. This could be explained by the particular neuronal network structure of rat SC.

Animals↗

PubMed1998

Directional coronary atherectomy for the treatment of Palmaz-Schatz in-stent restenosis.

Management of in-stent restenosis has become a significant challenge in interventional cardiology. The results of balloon angioplasty have been disappointing due to the high recurrence of restenosis at follow-up. Debulking of the restenotic tissue within the stents using directional coronary atherectomy (DCA) may offer a therapeutic advantage. We report the immediate clinical and angiographic outcomes and long-term clinical follow-up results of 45 patients (46 lesions), mean age 63+/-12 years, 73% men, with a mean reference diameter of 2.9+/-0.6 mm, treated with DCA for symptomatic Palmaz-Schatz in-stent restenosis. DCA was performed successfully in all 46 lesions and resulted in a postprocedural minimal luminal diameter of 2.7+/-0.7 mm and a residual diameter stenosis of 17+/-10%. There were no in-hospital deaths, Q-wave myocardial infarctions, or emergency coronary artery bypass surgeries. Four patients (9%) suffered a non-Q-wave myocardial infarction. Target lesion revascularization was 28.3% at a mean follow-up of 10+/-4.6 months. Kaplan-Meier event-free survival (freedom from death, myocardial infarction, and repeat target lesion revascularization) was 71.2% and 64.7% at 6 and 12 months after DCA, respectively. Thus, DCA is safe and efficacious for the treatment of Palmaz-Schatz in-stent restenosis. It results in a large postprocedural minimal luminal diameter and a low rate of both target lesion revascularization and combined major clinical events at follow-up.

Angioplasty, Balloon↗

PubMed1998

Migration, ethnicity and environment: HIV risk factors for women on the sugar cane plantations of the Dominican Republic.

OBJECTIVE: To determine risk factors for HIV infection among women living in the sugar cane plantation communities (bateyes) of a large private sugar cane company in the Dominican Republic. DESIGN: Cross-sectional study of sexually active female volunteers living in the bateyes. METHODS: Of 98 bateyes, 23 were randomly selected and visited by a mobile medical unit, to interview, examine and test volunteers for seroreactivity to HIV and syphilis. RESULTS: The 490 subjects ranged in age from 16 to 72 years (median, 37 years); 53% were born in Haiti, 36% in Dominican Republic bateyes, and 12% elsewhere in the Dominican Republic; 58% had no formal education; and 87% had no income. HIV seropositivity was found in 28 women (5.7%), including 8.8% of those aged < 35 years. By logistic regression analysis, HIV infection was independently associated with age < 35 years [odds ratio (OR), 4.5; P < 0.01), being single with children (OR, 4.3; P < 0.01), more than one lifetime sex partners (OR, 3.4; P = 0.06), engaging in sex during menses (OR, 3.2; P = 0.02), and self-description as a prostitute (OR, 4.4; P = 0.05)1. For Haitian women, those coming to the Dominican Republic alone were more likely to have HIV infection than those coming with a male partner. Less than 4% of women reported condom use at last intercourse. CONCLUSIONS: Women in the bateyes have a much higher rate of HIV infection than that estimated for women in the general population of Dominican Republic and a rate comparable to that of female sex workers in the Dominican Republic. AIDS prevention in the bateyes should address condom education and distribution as well as employment opportunities and education for women.

Adolescent↗

PubMed1998

Retroviral transfer and long-term expression of the adrenoleukodystrophy gene in human CD34+ cells.

Adrenoleukodystrophy (ALD) is a demyelinating disease of the central nervous system that results from a genetic deficiency of ALDP, an ABC protein involved in the transport of very long-chain fatty acids (VLCFAs). The cloning of the ALD gene and the positive effects of allogeneic bone marrow transplantation support the feasibility of a gene therapy approach. We report the retroviral transfer of the ALD cDNA to peripheral blood and bone marrow CD34+ cells from control donors and ALD patients. Prestimulation of these cells with cytokines, followed by infection with the M48-ALD retroviral vector, resulted in 20% transduction efficiency (4-40%) and expression of the vector-encoded ALDP in 20% of CD34+ cells (7.3-50%). Long-term culture (LTC) of transduced CD34+ cells from two ALD patients showed efficient transduction (24-28%) and stable expression (25-32%) of ALDP in derived clonogenic progenitors at 3 weeks of culture. The expression of ALDP in CFU cells derived from 5 and 6 weeks of LTC confirmed the effective transduction of LTC-initiating cells. Expression of ALDP was observed in CD68+ CFU-derived cells, suggesting that monocyte-macrophages, the target bone marrow cells in ALD, were produced from transduced progenitor cells. VL-CFA content was corrected in LTC and CFU-derived cells in proportion to the percentage of transduced cells, indicating that the vector-encoded ALDP was functional. Although not efficient yet to allow a clinical perspective, these results demonstrate the feasibility of ALD gene transfer into CD34+ cells of ALD patients.

