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Guntupalli KK, Bandi V. Rheumatologic emergencies in the intensive care unit. Crit Care Clin 2002. [DOI: 10.1016/s0749-0704(02)00032-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Patients with systemic rheumatic diseases may be admitted to the ICU because of worsening of or development of a new manifestation of the rheumatic disease, infections caused by immunosuppression, or adverse effects of drugs used to treat rheumatic diseases. Sometimes an unrelated, acute disorder may become life threatening because of the underlying rheumatic disorder. Rheumatoid arthritis is the most common rheumatic disease seen in ICU patients, followed by systemic lupus erythematosus and scleroderma. These three conditions together account for up to 75% of rheumatic cases admitted to the ICU. The respiratory system is the organ system most commonly affected in the acute process, followed by the renal, gastrointestinal, and nervous systems. More than 50% of admissions result from infections, and 25% to 35% result from exacerbation of the underlying rheumatic condition. In about 20% of patients, the rheumatic disorder may be diagnosed for the first time in the ICU. An aggressive approach should be pursued to establish the diagnosis of either disease exacerbation or infection. Delay in instituting appropriate immunosuppressive or antimicrobial therapy may result in multiple organ system failure and a poor outcome. The mortality rate in patients with rheumatic disease exceeds that predicted by the APACHE II or SAPS II scores and is higher than that in nonrheumatologic ICU admissions. The mortality may exceed 50% in patients admitted for infection; the prognosis is comparatively better for patients with exacerbations of disease activity. Renal failure, coma, and acute abdomen are predictors of poor outcome. Early recognition of abdominal complications requiring surgical intervention may help reduce mortality.
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Affiliation(s)
- Namieta M Janssen
- Immunology, Allergy and Rheumatology Section, Department of Medicine, Baylor College of Medicine, One Baylor Plaza 672E, Houston, TX 77030, USA
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Affiliation(s)
- K K Guntupalli
- Pulmonary Department, Ben Taub General Hospital and Baylor College of Medicine, Houston, Texas 77030, USA
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Abstract
The majority of clinicians will encounter patients with heat-related illness in one form or the other. Early recognition and management are important to prevent morbidity and mortality. In children and elderly, the clinical signs may be subtle and in such situations a sound knowledge of heat-related illnesses is crucial. Besides diagnosing and treating heat-related illnesses, it is equally important to know how to prevent them as they are easily preventable.
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Affiliation(s)
- R Khosla
- Division of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
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Atmar RL, Guy E, Guntupalli KK, Zimmerman JL, Bandi VD, Baxter BD, Greenberg SB. Respiratory tract viral infections in inner-city asthmatic adults. Arch Intern Med 1998; 158:2453-9. [PMID: 9855383 DOI: 10.1001/archinte.158.22.2453] [Citation(s) in RCA: 173] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Respiratory tract viral infections (RTVIs) have been identified frequently in association with asthma exacerbations in children, but few studies have shown similar rates of viral infections in adults with asthma. Further studies using newer diagnostic techniques to evaluate the frequency of RTVIs in adults with acute exacerbations of asthma need to be performed. METHODS Twenty-nine asthmatic adults were recruited from the pulmonary clinic of an urban county hospital and were followed up in a longitudinal cohort study for signs and symptoms of asthma and RTVI. One hundred twenty-two asthmatic adults presenting to the emergency department (ED) of the same hospital with acute symptoms of asthma underwent evaluation for RTVI in a cross-sectional prevalence study. In both studies, respiratory secretions and paired serum samples were collected from subjects with acute wheezing episodes and evaluated using virus culture, serologic testing, and reverse transcription-polymerase chain reaction (RT-PCR). RESULTS In the longitudinal cohort study, 138 respiratory illnesses, of which 87 were asthma exacerbations, were evaluated; 41% of all illnesses and 44% of asthma exacerbations were associated with an RTVI. In the ED study, 148 asthma exacerbations were evaluated; 55% were associated with an RTVI. An RTVI was identified in 21 (50%) of 42 of the subjects hospitalized in the ED study. Picornaviruses (rhinoviruses), coronaviruses, and influenza viruses were the most commonly identified causes of RTVI. Forty-six (60%) of the 77 picornavirus infections and 22 (71%) of the 31 coronavirus infections were identified only using RT-PCR. CONCLUSIONS Asthmatic exacerbations in adults are frequently associated with an RTVI. Identification of such infections often requires newer diagnostic methods, such as virus-specific RT-PCR. The high frequency of RTVIs identified in association with asthmatic exacerbations in adults from the inner city suggests that strategies for the prevention of RTVI should be targeted toward this population.
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Affiliation(s)
- R L Atmar
- Department of Medicine, Baylor College of Medicine, Ben Taub General Hospital, Houston, Tex, 77030, USA
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57
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Hanania NA, Pope C, Guntupalli KK. Acute respiratory distress syndrome. Inhaled nitric oxide. Respir Care Clin N Am 1998; 4:695-709. [PMID: 9881400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
There is enough evidence to support the short-term beneficial effects and safety of administering inhaled NO to ARDS patients. This effect may be potentiated when inhaled NO is administered in conjunction with other therapies. The full spectrum of effects of inhaled NO remains to be elucidated. Long-term benefit in terms of mortality and duration of mechanical ventilation has not been demonstrated; more randomized trials probing these effects are needed.
