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Orlowski JP, Jaynes CL, Spees EK. Practical reduction of transplantation costs. Use of commercial transportation instead of charter aircraft for sharing pancreas grafts. ARCHIVES OF SURGERY (CHICAGO, ILL. : 1960) 1993; 128:1111-4. [PMID: 8215871 DOI: 10.1001/archsurg.1993.01420220031004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To demonstrate cost savings in pancreas transplantation through use of commercial organ transportation. DESIGN Retrospective study. SETTING Independent Organ Procurement Organization, Denver, Colo. SUBJECTS Forty-three consecutive pancreas grafts recovered by Colorado transplantation surgeons and transported via charter aircraft (53.4%) or commercial airlines (46.6%) to transplantation centers outside Colorado. MEASUREMENTS Actuarial graft survival at 1 year was calculated. Transportation costs were also obtained. MAIN RESULTS Transportation of organs via charter aircraft cost an average of $3658.37 compared with an average of $102.40 for commercial airline transportation (average cost difference, $3555.97). Graft survival was 73.9% for chartered grafts vs 80.0% for commercially shipped grafts. Mean preservation times were 13 hours 54 minutes for chartered grafts vs 17 hours 50 minutes for commercial transportation. CONCLUSION Our data demonstrated a significant cost savings when pancreas grafts were transported via commercial airlines instead of chartered aircraft. These cost savings were obtained without negative sequelae in clinical outcome, encouraging widespread use of commercial airlines for transporting shared pancreas grafts.
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Porembka DT, Kier A, Sehlhorst S, Boyce S, Orlowski JP, Davis K. The pathophysiologic changes following bile aspiration in a porcine lung model. Chest 1993; 104:919-24. [PMID: 8365309 DOI: 10.1378/chest.104.3.919] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Aspiration of bile is an underpublicized aspiration syndrome. Using a porcine lung model, the physiologic response and the histopathology of lung tissue were evaluated after the intratracheal instillation of sublethal doses of bile. Twenty-one domestic swine (11 to 19 kg) were the studied population. Three groups of five swine were evaluated: a control group received intratracheal physiologic saline (pH 7.45); study group 1 received strained gastric contents (pH 2.24); and study group 2 received strained bile (pH 7.19). All animals received the solutions at 0.5 ml/kg intratracheally. Lungs of six additional animals were studied (two gastric, two bile, and two physiologic saline) after aspiration by scanning electron microscopy (SEM). A seventh untreated animal was used as the SEM control. The physiologic data were analyzed using analysis of variance for repeated measures. The SEM and histopathologic results were graded by an observer blinded to the groups and were analyzed using the analysis of variance (ANOVA) and Scheffe tests. The group with bile aspiration was consistently characterized by significant deterioration of PaO2, the alveolar-arterial (A-a) gradient, shunt fraction, and static compliance (p < 0.01); and the light histopathologic and SEM findings demonstrated pathologic changes in the bile-exposed lung (p < 0.05) greater than the gastric- or saline-exposed lungs. It is concluded that bile aspiration produces a severe chemical pneumonitis leading to noncardiac pulmonary edema.
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Sato T, Orlowski JP, Zborowski M. Experimental study of extracorporeal perfusion for septic shock. ASAIO J 1993; 39:M790-3. [PMID: 8268646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The authors evaluated the efficacy of treatment by extracorporeal perfusion on experimental canine septic shock. Canine septic shock was produced by intravenous infusion of Escherichia coli endotoxin and treated by three techniques: no treatment (Sham), hemoperfusion over Polymyxin B immobilized fiber (PMX), and plasma perfusion over anion exchange resin (Resin). The 24 hr survival rates of the Sham, PMX, and Resin groups were 0%, 80%, and 40%, respectively. In the PMX group, blood pressure was significantly better over 6 hr than that recorded in the Sham group. In the PMX group, phagocytic function evaluated by neutrophil function, opsonic index, and complement were better than that of the Sham group. In addition, blood endotoxin levels in the PMX group were significantly lower, resulting in a significant suppression of TNF release. In the Resin group, some parameters were significantly better than those of the Sham group, but the efficacy of this treatment was less than that of the PMX treatment. Hemoperfusion over Polymyxin B immobilized fibers can detoxify circulatory endotoxin, resulting in improvement of systemic and organic disorders caused by sepsis.