3T3 Cells↗

PubMed1998

Comparison of primary coronary stenting to primary balloon angioplasty with stent bailout for the treatment of patients with acute myocardial infarction.

This study compares the immediate and long-term outcomes of a primary coronary stenting strategy with primary balloon angioplasty with stent bailout in the treatment of patients with acute myocardial infarction (AMI). One hundred forty-seven consecutive patients who underwent primary balloon angioplasty with stent bailout (n = 94) or primary stenting (n = 53) for AMI were clinically followed for 8.1 +/- 5.7 and 8.5 +/- 4.5 months, respectively. Immediate results, as well as in-hospital and long-term ischemic events (death, reinfarction, and repeat revascularization) were compared between both groups. Angiographic success was 91.5% in the balloon angioplasty group and 94% in the stent group. In-hospital and late follow-up combined ischemic events were 22 of 94 (23%) versus 0 of 53 (0%); p < 0.001 and 33 of 78 (42%) versus 13 of 53 (25%), p = 0.04 for the balloon angioplasty and stent groups, respectively. At 6 months, the cumulative probability of repeat target lesion revascularization was higher in the balloon angioplasty group (47% vs 18%, p = 0.0006) as was the probability of late target revascularization (36% vs 18%, p = 0.046); the cumulative event-free survival after 6 months was significantly lower in the balloon angioplasty group (44% vs 80%, p = 0.0001). This study demonstrates that a primary stent placement strategy in patients with AMI is safe, feasible, and superior to primary balloon angioplasty with stent bailout. Primary stenting results in a larger postprocedural minimal luminal diameter, a lower early and late recurrent ischemic event rate, and a lower incidence of target lesion revascularization at follow-up.

Angioplasty, Balloon, Coronary↗

PubMed1998

Pharmacologic treatment of hypertension in the Department of Veterans Affairs during 1995 and 1996.

Patterns of antihypertensive drug use, the cost of this care and potential savings with changes of treatment patterns, were studied for all hypertensives treated at US Veterans Affairs (VA) medical facilities for fiscal years 1995 and 1996. Data was aggregated by individual medication as well as by antihypertensive drug class. Cost estimates were based on median cost and number of units for each dosage form of each medication dispensed at all facilities. Potential savings were estimated by substituting beta-blockers or diuretics for calcium antagonists. In a subset of patients the prevalence of hypertension, and among hypertensives the prevalence of coronary artery disease, congestive heart failure, and diabetes mellitus, was determined. For these patients, patterns of treatment by antihypertensive drug class was examined. For all VA facilities, of the 10 most frequently prescribed antihypertensives in 1995, four were calcium antagonists, two angiotensin converting enzyme (ACE) inhibitors, two beta-blockers, and two diuretics. In 1996, this was changed by the addition of an ACE inhibitor and the subtraction of a diuretic combination. Calcium antagonists accounted for 37% of treatment days in 1995 and 35% in 1996, ACE inhibitor use went from 34% to 36%, beta-blockers from 17% to 18%, and diuretic use remained at 12%. In 1996, approximately 86.6 million dollars were spent on calcium antagonists, 51.8 million on ACE inhibitors, 7.9 million on beta-blockers, and 3.6 million on diuretics. The estimated annual cost savings for each 1% conversion of calcium antagonists to beta-blockers would be $713,000 and to diuretics $758,000. In a subset of 7526 hypertensive patients with known comorbid conditions, calcium antagonists and ACE inhibitors were also the most commonly used drug classes for all categories of patients, including those without coronary artery disease, congestive heart failure, and diabetes mellitus. Calcium antagonists and ACE inhibitors were the most commonly dispensed antihypertensives at VA facilities for both 1995 and 1996, with a small decrease in calcium antagonist use from 1995 to 1996. The cost implications of these practice patterns as compared with the primary use of diuretics and beta-blockers are enormous.

Adrenergic beta-Antagonists↗

PubMed1998

Microinvasive laparoscopic cholecystectomy in pediatric patients.