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Affiliation(s)
- N A Hanania
- Department of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
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58
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Abstract
Mechanical ventilation in a patient with obstructive airway disease may be a lifesaving measure; however, it may also be associated with significant morbidity and mortality. It is important for a physician to be familiar with the potential complications of mechanical ventilation in this group of patients and to know how to avoid them by carefully applying safe ventilator strategies. The cornerstone of such strategies is to minimize minute ventilation, maximize time for expiration, and avoid hyperinflation of the lung. Several bedside parameters (iPEEP, VEI, Pplat) that reflect presence of gas trapping and potential hyperinflation may be measured. In addition to mechanical ventilation, management should include inhaled bronchodilators and systemic corticosteroid therapies. In the event controlled hypoventilation is necessary, sedation with or without the use of muscle relaxants may be required. Unconventional therapies such as the use of Heliox, magnesium sulfate, ketamine, and inhalational anesthetics may be attempted in severe cases that do not respond to conventional management. With appropriate use of ventilator strategies, a reduction in the mortality and morbidity of patients with obstructive airway disease requiring mechanical ventilation has recently been noted.
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Affiliation(s)
- S Jain
- Baylor College of Medicine, Houston, Texas, USA
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59
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Guntupalli KK, Eschenbacher W. Usefulness of the Flow Volume Loop. Chest 1998. [DOI: 10.1378/chest.113.3.847-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
Acute Respiratory Distress Syndrome (ARDS) occurs in a wide range of adult and pediatric critical care settings. This article provides an overview of ARDS including the controversies in definition, a summary of pathophysiology, diagnosis, clinical presentation, and management options. The article also attempts to emphasize new management options in the management of ARDS, and highlights differences between adults and children.
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Abstract
OBJECTIVE We sought to study the prevalence of angiotensin-converting enzyme (ACE) inhibitors, a cause of angioedema, and investigate any association between clinical findings at the time of presentation and clinical outcome. DESIGN AND SETTING Retrospective review of the charts of all patients presenting with angioedema to the emergency department at our tertiary referral teaching hospital or clinics over a 4-year period. The charts were reviewed for documentation of chief complaint(s), physical findings, medical treatment, need for laryngoscopy and/or endotracheal intubation, triage, and probable etiology. RESULTS Of the 40 patients presenting with angioedema in this study, 15 cases were caused by ACE inhibitors. They were the most common cause of angioedema, accounting for 38% of all cases. The incidence of ACE inhibitor-induced angioedema is estimated to be 0.14%. More patients with angioedema secondary to ACE inhibitors had complaints of odynophagia (p < 0.02), whereas only patients with non-ACE inhibitor causes of angioedema presented with pruritus (p < 0.02). Furthermore, patients presenting with an acute reaction within 24 h of exposure to the causative agent were more likely to require inpatient monitoring (p < 0.05). Both odynophagia and edema of the tongue were significant predictors for undergoing laryngoscopy (p < 0.001 and p < 0.02, respectively) and admission to the hospital (p < 0.05). CONCLUSION ACE inhibitors are the number one cause of acute angioedema in this tertiary referral teaching hospital. Odynophagia and tongue swelling at the time of presentation had significant implications for diagnostic intervention and admission to the hospital.
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Affiliation(s)
- R Agah
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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62
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Alvarez F, Bandi V, Stager C, Guntupalli KK. Detection of Pneumocystis carinii in tracheal aspirates of intubated patients using calcofluor-white (Fungi-Fluor) and immunofluorescence antibody (Genetic Systems) stains. Crit Care Med 1997; 25:948-52. [PMID: 9201045 DOI: 10.1097/00003246-199706000-00009] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To compare the detection rate of Pneumocystis carinii in endotracheal aspirates with that rate in bronchoalveolar lavage fluid, using calcofluor-white (Fungi-Fluor) and immunofluorescence antibody (Genetic Systems) staining methods. DESIGN Prospective, consecutive cases. SETTING Medical intensive care unit at Ben Taub General Hospital. PATIENTS Thirty-one intubated patients admitted with respiratory failure and suspected P. carinii pneumonia. INTERVENTIONS An endotracheal aspirate specimen was obtained after maximally advancing a closed-system suction catheter, instilling aliquot portions of saline, and suctioning the lavage fluid. This procedure was followed within 30 mins by fiberoptic bronchoscopy and bronchoalveolar lavage. MEASUREMENTS AND MAIN RESULTS Endotracheal aspirate and bronchoalveolar lavage specimens from each patient were mixed with Saccomano's fixative, blended, and centrifuged. Using a modified method for P. carinii cysts, the sediment was stained with the test calcofluor-white stain Solution A and the test antibody stain. The test antibody stain on the bronchoalveolar lavage specimens was positive for P. carinii for 13 patients and was used as the standard for comparison. In the endotracheal aspirate specimens, the test antibody stain detected 12 (92%) P. carinii-positive patients while the test calcofluor-white stain detected ten (77%) P. carinii-positive patients. CONCLUSIONS We described a simple method for obtaining, processing, and staining endotracheal aspirate specimens for P. carinii. Obtaining an endotracheal aspirate specimen did not require specially trained personnel or a specialized and more expensive catheter, and was not associated with any complications.
