Small bowel perforation after a quad cough maneuver.
Explore the source record for details and available documents.
Adult↗
Biomedical subjects
J Pearl
Publications and source records attributed to J Pearl.
Utility of routine serial computed tomography for blunt intracranial injury.
BACKGROUND: To determine the utility of routine serial head computed tomography (H-CT) for predicting need for invasive neurosurgical intervention in patients with blunt intracranial injuries (BICI). METHODS: Patients treated at a Level I trauma center with BICI over a 4-year period were reviewed. RESULTS: Of the 4,273 blunt trauma patients evaluated, 9.7% (415/4,273) were diagnosed as having BICI. Invasive intervention (craniotomy, ICP monitoring, ventriculostomy, or angiogram) was performed in 41.2% (171/415) of patients with BICI. Of these, 94.7% (162/171) had the procedure performed as a result of the initial H-CT. The remaining 5.3% (9/171) had the intervention performed as a result of a subsequent H-CT. Serial H-CT documented worsening of BICI in 32.3% (64/198) of the patients, but only those who had significant corresponding clinical deterioration had an invasive procedure as a result. CONCLUSION: In patients with an unchanged or normal neurologic exam, a routine serial H-CT did not influence subsequent invasive neurosurgical intervention.
Adolescent↗
Efficacy and safety of ten day moxifloxacin 400 mg once daily in the treatment of patients with community-acquired pneumonia. Community Acquired Pneumonia Study Group.
Community-acquired pneumonia (CAP) remains a common and serious illness with approximately 2-4 million cases reported annually. Management of CAP is therapeutically challenging due to the increasing prevalence of penicillin- and macrolide-resistant pneumococci and beta-lactamase producing Haemophilus influenzae, as well as the increased recognition of 'atypical' pathogens, such as Chlamydia pneumoniae and Mycoplasma pneumoniae, and the frequent need for empiric therapy. We aimed to evaluate the safety and efficacy of moxifloxacin in the treatment of patients with CAP. To do this we carried out a prospective, uncontrolled, non-blind, Phase III clinical trial, in 27 U.S. centers. Patients included in the study were over 18 years of age with signs and symptoms of CAP confirmed by evidence of a new or progressive infiltrate on chest radiograph. The intervention used was moxifloxacin 400 mg PO once daily for 10 days. Sputum samples were collected pretherapy for Gram stain and culture for typical organisms. Culture and serological testing for Chlamydia pneumoniae and Mycoplasma pneumoniae was also performed. Susceptibility to moxifloxacin was determined by disk diffusion and MIC. Clinical and bacteriological responses were determined at the end of therapy (0-6 days post-therapy), follow-up (14-35 days post-therapy) and overall (end of therapy plus follow-up). Analyses were performed on both valid for efficacy and intent-to-treat populations. The primary efficacy variable was overall clinical resolution. Of 254 patients enrolled in the Study, 196 patients were included in the efficacy analyses. The majority of patients were male (58%) and Caucasian (85%) with a mean age of 49 years (range: 18 to 85 years). Only 3% of patients were hospitalized pretherapy. The most common pretherapy organisms identified, by culture or serology, in the valid for efficacy population (i.e. 147 organisms among 116 patients), were: Chlamydia pneumoniae (n=63; 54%), Mycoplasma pneumoniae (n=29; 25%), Streptococcus pneumoniae (n=14; 12%) and Haemophilus influenzae (n=13; 10%). End of therapy, follow-up and overall clinical resolution rates for the valid for efficacy population were 94%, 93% and 93%, respectively. The 95% CI for the overall clinical resolution rate was 88.1%, 95.9%. The overall bacteriological response for patients diagnosed by culture or serological criteria, was 91% (95% CI=84%, 96%). For patients who only met serological criteria for infection, the overall bacteriological response was 94% (60/64). Bacterial response rates for the four most commonly isolated pathogens were: 89% (56/63) for C. pneumoniae, 93% (27/29) for M. pneumoniae, 93% (13/14) for S. pneumoniae and 85% (11/13) for H. influenzae. Drug-related adverse events were reported in 33% (85/254) of moxifloxacin-treated patients. Nausea (9%), diarrhea (6%) and dizziness (4%) were the most commonly reported adverse events. Atypical organisms were isolated in high frequency among patients with CAP. Moxifloxacin 400 mg once daily for 10 days was effective and well-tolerated in the treatment of these adult patients with CAP. Moxifloxacin offers an effective treatment alternative for CAP due to both typical and atypical bacterial pathogens.