Although cholelithiasis is uncommon in children, its laparoscopic treatment has progressively become more popular among pediatric surgeons. This is due in part to the fact that compared with the open technique, laparoscopic treatment is less invasive as well as more cost-effective. A review of the literature indicates that it has been customary to use at least one 10-mm port to permit application of the 10-mm endoscopic clip applier for ligation of the cystic duct and artery. We report our experience with two patients in whom a laparoscopic cholecystectomy was performed by use of a 5-mm endoscopic clip applier and a 3-mm laparoscope. The application of a 5-mm clip applier obviated the need for a 10-mm port. It also saved an additional step by eliminating the exchange from the laparoscope to the 10-mm endoscopic clip applier through the 10-mm port. Furthermore, the use of a 3-mm telescope through the smallest port (<5 mm) would achieve a better cosmetic outcome.

Child↗

PubMed1998

Syringocystadenoma papilliferum of the male breast.

A 39-year-old man presented with a 2-cm, mildly tender mass in the right breast of many years' duration. Microscopic examination showed a syringocystadenoma papilliferum. Because of its location in the breast, we studied the lesion for immunohistochemical markers for apocrine differentiation. Gross cystic disease fluid protein-15 (GCDFP-15) staining yielded negative results in the cystic luminal epithelial cells, whereas GCDFP-15 and lysozyme staining yielded strongly positive results in the epithelial cells of adjacent tubular apocrine glands. Focal strong lysozyme positivity was seen in the cystic luminal epithelial cells. These findings do not support apocrine differentiation in this case, despite its location in the breast, an organ rich in specialized apocrine (lactiferous) glands. To our knowledge, this represents the first reported case of syringocystadenoma papilliferum of the male breast. We present the clinical and pathologic features of this unusual case and a review of the literature.

Adenoma, Sweat Gland↗

PubMed1998

Failure to differentiate Cryptosporidium parvum from C. meleagridis based on PCR amplification of eight DNA sequences.

In order to determine the specificities of PCR-based assays used for detecting Cryptosporidium parvum DNA, eight pairs of previously described PCR primers targeting six distinct regions of the Cryptosporidium genome were evaluated for the detection of C. parvum, the agent of human cryptosporidiosis, and C. muris, C. baileyi, and C. meleagridis, three Cryptosporidium species that infect birds or mammals but are not considered to be human pathogens. The four Cryptosporidium species were divided into two groups: C. parvum and C. meleagridis, which gave the same-sized fragments with all the reactions, and C. muris and C. baileyi, which gave positive results with primer pairs targeting the 18S rRNA gene only. In addition to being genetically similar at each of the eight loci analyzed by DNA amplification, C. parvum and C. meleagridis couldn't be differentiated even after restriction enzyme digestion of the PCR products obtained from three of the target genes. This study indicates that caution should be exercised in the interpretation of data from water sample analysis performed by these methods, since a positive result does not necessarily reflect a contamination by the human pathogen C. parvum.

Animals↗

PubMed1998

Budesonide affects allergic mucociliary dysfunction.

Airway inflammation characterized by neutrophils and free elastase contributes to allergic mucociliary dysfunction. Glucocorticosteroids are the most important anti-inflammatory agents used in the treatment of asthma, but their effect on allergic mucociliary dysfunction is not known. Therefore, we assessed both the prophylactic and therapeutic effects of the glucocorticosteroid budesonide on antigen-induced mucociliary dysfunction in sheep. Tracheal mucus velocity (TMV), a marker of mucociliary clearance, was measured by using a roentgenographic technique. When budesonide was administered either 30 min before or 1 h after airway challenge with Ascaris suum, the antigen-induced fall in TMV at 6 h was prevented. The effects on TMV at 8 and 24 h after challenge were also determined when budesonide and, for comparative purposes, alpha1-protease inhibitor were given 6 h after antigen challenge. Budesonide treatment improved TMV at 8 h, but TMV was not significantly different from antigen alone at 24 h. Treatment with alpha1-protease inhibitor, however, caused only a significant reversal of the antigen-induced fall in TMV at 24 h after challenge; this indicates a more prolonged effect than budesonide. Our results suggest that antiproteases may have a potential role as a therapeutic approach to mucociliary dysfunction in asthma and provide evidence for another means by which glucocorticosteroids contribute to the control of the disease.

Aerosols↗

PubMed1997

Trends in antihypertensive drug use in the United States: do the JNC V recommendations affect prescribing? Fifth Joint National Commission on the Detection, Evaluation, and Treatment of High Blood Pressure.