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Affiliation(s)
- F Alvarez
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Abstract
India is a vast democracy of nearly one billion people. Before the British rule ended in 1947, the life span of an Indian was a mere 21 years. Within a short span of 50 years, it increased to an impressive 63 years, largely due to public health measures initiated by the government. This created a pool of more than 300 million middle class Indians who could afford the benefits of modern and specialized care when needed. Critical care medicine, as practiced in the West, is still confined to large Metropolitan areas. A large pool of expatriate Indian physicians from all over the world are helping bridge the resource gap between the West and India by transfer of technology and providing appropriate training to physicians and paramedical personnel. This article describes the history and current status of development of critical care medicine in India.
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Affiliation(s)
- K K Guntupalli
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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Abstract
OBJECTIVES Caring for acutely ill patients imposes significant demands on physicians. The environment and stresses of the ICU may lead to the burnout syndrome. The purpose of this study was to evaluate the prevalence of burnout among internal medicine intensivists and the contributing factors present in ICU practice. DESIGN Mailed survey utilizing the Maslach Burnout Inventory (MBI). Increasing burnout has been shown to be associated with low levels on personal achievement and high scores on depersonalization and emotional exhaustion. SUBJECTS Random sample of members of the Internal Medicine Section of the Society of Critical Care Medicine. MEASUREMENTS AND MAIN RESULTS 248 people responded: 220 (88.7%) males and 28 females. Mean age of all respondents was 41.6 +/- 6.7 years. The majority (58.1%) worked in large hospitals (> 400 beds); 55.6% devoted more than 50% of their time to critical care. The emotional exhaustion subscale of the MBI averaged 22.2 +/- 9.5, with a third of respondents scoring in the high range. The depersonalization score averaged 7.1 +/- 5.1%, with 20.4% of respondents scoring in the high range. Similarly personal achievement subscores were poor, with a mean value of 30.9 +/- 6.4%, with 59% scoring in the low range. High levels of emotional exhaustion were associated with anticipating leaving critical care before retirement. CONCLUSIONS Burnout as measured by the MBI appears to be common in internal medicine intensivists. High levels of emotional exhaustion and depersonalization are related not only to patient care issues but also to a poor support system.
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Affiliation(s)
- K K Guntupalli
- Department of Pulmonary/Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
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Anzueto A, Baughman RP, Guntupalli KK, Weg JG, Wiedemann HP, Raventós AA, Lemaire F, Long W, Zaccardelli DS, Pattishall EN. Aerosolized surfactant in adults with sepsis-induced acute respiratory distress syndrome. Exosurf Acute Respiratory Distress Syndrome Sepsis Study Group. N Engl J Med 1996; 334:1417-21. [PMID: 8618579 DOI: 10.1056/nejm199605303342201] [Citation(s) in RCA: 425] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with acute respiratory distress syndrome (ARDS) have a deficiency of surfactant. Surfactant replacement improves physiologic function in such patients, and preliminary data suggest that it may improve survival. METHODS We conducted a prospective, multicenter, double-blind, randomized, placebo-controlled trial involving 725 patients with sepsis-induced ARDS. Patients were stratified according to the risk of death at base line (indicated by their score on the Acute Physiological and Chronic Health Evaluation [APACHE III] index) and randomly assigned to receive either continuously administered synthetic surfactant (13.5 mg of dipalmitoylphosphatidylcholine per milliliter, 364 patients) or placebo (o.45 percent saline; 361 patients) in aerosolized form for up to five days. RESULTS The demographic and physiologic characteristics of the two treatment groups were similar at base line. The mean (+/- SD) age was 50 +/- 17 years in the surfactant group and 53 +/- 18 years in the placebo group, and the mean APACHE III scores at randomization were 70.4 +/- 25 and 70.5 +/- 25, respectively. Hemodynamic measures, measures of oxygenation, duration of mechanical ventilation, and length of stay in intensive care unit did not differ significantly in the two groups. Survival at 30 days was 60 percent for both groups. Survival was similar in the groups when analyzed according to APACHE III score, cause of death, time of onset and severity of ARDS, presence or absence of documented sepsis, underlying disease, whether or not there was a do-not-resuscitate order, and medical center. Increased secretions were significantly more frequent in the surfactant group; the rates of other complications were similar in the two groups. CONCLUSIONS The continuous administration of aerosolized synthetic surfactant to patients with sepsis-induced ARDS had no significant effect on 30-day survival, length of stay in the intensive care unit, duration of mechanical ventilation, or physiologic function.
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Affiliation(s)
- A Anzueto
- University of Texas Health Science Center at San Antonio, USA
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67
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Rocha P, Awe RJ, Guy ES, Gaines V, Banez EI, Stager CE, Guntupalli KK. A rapid and inexpensive method for processing induced sputum for detection of Pneumocystis carinii. Am J Clin Pathol 1996; 105:52-7. [PMID: 8561088 DOI: 10.1093/ajcp/105.1.52] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The authors describe a method to process induced sputum specimens for detection of Pneumocystis carinii which is simple, rapid and inexpensive. Induced sputum and bronchoalveolar lavage (BAL) were obtained within a 24-hour period from 41 patients who were HIV-positive and had pulmonary symptoms suspicious for P carinii pneumonia. Induced sputum or BAL fluid was placed into Saccomanno's fixative, blended, and centrifuged. The sediment was stained for P carinii cysts by a modified method with Fungi-Fluor Solution A (Polysciences, Warington, PA) and the Genetic Systems Pneumocystis carinii Immunofluorescence Antibody (Genetic Systems, Seattle, WA). The Genetic Systems stain on the BAL specimen was positive in 35 patients and was the standard for comparison. With a single induced sputum, the Genetic Systems stain detected 31 (89%) positive patients, whereas the Fungi-Fluor stain detected 21 (60%). The sensitivity for detecting P carinii cysts in induced sputum was significantly greater (P < 0.05) for the Genetic Systems stain.
