Showing papers by "Detroit Receiving Hospital published in 1991"

Effect of ibuprofen in patients with severe sepsis: a randomized, double-blind, multicenter study. The Ibuprofen Study Group.

Abstract: Objective To evaluate the safety and physiologic actions of ibuprofen in patients with severe sepsis. Design Randomized, double-blind, placebo-controlled trial. Setting Three university hospital medical ICUs. Patients Twenty-nine patients with clinical evidence of sepsis and the need for hemodynamic monitoring with a pulmonary artery flotation catheter. Interventions Thirteen patients received placebo and 16 received ibuprofen that consisted of 600 mg (n = 11) or 800 mg (n = 5) iv over 20 mins, followed by three 800-mg doses administered as a rectal solution every 6 hrs. The initial iv dose was given within 4 hrs of the presumptive diagnosis of sepsis. Measurements and main results The peak circulating total ibuprofen concentration after the iv dose (49.4 +/- 4.5 micrograms/mL, mean +/- SEM) was higher than peak concentrations after the three rectal doses (17.0 +/- 2.7, 16.4 +/- 3.0, 16.0 +/- 3.1 micrograms/mL). Both routes of ibuprofen administration were well tolerated. Frequent monitoring for gastrointestinal bleeding and assessment of renal and hepatic function failed to demonstrate significant differences between ibuprofen and placebo. Because a trend for reduced creatinine clearance was observed at 8 hrs in the ibuprofen group, nephrotoxicity of this drug in sepsis cannot be excluded. Temperature decreased significantly within 4 hrs of the initial dose of investigational therapy in patients who received ibuprofen (38.5 +/- 0.3 degrees to 37.0 +/- 0.2 degrees C, p less than .001). However, despite this significant change in temperature, we were unable to detect significant differences in hemodynamic and respiratory values or survival when ibuprofen-treated patients were compared with controls. Conclusions Ibuprofen was well tolerated when administered iv and rectally to patients with severe sepsis, although drug absorption was poor with the rectal route. Significant antipyretic effects of ibuprofen were demonstrated. Although an excellent safety profile characterized ibuprofen in this study, the absence of ibuprofen-associated toxicity may have been secondary to poor rectal absorption of the drug. Our results support the continued clinical investigation of ibuprofen in sepsis, using an all-intravenous route of administration.

Comparative effect of protein binding on the killing activities of teicoplanin and vancomycin.

Abstract: The effect of protein binding on the activity of teicoplanin against Staphylococcus aureus was evaluated. Bactericidal rates of teicoplanin in cation-supplemented Mueller-Hinton broth (SMHB) and in a 1:1 mixture of pooled human serum and cation-supplemented Mueller-Hinton broth (PHS-SMHB) were compared with those of vancomycin. Eight concentrations of each drug ranging from 15 to 150 micrograms/ml were studied in two series which correspond to the concentrations in serum achieved with low- (6 mg/kg of body weight once daily) and high-dose (30 mg/kg once daily) teicoplanin. Overall, the bactericidal rate of teicoplanin was lower than that of vancomycin. In the presence of serum, the bactericidal rate of teicoplanin in PHS-SMHB was lower than that in SMHB, often resulting in only one log10 drop in CFU over a 24-h period. There was no statistical difference in the bactericidal rates of high- and low-concentration teicoplanin in either medium. Additionally, concentration-dependent killing in SMHB was not evident with either agent. The bactericidal rates of teicoplanin and vancomycin in a 1:1 mixture of serum ultrafiltrate and SMHB at 60 micrograms/ml were also studied. It was noted that the bactericidal rate of neither agent was affected by the presence of serum ultrafiltrate. This finding is consistent with teicoplanin's high degree of protein binding (reported to be greater than 90% in undiluted serum) and further substantiates the hypothesis that only the free drug is active against microorganisms. These data support protein binding as being a factor in teicoplanin activity against S. aureus.

Resident interpretation of emergency computed tomographic scans.

Abstract: Our busy, urban emergency room is staffed by radiology residents after working hours. To determine the accuracy of our residents' interpretations of emergency cranial computed tomographic (CT) scans, the authors reviewed the preliminary reports of our residents for a two-month period. A total of 289 cranial CT scans were retrospectively reviewed and the resident interpretation judged acceptable, minor error, moderate error, or major error. Six of 289 neurologic examinations (2%) had moderate (4) or major (2) errors. The mistakes all involved misinterpretation of cerebral hemorrhage. The 98% accuracy in interpretation of cranial CT is higher than the accuracy reported with emergency plain film (PF) interpretation.

Methohexital: a practical review for outpatient dental anesthesia.