CONTEXT: The choice of pharmacological treatment for the approximately 50 million people in the United States with hypertension has important therapeutic and financial implications. OBJECTIVES: To describe national antihypertensive medication prescribing patterns for 1992 and 1995; to explore the influence of the Fifth Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC V), published in 1993, which recommended diuretics and beta-blockers as first-line antihypertensive therapy unless contraindicated; and to estimate the impact of these prescribing patterns on the cost of antihypertensive treatment. DESIGN: All prescriptions for drugs approved for the treatment of hypertension dispensed by 35000 retail pharmacies were tabulated for 1992 and 1995 (62% of all US retail pharmacies were surveyed). MAIN OUTCOME MEASURES: Number of prescriptions for each dosage form of medication and national cost estimates based on wholesale costs of medications dispensed. RESULTS: In 1992, of the 10 most frequently prescribed antihypertensive drugs, 3 were calcium antagonists, 3 were angiotensin-converting enzyme (ACE) inhibitors, 3 were beta-blockers, and 1 was the combination of triamterene and hydrochlorothiazide. In 1995, 4 were calcium antagonists, 3 were ACE inhibitors, 1 was a beta-blocker, 1 was the combination of triamterene and hydrochlorothiazide, and 1 an alpha-blocker. In 1992, calcium antagonists accounted for 33% of antihypertensive prescriptions compared with 38% in 1995, ACE inhibitor use went from 25% to 33%, beta-blocker use from 18% to 11%, and diuretic use from 16% to 8%. The estimated wholesale costs for calcium antagonists in 1995 dollars increased from $2.67 billion in 1992 to $2.86 billion in 1995; ACE inhibitor costs increased from $1.37 billion to $1.67 billion; costs for diuretics declined from $353 million to $168 million; and costs for beta-blockers declined from $763 million to $433 million. CONCLUSIONS: From 1992 to 1995 use of calcium antagonists and ACE inhibitors for treatment of hypertension increased and diuretics and beta-blockers declined, suggesting that the recommendations from JNC V had little effect on prescribing patterns. The cost implications of these practice patterns are enormous.

Antihypertensive Agents↗

PubMed1997

Initial frequency of alleles for resistance to Bacillus thuringiensis toxins in field populations of Heliothis virescens.

The risk of rapid pest adaptation to an insecticide is highly dependent on the initial frequency of resistance alleles in field populations. Because we have lacked empirical estimates of these frequencies, population-genetic models of resistance evolution have relied on a wide range of theoretical estimates. The recent commercialization of genetically engineered cotton that constitutively produces an insecticidal protein derived from the biocontrol agent, Bacillus thuringiensis (Bt) has raised concern that we lack data needed to quantify the risk of insect pests such as Heliothis virescens rapidly adapting to this ecologically valuable class of toxins. By individually mating over 2,000 male H. virescens moths collected in four states to females of a Bt toxin-resistant laboratory strain, and screening F1 and F2 offspring for tolerance of the toxic protein, we were able to directly estimate the field frequency of alleles for resistance as 1.5 x 10(-3). This high initial frequency underscores the need for caution in deploying transgenic cotton to control insect pests. Our single-pair mating technique greatly increases the efficiency of detecting recessive resistance alleles. Because alleles that decrease target site sensitivity to Bt toxins and other insecticides are often recessive, this technique could be useful in estimating resistance allele frequencies in other insects exposed to transgenic insecticidal crops or conventional insecticides.

Journal Article↗

PubMed1997

Risk factors for oxacillin/methicillin resistance in coagulase-negative staphylococci.

The clinical variables associated with isolation of oxacillin- and methicillin-resistant, coagulase-negative staphylococci (CNS) from blood cultures of hospitalized patients were studied. One hundred CNS strains (49 oxacillin-susceptible; 51 oxacillin-resistant) isolated consecutively from one of two or more sets of blood cultures were collected. Only two variables were independently associated with recovery of oxacillin/methicillin-resistant strains by a multivariate analysis: length of hospital stay > 10 days (OR 5.2, 95% CI = 1.7-15.7), and administration of antimicrobial agents in the previous 14 days (OR 4.5, 95% CI = 1.7-11.7). Analysis of the antibiotics administered indicated that only beta-lactams were associated with a statistically significant risk of resistance to oxacillin/methicillin (OR of beta-lactams vs no antibiotics = 6.94, 95% CI = 1.9-25.3; OR of non-beta-lactams vs no antibiotics = 2.64, 95% CI = 0.8-8.3). Length of hospital stay (especially > 10 days) and prior administration of antimicrobial agents (mainly beta-lactams) independently predicted the presence of oxacillin/methicillin-resistant CNS in blood cultures.

Cross Infection↗

PubMed1997

Laparoscopic technique in the management of Spigelian hernia.

Spigelian hernias are uncommon, and preoperative diagnosis is often difficult. The use of the laparoscope has simplified the diagnosis and subsequent repair of these rare hernias. We report a case diagnosed and repaired using laparoscopic techniques of fascia approximation, mesh reinforcement, and reperitonization.