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Affiliation(s)
- P Rocha
- Department of Pulmonary Medicine, Ben Taub General Hospital, Houston, TX 77030, USA
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68
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Interiano B, Guntupalli KK. Clinical aspects of asthma. Curr Opin Pulm Med 1996; 2:60-5. [PMID: 9363116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Asthma, one of the most common medical conditions during pregnancy, provides health care workers with an opportunity to diagnose, educate, and treat these patients. With proper fetal and maternal monitoring, outcome is good both for the mother and the baby. Elderly patients constitute a special group for whom asthma is underdiagnosed and undertreated. Exercise is a common trigger for asthma. The three factors determining exercise-induced asthma are minute ventilation, climatic conditions, and bronchial hyperreactivity. In vocal cord dysfunction, abnormal adduction of vocal cords causes airway obstruction. Vocal cord dysfunction can occur by itself or along with asthma and can be mistaken for asthma.
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Abstract
OBJECTIVES To review the pathophysiology, presentation and treatment of isoniazid (INH) intoxication. DATA SOURCES Human, animal and modeling studies published since 1940 identified through MEDLINE and a review of the bibliographies of relevant articles. STUDY SELECTION AND DATA EXTRACTION The studies identified were reviewed with emphasis on the most recent. Earlier studies were selected for their historical value and relevance to the clinical setting. DATA SYNTHESIS Isoniazid overdose is a potentially fatal intoxication. The incidence of tuberculosis has recently increased in the United States and therefore the frequency of INH overdose may also increase. Patients with INH overdose may present with nausea, vomiting, ataxia, symptoms reminiscent of atropine intoxication, coma and grand mal seizures. Lactic acidosis is revealed by laboratory evaluation. Treatment requires admission to the ICU for ventilatory support, and management of seizures and acid-base abnormalities. Pyridoxine, in a dose equivalent to the amount of INH ingested, is the only effective antidote. CONCLUSIONS INH overdose should be suspected in any patient presenting with seizures and metabolic acidosis. Prognosis is good when treatment is instituted early.
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Affiliation(s)
- F G Alvarez
- Pulmonary/Critical Care Department, Ben Taub General Hospital, Houston, Texas 77030, USA
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Baghaie AA, Mojtahedzadeh M, Levine RL, Fromm RE, Guntupalli KK, Opekun AR. Comparison of the effect of intermittent administration and continuous infusion of famotidine on gastric pH in critically ill patients: results of a prospective, randomized, crossover study. Crit Care Med 1995; 23:687-91. [PMID: 7712759 DOI: 10.1097/00003246-199504000-00017] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To compare the effects of intermittent intravenous administration and continuous intravenous infusion of famotidine on gastric pH in critically ill patients. DESIGN A prospective, randomized, crossover study of continuous infusion and bolus administration of famotidine in critically ill patients. SETTING A 14-bed medical intensive care unit (ICU) of a 500-bed county hospital. PATIENTS Medical ICU patients requiring stress ulcer prophylaxis. INTERVENTIONS Patients were randomized to receive an equivalent dose of famotidine by continuous infusion or intravenous bolus for 24 hrs, and then were crossed over to the other arm of the study. MEASUREMENTS AND MAIN RESULTS Critically ill patients who met the inclusion criteria were randomly assigned to receive famotidine 20 mg i.v. over 10 mins, every 12 hrs or a continuous infusion of 1.7 mg/hr for 24 hrs. After a 16-hr washout period, patients crossed over to the other arm of the study. Gastric pH was monitored continuously for 24 hrs. A total of 710 gastric pH measurements were obtained for each phase of the study. The mean area under the pH-time curve for a 24-hr period was higher for continuous infusion than bolus administration (p = .05). Continuous infusion of famotidine maintained a gastric pH of > or = 4 over a longer time period than bolus administration (20.8 hrs vs. 12.6 hrs, respectively; p < .01). Onset of therapeutic gastric pH for continuous infusion was slightly delayed as compared with bolus administration. CONCLUSIONS Continuous infusion of famotidine is more effective than an equivalent dose given by intermittent bolus in maintaining the appropriate gastric pH necessary for prevention of stress ulceration. Delayed onset of effect may warrant a priming dose when famotidine is given by continuous infusion.
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Affiliation(s)
- A A Baghaie
- Department of Pharmacy Practice, Texas Southern University College of Pharmacy and Health Sciences, Houston 77004, USA
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71
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Stager CE, Fraire AE, Kim HS, Estrada R, Davis JR, Greenberg D, Guy ES, Guntupalli KK, McBride RA. Modification of the fungi-fluor and the genetic systems fluorescent antibody methods for detection of Pneumocystis carinii in bronchoalveolar lavage specimens. Arch Pathol Lab Med 1995; 119:142-7. [PMID: 7531427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Four hundred forty-five bronchoalveolar lavage specimens from patients with the human immunodeficiency virus were preserved in Saccomano's fixative and stained for Pneumocystis carinii cysts by a modified method with Fungi-Fluor Solution A (Polysciences, Warrington, Pa) and the Genetic Systems Pneumocystis carinii Immunofluorescence Antibody (Genetic Systems Corp, Seattle, Wash). The majority of patients had been treated for suspected P carinii pneumonia for a few days prior to collection of bronchoalveolar lavage specimens. P carinii cysts were detected in 194 (43.6%) specimens. Both stains identified P carinii in 166 (37.3%) specimens and were negative in 251 (56.4%), yielding a concordance rate of 93.7%. P carinii cysts were detected in 25 (5.6%) specimens by the Genetic Systems stain only, and in 3 (0.7%) specimens by the Fungi-Fluor stain only. The sensitivity for detecting cysts of P carinii was significantly greater with the Genetic Systems stain (P < .01).
