Chest
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One hundred seven acutely ill ventilated patients were prospectively studied to ascertain the severity and frequency of alterations in gas exchange and hemodynamic parameters during brief bronchoscopy. Sedation was performed using midazolam (0.1 mg/kg IV) without topical anesthesia. An average decline in PaO2 of 26 percent was observed at the end of the procedure, compared to the baseline value, and this was associated with a mild increase in PaCO2 in spite of the use of a special adapter. ⋯ Fourteen patients developed hypoxemia of less than 60 mm Hg on FIO2 adjusted to 0.8. Of the ten risk factors univariately associated with hypoxemia, only the presence of ARDS (p less than 0.001) and "fighting" the ventilator during the procedure (p less than 0.05) remained significant after stepwise logistic regression. Attempts to prevent hypoxemia in critically ill patients should focus on inducing complete sedation, with careful attention to hemodynamic status, or providing maximal levels of oxygen to the ventilator (or both).
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Comparative Study
Agreement between noninvasive oximetric values for oxygen saturation.
We made an assessment of five pulse oximeters in regard to their ability to replace the HP ear oximeter as a noninvasive measurement of SaO2. Trials were performed during isocapnic progressive hypoxia (SaO2 range, 99 to 70 percent) in 22 white and six black subjects. Comparisons between values of SaO2 by oximetry were analyzed by comparing the difference of values by the two methods against their mean. ⋯ The distribution of differences between pulse oximeters and the HP were larger below 80 percent than above 85 percent. We conclude that pulse oximeters give higher values than the HP, a tendency which is more pronounced in black than in white subjects. While the limits of agreement are better at saturations above 85 percent, the 95 percent confidence limits of agreement between pulse oximeters and the HP are rather large (+/- 10 percent) and unacceptable for assuming that pulse oximeters will provide the same values as found in clinical studies using the HP.
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We present a patient who had chronic, bilateral pleural effusions without evidence of parenchymal, retrocardiac or mediastinal masses. A CAT scan of the abdomen and chest revealed the extension of a large abdominal pseudocyst through the diaphragm into the posterior mediastinum. The pseudocyst resolved with conservative management.
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Randomized Controlled Trial Multicenter Study Clinical Trial
Role of aspirin with thrombolytic therapy in acute myocardial infarction.
Thrombolytic therapy has been shown to limit infarct size, improve ventricular function, and decrease mortality in suspected evolving myocardial infarction (MI). Aspirin therapy also decreases mortality as well as stroke and reinfarction in suspected evolving MI. ⋯ The use of aspirin with thrombolysis also protects against the increase in reinfarction observed when thrombolytic therapy is given alone. While ongoing research is evaluating the optimal thrombolytic agent as well as the possible role of heparin, it is already clear that the use of aspirin with thrombolytic therapy will significantly decrease reinfarction, stroke, and vascular mortality in suspected evolving MI.
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Multicenter Study Clinical Trial
GISSI trials in acute myocardial infarction. Rationale, design, and results.
The first Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto (GISSI) study showed striking evidence of the effectiveness and safety of intravenous thrombolytic treatment in acute myocardial infarction (MI). Since publication in The Lancet, the original report has become a reference work for every paper which deals with thrombolysis. In addition to GISSI's scientific value, these studies applied formal research to routine clinical practice outside of referral centers. ⋯ The package of treatments recommended after extensive discussion with all the investigators (beta-blocker, aspirin, nitrates) was widely adopted. Now, only five years after the start of the GISSI-1, the overall mortality of Italian patients with acute MI has decreased from 13.0 percent to about 9 percent, and the number of patients with acute MI arriving in hospital within 1 h of the onset of symptoms has increased 50 percent. It is the wish of the GISSI investigators that this approach to treating acute MI will be regarded and acknowledged as their major contribution to the problem.