Abstract: Methohexital is an ultrashort-acting barbiturate widely used in dentistry because of its rapid onset, predictable effects, and short duration of action. Like other barbiturates, methohexital exerts its effects through the gamma-aminobutyric acid (GABA) receptor complex. By binding to its own receptor on the complex, methohexital augments the inhibitory effect of GABA on neurons and additionally can exert a similar effect independent of GABA. After intravenous injection, maximal brain concentrations are achieved within 30 sec and then quickly fall as the drug is redistributed to other tissues, yielding a duration of action after a single dose of 4 to 7 min. Hepatic metabolism accounts for elimination of the drug. Methohexital at conventional doses in healthy individuals is a mild respiratory depressant with modest cardiovascular effects. Adverse effects, however, can include apnea, cardiovascular depression, laryngospasm, hiccough, and allergic-like reactions. Although more recently introduced drugs, such as midazolam, etomidate, and propofol, have specific advantages, methohexital remains a drug of choice for dental outpatient anesthesia because of its low cost, rapid onset, short duration, lack of secretory or emetic properties, and proven history.

Massive hemorrhage associated with pancreatic pseudocyst : successful treatment by pancreaticoduodenectomy

Abstract: Major hemorrhage arising from a pseudocyst in the head of the pancreas is a rare and difficult clinical problem. Successful management of this condition by pancreaticoduodenectomy is presented. Arteriographic embolization of the bleeding inferior pancreaticoduodenal artery was not technically possible. Review of the literature suggests pancreaticoduodenectomy constitutes the best definitive management of this problem when embolization is not possible.

The challenging case conference: an integrated approach to resident education and support.

Abstract: THE INTELLECTUAL and emotional challenges that confront the physician in training may lead to distress and potential impairment. TM In addition, patients often express frustration with an increasingly complex and sometimes impersonal health care process. Accreditat ion bodies such as the American Board of Internal Medicine have identified the complementary roles of biomedical knowledge and humanistic skills as training objectives. ~ In response, training programs have att empted to develop sensitive approaches to the assessment and re inforcement of professional behaviors reflecting integrity, compassion, and respect. 6-s Examples of these efforts have included deve lopment of Balint groups, resident support groups, increased emphasis on training in communica t ion skills, and modification of the training environment. Hospitals have responded through patient-care-focused services such as ombudsmen, mediators, and ethics committees, which may address sources of patient frustration.9-1 While each of these approaches may prove valuable, none has as its pr imary focus the educat ion and emotional support of the resident physician in the context of the traditional month-long inpatient rotation. In an effort to reduce the frustration exper ienced by physicians and their patients, to p romote interactive problem solving skills, and, potentially, to improve patient care, the faculty of a primary care internal medic ine training program have implemented a \"chal lenging case confe rence\" as a regular componen t of ongoing hospital-based teaching activities. The focus of this conference has been the explorat ion of emotional ly evocative situations exper ienced by resident physicians in the courses of their patient care activities. The purpose of this report is to summarize our first four years' exper ience in conduct ing these conferences, to examine the range of problems presented and ap-

Group psychotherapy in an acute inpatient setting: techniques that nourish self-esteem.

Abstract: This article describes a conceptual model and reparative techniques used in group therapy in a 15-bed acute inpatient psychiatric unit located in a 340-bed metropolitan trauma center. The group meets daily for 1 hr. The population reflects patients suffering from chronic mental illness and polysubstance abuse and those adapting to such complex medical problems as AIDS, spinal cord injuries, burns, and so forth. Using Roy and Roberts's (1981) adaptive modes of self-concept and interdependency, I describe how narcissism, the psychic structure designed to protect, repair, and restore the wounded self-esteem (Stolorow & Lachman, 1980), sustains group adaptations at the pregroup level. Lonergon (1980) described the pregroup phase as "parallel talk." It is similar to "parallel play" and generally reflects the developmental arrest or adaptive regression of individual group members. At this stage, group membership consists of a collection of individuals who use each other as an audience to whom they can express their narcissistic needs. Often, repeated blows to the patient's self-esteem result in a pervasive sense of powerlessness and helplessness. Patients gradually lose touch with their "real self" and become increasingly dependent on external cues to determine their feelings and behavior. The adaptive narcissistic need to depend on other people to feel whole suggests that group therapy can be a powerful tool in treating patients who suffer profound wounds to the self-esteem, prevalent in the population described. The reparative techniques used by the group therapist to initiate group involvement require the ability to tolerate and value a continuous pregroup phase. The patient with narcissistic behavior both craves and undermines attempts at group involvement.(ABSTRACT TRUNCATED AT 250 WORDS)