Adolescent↗
Evaluation of a fiberoptic blood gas monitor in neonates with congenital heart disease.
BACKGROUND: Blood gas analysis is extremely important in perioperative management of neonates with congenital heart disease, where ventilator manipulation of the pulmonary vascular resistance is crucial. Delays in blood gas analysis resulting from transport of samples to a central laboratory may compromise management of these patients. Furthermore, neonates with congenital heart defects may have lower arterial oxygen (PaO2) levels due to intracardiac right-to-left shunting. We evaluated the Sensicath System in neonatal patients following cardiac surgery by simultaneously measuring specimens on the central laboratory blood gas analyzer. METHODS: After patients returned from the operating room, the Sensicath System was connected to the arterial line. Blood was pulled across the sensor and re-infused to the patient after analysis. The accuracy and precision of the Sensicath System blood gas analysis results were assessed by comparison to simultaneous samples analyzed with a Corning 855 analyzer. The specimen-result turnaround time was recorded. 97 samples from 5 patients were compared. RESULTS: Blood gas analysis results from the Sensicath System showed acceptable accuracy and precision: partial pressure of oxygen (PO2), r2 = 0.89, bias = -4.5 mm Hg, precision = 11.8; partial pressure of carbon dioxide (PCO2), r2 = 0.59, bias = -0.4 mm Hg, precision 6.2; pH, r2 = 0.78, bias = 0.03 mm Hg, precision 0.03. The central lab specimen-result turnaround time was 13.8 +/- 7.1 minutes. The Sensicath System provided results after a 60-second analysis time with no blood loss. CONCLUSIONS: When compared to a Corning 855 blood gas analyzer, the Sensicath System was found to provide acceptable blood gas values, with no iatrogenic blood loss. This system may be especially helpful in infants with congenital heart defects, since rapid results are necessary for optimal patient care.
Blood Gas Analysis↗
Comparison of laparoscopic ultrasonography and fluorocholangiography in 300 patients undergoing laparoscopic cholecystectomy.
BACKGROUND: This study compares laparoscopic ultrasonography to fluorocholangiography in detecting common bile duct (CBD) stones and delineating biliary anatomy. METHODS: A prospective nonrandomized study of 300 consecutive patients undergoing laparoscopic cholecystectomy in a university hospital was performed. After port placement but before dissection, laparoscopic ultrasonography of the extrahepatic CBD was performed in both transverse and longitudinal planes. Cystic duct fluorocholangiography was attempted in all patients. RESULTS: Of 300 patients, CBD stones were detected in 26 (9%) with 25 of these (96%) detected on laparoscopic ultrasonography. Sonography identified the location and size of the CBD as well as anomalous anatomy prior to dissection. No CBD injuries were encountered. End-fire transducers were easier to use than rigid or flexible side-fire transducers; all gave excellent image quality. CONCLUSIONS: In this large study, laparoscopic ultrasonography and fluorocholangiography were equally sensitive in detecting CBD stones. Sonography delineates the biliary anatomy noninvasively and does not require dissection or opening of the biliary system. Laparoscopic ultrasonography may improve the safety of laparoscopic cholecystectomy, especially in cases of acute inflammation or distorted anatomy.
Cholangiography↗
Causal diagrams for epidemiologic research.
Causal diagrams have a long history of informal use and, more recently, have undergone formal development for applications in expert systems and robotics. We provide an introduction to these developments and their use in epidemiologic research. Causal diagrams can provide a starting point for identifying variables that must be measured and controlled to obtain unconfounded effect estimates. They also provide a method for critical evaluation of traditional epidemiologic criteria for confounding. In particular, they reveal certain heretofore unnoticed shortcomings of those criteria when used in considering multiple potential confounders. We show how to modify the traditional criteria to correct those shortcomings.
Epidemiologic Methods↗
My struggle to provide natural family planning.
Explore the source record for details and available documents.
Family Planning Services↗
Mycotic aneurysm: a diagnostic challenge.
Explore the source record for details and available documents.
Abdominal Pain↗
Causal inference from indirect experiments.