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Orlowski JP, Smith ML, Van Zwienen J. Medical decisions concerning the end of life in children in The Netherlands. AMERICAN JOURNAL OF DISEASES OF CHILDREN (1960) 1993; 147:613-4. [PMID: 7685144 DOI: 10.1001/archpedi.1993.02160300019014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Orlowski JP. Evidence that thyroxine (T-4) is effective as a hemodynamic rescue agent in management of organ donors. Transplantation 1993; 55:959-60. [PMID: 8475575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Smith ML, Orlowski JP. Reply. Cleve Clin J Med 1993. [DOI: 10.3949/ccjm.60.2.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Orlowski JP, Spees EK. Improved cardiac transplant survival with thyroxine treatment of hemodynamically unstable donors: 95.2% graft survival at 6 and 30 months. Transplant Proc 1993; 25:1535. [PMID: 8442178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Orlowski JP, Collins RL, Cancian SN. Forgoing life-supporting or death-prolonging therapy: a policy statement. Cleve Clin J Med 1993; 60:81-5. [PMID: 8443941 DOI: 10.3949/ccjm.60.1.81] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Avoiding death is not always the preeminent goal of health care, and decisions about the use of life-supporting treatment may either hasten or forestall death. What are the health care professional's responsibilities regarding the use of life-supporting therapy? This report offers general and specific guidelines for termination of life-supporting treatment.
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Abstract
Pediatric euthanasia is currently practiced in the Netherlands on newborns, infants, children, and adolescents, although exact numbers are not known. Euthanasia in the Netherlands is generally assumed to be active and voluntary, but some cases of pediatric euthanasia would have to be characterized as nonvoluntary. Much of the motivation behind the euthanasia movement and the performance of pediatric euthanasia in the Netherlands is a genuine, compassionate desire to alleviate pain and suffering. In this study, we review the Dutch experience, with particular attention to the current practice of euthanasia on newborns, infants, children, and adolescents. We discuss pediatric euthanasia from an ethical point of view. We assert that more effective pain control, better symptom management, and psychosocial support of the dying and their families would alleviate the perception of suffering, and reduce the perceived need to resort to euthanasia.
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Orlowski JP. How much resuscitation is enough resuscitation? Pediatrics 1992; 90:997-8. [PMID: 1437445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Abstract
OBJECTIVE To assess changes in the terminal care of critically ill patients before and after the institution of do-not-resuscitate (DNR) order policies, and policies on the care of the hopelessly ill. DESIGN Retrospective chart review that comprises the following groups: 82 consecutive deaths from 1981 to 1982, representing our older practice pattern of frequent utilization of terminal resuscitative efforts (group A); 37 consecutive deaths between June and December 1987, the 6-month period immediately preceding the adoption of the DNR policy (group B); and 61 consecutive deaths in calendar year 1988 after the DNR policy went into effect (group C). SETTING Surgical ICU of a large tertiary care center. PATIENTS Consecutive patients who died during the study periods before and after the implementation of a DNR policy. INTERVENTIONS The implementation of hospital-wide policies on DNR orders and care of the hopelessly ill patient. MEASUREMENTS AND MAIN RESULTS There were no significant differences between the three groups for age, Acute Physiology and Chronic Health Evaluation II scores, Mortality Risk Ratio scores, or lengths of ICU stay. There was a significant (p less than .0001) decrease in the frequency of terminal resuscitative efforts, as evidenced by a decrease from 52% in group A to 3% in group C. The preterminal identification and acceptance of imminent death increased over the study period with an increase (p less than .0001) in the application of DNR orders from 46% in group A to 98% in group C. The ability to withdraw support increased (p less than .0001) from 23% in group A to 73% in group C. CONCLUSIONS We believe that our data exemplify how our ICU has been able to identify hopelessly ill patients, and how it has implemented specific levels of care that take into account not only medical prognostication, but also the wishes of the patients and their families, while maintaining an atmosphere of comfort and dignity. We demonstrated an important change in the philosophy of care for hopelessly ill patients, which was associated with the institution of DNR policies.
