Showing papers by "Detroit Receiving Hospital published in 2002"
TL;DR: In vitro data support in vitro data that suggest bactericidal activity of beta-lactams is optimized at concentrations approximately 4 x MIC, and should be validated by large prospective clinical trials.
Abstract: We conducted a prospective, open-label study to delineate a relationship between exposure and outcomes in 36 patients treated with cefepime. Twenty patients had documented Gram-negative infections. Timed blood and urine samples were obtained at steady state to determine pharmacokinetic and pharmacodynamic parameters. Microbiological success was significantly correlated with the proportion of the dosing interval that cefepime concentrations exceeded 4.3 x MIC. Our results support in vitro data that suggest bactericidal activity of beta-lactams is optimized at concentrations approximately 4 x MIC. These results should be validated by large prospective clinical trials.
230 citations
TL;DR: The increasing abuse of MDMA, flunitrazepam, ketamine hydrochloride, and GHB, particularly by young people in social settings such as clubs, should put health care professionals on guard to recognize and manage serious reactions.
Abstract: The abuse of methylenedioxymethamphetamine (MDMA), flunitrazepam, ketamine hydrochloride, and gamma-hydroxybutyrate (GHB) is discussed. Club drugs are chemical substances used recreationally in social settings. Use is increasingly frequent among young people, especially during all-night dance parties. All four agents have been classified as controlled substances. MDMA ("ecstasy") is available as a tablet, a capsule, and a powder; formulations may contain many adulterants. MDMA increases the release of neurotransmitters. The desired effects are euphoria, a feeling of intimacy, altered visual perception, enhanced libido, and increased energy. The most common adverse effects are agitation, anxiety, tachycardia, and hypertension. More serious adverse effects include arrhythmias, hyperthermia, and rhabdomyolysis. Flunitrazepam is a potent benzodiazepine. At higher doses, the drug can cause lack of muscle control and loss of consciousness. Other adverse effects are hypotension, dizziness, confusion, and occasional aggression. Ketamine is a dissociative anesthetic used primarily in veterinary practice. It may be injected, swallowed, snorted, or smoked. Like phencyclidine, ketamine interacts with the N-methyl-D-aspartate channel. Analgesic effects occur at lower doses and amnestic effects at higher doses. Cardiovascular and respiratory toxicity may occur, as well as confusion, hostility, and delirium. GHB, a naturally occurring fatty acid derivative of gamma-aminobutyric acid, was introduced as a dietary supplement. Increasing doses progressively produce amnesia, drowsiness, dizziness, euphoria, seizures, coma, and death. Flunitrazepam, ketamine, and GHB have been used to facilitate sexual assault. Supportive care is indicated for most cases of club drug intoxication. The increasing abuse of MDMA, flunitrazepam, ketamine hydrochloride, and GHB, particularly by young people in social settings such as clubs, should put health care professionals on guard to recognize and manage serious reactions.
179 citations
TL;DR: Continuous gastric feeding is better tolerated than B feedings in patients with acute brain injuries and use of common medications including sucralfate and propofol were associated with FI.
Abstract: Brain injured patients may exhibit altered gastric emptying; thus, some believe post-pyloric feeding to be tolerated better than gastric feeding Reliable post-pylorus access can be difficult to obtain, so gastric feeding remains the preferred route for administering nutrition Feeding intolerance may be associated with increased complications and costs We sought to compare bolus (B) versus continuous (C) gastric feeding in brain injured patients This retrospective cohort study was carried out at a neurological/neurosurgical intensive care unit at a Level 1 trauma and tertiary referral center Our subjects were 152 consecutive patients over two years Use of B or C feedings was based on clinicians' preferences Abdominal examination and gastric residuals (> 75 mL over four hours) defined feeding intolerance (FI) Putative risks for FI were compared between the groups Demographic characteristics were similar between groups B (n = 86) and C (n = 66) Feeding intolerance occurred more often in group B than in group C (605% vs 379%, p = 0009) Group C patients achieved 75% of nutritional goals faster than group B patients (median 33 vs 46 days; p = 003) Prokinetic agent use was similar between the groups and did not reduce the time to achieve nutritional goals There was a trend towards a reduction in the incidence of infections in group C (p = 005) Independent predictors of FI included: sucralfate (OR 23), propofol (OR 21), pentobarbital (OR 39) or paralytic (OR 3) use; older age (OR 5); days receiving mechanical ventilation (OR 12); and admission diagnosis of either intracerebral hemorrhage (OR 22) or ischemic stroke (OR 19) Continuous gastric feeding is better tolerated than B feedings in patients with acute brain injuries Use of prokinetic agents did not affect time to achievement of nutritional goals Use of common medications including sucralfate and propofol were associated with FI
99 citations
TL;DR: Equilibrium ultrasound can be performed quickly and accurately by nonphysician personnel with excellent accuracy and Pulmonary ultrasound appears promising; blinded verification of the utility of ultrasound in patients with extremity injury should be performed to determine whether extremity and respiratory evaluation is added to the FAST examination.