An indirect experiment is a study in which randomized control is replaced by randomized encouragement, that is, subjects are encouraged, rather than forced, to receive a given treatment program. The purpose of this paper is to bring to the attention of experimental researchers simple mathematical results that enable us to assess, from indirect experiments, the strength with which causal influences operate among variables of interest. The results reveal that despite the laxity of the encouraging instrument, data from indirect experimentation can yield significant and sometimes accurate information on the impact of a program on the population as a whole, as well as on the particular individuals who participated in the program.
Humans↗
Prospective evaluation of the safety and efficacy of laparoscopic jejunostomy.
We prospectively assessed the safety and efficacy of laparoscopic jejunostomy done by 11 surgeons in 8 medical centers using the T-fastener technique. In all, 23 men and 13 women aged 19 to 84 (mean, 59) years required enteral feeding, but could not undergo gastrostomy and had no contraindication to laparoscopy. Of these patients, 12 had head and neck cancer and 11 had neurologic swallowing dysfunction. The procedure took 25 to 180 minutes (mean, 75). Three (8%) early cases were converted to open jejunostomy because of accidental enterotomies caused by inappropriate techniques that were avoided in later cases. Minor technical problems, such as passing a needle through the back wall of the jejunum, occurred in 7 patients, but they were easily corrected and produced no complications. Feedings were routinely begun within 24 hours of the surgical procedure. All jejunostomy catheters functioned well. This is a safe and effective technique when done by experienced laparoscopic surgeons, and serious complications are rare.
Adult↗
Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome.
The impact of a new therapy that includes pressure-controlled inverse ratio ventilation followed by extracorporeal CO2 removal on the survival of patients with severe ARDS was evaluated in a randomized controlled clinical trial. Computerized protocols generated around-the-clock instructions for management of arterial oxygenation to assure equivalent intensity of care for patients randomized to the new therapy limb and those randomized to the control, mechanical ventilation limb. We randomized 40 patients with severe ARDS who met the ECMO entry criteria. The main outcome measure was survival at 30 days after randomization. Survival was not significantly different in the 19 mechanical ventilation (42%) and 21 new therapy (extracorporeal) (33%) patients (p = 0.8). All deaths occurred within 30 days of randomization. Overall patient survival was 38% (15 of 40) and was about four times that expected from historical data (p = 0.0002). Extracorporeal treatment group survival was not significantly different from other published survival rates after extracorporeal CO2 removal. Mechanical ventilation patient group survival was significantly higher than the 12% derived from published data (p = 0.0001). Protocols controlled care 86% of the time. Average PaO2 was 59 mm Hg in both treatment groups. Intensity of care required to maintain arterial oxygenation was similar in both groups (2.6 and 2.6 PEEP changes/day; 4.3 and 5.0 FIO2 changes/day). We conclude that there was no significant difference in survival between the mechanical ventilation and the extracorporeal CO2 removal groups. We do not recommend extracorporeal support as a therapy for ARDS. Extracorporeal support for ARDS should be restricted to controlled clinical trials.
Adult↗
Ethical implications of standardization of ICU care with computerized protocols.
Ethical issues related to the use of computerized protocols to control mechanical ventilation of patients with Acute Respiratory Distress Syndrome (ARDS) are identical to the ethical issues surrounding the use of any therapy or intervention. Four ethical principles must be considered: nonmaleficence, beneficence, autonomy, and distributed justice. The major ethical challenges to computerized protocol use as a specific application of clinical decision support tools are found within the principles of nonmaleficence and of beneficence. The absence of credible outcome data on which ARDS patient survival probabilities with different therapeutic options could be based is a constraint common to most ICU clinical decision making. Clinicians are thus deprived of the knowledge necessary to define benefit and are limited to beneficent intention in clinical decisions. Computerized protocol controlled decision making for the clinical management of mechanical ventilation for ARDS patients is ethically defensible. It is as well supported as most ICU therapy options.
Clinical Protocols↗
Rational use of broad-spectrum antibiotics in the elderly.
Explore the source record for details and available documents.
Aged↗
The 24-hour D/P ratio is a convenient screen for identifying altered peritoneal transport rates.
