James Gasperino

Gender is a risk factor for lung cancer

Results of epidemiological studies suggest that, after one controls for the number of cigarettes smoked, women have a three times higher risk of getting lung cancer than men. Although the mechanism(s) explaining this gender-dependent difference in lung cancer risk is not known, it is thought that endocrine factors may play an important role. Normal human bronchial epithelial cells contain estrogen receptors and synthesize 17β-estradiol (E(2)) and estrone (E(1)), which can undergo further metabolism into the catechol estrogens, 4-hydroxyestradiol (4-OHE(2)) and 4-hydroxyestrone (4-OHE(1)), respectively. Catechol estrogens are formed from E(2) by the actions of cytochrome p450 1B1 (CYP1B1). CYP1B1 is present in normal human bronchial epithelial) cells, and its activity is increased by cigarette smoking. Both 4-OHE(1) and 4-OHE(2) are mutagenic and carcinogenic and may exert their biological effects by inducing DNA adducts in cancer-related genes, including the tumor suppressor gene p53 and the proto-oncogene K-ras. Women with lung cancer have a different p53 mutational spectrum and a higher frequency of K-ras mutations than do men with lung cancer. Both clinical and basic research studies support the hypothesis that E(2) and cigarette smoking are cofactors in lung carcinogenesis in women. More specifically, cigarette smoke stimulates metabolism of E(2) into the genotoxic metabolites, 4-OHE(1) and 4-OHE(2,) which interact with DNA in cancer-related genes, including the tumor suppressor gene, p53, and the proto-oncogene K-ras, two genes frequently mutated in patients with lung cancer. E(2) may stimulate cellular proliferation and enhance tumor growth.

The Leapfrog initiative for intensive care unit physician staffing and its impact on intensive care unit performance: A narrative review

The field of critical care has changed markedly in recent years to accommodate a growing population of chronically critically ill patients. New administrative structures have evolved to include divisions, departments, and sections devoted exclusively to the practice of critical care medicine. On an individual level, the ability to manage complex multisystem critical illnesses and to introduce invasive monitoring devices defines the intensivist. On a systems level, critical care services managed by an intensivist-led multidisciplinary team are now recognized by their ability to efficiently utilize hospital resources and improve patient outcomes. Due to the numerous cost and quality issues related to the delivery of critical care medicine, intensive care unit physician staffing (IPS) has become a charged subject in recent years. Although the federal government has played a large role in regulating best practices by physicians, other third parties have entered the arena. Perhaps the most influential of these has been The Leapfrog Group, a consortium representing 130 employers and 65 Fortune 500 companies that purchase health care for their employees. This group has proposed specific regulatory guidelines for IPS that are purported to result in substantial cost containment and improved quality of care. This narrative review examines the impact of The Leapfrog Groups recommendations on critical care delivery in the United States.

Malignant Nerve Sheath Tumor of the Spinal Accessory Nerve: A Unique Presentation of a Rare Tumor

Background Malignant peripheral nerve sheath tumors (MPNSTs), sarcomas originating from tissues of mesenchymal origin, are rare in patients without a history of neurofibromatosis. Case Report We report a case of an MPNST of the spinal accessory nerve, unassociated with neurofibromatosis, which metastasized to the brain. The tumor, originating in the intrasternomastoid segment of the spinal accessory nerve, was removed. Two years later, the patient presented with focal neurological deficits. Radiographic findings revealed a well-defined 2.2×2.2×2.2 cm, homogeneously enhancing mass in the left parieto-occipital region of the brain surrounded by significant vasogenic edema and mass effect, culminating in a 1-cm midline shift to the right. The mass was surgically removed. The patient had nearly complete recovery of vision, speech, and memory. Conclusions To our knowledge, this is the first documented case of an MPNST arising from an extracranial segment of the spinal accessory nerve and metastasizing to the brain.

Cocaine-induced agitated delirium: a case report and review.

Cocaine use continues to be a major public health problem in the United States. Although many of the initial signs and symptoms of cocaine intoxication result from increased stimulation of the sympathetic nervous system, this condition can present as a spectrum of acuity from hypertension and tachycardia to multiorgan system failure. Classic features of acute intoxication include tachycardia, arterial vasoconstriction, enhanced thrombus formation, mydriasis, psychomotor agitation, and altered level of consciousness. At the extreme end of this toxidrome is a rare condition known as cocaine-induced agitated delirium. This syndrome is characterized by severe cardiopulmonary dysfunction, hyperthermia, and acute neurologic changes frequently leading to death. We report a case of cocaine-induced agitated delirium in a man who presented to our institution in a paradoxical form of circulatory shock. Rapid evaluation, recognition, and proper management enabled our patient not only to survive but also to leave the hospital without neurologic sequelae.

Integrating Palliative Care into Critical Care: A Quality Improvement Study.

Background: Many terminally ill patients experience an increasing intensity of medical care, an escalation frequently not consistent with their preferences. In 2009, formal palliative care consultation (PCC) was integrated into our medical intensive care unit (ICU). We hypothesized that significant differences in clinical and economic outcomes exist between ICU patients who received PCC and those who did not. Methods: We reviewed ICU admissions between July and October 2010, identified 41 patients who received PCC, and randomly selected 80 patients who did not. We measured clinical outcomes and economic variables associated with patients’ ICU courses. Results: Patients in the PCC group were older (average 64 years, standard deviation [SD] 19.2 vs 55.6 years, SD 14.5; P = .021) and sicker (median Acute Physiology and Chronic Health Evaluation IV score 85.5, interquartile range [IQR] 60.5-107.5 vs 60, IQR 39.2-74.75; P < .001) than the non-PCC controls. PCC patients received significantly more total days of ICU care on average (8 days, IQR 4-15 vs 4 days, IQR 2-7; P < .001), had more ICU admissions, and were more likely to die during their ICU stay (64.3% vs 12.5%, P < .001). Median total hospital charges per patient attributable to ICU care were higher in the PCC group than in the controls (US

Hypertriglyceridemic Pancreatitis Caused by the Oral Contraceptive Agent Estrostep

315,493, IQR US

Evaluation of the Clinical Utility of Routine Daily Chest Radiography in Intensive Care Unit Patients With Tracheostomy Tubes: A Retrospective Review.

156,470-US

Severe Drug-Induced Linear IgA Bullous Dermatosis: Not Everything is Steven Johnsons Syndrome

486,740 vs US

Withdrawal of Mechanical Ventilation: A Systematic Review and Approach Following Two Unusual Cases

116,934, IQR US

Agreement Between Sputum Culture and Diagnostic Bronchial Alveolar Lavage (BAL) in Critically Ill Patients

54,750-US