Search PubMed⌕ Search

Biomedical subjects

R Beale

Publications and source records attributed to R Beale.

At least 19 recordsLinked to original sources
PubMed2002

Graft infection.

Explore the source record for details and available documents.

Blood Vessel Prosthesis↗
PubMed2001

Reduction in mortality after inappropriate early discharge from intensive care unit: logistic regression triage model.

OBJECTIVE: To develop a predictive model to triage patients for discharge from intensive care units to reduce mortality after discharge. DESIGN: Logistic regression analyses and modelling of data from patients who were discharged from intensive care units. SETTING: Guy's hospital intensive care unit and 19 other UK intensive care units from 1989 to 1998. PARTICIPANTS: 5475 patients for the development of the model and 8449 for validation. MAIN OUTCOME MEASURES: Mortality after discharge and power of triage model. RESULTS: Mortality after discharge from intensive care was up to 12.4%. The triage model identified patients at risk from death on the ward with a sensitivity of 65.5% and specificity of 87.6%, and an area under the receiver operating curve of 0.86. Variables in the model were age, end stage disease, length of stay in unit, cardiothoracic surgery, and physiology. In the validation dataset the 34% of the patients identified as at risk had a discharge mortality of 25% compared with a 4% mortality among those not at risk. CONCLUSIONS: The discharge mortality of at risk patients may be reduced by 39% if they remain in intensive care units for another 48 hours. The discharge triage model to identify patients at risk from too early and inappropriate discharge from intensive care may help doctors to make the difficult clinical decision of whom to discharge to make room for a patient requiring urgent admission to the unit. If confirmed, this study has implications on the provision of resources.

APACHE↗
PubMed2001

Immunologically enhanced enteral nutrition: current status.

With increasing interest in enteral feeding and the role of the gut in the development of infection and multiple organ failure in critically ill patients, the use of enteral feedings enriched with immune-enhancing ingredients is attracting considerable interest. This approach to modulating the immune and inflammatory responses has become known as immunonutrition, and many products are now available for clinical use. Several have been subjected to clinical study in various patient groups, with encouraging results in terms of reducing infection rates and length of hospital stay. They appear to benefit both critically ill patients and patients undergoing major surgery, particularly when feeding is started preoperatively. Two systematic reviews have been published, both with positive results. Nevertheless, as new products become available they should be subjected to controlled clinical trials, especially because several of the mechanisms involved are not yet fully understood.

Adjuvants, Immunologic↗
PubMed2000

Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution.

OBJECTIVE: Transpulmonary double-indicator dilution is a useful monitoring technique for measurement of intrathoracic blood volume (ITBV) and extravascular lung water (EVLW). In this study, we compared a simpler approach using single arterial thermodilution derived measurements of ITBV and EVLW with the double-indicator dilution technique. DESIGN: Prospective observational clinical study. SETTING: Surgical intensive care units of two university hospitals. PATIENTS AND METHODS: Global end-diastolic volume (GEDV) derived from single thermodilution was used for calculation of ITBV. Structural regression analysis of the first two thermo-dye dilution measurements in a derivation population of 57 critically ill patients (38 male, 19 female, 18-79 years, 56 +/- 15 years) revealed ITBV = (1.25 x GEDV)-28.4 (ml). This equation was then applied to all first measurements in a validation population of 209 critically ill patients (139 male, 70 female, 10-88 years, mean 53 +/- 19 years), and single-thermodilution ITBV (ITBV(ST)) and EVLW (EVLW(ST)) was calculated and compared to thermo-dye dilution derived values (ITBV(TD), EVLW(TD)). For inter-individual comparison, absolute values for ITBV and EVLW were normalised as indexed by body surface area (ITBVI) and body weight (EVLWI), respectively. MEASUREMENTS AND RESULTS: Linear regression analysis yielded a correlation of ITBVI(ST) = (1.05 x ITBVI(TD))-58.0 (ml/m2), r = 0.97, P < 0.0001. Bias between ITBVI(TD) and ITBVI(ST) was 7.6 (ml/m2) with a standard deviation of 57.4 (ml/m2). Single-thermodilution EVLWI (EVLWI(ST)) was calculated using ITBVI(ST) and revealed the correlation EVLWI(ST) = (0.83 x EVLWI(TD)) + 1.6 (ml/kg), r = 0.96, P < 0.0001. Bias between EVLWI(TD) and EVLWI(ST) was -0.2 (ml/kg) with a standard deviation of 1.4 (ml/kg). In detail, EVLWI(ST) systematically overestimated EVLWI(TD) at low-normal values for EVLWI and underestimated EVLWI at higher values (above 12 ml/kg). CONCLUSION: Determinations of ITBV and EVLW by single thermodilution agreed closely with the corresponding values from the double-indicator technique. Since transpulmonary single thermodilution is simple to apply, less invasive and cheaper, all these features make it a promising technique for the bedside. Nevertheless, further validation studies are needed in the future.