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Orlowski JP, Wateska L. The effects of pharmaceutical firm enticements on physician prescribing patterns. There's no such thing as a free lunch. Chest 1992; 102:270-3. [PMID: 1623766 DOI: 10.1378/chest.102.1.270] [Citation(s) in RCA: 248] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We examined the impact on physician prescribing patterns of pharmaceutical firms offering all-expenses-paid trips to popular sunbelt vacation sites to attend symposia sponsored by a pharmaceutical company. The impact was assessed by tracking the pharmacy inventory usage reports for two drugs before and after the symposia. Both drugs were available only as intravenous preparations and could be used only on hospitalized patients. The usage patterns were tracked for 22 months preceding each symposium and for 17 months after each symposium. Ten physicians invited to each symposium were interviewed about the likelihood that such an enticement would affect their prescribing patterns. A significant increase in the prescribing pattern of both drugs occurred following the symposia. The usage of drug A increased from a mean of 81 +/- 44 units before the symposium to a mean of 272 +/- 117 after the symposium (p less than 0.001). The usage of drug B changed from 34 +/- 30 units before the symposium to 87 +/- 24 units (p less than 0.001) after the symposium. These changed prescribing patterns were also significantly different from the national usage patterns of the two drugs by hospitals with more than 500 beds and major medical centers over the same period of time. These alterations in prescribing patterns occurred even though the majority of physicians who attended the symposia believed that such enticements would not alter their prescribing patterns.
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Wiedemann HP, Orlowski JP. A Practical Guide to Pediatric Intensive Care (3rd Edition). Cleve Clin J Med 1991. [DOI: 10.3949/ccjm.58.6.540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Basheda SG, Mehta AC, De Boer G, Orlowski JP. Endobronchial and parenchymal juvenile laryngotracheobronchial papillomatosis. Effect of photodynamic therapy. Chest 1991; 100:1458-61. [PMID: 1935314 DOI: 10.1378/chest.100.5.1458] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Juvenile laryngotracheobronchial papillomatosis (JLTBP) is a recurrent, prolonged disease usually confined to the upper airway. Rarely, tracheobronchial tree or lung parenchymal involvement occurs. The various therapeutic interventions are often unsuccessful once extralaryngeal involvement becomes apparent. Photodynamic therapy (PDT) has been successful in eradicating JLTBP in a few case reports. We present a case of extensive JLTBP with parenchymal involvement treated with multiple courses of PDT. We demonstrated temporary regression of endobronchial papillomas, but no change in parenchymal lesions. Recurrent endobronchial disease was most likely related to reinfection from parenchymal lesions inaccessible to PDT.
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Singer LT, Hill BP, Orlowski JP, Doershuk CF. Medical and social factors as predictors of outcome in infant tracheostomy. Pediatr Pulmonol 1991; 11:243-8. [PMID: 1722034 PMCID: PMC4940850 DOI: 10.1002/ppul.1950110310] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We examined the relative impact of infant tracheostomy in comparison to associated medical and social factors, on developmental outcome as part of a cross-sectional follow-up of 32 children. These children had no mental retardation, physical handicap, or severe neurological problems, but had a history of long-term tracheostomy in infancy, ranging from 3 to 146 months duration. Medical factors evaluated included prematurity, neurological status, severity of illness, and number of weeks hospitalized. Social factors included parental education and occupation. Outcome measures included IQ, language quotient, growth parameters, and behavioral competence. Correlation analyses, stepwise multiple regression analyses, and t-tests were used. Early medical illnesses were significant predictors of cognitive, language, and growth outcome. Severity of medical complications at birth and the presence of any neurological problem predicted 49% of the variance in IQ at follow-up. Social class was the only variable to predict behavioral outcome, accounting for 28% of the variance. For children without confounding medical conditions, tracheostomy had a negative impact on overall language and auditory comprehension. Once children with confounding medical risk factors were removed from the sample, children with history of infant tracheostomy exhibited significantly lower overall mean language scores (106 versus 120), and lower mean language comprehension scores (104 versus 119) than a matched comparison group.
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Spees EK, Orlowski JP, Temple DM. The successful use of marginal cadaveric donor kidneys. Transplant Proc 1990; 22:1382-3. [PMID: 2389336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Kraus DH, Rehm SJ, Orlowski JP, Tubbs RR, Levine HL. Upper airway obstruction due to tonsillar lymphadenopathy in human immunodeficiency virus infection. ARCHIVES OF OTOLARYNGOLOGY--HEAD & NECK SURGERY 1990; 116:738-40. [PMID: 2340129 DOI: 10.1001/archotol.1990.01870060096021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Head and neck manifestations of human immunodeficiency virus (HIV) infection are common and include diffuse cervical lymphadenopathy, cutaneous and mucosal Kaposi's sarcoma, mucosal herpes simplex infection, upper aerodigestivetractcandidiasis, and parotidlymphadenopathy and cysts. Recurrent otitis media and chronic sinusitis have been noted in the pediatric HIV population. We describe a patient with HIV-associated tonsillar and adenoid lymphadenopathy and upper airway obstruction. Pathologic analysis of the tonsillar tissue revealed severe lymphofollicular hyperplasia similar to that of other lymphoid tissue in HIV infection. The importance of symptomatic treatment of the airway obstruction is stressed.
