Harakh V. Dedhia

Beneficial effect of norepinephrine in the treatment of circulatory shock caused by tricyclic antidepressant overdose

The beneficial effect of dopamine in circulatory shock induced by tricyclic antidepressants (TCA) overdose may be decreased due to compromise of the endogenous stores of norepinephrine caused by TCA. The successful outcome of two cases of TCA overdose complicated by hypotension, unresponsive to an initial treatment with physostigmine fluid challenge and dopamine (greater than 15 micrograms/kg/min) but subsequently responsive to an infusion of norepinephrine is reported.

Association of Medication Adherence with Workplace Productivity and Health-Related Quality of Life in Patients with Asthma

Objective. Examine the association of medication adherence with workplace productivity and health-related quality of life (HRQL) in asthma patients. Methods. Adult patients with asthma in a state health insurance program identified from medical claims (July 2001–June 2003) were mailed a three-part survey to measure HRQL (St. Georges Respiratory Questionnaire), workplace productivity (Workplace Productivity Short Inventory), and self-reported medication adherence (Morisky Scale). Results. The symptoms domain had the worst HRQL scores, followed by the activity and impacts domains; 39% of the participants reported themselves as “high” adherent, whereas 19% were “medium,” and 42% were “low” adherent. Asthma resulted in productivity losses of

Impact of a Multimodal Antimicrobial Stewardship Program on Pseudomonas aeruginosa Susceptibility and Antimicrobial Use in the Intensive Care Unit Setting

597 ±

Surviving a Mine Explosion

1,024 (absenteeism) and

Hyperoxia-Induced Alterations of Rat Alveolar Lavage Composition and Properties

658 ±

Endoscopic laser therapy for respiratory distress due to obstructive airway tumors

1,808 (presenteeism) per enrollee per year. Conclusions. Asthma was associated with HRQL detriments and workplace productivity losses.

Doripenem: position in clinical practice

Objective. To study the impact of our multimodal antibiotic stewardship program on Pseudomonas aeruginosa susceptibility and antibiotic use in the intensive care unit (ICU) setting. Methods. Our stewardship program employed the key tenants of published antimicrobial stewardship guidelines. These included prospective audits with intervention and feedback, formulary restriction with preauthorization, educational conferences, guidelines for use, antimicrobial cycling, and de-escalation of therapy. ICU antibiotic use was measured and expressed as defined daily doses (DDD) per 1,000 patient-days. Results. Certain temporal relationships between antibiotic use and ICU resistance patterns appeared to be affected by our antibiotic stewardship program. In particular, the ICU use of intravenous ciprofloxacin and ceftazidime declined from 148 and 62.5 DDD/1,000 patient-days to 40.0 and 24.5, respectively, during 2004 to 2007. An increase in the use of these agents and resistance to these agents was witnessed during 2008–2010. Despite variability in antibiotic usage from the stewardship efforts, we were overall unable to show statistical relationships with P. aeruginosa resistance rate. Conclusion. Antibiotic resistance in the ICU setting is complex. Multimodal stewardship efforts attempt to prevent resistance, but such programs clearly have their limits.

ARDS associated with the use of sympathomimetics and glucocorticoids for the treatment of premature labor

p m d t s v p g a t u M i c c x n January 2006, an explosion in the Sago mine in central est Virginia resulted in 14 trapped miners. Approxiately 41 hours later, one lone survivor was found and rought to medical care. It became apparent that the surivor had not suffered blast injuries, but rather hypoxia and xposure to toxic gases, dehydration, and rhabdomyolysis. uring rapid prehospital care, followed by acute resuscitaion and hospitalization, this patient demonstrated many lassic features of carbon monoxide toxicity, including neuologic, cardiac, and renal dysfunction. In addition, the atient suffered from respiratory failure. Rapid resuscitaion with end-organ perfusion and hyperbaric oxygen therpy treatment resulted in a dramatic improvement in all reas. After inpatient rehabilitation, the patient has reurned to his wife, children, and family and is conversant nd ambulating. This article explores the causes of these nique injuries, and a medical explanation for the extent of ecovery in the sole survivor. To our knowledge, this is the irst case of a survivor of prolonged exposure in a mining ccident.

High-dose magnesium sulfate attenuates pulmonary oxygen toxicity

Although lethal exposures of most animal species to oxygen result in a reduced amount of surfactant phospholipids (PL), hyperoxia in rats leads to elevated levels of PL on the alveolar surface. Because of this different response, a study was made of the amount, composition, surface properties, and subfraction distribution (obtained by differential centrifugation) of alveolar lavage materials from rats exposed to > 95% oxygen for 64 h. The exposures lead to severe lung damage, which includes the appearance of pleural effusion, pulmonary edema, and increased protein levels on the alveolar surface. However, the PL levels of lavage fluid are increased two- to threefold, and the PL composition is altered. In O2-exposed rats, only 39(+/- 1)% of the phospholipid is disaturated phosphatidylcholine (DSPC), the major surface active component of surfactant, as compared to 46(+/- 1)% DSPC in lavage from control animals. The distribution of PL and DSPC in subfractions of lavage materials obtained by differential centrifugation is approximately reversed following hyperoxia. In lavage from control animals, 36% of the PL is in the heavier, more dense subfractions and 64% is in the lighter, less dense subfractions, while 72% is heavier and 28% lighter in lavage from O2-exposed animals. Measurements of surface properties with the Wilhelmy balance indicate that the ability of the lavage materials to reduce surface tension is impaired following hyperoxia. Thus, lethal exposures of rats to oxygen lead to increased amounts of surfactant on the alveolar surface, but the surface properties of the surfactant are impaired, probably due to reduced levels of DSPC, increased amounts of protein, and alterations in its physical form.

Positive-pressure ventilation with positive end-expiratory pressure and atrial natriuretic peptide release

Neodymium-YAG laser therapy for unresectable malignant airway obstructions has a promising future. Nine patients with moderate to severe respiratory distress all experienced rapid relief of dyspnea and substantial improvement in pulmonary function within hours to days after treatment with laser phototherapy. The quality of life and survival was improved in otherwise hopeless cases. A nonfatal case of pneumothorax was the only major complication.