Adolescent↗
PubMed2000

Cardiac function after intermittent antegrade warm blood cardioplegia: contribution of the double-indicator dilution technique.

OBJECTIVE: To evaluate cardiac performance following coronary artery surgery using two different techniques of cardioplegia. DESIGN: Randomized prospective study. SETTING: Adult cardiothoracic intensive care unit in a university hospital. STUDY POPULATION: Thirty patients undergoing isolated coronary surgery. INTERVENTIONS: Patients were randomized to receive either intermittent antegrade warm blood cardioplegia with normothermic bypass (group 1) or combined antegrade and retrograde cold crystalloid cardioplegia with hypothermic bypass (group 2). Hemodynamic evaluation included conventional measurements from a pulmonary artery catheter and data obtained by thermal dye dilution utilizing an arterial thermistor-tipped fiberoptic catheter. RESULTS: The only major difference between groups was a significantly higher right atrial pressure in group 2, from 4 h to 24 h after surgery (8.8 +/- 2.6 vs. 11.8 +/- 3.2 mmHg at 4 h and 11 +/- 3.1 vs. 8.5 +/- 1.8 mmHg at 24 h, P = 0.04). After cold cardioplegia a significant increase in right atrial pressure was observed (7.5 +/- 3.1 before surgery vs. 11.4 +/- 3 mmHg at 8 h, P = 0.003) whereas right ventricular end diastolic volume index did not increase significantly, suggesting impaired right ventricular diastolic compliance in this group. CONCLUSIONS: Until 24 h after surgery cold cardioplegia is associated with impaired right ventricular filling, which seems better preserved by intermittent antegrade warm blood cardioplegia. End-diastolic volume measurement with the double-indicator technique allows differentiation between systolic and diastolic dysfunction.

Analysis of Variance↗
PubMed1997

Liver function and splanchnic ischemia in critically ill patients.

STUDY OBJECTIVE: To investigate the concept that splanchnic ischemia leads to hepatic dysfunction in the critically ill. DESIGN: Prospective study and analysis of patient data. SETTING: A general ICU in an inner-city London teaching hospital. PATIENTS: Twenty-seven consecutive critically ill patients with evidence of inadequate tissue perfusion requiring pulmonary artery catheterization and mechanical ventilation. MEASUREMENTS: In all patients, we measured the hepatic metabolism of lidocaine (lignocaine) to monoethylglycinexylidide (MEGX) and the clearance of indocyanine green (both dynamic, flow-dependent tests of hepatic function) over the first 3 days following admission to the ICU. These were compared with results of standard liver function tests and related to tonometric assessment of gastric intramucosal pH (pHim) and outcome. RESULTS: There were no significant differences in bilirubin, aspartate aminotransferase, alkaline phosphatase, and prothrombin levels, or in indocyanine green clearance between survivors and nonsurvivors. On day 3, the median MEGX level was higher in survivors than in nonsurvivors (16 vs 2.4 ng/mL, p < 0.001), and the median MEGX level in nonsurvivors fell over the 3 days (20.6 to 2.4 ng/mL, p < 0.002). MEGX levels were significantly correlated with pHim (Spearman rank correlation coefficient [Rs] = 0.69, p < 0.001) as were the changes in the two measurements over the 3 days (Rs = 0.46, p < 0.02). The MEGX formation test and gastric pHim were the most discriminatory with regard to death and survival. CONCLUSIONS: Our findings suggest that critically ill patients develop significant hepatic dysfunction that is associated with a poor outcome. This is likely to be due to a mismatch between hepatic metabolic demand and blood flow, and the MEGX formation test appears to be an extremely effective means of assessing liver function and flow in this group of patients.

