Medicine Chest News - Part 2

educational programsOne hundred years ago, the profession put in place a system of self-regulation that was designed to distinguish the quacks from the qualified. Individual physicians had to graduate from an accredited school, accredited residency program, and to maintain participation in accredited CE. Individuals were certified, and their educational programs were accredited. This system achieved its end, and it is now distinctly unusual for those not qualified to practice medicine to be engaged in practice.

As the profession developed a serious commitment to improving patient care, it became apparent that the “qualified” model was not up to the task. A competency movement emerged that required that individual physicians demonstrate competence. Over time, however, it has become clear that high-quality health care depends on more than traditional physician competence. Improving patient care is dependent on system attributes, including the functioning of individuals across disciplines and professions, and teamwork became important. Improving individual performance is necessary but not sufficient. Hence, the Josiah Macy, Jr. Foundation Conference participants recommended that two of the oversight bodies in the medical and nursing professions should work together to establish a single accrediting organization. We recommended that the Accreditation Council for Continuing Medical Education and the American Nurses Credentialing Center explore new and very important territory: accrediting lifelong learning across their professions using the principles of practice-based learning and improvement; new technologies including the internet, point-of-care information, and simulation; and the ethical principles detailed in the Josiah Macy, Jr. Foundation Conference report. Linkages between system performance and individual learning should be established as part of the accountability to the public espoused by both professions. The two organizations, along with the Accreditation Council for Pharmacy Education, have recently announced that they have developed a proposal for joint accreditation.

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bronchospasmIn the three cases presented, bronchospasm was detected at the end of the bypass period, when the first attempts to inflate the lungs were accompanied by expiratory wheezing, high inflation pressures and difficulty in deflation of the lungs. Mechanical causes for wheeing include tracheobronchial obstruction, cardiac wheezing and pneumothorax. Tracheobronchial obstruction was ruled out by investigation with a fiberoptic bronchoscope. Cardiac wheezing will be accompanied by elevated left atrial pressure and alveolar edema, neither of which was noted in our patients. Although pneumothorax can produce wheezing and elevated inflation pressures, it is not likely to cause both lungs to appear overly inflated and crowd the mediastinum.

There are several possible non-mechanical etiologies of bronchospasm after cardiopulmonary bypass. One of these possibilities is activation of C3a and C5a complement anaphylatoxins during cardiopulmonary bypass. Activation of C3a and C5a complement-derived anaphylatoxins is a common occurrence during cardiopulmonary bypass, and the pump-oxygena-tor is the usual site of complement activation. High oxygen concentrations and mechanical denaturation induced by frothing in the bubble oxygenator are believed to activate the alternate (and possibly the classic) pathway. Anaphylatoxins are inflammatory mediators that stimulate the release of mast cell histamine, contract bronchial smooth muscle and increase vascular permeability. The levels of C3a and C5a complements correlate with the duration of cardiopulmonary bypass. These complement-derived inflammatory mediators have also been postulated to contribute to the pathogenesis of “post-pump syndromes.”

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prolonged intensive care therapyWe recruited 56 consecutive patients following elective prosthetic replacement of the thoracoabdominal aorta. Six patients were excluded because they could not be extubated within < 48 h. Of these, five patients developed paraplegia, and four of them died, while the other two patients survived after prolonged intensive care therapy.

Accordingly, 50 patients were randomized (control group, 25 patients; study group, 25 patients). The subcategories of thoracoabdominal aortic aneurysms (using the Crawford classification) were evenly distributed within the control and study groups (type I, 5 vs 3 patients, respectively; type II, 9 vs 9 patients, respectively; type III, 11 vs 13 patients, respectively; difference not significant). Demographic data and data on the surgical procedures are shown in Table 1. It is worth mentioning that in both the study and control groups 7 of the 25 patients were active smokers. The incidences of a preoperative diagnosis of COPD were not different (control group, 12 of 25 subjects; study group, 13 of 25 patients; difference not significant) between both groups. One patient in the study group had undergone a tracheotomy for prolonged mechanical ventilation after pneumonia several years before. There were no other statistically significant differences between the control group and the study group. However, in all patients intraoperative catecholamine therapy was necessary, and the mean blood loss exceeded 4 L.

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IL-8We have used induced sputum samples and counted cells expressing HO-1, iNOS, and nitroty-rosine, and levels of soluble inflammatory mediators in patients with COPD who were hospitalized for severe exacerbation compared to stable state. The results showed significantly increased MPO, IL-8, nitrotyrosine, and HO-1 expression in patients during exacerbation relative to the stable state. These findings provide further insight into the pathogenesis of COPD exacerbations.

There are several limitations regarding our study. First, we did not examine them for evidence of acute viral infection, or for infection with chlamydia or mycoplasma, which are often detected during COPD exacerbations. Second, it was difficult to accurately differentiate between chronic bacterial colonization of the respiratory tract and acute infection. We tried to overcome this difficulty by comparing sputum samples obtained from patients during exacerbations with those obtained from the same patients in the stable state. Third, due to significant comorbidities in the majority of COPD patients who were admitted for severe exacerbations, we were only able to recruit a relatively limited number of patients. However, the power of our results was tested, and it was found to be > 80%. Therefore, a type 1 statistical error is unlikely. Fourth, the present study used sputum analysis to assess airway inflammation. It is known that dithiothreitol (DTT), a reducing agent that is regularly used to homogenize sputum, may affect the detection of inflammatory mediators in the sputum sol phase. However, other investigators have shown good recovery of sputum ECP, MPO, IL-8, and GM-CSF using commercial immunoassays, as well as no effect of DTT on their standard curves. Even if DTT affects any of these measurements, comparability between samples obtained from patients during exacerbations or while in the stable state was preserved.