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Orlowski JP, Campbell P, Goldstein S. Reye's syndrome: a case control study of medication use and associated viruses in Australia. Cleve Clin J Med 1990; 57:323-9. [PMID: 2364532 DOI: 10.3949/ccjm.57.4.323] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The records of 49 cases of Reye's syndrome at three pediatric hospitals in Australia are compared with 94 controls. The diagnosis of Reye's syndrome was confirmed pathologically in 42 of 49 cases (86%). Aspirin or salicylate ingestion occurred in only 4 (8%), and paracetamol (acetaminophen) ingestion in 12 (24%) (P greater than 0.05 by chi-square analysis). Of the controls, 3 (3%) had taken aspirin and 39 (41%) had taken paracetamol. Associated viruses included paramyxoviruses, picornaviruses, reoviruses, adenoviruses, and occasional varicella-zoster (herpesvirus). No influenza A or B viruses were recovered from any patient. This case control study of Reye's syndrome in Australia confirmed a lack of association between aspirin ingestion and the development of Reye's syndrome.
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Spees EK, Orlowski JP, Temple DR, Kam I, Karrer IF. Efficacy of simultaneous cadaveric pancreas and liver recovery. Transplant Proc 1990; 22:427-8. [PMID: 2326943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
When intravenous access cannot be obtained in an emergency, the endotracheal route of emergency drug administration can be used for epinephrine, atropine, and lidocaine. Optimal drug dosages for endotracheal administration as well as the amount and type of diluent are presently unknown. We compared central intravenous, peripheral intravenous, intraosseous, and intratracheal administration of epinephrine 1:10,000 in both normotensive and hemorrhagic shock dogs. The shock model consisted of 50% blood volume depletion over 15 min. Epinephrine was administered in a dose of 0.01 mg/kg (0.1 cc/kg) by the intraosseous route, central, and peripheral intravenous routes followed by a 5 cc normal saline flush. Intratracheal administration consisted of epinephrine 0.01 and 0.02 mg/kg diluted 1:1 and 1:2 with normal saline or sterile water and administered deep into the tracheo-bronchial tree using a 30-cm catheter. The effect of epinephrine was assessed by the response of the arterial blood pressure. Epinephrine was equally effective by the intraosseous, central intravenous, and peripheral intravenous routes in terms of time to onset of action, time to peak effect, and magnitude of effect on systolic, diastolic, and mean arterial pressures in both the shock and non-shock animals. The duration of effect was significantly longer (P less than 0.02) for the intraosseous route of administration. The endotracheal route of administration was unreliable and not reproducible in either the normotensive or shock animals. In 8/12 episodes in normotensive animals, including 5 trials with double doses of 0.02 mg/kg and dilutions of 1:1 and 1:2, and in 4/9 studies with shock animals including three with double doses, there was no discernable response of systolic or diastolic blood pressure.
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Spees EK, Orlowski JP, Springer J, Young D, Temple DR, Kam I, Karrer F, Kortz W, Schorr WJ, Narrod J. Evolution of the Colorado Organ Recovery Systems. Transplant Proc 1990; 22:326-9. [PMID: 2326902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Spees EK, Orlowski JP, Kam I, Karrer F, Dunn SM. Are pediatric donors well utilized? Transplant Proc 1990; 22:359-60. [PMID: 2326915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Spees EK, Orlowski JP, Fitting KM, Temple DM, Reynolds CP. Successful use of cadaver kidneys from diabetic donors for transplantation. Transplant Proc 1990; 22:378-9. [PMID: 2326923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Spees EK, Orlowski JP, Schorr WJ, Temple DM, Fink DW, Bruno AJ. Successful use of polycystic cadaver donor kidneys. Transplant Proc 1990; 22:374-5. [PMID: 2183419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Orlowski JP. Development of policies on brain death, care of the hopelessly ill, and do not resuscitate. Cleve Clin J Med 1990; 57:25-9. [PMID: 2306865 DOI: 10.3949/ccjm.57.1.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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