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PubMed2001

Immune recovery vitritis and uveitis in AIDS: clinical predictors, sequelae, and treatment outcomes.

PURPOSE: To determine 1) clinical predictors of an inflammatory syndrome associated with cytomegalovirus (CMV) retinitis (immune recovery vitritis or uveitis [IRV or IRU]); 2) clinical sequelae of IRV; and 3) the effect of corticosteroid treatment on visual acuity. METHODS: A cohort study from the AIDS Ocular Research Unit of the University of California, San Diego, and a case series from the Cleveland Clinic consisted of patients who had acquired immunodeficiency syndrome and inactive CMV retinitis who responded to highly active antiretroviral therapy (HAART) with CD4 T-lymphocyte levels >60 cells/mm3. The cohort was followed for a median of 13.5 months following increase in CD4 count. The authors studied the occurrence of IRV, defined as symptomatic (vision decrease and/or floaters) vitritis of 1+ or greater severity associated with inactive CMV retinitis. Macular edema or epiretinal membrane formation was determined by clinical examination and fluorescein angiography. Five eyes were treated with sub-Tenon corticosteroid injections. RESULTS: In the cohort study, 19 (63%) of 30 HAART responders developed IRV (26 eyes). The clinical spectrum of inflammation included vitritis, papillitis, macular edema, and epiretinal membranes. Eyes with CMV surface area >30% of the retina were at the highest risk (relative risk = 4.5) of developing IRV (P = 0.03). During follow-up, inflammation persisted without treatment for a median of 20 weeks and 14 patients (16 eyes) developed macular changes. Treatment resulted in vision improvement without reactivation of retinitis. Histology and immunohistochemistry of associated epiretinal membranes showed evidence of chronic inflammation with a predominant T-lymphocyte cell population. In the case series, 3 (38%) of 8 HAART responders developed IRV (4 eyes). All four eyes were treated and resulted in visual acuity improvement of one line. CONCLUSIONS: Symptomatic IRV or IRU develops in a significant number of patients with CMV retinitis following successful HAART. Eyes with CMV surface area >30% of the retina are at the greatest risk. Eyes with IRV respond favorably to antiinflammatory therapy without reactivation of retinitis. Immune recovery vitritis may be the result of an immunologic reaction to latent CMV antigens in the eye in which T-lymphocytes play a role.

AIDS-Related Opportunistic Infections↗
PubMed1986

Rapid identification of yeasts by semi-automated and conventional methods.

Five different methods for the identification of significant yeast from clinical specimens were compared for their reliability, rapidity and cost-effectiveness. Three commercial methods consisted of semi-automated Abbott's yeasts identification system using MS-2 (Abbott Laboratories, Diagnostic Division, Irving, Texas), API 20C (Analytab Products, Inc., Plainview, NY) and Uni-Yeast-Tek (Flow Labs, Inc., MacLean, VA). Two conventional methods included the modified dye-plur plate auxanographic and rapid tube assimilation method. The 242 coded clinical isolates used in this study included 20 species of Candida, Cryptococcus, Saccharomyces Geotrichum, Rhodotorula, Torulopsis and Trichosporon. The identification accuracies with all the systems ranges between 92.3% to 97.5%. Results were available with Abbott's MS-2 within 24 h, with rapid tube assimilation method in 6-48 h and in 72 h with other systems. Rapid tube assimilation and dye-pour-plate auxanographic methods were least expensive, with labour and material costing around $1.00 per identification, whereas the commercial system cost a little over $5.00.

Autoanalysis↗
PubMed2003

[Effect of combination of nitric oxide inhalation and inverse ratio ventilation in endotoxin-induced acute respiratory distress syndrome in sheep].

OBJECTIVE: To observe the effect of combination of nitric oxide (NO) inhalation and inverse ratio ventilation (IRV) on oxygenation and hemodynamics in endotoxin-induced acute respiratory distress syndrome (ARDS) in sheep. METHODS: Sheep ARDS model was induced by an intravenous infusion of low dose endotoxin, and then animals were randomly divided into two groups. (1) NO group (n=6), inhalation of 40x10(-6) nitric oxide. (2) Combination group (n=6), receiving mechanical ventilation with IRV (inspiratory-to-expiratory ratio of 2:1) and inhalation of 40x10(-6) NO. The dynamic changes in gas exchange and hemodynamics were measured with the aid of Swan-Ganz catheter and arterial blood gas analysis before and after the onset of, ARDS and 30 minutes after treatment. RESULTS: The combination of IRV and 40x10(-6) NO inhalation rapidly reduced mean pulmonary arterial pressure (MPAP), increased PaO(2), decreased P((A-a))O(2), and Qs/Qt without inducing significant change in systemic hemodynamics, and it was a more effective method of correcting hypoxemia than inhalation of nitric oxide alone. NO inhalation did not change the airway pressure of the model, but the combined treatment resulted in reduction of peak inspiratory pressure and increase of mean airway pressure. CONCLUSION: The combined use of IRV and NO inhalation has an additive effect on improving oxygenation in endotoxin-induced acute respiratory distress syndrome in sheep.