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Affiliation(s)
- C E Stager
- Department of Pathology, Baylor College of Medicine, Houston, Tex
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72
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Abstract
Takayasu's arteritis is an uncommon condition affecting predominantly young women. Because the disorder affects women in childbearing age, it may be recognized the first time during pregnancy. Various cardiovascular events may occur in the perinatal period. We describe a patient with Takayasu's arteritis who presented with massive hemoptysis. To our knowledge, this manifestation has not been documented previously.
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Affiliation(s)
- M P Rocha
- Department of Internal Medicine, Baylor College of Medicine, Houston
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73
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Subramanian D, Guntupalli KK. Diagnosing obstructive lung disease. Why is differentiating COPD from asthma important? Postgrad Med 1994; 95:69-70, 75-8, 83-5. [PMID: 8202424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) and asthma are the main causes of obstructive lung disease, and mortality rates of both diseases are on the increase. Smoking is the major risk factor for COPD. Airway hyperreactivity and reversibility of airflow obstruction, once considered hallmarks of asthma, may also be seen in COPD. Asthma is increasingly being recognized as a chronic inflammatory airway disease. COPD and asthma can be diagnosed through careful history taking, physical examination, spirometry, and other ancillary tests. More widespread use of peak expiratory flow rates should aid in diagnosis and monitoring.
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Rocha MP, Fraire AE, Guntupalli KK, Greenberg SD. Lung cancer in the young. Cancer Detect Prev 1994; 18:349-355. [PMID: 7812981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Lung cancer is uncommon in individuals age 40 or less. We reviewed the Cancer Registry files of the Ben Taub General Hospital (Houston, TX) from 1971 to 1989 and identified 1678 patients with a documented diagnosis of lung cancer. Among these 1678 patients, 50 (2.98%) were age 40 or less. Thirty-five (70%) of the 50 patients were men and 15 (30%) were women. Their median age was 37 (range of 24 to 40). A smoking history was available in 37 patients. Thirty-five (94.5%) of the 37 patients who were smokers had a > 20-pack per year history of smoking. Four patients were intravenous drug abusers, and one of these four tested positive for the immunodeficiency virus. Twenty-seven (54%) had adenocarcinoma, eight (16%) had squamous cell carcinoma, and six (12%) had other nondescript, nonsmall-cell carcinoma types. In contrast, the proportion of adenocarcinoma for the (all-age) group of 1678 patients with lung cancer was 28.2%. This difference in the proportion of adenocarcinoma between the two age groups was statistically significant (Pearson's Chi 2, 13.7039, p < 0.0005). Thirty-one (77.5%) of the 50 patients had unresectable disease at diagnosis (12 had stage IIIb and 19 had stage IV). The median survival from diagnosis was 26 weeks. These findings suggest that (1) smoking is an important risk factor for this subset of young patients, (2) the proportion of adenocarcinoma is higher in the young compared with the entire group of lung cancer patients, which included patients of all ages, and (3) young patients tend to present with advanced disease at diagnosis, resulting in an extremely poor survival.
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Affiliation(s)
- M P Rocha
- Department of Pulmonary Medicine, Baylor College of Medicine, Houston, TX
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75
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Groeger JS, Guntupalli KK, Strosberg M, Halpern N, Raphaely RC, Cerra F, Kaye W. Descriptive analysis of critical care units in the United States: patient characteristics and intensive care unit utilization. Crit Care Med 1993; 21:279-91. [PMID: 8428482 DOI: 10.1097/00003246-199302000-00022] [Citation(s) in RCA: 209] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To gather data about occupancy, admission characteristics, patients' ages, and types of therapy utilized in ICUs in the United States. DESIGN AND SETTING Survey instruments were mailed to the administrators of 4,233 hospitals to gather information from the medical director of the institutions' respective ICUs for the purpose of developing a database on ICUs in the United States. The sampling frame for this study was based on all American Hospital Association (AHA) hospitals stating they had ICUs. MEASUREMENTS Census questionnaires solicited information on occupancy, where the patients were admitted from, length of stay, therapies rendered, intensive care diagnoses, and resuscitation status, as well as other information. MAIN RESULTS Data were obtained regarding 32,850 ICU beds, with 25,871 patients from 2,876 separate ICUs in 1,706 hospitals in the United States. The census response rate was 40% of the AHA hospitals that stated they had ICUs, with specific ICU data on 38.7% of the nation's ICUs. Overall, the responding units reported a mean occupancy rate of 84% of total bed capacity and 87% of available beds. As hospital size increased, so did ICU occupancy. Nearly 17% of all of the critical care patients had been in the units for > 14 days. More precisely, 49% of all responding units indicated that they had one or more "chronic" (> 14-day length of stay) patients. Most patients were admitted to the units from the emergency room (38%), operating room/postanesthesia care unit (22%), and the general hospital floor (16%). Neonatal units were exceptions to this observation, where most patients came from the delivery room (60%). Admission from other hospitals represented a significantly larger group of patients in the cardiac care, pediatric, and neonatal units. Respondents indicated that many of their current patients were elderly, with 43% of these patients aged 65 to 84 yrs and with 4% being > or = 85 yrs of age. The 47% of patients > or = 65 yrs of age increased to 58% when the neonatal and pediatric units were eliminated from the analyses. For all units responding to the survey, the leading primary admitting intensive care diagnoses were postoperative management, ischemic heart disorder, respiratory insufficiency/failure, and prematurity. Elimination of units predominantly treating children (pediatric and neonatal) from the analysis left "adult" units with three primary admitting diagnoses: ischemic heart disease, postoperative management, and respiratory insufficiency/failure with variation according to specific unit type. The leading diagnoses in pediatric units were respiratory insufficiency/failure, postoperative management, and congenital abnormalities. For neonatal units, prematurity was the primary admitting diagnosis, accounting for 59% of these units' patients. Respondents reported 5.3 +/- 10.9% of patients had received cardiopulmonary resuscitation (CPR) before admission into the critical care unit. Only 6.0 +/- 11.9% of patients in these critical care units had instructions that CPR not be performed while in the unit. CONCLUSIONS This report should be viewed as the beginning step of an effort to improve both the information base available on critical care medicine and the performance of ICUs. Our survey findings provide an introduction into the everyday workings of critical care units throughout the United States. Research is required to determine which patients will benefit from intensive care and how to efficiently utilize the vast technology we have available for them in a world with limited financial resources, an aging population, and a multiplicity of societal and ethical concerns.