Critical Illness↗
PubMed1997

Age and continuous lactose challenge modify lactase protein expression and enzyme activity in gut epithelium in the rat.

The activity of lactase enzyme declines after weaning. This study was to investigate changes in the lactase expression in the whole gastrointestinal tract during the development and the possibility that this and activity can be induced by lactose. Expression of lactase protein in the gut of 1-12-weeks old rats was studied by immunocytochemistry. Possible induction was evaluated by immunohistochemical and biochemical techniques in 8-week-old rats after lactose challenge for seven days. Lactase immunoreactivity was detected only in the small intestine and it decreased 20% during the week after weaning. A steady level of 40% lower than in the sucklings was found in the adult rats. In the lactose-challenged rats the optical density of immunoreactivity increased by about 30% in those that consumed the highest concentration of lactose. In the proximal jejunum, elevation of the enzymatic activity was three-fold. In the rat lactase protein expression decreased rapidly after weaning and expression and activity were induced by lactose-rich diet, most notably in the proximal jejunum.

Age Factors↗
PubMed1996

Central venous pressure, pulmonary artery occlusion pressure, intrathoracic blood volume, and right ventricular end-diastolic volume as indicators of cardiac preload.

PURPOSE: Central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP) and right ventricular end-diastolic volume (RVEDV) are often regarded as indicators of both circulating blood volume and cardiac preload. to evaluate these relationships, the response of each variable to induced volume shifts was tested. The relationships between these variables and cardiac index (CI) and stroke volume index (SVI) was also recorded to assess the utility of each variable as an indicator of cardiac preload. The responses of the new variable intrathoracic blood volume (ITBV) to the same maneuvers was also tested. To examine the effects of changes in cardiac output alone on ITBV, the effects of infusing dobutamine were studied. MATERIALS AND METHODS: Ten anesthetized piglets were studied during conditions of normovolemia, hypovolemia, and hypervolemia. The effects of an infusion of dobutamine were examined under normovolemia and hypovolemia. Cardiac output was measured by thermo-dilution, and ITBV was measured by double-indicator dilution. RESULTS: CI was correlated to CVP with r2 = .42 (P < or = .01), to PAOP with r2 = .43 (P < or = .01), to RVEDV index with r2 = .21 (P < or = .01), and to ITBV with r2 = .78 (P < or = .01) (pooled absolute values). Bias (mean difference of the percent changes with normovolemia = 100%) +/- 1 SD; for SVI - ITBV index was 1 +/- 22%, for SVI - CVP it was -128 +/- 214%; for SVI - PAOP it was -36 +/- 46%; and for SVI - RVEDV index it was 1 +/- 29%. Dobutamine infusion increased heart rate (to about 190 x min-1 and CI by 30% in normovolemia and hypovolemia, while ITBV remained basically unchanged. CONCLUSIONS: Under the experimental conditions chosen neither CVP, PAOP, nor RVEDV reliably indicated changes in circulating blood volume, nor were they linearly and tightly correlated to the resulting changes in SVI. ITBV reflected both changes in volume status and the resulting alteration in cardiac output. The possibility that ITBV might be cardiac output-dependent was not supported. ITBV, therefore, shows potential as a clinically useful indicator of overall cardiac preload.

Analysis of Variance↗
PubMed1994

Protecting the gut and the liver in the critically ill: effects of dopexamine.