Administration, Inhalation↗
PubMed1988

Surgical sterilization at the time of cesarean delivery.

The cesarean section operation has been recognized for more than a century as an ideal time for the obstetrician to effect sterilization, usually with minimal morbidity, by way of one of the methods of tubal ligation. The physician must choose between simple, quick methods such as the Pomeroy or Parkland, with their slightly higher but acceptable failure rates, or the more elaborate and foolproof methods that involve burial of the tubal ends, such as the Irving or Uchida, which are technically more difficult and time consuming. The authors stress that whichever procedure is utilized, the surgeon must resist the desire to elaborate on proven techniques; otherwise, higher than published failure rates may result. It is important for the patient to understand the risks, both of immediate morbidity and remote failure, and to give her informed consent. Attentive presterilization counseling may identify the patient who will regret the loss of her fertility.

Cesarean Section↗
PubMedDate not supplied

[Laser coagulation and cryocoagulation in the treatment of isolated retinal angiitis].

Isolated retinal vasculitis (IRV) is a form of retinal vasculitis without other inflammations of the eye or systemic vasculitis. Occlusion of retinal vessels without subsequent retinal ischemia and neovascularization is one of the main problems in the management of such patients. Laser photocoagulation seems to be a method to control this problem. Argon laser photocoagulation was used in the treatment of 34 IRV patients (56 eyes) (29 men and 15 women aged 25-41 years, mean age 32.9 +/- 5.2 years). A total of 168 sessions were carried out. Regression of neovascularization was achieved in 29 of 44 eyes (79.5%). Additional cryotherapy had to be performed in 15 eyes, good results were attained in 9 eyes (60%). Patients treated with prednisolone in a daily dose of 10-20 mg during laser coagulation had IRV recurrences more rarely than those treated with lower doses (5 mg) (0-6.7% vs. 50%, p < 0.0013), those treated with metipred-depot for 7-14 days (0-6.7% vs. 53.8-66.6%, p < 0.0023), or untreated ones (0-6.7% vs. 73.9%, p < 0.0000).

Adult↗
PubMed2001

[Effect of inverse ratio ventilation on hemodynamics and oxygen metabolism in sheep with acute respiratory distress syndrome].

OBJECTIVE: To observe the effect of inverse ratio ventilation (IRV) on hemodynamics and oxygen metabolism in sheep with acute respiratory distress syndrome (ARDS). METHODS: Twelve ARDS sheep induced by LPS were admitted to this study, and received mechanical ventilation with volume controlled (VC) and pressure controlled ventilation (PC) (conventional ratio and inverse ratio) at the same level of total positive end expiratory pressure (PEEPt), data of hemodynamics and oxygen metabolism were collected at 30 min after the onset of each mode. RESULTS: With PC, peak airway pressure was lower than that with VC, but mean airway pressure was higher with IRV. At the same level of PEEPt, there was no difference in hemodynamics and oxygen metabolism between VC and VC-IRV, same as PC and PC-IRV. But compared with VC, arterial oxygen pressure and arterial oxygen saturation with PC-IRV were lower significantly (P < 0.05). CONCLUSION: PEEPt was a very important factor to improve oxygenation, short-term IRV was not better than VC or PC.

Acute Disease↗
PubMed1993

[Cardiopulmonary effects of CPPV (continuous positive pressure ventilation) and IRV (inverse ratio ventilation) in experimental myocardial ischemia].

