Chest
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The aim of the study was to identify risk factors for early onset pneumonia (EOP) in trauma patients, in order to seek possible intervention strategies. ⋯ In a trauma population, a combined severe abdominal and thoracic trauma represents a major risk factor for EOP. Mechanical ventilation administered during the first days after trauma seems to reduce the risk of EOP. As reported in previous studies, mechanical ventilatory support lasting more than 5 days is associated with an increased risk of LOP.
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To evaluate wrist compression as a test to identify low radial from low systemic pressure and to see if the gradient found after cardiopulmonary bypass is also present whenever hand vascular resistance may decrease. ⋯ The systemic-radial artery pressure gradient seen at the end of cardiopulmonary bypass seems to be a phenomenon common to patients with decreased hand vascular resistance. Wrist compression decreases or abolishes the gradient in most cases. It does not produce false positives, so an increase indicates a greater aortic than radial pressure. The difference is likely to be only temporary.
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The lung injury in adult respiratory distress syndrome (ARDS) has been associated with increased expiratory hydrogen peroxide (H2O2) concentrations. Furthermore, patients with sepsis and ARDS are reported to have greater serum scavenging of H2O2 than patients with ARDS only. We hypothesized that the systemic presence of H2O2 would be detectable in the urine of these two groups of patients and that, in the case of ARDS sepsis, the relative contribution of each disease to the production this analyte would be discernible. Accordingly, we used an in vitro radioisotope assay to follow the weekly course of urine H2O2 levels in ARDS patients with and without sepsis, and in samples from control non-ARDS patients with sepsis with indwelling urinary catheters and in samples provided by healthy volunteers. ⋯ Lung injury scores did not differentiate patients with ARDS and sepsis from patients with ARDS only during the first 10 days in the ICU; however, urine H2O2 levels were significantly greater in the patients with ARDS and sepsis. Moreover, despite no initial difference in lung injury, patients who did not survive ARDS and sepsis had consistently greater urine H2O2 concentration than patients who survived sepsis. The urine H2O2 level in the ARDS-only group was about 70 percent of the level in the survivor ARDS and sepsis group, suggesting that ARDS alone is the major contributor to the H2O2 oxidant processes during combined ARDS and sepsis. Furthermore, these studies demonstrate that urine H2O2 may be a useful analyte to differentiate the severity of oxidant processes in patients with ARDS and sepsis albeit the prognosis appears to be survival or nonsurvival.
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We recently observed a striking increase in multidrug-resistant tuberculosis (MDR-TB) among patients admitted to the Chest Service at Bellevue Hospital Center in New York. We reviewed the laboratory susceptibility test results of 4,681 tuberculosis (TB) cases over the past 20 years, Combined resistance to isoniazid and rifampin increased from 2.5 percent in 1971 to 16 percent in 1991 with higher rates noted for individual drugs. ⋯ We conclude that the epidemics of AIDS and TB are complicated by a third epidemic of MDR-TB. This third epidemic requires urgent attention to achieve more rapid diagnosis, to develop new therapeutic regimens, and to address the social and hospital environment ot care for these individuals.
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Current treatment strategies for asthma and chronic obstructive pulmonary disease (COPD) emphasize the inhalation route, yet patients often misuse metered-dose inhalers (MDI). To address this problem, patient education by medical personnel has been recommended and a variety of alternate inhaler devices have been developed. ⋯ We conclude that (1) many medical personnel responsible for monitoring and instructing patients in optimal inhaler use lack rudimentary skills with these devices, (2) nurses and physicians seldom receive formal training in the use of inhaling devices, and (3) newer inhaling devices designed to obviate problems of technique are at present less likely to be used well by medical personnel soon after their introduction.