Female↗

PubMed1997

Additive beneficial effects of the prone position, nitric oxide, and almitrine bismesylate on gas exchange and oxygen transport in acute respiratory distress syndrome.

OBJECTIVE: To test the hypothesis that prone position ventilation, nitric oxide, and almitrine bismesylate, each acting by a different mechanism to improve arterial oxygenation, could exert additive beneficial effects when used in combination in patients with severe acute respiratory distress syndrome (ARDS). DESIGN: Prospective, nonrandomized, interventional study. SETTING: Medical and surgical intensive care units at a university tertiary care center. PATIENTS: Twelve patients with ARDS and severe hypoxemia, defined as PaO2/FIO2 of < or = 150 and FIO2 of > or = 0.6, with pulmonary artery occlusion pressure of < 18 mm Hg. INTERVENTIONS: Inhaled nitric oxide (20 parts per million for 15 mins) in the supine and prone position, and intravenous almitrine bismesylate while prone (1 mg/kg/hr for 60 mins), alone or combined with nitric oxide. MEASUREMENTS AND MAIN RESULTS: Hemodynamic, blood gas, and gas exchange measurements were performed at sequential time points as follows: a) baseline supine; b) nitric oxide in the supine position; c) after return to baseline supine; d) after 30 mins prone; e) after 120 mins prone; f) nitric oxide while prone; g) after return to baseline prone; h) almitrine bismesylate prone; and i) nitric oxide and almitrine bismesylate combined, for 15 mins prone. Patients were considered responders to the prone position if a gain in PaO2 of > or = 10 torr (> or = 1.3 kPa) or a gain in the PaO2/FIO2 ratio of > or = 20 was observed. Seven patients (58%) responded to being turned prone. Compared with supine baseline conditions, nitric oxide and supine position increased arterial oxygen saturation from 89 +/- 1 (SD)% to 92 +/- 3% (p < .05) and nitric oxide plus prone position increased arterial oxygen saturation (94 +/- 3% vs. 89 +/- 4%, p < .05) and decreased the alveolar-arterial oxygen difference from 406 +/- 124 torr (54 +/- 15 kPa) to 387 +/- 108 torr (51 +/- 14 kPa) (p < .05). Almitrine bismesylate increased PaO2/FIO2 vs. baseline (122 +/- 58 vs. 84 +/- 21, p < .05). Almitrine bismesylate decreased the alveolar-arterial oxygen difference vs. baseline from 406 +/- 124 torr (53.9 +/- 16.5 kPa) to 386 +/- 112 torr (51.3 +/- 14.8 kPa) and vs. nitric oxide and supine position from 406 +/- 111 torr (53.9 +/- 14.7 kPa) to 386 +/- 112 torr (51.3 +/- 14.8 kPa) (p < .05). Prone position alone did not improve oxygenation. However, the combination of nitric oxide and almitrine bismesylate increased PaO2/FIO2 vs. nitric oxide supine and nitric oxide prone conditions (147 +/- 69 vs. 84 +/- 25 and 91 +/- 18, respectively; p < .05). In patients responding to the prone position (n = 7), combining nitric oxide and almitrine bismesylate led to further improvement in PaO2 compared with the prone position alone, with PaO2 increasing from 78 +/- 12 torr (10.3 +/- 1.6 kPa) to 111 +/- 55 torr (14.7 +/- 7.3 kPa) (p < .05), which was not the case when either nitric oxide or almitrine bismesylate was added separately. Heart rate and cardiac output were increased by almitrine bismesylate compared with all other measurements. Mean pulmonary arterial pressure was decreased by nitric oxide (27 +/- 7 vs. 30 +/- 7 mm Hg nitric oxide supine vs. baseline supine and 29 +/- 7 vs. 33 +/- 8 mm Hg nitric oxide prone vs. baseline prone, p < .05) and increased by almitrine bismesylate (36 +/- 9 vs. 30 +/- 7 mm Hg baseline supine, 27 +/- 7 mm Hg nitric oxide supine, 33 +/- 8 mm Hg baseline prone, and 29 +/- 7 mm Hg nitric oxide prone; p < .05). The increase in mean pulmonary arterial pressure was totally abolished by nitric oxide (31 +/- 5 vs. 36 +/- 9 mm Hg, p < .05). Minute ventilation, respiratory system compliance, physiologic deadspace, and PaCO2 remained unchanged. CONCLUSION: In ARDS patients with severe hypoxemia, arterial oxygenation can be improved by combining the prone position, nitric oxide, and almitrine bismesylate, without deleterious effects.

APACHE↗