Continuous positive pressure ventilation (CPPV) is an established therapy for treatment of acute respiratory failure (ARF). However, cardiac performance may be severely disturbed due to elevated intrathoracic pressure, inducing a decrease in cardiac output (CO) and oxygen delivery (DO2). Alternatively, mechanical ventilation with prolonged inspiratory to expiratory duration ratio (inversed ratio ventilation IRV) has been successfully used in ARF. No data are available about IRV in acute haemodynamic oedema. Thus, the cardiopulmonary effects of CPPV (positive end-expiratory pressure [PEEP] = 10 cm H2O) and IRV (inspiration to expiration duration ratio [I:E] = 3.0) were studied in nine dogs (body weight 29.9 +/- 4.3 kg) before and after induction of myocardial ischaemia. METHODS. Continuous intravenous anaesthesia and muscle paralysis were provided by 1.2 mg.kg-1 x h-1 piritramide and 0.08 mg.kg-1 x h-1 pancuronium, and the animals were ventilated with intermittent positive pressure ventilation (IPPV) as reference method. Cardiocirculatory performance was determined by means of heart rate (HR), mean arterial pressure (MAP), mean pulmonary arterial pressure (MPAP), central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP) and left ventricular end-diastolic pressure (LVEDP). Cardiac output (CO) was determined by thermodilution method. Systemic vascular resistance (SVR) was calculated. Pulmonary function was assessed by arterial and mixed venous blood gas tension for oxygen (PaO2, PvO2) and carbon dioxide (PaCO2). Functional residual lung capacity (FRC) was measured by means of the foreign gas wash-in method using helium as inert gas, and determination of extravascular lung water (EVLW) using the thermal-dye indicator technique. CPPV and IRV were studied in random sequence in the control phase and 60 min after induction of acute left ventricular ischaemia, which was achieved by occlusion of the ramus interventricularis anterior. RESULTS. During the control phase CPPV induced an increase in MPAP (P < 0.05), CVP (P < 0.05) and PAOP (P < 0.05). HR and MAP remained unchanged, whereas CO decreased by 16% (P < 0.05). FRC was elevated by 25 ml.kg-1 (P < 0.01), but not EVLW (9.1 +/- 3.5 ml.kg-1). There was no improvement in oxygenation; instead, oxygen delivery (DO2) decreased (P < 0.05). During inversed ratio ventilation MPAP, CVP, PAOP increased, but less than during CPPV. FRC was elevated mu 7.0 ml.kg-1 (P < 0.05), which was significantly less than during CPPV (P < 0.05). EVLW revealed no differences. During IPPV in the ischaemia phase cardiopulmonary performance deteriorated significantly. CO decreased by 19% (P < 0.05), whereas HR, MPAP, CVP and PAOP increased (P < 0.05). PaO2 was lower (P < 0.05) and alveolo-arterial PO2 gradient (PAaO2) increased (P < 0.05). All animals revealed moderate pulmonary oedema (EVLW = 15.1 +/- 8.4 ml.kg-1) (P < 0.01) and a lower FRC. Mechanical ventilation with PEEP significantly improved oxygenation and FRC; however, DO2 was slightly lower than during IPPV (not significant). IRV elevated PaO2, FRC and DO2, since CO was not depressed when compared with IPPV. CONCLUSIONS. CPPV and IRV may induce a recruitment of collapsed or hypoventilated lung areas, which is more pronounced during CPPV. During both modes of ventilation, oxygenation was improved without apparent changes in EVLW. Haemodynamic performance was more impaired during CPPV, and no improvement of left ventricular function secondary to an elevated intrathoracic pressure was observed. Occlusion of the RIVA coronary artery typically induces an infarction of 35% of left ventricular muscle mass; however, non-ischaemic myocardium reveals an unchanged or increased contractility. Thus, a reduction of left ventricular preload secondary to CPPV mainly contributes to haemodynamic depression, which is less pronounced during IRV due to a lower peak inspiratory airway pressure and mean airway pressure. IRV may be useful for mechanical ventCntCo

Animals↗
PubMed1990

Octreotide and gastrointestinal fistulae.

The place of somatostatin and its analogues in the management of gastrointestinal fistulae is reviewed, drawing attention to the difficulty of assessing treatments that influence spontaneous closure. Sixteen patients with gastric, small bowel, and pancreatic fistulae were randomized to receive octreotide injections (100 micrograms t.i.d.) or placebo for 12 days. Spontaneous fistula closure occurred in 7 at a mean of 37 days after entering the trial. A second study is underway with greater patient numbers recruited from peripheral hospitals and with an increased period of octreotide medication (21 days).

Adult↗
PubMed1997

Recent advances in managing non-small-cell lung cancer: 1. Clinical aspects of diagnosis and staging.

Lung cancer is the leading cause of death from cancer in Australian adults. Over 90% of lung cancers are due to exposure to tobacco smoke. Female smokers are more susceptible to developing lung cancer than male smokers. The overall survival of non-small-cell lung cancer is 13%, having increased from 6% over the past 30 years. The development of new, unexplained respiratory or systemic symptoms in a heavy smoker or ex-smoker should raise the suspicion of lung cancer. Early detection and consideration of tumour resection for all operable tumours are the main strategies for improving the cure rate of non-small-cell lung cancer at present. Reducing the prevalence of smoking remains the best method for reducing lung cancer deaths.

Adult↗