OBJECTIVE: To measure the clinical effects of dopexamine on systemic and splanchnic perfusion in critically ill patients. DESIGN: Prospective study. SETTING: General intensive care unit. PATIENTS: Ten patients with sepsis syndrome, acute respiratory failure, and at least one other organ system in failure. The median age of the patients was 62.5 yrs (range 29 to 78), and the median admission Acute Physiology and Chronic Health Evaluation (APACHE) II score was 24 points (range 14 to 38). INTERVENTIONS: Timed infusion of dopexamine to a maximum dose of 6 micrograms/kg/min. MEASUREMENTS AND MAIN RESULTS: Systemic hemodynamics and oxygen transport variables were obtained from measurements after arterial and pulmonary artery catheterization. Gastric intramucosal pH and hepatic blood flow/function measurements were made by tonometry and indocyanine green clearance, respectively. All measurements were made before dopexamine infusion, after 1 hr of dopexamine infusion, and again 1 hr after the infusion ended. Cardiac index increased with dopexamine from a baseline median of 4.0 L/min/m2 (range 1.2 to 5.5) to 4.8 L/min/m2 (range 1.5 to 8.03) (p < .01), and returned to its previous level 1 hr after the infusion ended (median 4.0 L/min/m2 [range 1.4 to 5.8], p < .01). During dopexamine infusion, gastric intramucosal pH improved significantly from a median baseline level of 7.21 (range 7.04 to 7.50) to 7.28 (range 7.13 to 7.46, p < .05). This improvement in gastric intramucosal pH was maintained (median 7.36 [range 7.13 to 7.46]) after the infusion ended. Indocyanine green half-life decreased but not significantly with dopexamine (medians before and during the infusion were 6.6 and 6.3 mins, respectively). Indocyanine green half-life increased significantly 1 hr after the infusion ended (median 7.4 mins [range 4.4 to 14.8], p < .05), and changes in cardiac index correlated with changes in indocyanine green half-life (Rs2 = 0.60, p < .001). Changes in gastric intramucosal pH were unrelated to all other measurements. CONCLUSIONS: Dopexamine improves gastric intramucosal pH, and thus, splanchnic oxygenation. This improvement in gastric intramucosal pH appears to be independent of dopexamine's systemic effects.

Acute Disease↗
PubMed1993

Assessment of splanchnic oxygenation by gastric tonometry in patients with acute circulatory failure.

OBJECTIVE: To investigate the importance of splanchnic ischemia in patients with acute circulatory failure by comparing gastric intramucosal pH as measured by tonometry with conventional methods of assessing adequacy of tissue oxygenation. DESIGN: Prospective cohort of patients with acute circulatory failure in first 24 hours after admission to the intensive care unit. SETTING: Two general intensive care units in London, England. PATIENTS: Consecutive sample of 83 patients of varying diagnostic categories that required pulmonary artery catheterization. MAIN OUTCOME MEASURES: Gastric intramucosal pH and hemodynamic, oxygen transport, and metabolic variables were measured on admission and at 12 hours and 24 hours after admission. Prediction of outcome (death or survival) by each measurement was assessed by sensitivity, specificity, and logistic regression analysis. RESULTS: Mean 24-hour Acute Physiology and Chronic Health Evaluation (APACHE II) score was 20.3. There were significant differences in mean gastric intramucosal pH between survivors and nonsurvivors on admission and at 24 hours, (7.40 vs 7.28, 7.40 vs 7.24, respectively; P < .001). Admission heart rate was higher (116 vs 101 beats per minute; P < .003) and mean arterial pressure lower (82 vs 97 mm Hg; P < .01) in nonsurvivors. There were no consistent differences in cardiac index, oxygen delivery, and oxygen uptake between survivors and nonsurvivors. Admission arterial pH was significantly lower (7.3 vs 7.36; P < .003), base excess more negative (-5.3 vs -1.9; P < .001), and lactate concentration higher (3.14 vs 1.91 mmol/L; P < .03) in nonsurvivors. Gastric intramucosal pH had a sensitivity of 88% for predicting death and a likelihood ratio of 2.32, higher than for any other variable. Only gastric intramucosal pH at 24 hours independently predicted outcome. CONCLUSIONS: Gastric intramucosal pH was the most reliable indicator of adequacy of tissue oxygenation in this group of patients. Inadequate regional blood flow as detected by a reduction in gastric intramucosal pH, but not by systemic measures, is an important contributor to morbidity and mortality in intensive care units.

Aged↗
PubMed1992

Pancoast tumor: use of MRI for tumor staging.

Pancoast tumors (superior sulcus tumors) are apical lung cancers that may cause any or all of the symptoms originally described in 1932 as Pancoast's syndrome. We have presented a case report and a review of pertinent literature on the treatment of this tumor. Our patient was treated with preoperative radiation and en bloc tumor resection, the current standard of care for cure of Pancoast tumor. We support an aggressive approach in the treatment of this tumor, as radiation followed by radical tumor resection offers good palliation and the best chance for cure. Magnetic resonance imaging has emerged as the procedure of choice to assess the local extent of tumor, and in our patient, MRI accurately predicted that the tumor was resectable.

Female↗