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Affiliation(s)
- J S Groeger
- Society of Critical Care Medicine, Anaheim, CA 92808-2214
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Abstract
OBJECTIVE The specific aim of this investigation was to evaluate the proficiency of health care providers and patients in the proper use of metered-dose inhalers. DESIGN, SETTING, AND PARTICIPANTS Health care providers, which include house staff, nurses, and respiratory care practitioners who provide care to patients with asthma in the primary general medicine clinic or the pulmonary medicine clinic of a university-county hospital in which patients were referred, were surveyed and assigned a performance score regarding the knowledge base of the appropriate use of metered-dose inhalers. Patients who attended the primary care general medicine and pulmonary subspecialty clinic were also assessed as to their proficiency in the use of metered-dose inhalers. RESULTS A significant percentage of patients had a poor understanding of the technique used with the metered-dose inhaler. House staff and nursing staff were also less proficient in the proper use of the metered-dose inhaler. The respiratory care practitioners were the most knowledgeable of the health care providers. CONCLUSIONS This study confirms that a large percentage of patients use metered-dose inhalers improperly. It also demonstrates a significant lack of understanding by health care providers of the proper use of metered-dose inhalers. Furthermore, this study supports the use of respiratory care practitioners in the outpatient setting, since they were the most proficient among all the health care providers in the proper use of metered-dose inhalers.
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Affiliation(s)
- B Interiano
- Department of Medicine, Baylor College of Medicine, Houston, TX
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77
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Fraire AE, Guntupalli KK, Greenberg SD, Cartwright J, Chasen MH. Amiodarone pulmonary toxicity: a multidisciplinary review of current status. South Med J 1993; 86:67-77. [PMID: 8420020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Amiodarone, a benzofuran derivative, has proven useful in the control of serious cardiac arrhythmias. We reviewed the English language medical literature to characterize clinical, radiographic, scintigraphic, pathologic, diagnostic, and prognostic data concerning amiodarone pulmonary toxicity. Our review showed that features consistent with amiodarone pulmonary toxicity include exertional dyspnea, fever, and high sedimentation rates, usually in patients taking larger maintenance doses. Positive findings on gallium scan, foamy alveolar macrophages on lung biopsy or bronchoalveolar lavage, and resolution of abnormal chest roentgenogram upon withdrawal of amiodarone and/or institution of corticosteroid therapy support a diagnosis of amiodarone pulmonary toxicity. Conversely, maintenance doses of 400 mg or less daily, normal lung diffusing capacity and bronchoalveolar lavage or lung biopsy specimens without foamy alveolar macrophages are features that make amiodarone pulmonary toxicity unlikely. Amiodarone pulmonary toxicity should be considered in any patient who has new or clinical worsening of respiratory symptoms and/or abnormalities on chest roentgenogram. Congestive heart failure is often present in these patients and must be excluded before a diagnosis of amiodarone pulmonary toxicity can be considered. Amiodarone pulmonary toxicity also needs to be distinguished from pulmonary infection. Therefore, amiodarone pulmonary toxicity remains a clinical diagnosis relying upon a composite of clinical, radiographic, and histopathologic findings.
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Affiliation(s)
- A E Fraire
- Department of Pathology, Baylor College of Medicine, Houston, Tex
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78
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Abstract
The management of pyoderma gangrenosum often requires systemic drug therapy, such as corticosteroids, sulfones, or immunosuppressants, either alone or in combination. Inconsistent response to therapy is a source of frustration to both patient and physician. Several reports in the literature document the successful treatment of pyoderma gangrenosum with hyperbaric oxygen therapy. In our patient, a woman with severe rheumatoid arthritis and diabetes mellitus, hyperbaric oxygen therapy not only promoted healing of pyoderma gangrenosum but permitted reduction of systemic corticosteroids.