Peritoneal transport characteristics (PTC) may change without peritonitis, surgery, or other insults. Identifying patients with these changes is essential in adjusting the dialysis prescription to achieve optimal peritoneal dialysis on a long-term basis. Frequent standard peritoneal equilibration tests (PETs) become impractical as the population in individual programs expands. The time demands are burdensome to the nursing staff as well as to the patient. The accuracy of fast PETs is dependent upon the patient's exact adherence to the protocol steps. Utilizing the 24-hour D/P as a marker for altered PTCs has improved the efficiency of our approach to repeating standard PETs and ensuring dialysis adequacy. For adequacy studies, pooled 24-hour dialysate is routinely collected in our unit. The 24-hour D/P ratio correlates well with extrapolations from original PET data and the patient's current dwell times. Discrepancies noted between the patient's actual D/P ratio and the patient's expected D/P ratio alert the clinician to possible PTC changes.
Biological Transport↗
The microvascular distribution of cardioplegic solution in the piglet heart. Retrograde versus antegrade delivery.
The uniform distribution of cardioplegic solution to all areas of the microvasculature is considered critical for myocardial protection. Despite this, little information exists regarding the ability of retrogradely infused cardioplegic solution to perfuse the microvasculature of the heart. In this report, the microvascular distribution of retrogradely delivered cardioplegic solution was studied by means of a technique to quantitatively demonstrate capillary perfusion. Duroc piglet hearts were subjected to either antegrade (n = 4) or retrograde (n = 8) perfusion fixation with 2.5% glutaraldehyde and subsequently perfused with NTB-2 (an intracapillary marker). The results indicate that retrogradely delivered NTB-2 consistently perfused the anterior half of the intraventricular septum and the anterior and lateral free walls of the left ventricle but inconsistently perfused the posterior half of the intraventricular septum, the posterior wall of the left ventricle, and a small paraseptal region of the right ventricle. The remainder of the right ventricle was not perfused. In contradistinction, all regions of the heart were consistently perfused by the antegrade technique. In regions of the heart in which retrograde microvascular perfusion occurred, no statistical difference was found in the quantitative degree of capillary perfusion achieved by either the antegrade or retrograde technique. These results have important implications for planning strategies of myocardial protection and suggest that further investigation concerning the microvascular distribution of retrogradely delivered cardioplegic solution in human beings is merited.
Animals↗
Research in physiology, NIDCD.
Explore the source record for details and available documents.
Animals↗
Frequent amplification of the bcl-1 locus in poorly differentiated squamous cell carcinoma of the lung. The Lung Cancer Study Group.
The bcl-1 locus on chromosome 11 at band q13 has been shown to be rearranged in some chronic B lymphoid malignancies with the t(11;14)(q13;q32). Chromosome 11 abnormalities occur in solid tumors including squamous cell cancers and adenocarcinomas. We have recently reported the frequency amplification of the bcl-1 locus in squamous cell carcinomas of head and neck origin, and increased copy number also has been found in some breast adenocarcinomas. In this investigation, we analyzed the arrangement, copy number and expression of this locus in 111 primary non-small cell lung cancers. Bcl-1 was found to be amplified three- to 10-fold in seven fresh tumors. Whereas none of 51 adenocarcinomas showed bcl-1 amplification, six of 46 squamous cell carcinomas revealed an increase in bcl-1 copy number. This amplification was more frequently associated with larger and more poorly differentiated tumors. None of the cancers showed rearrangement of this locus.
Adenocarcinoma↗
Improved neonatal heart preservation with an intracellular cardioplegia and storage solution.
The optimal conditions for preservation of the neonatal heart for transplantation remain uncertain. An isolated, working neonatal piglet heart model was used to compare a standard extracellular-like cardioplegic solution followed by storage at 4 degrees C in normal saline for 12 hr (n = 8) to cardioplegia and storage at 4 degrees C for 24 hr in an intracellular-like solution (n = 7). Seven of eight hearts in the 12-hr Extracellular Group failed to regain function, with a maximum stroke work index (SWI), developed at a left ventricular end-diastolic pressure (LVEDP) of 9 mm Hg of 0.91 +/- 0.30 x 10(3) erg/g (mean +/- standard error of the mean), 7.1% of nonpreserved control hearts. In contrast, all hearts arrested and stored for 24 hr in the intracellular solution regained function with a maximum SWI, again at a LVEDP of 9 mm Hg of 9.51 +/- 1.98 X 10(3) erg/g, 73.7% of control (P less than 0.05). Ultrastructural changes seen by electron microscopy paralleled the functional results. We conclude that an intracellular arrest and storage solution may be superior to conventional solutions for extended preservation of the neonatal heart.
Animals↗