Abstract: Ultrasound is of prO)len accuracy in abdominal and thoracic trauma and may be useful to diagnose extremity injury in situations where radiography is not available such as military and space applications. We prospectively evaluated the utility of extremity , ultrasound performed by trained, non-physician personnel in patients with extremity trauma, to simulate remote aerospace or military applications . Methods: Patients with extremity trauma were identified by history, physical examination, and radiographic studies. Ultrasound examination was performed bilaterally by nonphysician personnel with a portable ultrasound device using a 10-5 MHz linear probe, Images were video-recorded for later analysis against radiography by Fisher's exact test. The average time of examination was 4 minutes. Ultrasound accurately diagnosed extremity, injury in 94% of patients with no false positive exams; accuracy was greater in mid-shaft locations and least in the metacarpa/metatarsals. Soft tissue/tendon injury was readily visualized . Extremity ultrasound can be performed quickly and accurately by nonphysician personnel with excellent accuracy. Blinded verification of the utility of ultrasound in patients with extremity injury should be done to determine if Extremity and Respiratory evaluation should be added to the FAST examination (the FASTER exam) and verify the technique in remote locations such as military and aerospace applications.
94 citations
TL;DR: It is found that carbamazepine exerts significant inhibitory effects on the cyclic AMP (cAMP) generating system and is likely mediated through an inhibitory guanine nucleotide binding protein‐independent mechanism.
Abstract: The anticonvulsant carbamazepine is an effective treatment both for epilepsy and for bipolar affective disorder, but the molecular mechanism(s) underlying its therapeutic effects have not been identified We have found that carbamazepine exerts significant inhibitory effects on the cyclic AMP (cAMP) generating system Within the clinical therapeutic range (approximately 50 microM), carbamazepine inhibited both basal and forskolin-stimulated cAMP production, without having any significant effects on phosphodiesterase activity Carbamazepine also exerted its inhibitory effects on the cAMP generating system in pertussis toxin-treated cells, suggesting that the action of carbamazepine was likely mediated through an inhibitory guanine nucleotide binding protein-independent mechanism A forskolin affinity purification column was used to purify adenylyl cyclases from rat cerebral cortex, and we found that carbamazepine inhibited both basal and forskolin-stimulated activity of purified adenylyl cyclase We also investigated the effects of carbamazepine on the levels of the transcription factor, cAMP response element binding protein in the phosphorylated (active) state, and found that carbamazepine significantly inhibited forskolin-induced phosphorylation of the cAMP response element binding protein The data indicate that carbamazepine inhibits adenylyl cyclase activity as well as the downstream effects of activation of adenylyl cyclase
79 citations
TL;DR: In this paper, the biomechanical data support the use of tensioned wire fixation to stabilize complex fractures of the proximal tibia, and the stability of a four-wire construct is comparable to the gold standard of dual plating internal fixation techniques.
79 citations
TL;DR: A number of novel antimicrobial combinations that may be useful against staphylococci and enterococci are suggested and warrant further investigation for the treatment of refractive infections due to multidrug-resistant gram-positive pathogens.