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Affiliation(s)
- V Wasserteil
- Department of Dermatology, Baylor College of Medicine, Houston, Texas 77030
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Groeger JS, Strosberg MA, Halpern NA, Raphaely RC, Kaye WE, Guntupalli KK, Bertram DL, Greenbaum DM, Clemmer TP, Gallagher TJ. Descriptive analysis of critical care units in the United States. Crit Care Med 1992; 20:846-63. [PMID: 1597041 DOI: 10.1097/00003246-199206000-00024] [Citation(s) in RCA: 136] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To gather data about available technology, staffing, administrative policies, and bed capacities of ICUs in the United States. DESIGN AND SETTING On January 15, 1991, survey instruments were mailed to the administrators of 4,233 hospitals to gather information from the medical director of the institutions' respective ICUs for the purpose of developing a database on ICUs in the United States. The sampling frame for this study was based on all American Hospital Association (AHA) hospitals that stated they have ICUs. MEASUREMENTS Census questionnaires solicited information on types of hospitals, types of ICUs, number of ICU beds open and closed, technology available to the unit, organizational structure and management of the ICU, as well as the staffing and certification of unit personnel. MAIN RESULTS Data were obtained on 32,850 ICU beds with 25,871 patients from 2,876 separate ICUs in 1,706 hospitals in the United States. Census responses came from units in all sizes of hospitals within all ten census regions in the country, all states, and all types of hospital sponsorship (federal, state, and local government, private nonprofit and private for profit). The census response rate was 40% of the AHA hospitals that stated that they have ICUs, with specific ICU data on 38.7% of the nation's ICUs. The number of ICUs per hospital increases with overall hospital size. The smallest hospitals (less than 100 beds) usually had only one ICU. As hospital size increased, the single, all inclusive medical/surgical/coronary care units diminished, and in hospitals with greater than 300 beds, specialization of units became prevalent. In absolute terms, hospitals had the following number of ICUs: 1.04 +/- 0.20 (less than or equal to 100 beds); 1.30 +/- 0.65 (101 to 300 beds); 2.37 +/- 1.58 (301 to 500 beds); and 3.34 +/- 2.21 (greater than 500 beds). ICU beds averaged, nationally, 8.09% of hospital-licensed beds with a median of 6.98%. Generally, medical units, pediatric units, coronary care units (CCUs), and medical/surgical/CCUs reported an average of 10 beds per unit. Neonatal units averaged 21 beds, and surgical units averaged 12 beds. The average ICU size, nationally, was 11.7 +/- 7.8 beds per unit. Available technology within hospitals and individual units was increased as hospital size increased; surgical units tended to have more available technology than other unit types. A wide range of organizational arrangements within hospitals determines where the ICU appears in an organizational chart and to whom unit management is accountable. Thirty-six percent of the units were located organizationally within the hospital's department of medicine, while 23% were considered "free standing," having no departmental affiliation. Although units must have a medical director, the perception as to whether this director supervises the day-to-day operation was different in larger vs. smaller hospitals. In hospitals with less than or equal to 100 beds, 72% of the units were perceived to be supervised by the medical director, whereas in larger hospitals (greater than 500 beds), 81% of units were supervised. Study results indicated that medical directors in pediatric, neonatal, and burn units most often were perceived to supervise the unit. Presently, 63% of all ICUs responding are directed by an internist. The next largest group to direct ICUs were surgeons, followed by pediatricians. Pediatrician involvement tended to be exclusive in pediatric and neonatal units. Surgeons directed most surgical and neurologic units and were involved in 21% of mixed medical/surgical units. Internists predominated in medical units and in CCUs, as well as in combined medical/surgical/CCUs. Direction by anesthesiologists, although relatively infrequent, predominated in the surgical unit. Critical care medicine certification of the medical director and attending staff of the ICU increased as hospital size increased, although only 44% of all units stated that thei
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Affiliation(s)
- J S Groeger
- Memorial Sloan-Kettering Cancer Center, New York, NY
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Klepper MS, Guntupalli KK, Interiano B, Dowell M, Greenberg SB. Postoperative respiratory failure secondary to Pneumocystis carinii pneumonia. Chest 1992; 101:1155-7. [PMID: 1313351 DOI: 10.1378/chest.101.4.1155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Pneumocystis carinii pneumonia (PCP) occurs frequently in individuals infected with the HIV virus. Malignancy, immunosuppressive drugs, and congenital immune deficiency may be associated with PCP. We describe a patient with stage 1 testicular carcinoma who developed hypoxemic respiratory failure two days after retroperitoneal lymph node dissection. Pneumocystis carinii organisms were demonstrated by catheter lavage samples and confirmed on bronchoalveolar lavage. Testing for HIV antibody by ELISA and the Western blot test were negative; HIV viral culture and polymerase chain reaction were also negative. Pneumocystis carinii pneumonia is unusual in localized surgically cured malignancies without obvious immunodeficiency and, to our knowledge, has not been described as a cause of postoperative respiratory failure.
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Affiliation(s)
- M S Klepper
- Department of Internal Medicine, Baylor College of Medicine, Houston
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81
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Guntupalli KK, Francis PB. Unilateral lung infiltrate. Lipoid pneumonia. Eur Respir J 1991; 4:125-7. [PMID: 2026233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A case of unilateral lipoid pneumonia, proven by alveolar lavage and transbronchial lung biopsy, is presented. Following a stroke, which resulted in difficulty in swallowing, the patient slept only on his right side accounting for the unilateral lung infiltrate. He had been taking mineral oil for several years accounting for the lipoid pneumonia.