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dynamic pulmonary volumeTable 1 summarizes the anthropometric characteristics of the patients and three normal subjects.

Table 2 shows the results of Pimax and PEmax. The reference value of the maximum static pressure for patients 2 and 3 is obtained from the equations of Gaultier and Zinman. For patient 1, the reference value of Leech and her associates is used. The measured results are expressed as a percentage of the reference value based on age, sex, and size of the individuals tested, as well as a percentage of the reference value based on vital capacity (VC) according to Gaultier and Zinman (Pim>vc and PEm,vc). Our results show that PEmax is slightly better preserved than Pimax, but this relation reversed for patients 1 and 3 when they are expressed as a percentage of predicted values based on VC.

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upper airwayObstructive sleep apnea is a serious medical disorder which has been associated with sudden death during sleep. Sleep-associated decreases in the electromyographic activity of the pharyngeal dilators allow the subatmospheric pressures generated during inspiration to collapse the upper airway. During these episodes of upper-airway occlusion, arterial oxyhemoglobin saturation (Sa02) decreases in association with concomitant elevations in systemic and pulmonary blood pressures. Throughout the apneic period, heart rate slows in proportion to the duration of apnea and the degree of oxyhemoglobin desaturation. Increased vagal efferent activity plays a significant role in mediating these reductions in heart rate, as atropine usually ameliorates the apnea-related bradycardias. The resumption of ventilation is associated with rapid cardioacceleration, which is considered to result from a decrease in vagal tone, probably combined with hypoxia-mediated increases in sympathetic neural activity. This repetitive sequence of events is responsible for the prominent sinus arrhythmia which is frequently observed during sleep in these patients. Marked sinus bradycardia (heart rate less than 40 beats per minute) and sinus pauses lasting from 2 to 17 seconds have been reported by different investigators to occur in as few as 9 percent to as many as 30 percent of the patients with obstructive sleep apnea. While severe bradyar-rhythmias are a potential mechanism for sudden death during sleep, repetitive ventricular ectopy degenerating to ventricular fibrillation is considered to be the more common dysrhythmia leading to sudden death. Because the relationship of ventricular ectopy to ap-neic events is less well established, the present study was undertaken to examine the relationship between ventricular ectopic activity and the severity of oxyhemoglobin desaturation in patients with obstructive sleep apnea.

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longterm therapyThe results of the present investigation demonstrate that the use of single standard doses of S and M in combination provide greater protection against the obstructive consequences of isocapnic HV of frigid air more than either drug alone. Within 60 min of administration, M and S individually attenuated between 30% and 54% of the airflow limitation in the control trial, respectively; however, the mixture blunted 82%, indicating an additive effect. Since thermal events, particularly exercise-induced bron-chospasm (EIB), are real-world stimuli that can adversely influence the lives of virtually all patients with asthma information of this type, when appropriately validated, could ultimately prove to be of great clinical value.

(P-adrenergic agonists have been the treatment of choice for EIB for a considerable time. In the last 15 years, the therapeutic benefits of the antileukotriene agents in the treatment of this condition have been recognized. However, there are some subjects who have little response to leukotrienes. The comparative effectiveness of each type of drug was not examined until the past few years. All of the available data to date, including those reported herein, indicate that, on average, both classes of compounds offer statistically similar degrees of prophylaxis. It was not until the work of Coreno and associates, however, that the amounts and duration of treatment required to produce benefits have been addressed. These investigators showed that longterm therapy with leukotriene blockers was not essential and that single doses of either a 5-lipoxygenase inhibitor or a cysteinyl leukotriene 1 receptor antagonist initiated sustained effects. In their study, protection developed within 60 min of ingestion of the available agents, including M, and remained stable for 8 to 12 h. The present findings concur nicely with these results. In addition, Dempsey et al and Hui and Barnes, as also reported in the present investigation, reported that therapy with a mixture of S and M produced greater bronchodilatation than therapy with M alone. Finally, these two drugs have been shown to provide additive protection against other bronchoprovocations. Dempsey et al found that single doses of M and S, when administered together to asthmatic individuals, blunted challenges with adenosine monophosphate more than the individual compounds. New ideas, new thoughts, new investigations and new technologies are overcroweded the web world nowadays. All news that you need at Canadian health care website, these news will help you to find a way out from such a deadlock from which you cannot have found the way for a long time.

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upright examinationThirteen-hundred and fifty-four technically adequate chest radiographic films of 167 patiehts were analyzed from November, 1980 to January, 1983. One-hundred and twenty-two (9 percent) were repeated because they were judged to be technically inadequate for interpretation due to motion, improper exposure, or inadequate patient positioning. All those repeated were judged to be adequate for interpretation.

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