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Guntupalli KK, Francis PB. Unilateral lung infiltrate. Lipoid pneumonia. Eur Respir J 1991. [DOI: 10.1183/09031936.93.04010125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A case of unilateral lipoid pneumonia, proven by alveolar lavage and transbronchial lung biopsy, is presented. Following a stroke, which resulted in difficulty in swallowing, the patient slept only on his right side accounting for the unilateral lung infiltrate. He had been taking mineral oil for several years accounting for the lipoid pneumonia.
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Guntupalli KK, Sladen A, Selker RG, Weinstock E, Wilks DH, Passmore J, Guntupalli JS. Effects of induced total-body hyperthermia on phosphorus metabolism in humans. Am J Med 1984; 77:250-4. [PMID: 6465174 DOI: 10.1016/0002-9343(84)90699-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The effects of total-body hyperthermia on phosphorus homeostasis are controversial. To evaluate the problem, 10 clearance studies were performed in seven patients undergoing total-body hyperthermia as an adjunct to the treatment of solid malignant tumors. Total-body hyperthermia was associated with significant reduction in plasma phosphorus concentration from a baseline value of 3.51 +/- 0.18 to 0.6 +/- 0.1 mg/dl (p less than 0.001), returning to baseline following cessation of total-body hyperthermia. The clearance of phosphorus increased from 15.2 +/- 2.5 to 26.1 +/- 3.1 ml per minute (p less than 0.01), and the fractional excretion of phosphorus increased from 11.37 +/- 2.2 to 47.68 +/- 9.7 percent (p less than 0.01). The reduction in plasma phosphorus during total-body hyperthermia was also associated with a significant reduction in the renal threshold phosphorus concentration from 3.17 +/- 0.16 to 0.38 +/- 0.08 (p less than 0.001). The changes in phosphorus homeostasis during total-body hyperthermia were independent of changes in circulating parathyroid hormone level, urinary cyclic AMP excretion, and arterial carbon dioxide tension.
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Guntupalli KK. Acute pulmonary edema. Cardiol Clin 1984; 2:183-200. [PMID: 6443344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Fluid movement from the pulmonary capillaries into the interstitial space occurs continuously and is drained by the lymphatics. With increased leakage or decreased clearance, excessive extravascular lung water accumulates, initially as interstitial edema and subsequently as alveolar edema. The most common cause of pulmonary edema is an increase in microvascular hydrostatic pressure. An increased permeability of the capillaries is the other mechanism of production of pulmonary edema. An acute, critical reduction in colloid osmotic pressure may play a contributory role in pulmonary edema even at normal hydrostatic pressures. Dyspnea, diaphoresis, and anxiety characterize the clinical picture. A history of heart disease and congestive heart failure may be present in CPE, whereas evidence of an inciting event or disease process suggests NCPE. Hypoxia, decreased lung compliance, and increased shunt fraction are seen in both types of pulmonary edema, but the duration of pulmonary edema tends to be more severe and prolonged in NCPE. Evidence of increased permeability in NCPE distinguishes it from CPE. Clinically, this is assumed when pulmonary edema is demonstrated at normal PCWP and when edema fluid protein concentration and COP are close to those of plasma. The management of pulmonary edema consists of the improvement of gas exchange by methods that range from supplemental oxygen administration to mechanical ventilatory support with PEEP, depending on the severity of the disturbance in lung function. Improvement in myocardial function and a decrease in pulmonary congestion are accomplished with diuretics and morphine; in those patients who do not respond to this therapy, manipulation of preload, afterload, and myocardial contractility by vasodilators and inotropic agents may be required. In acute pulmonary edema, intravenously administered agents with a short half-life and rapid onset of action are preferred. The role of colloids in the treatment of pulmonary edema is controversial. The indications for the use of corticosteroids in ARDS are controversial, and an optimum dose has not been determined. Many clinicians tend to choose steroids to treat these patients, but the value of these agents in this setting awaits the results of controlled trials now under way.
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Egol AB, Guntupalli KK. Intravenous infusion device artifact in the EEG-confusion in the diagnosis of electrocerebral silence. Intensive Care Med 1983; 9:29-32. [PMID: 6833625 DOI: 10.1007/bf01693703] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Intravenous infusion devices are routinely used in the intensive care unit to accurately regulate the delivery of various intravenous fluids and vasoactive drugs. These devices have been well described in the literature as the cause of various electrocardiographic artifacts. There has been little documentation in the literature implicating these devices as the etiology of artifacts in the electroencephalogram. The association of intravenous infusion devices with electroencephalographic artifacts became relevant during the brain death evaluation of two patients. The electroencephalograms, which were done for documentation of electrocerebral silence clearly showed activity in both patients which disappeared when the intravenous infusion devices were stopped. Possible mechanisms responsible for producing these artifacts include piezoelectric current, poor electrode contact, inadequate skin preparation, current leakage, static charges and electromagnetic activity. In the evaluation of patients for electrocerebral silence, it is important to both recognize and eliminate this artifact so that it is not confused with true electrocerebral activity.
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Sassano JJ, Sladen A, Franklin RH, Guntupalli KK. Management of hemorrhagic shock with hydroxyethyl starch, total-dose imferon infusion, and mass spectrophotometry. Crit Care Med 1982; 10:484-5. [PMID: 6177471 DOI: 10.1097/00003246-198207000-00017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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