Abstract: Use of combinations of antimicrobials that together achieve synergistic activities against targeted microorganisms is one potential strategy for overcoming bacterial resistance. As the incidence of infections caused by multidrug-resistant staphylococci and enterococci increases, the importance of devising additional synergistic drug combinations for these bacteria is magnified. We evaluated a number of antimicrobial combinations, with a focus on quinupristin-dalfopristin (Q-D), cefepime, and linezolid, using a previously described in vitro pharmacodynamic model. The combination of Q-D with either linezolid or vancomycin, as well as the combination of cefepime-vancomycin, resulted in enhanced killing (≥2-log10 increase in killing versus the most-active single agent) against methicillin-resistant Staphylococcus aureus (MRSA) 494. An improved effect (<2 log10 kill increase in kill) against MRSA 494 was noted for cefepime plus either Q-D or linezolid, as well as linezolid-vancomycin. Similar relationships were observed for a methicillin-susceptible S. aureus isolate (isolate 1199). Against methicillin-resistant S. epidermidis R444, enhanced killing was achieved with the combination of cefepime-linezolid, while improvement was noted for vancomycin with either cefepime or linezolid. The combination of cefepime and vancomycin also achieved enhanced killing against a glycopeptide-intermediate-susceptible S. aureus isolate (isolate 992). The combination of linezolid and doxycycline achieved an enhanced effect against vancomycin-resistant Enterococcus faecalis (VREFc) and E. faecium. Q-D plus ampicillin or linezolid resulted in similar enhancement of activity against the VREFc isolate. The results of this study suggest a number of novel antimicrobial combinations that may be useful against staphylococci and enterococci. Combination regimens including cefepime, Q-D, and/or linezolid warrant further investigation for the treatment of refractive infections due to multidrug-resistant gram-positive pathogens.
79 citations
TL;DR: It is demonstrated that oritavancin's activity does not seem to be influenced by the growth phase of the organisms or the pH of the environment when tested against sensitive strains of S. aureus and E. faecium in stationary growth phase, as seen in infective endocarditis or when organisms are exposed to an acidic environment.
Abstract: Oritavancin (LY333328) is a novel glycopeptide with activity against Gram-positive bacteria such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecium. We compared the effects of pH and growth phase on the activity of oritavancin and vancomycin against methicillin-resistant S. aureus and vancomycin-susceptible and -resistant E. faecium. Killing curve methods were used to evaluate the effect of growth phase (stationary versus exponential) and pH (6.4, 7.4 and 8.0). An inoculum of 10(6) cfu/mL was used for all experiments. Growth phase of S. aureus and vancomycin-susceptible E. faecium did not influence the rate and killing activity of oritavancin. The rate of killing by oritavancin against the vancomycin-resistant E. faecium strain was significantly faster and the reduction in cfu/mL at 24 h was significantly greater when the organism was in exponential compared with stationary growth phase (P < 0.05). In exponential growth phase, time to 99.9% killing was achieved in 0.6 +/- 0.01 h for the vancomycin-resistant strain, whereas in stationary growth phase, oritavancin did not decrease the inoculum by 99.9% within 24 h. Oritavancin's activity against S. aureus and vancomycin-susceptible E. faecium was not influenced by the pH conditions tested. Oritivancin's killing activity against the vancomycin-resistant E. faecium strain was significantly enhanced when tested at pH 7.4 and 8.0 (P < 0.05). Our study has demonstrated that oritavancin's activity does not seem to be influenced by the growth phase of the organisms or the pH of the environment when tested against sensitive strains of S. aureus and E. faecium. However, oritavancin's activity might be reduced against vancomycin-resistant E. faecium strains in stationary growth phase, as seen in infective endocarditis or when organisms are exposed to an acidic environment.
74 citations
TL;DR: Development and implementation of protocols for the selection, use, and monitoring of sedatives and NMBA through a multidisciplinary team approach may be a beneficial way to provide safe and cost-effective therapy to critically ill pediatric patients.
Abstract: OBJECTIVES: To describe the sedative and neuromuscular blocking agents (NMBA) that are currently used in pediatric intensive care units across the country and to assess the use of written protocols for their use, criteria used for selecting these agents, monitoring practices, and clinicians responsible for making therapeutic decisions in the pediatric intensive care units. DESIGN: A questionnaire was mailed to pediatric attending physician members of the Society of Critical Care Medicine practicing in the United States in January 1997. A cover letter was also enclosed that explained the purpose of the survey and asked the respondent to forward the questionnaire to a colleague if unable to complete. RESULTS: A total of 176 questionnaires were returned, which represented 145 pediatric institutions across the country, for a response rate of 51%. The agents reported to be used most often for sedation were the opioids and benzodiazepines, which were used for >72 hrs. The NMBA used were vecuronium and pancuronium, which were used for >48 hrs. Newer agents such as propofol and cisatracurium were being used by some clinicians as well. Respondents primarily use the intravenous route of administration as either intermittent bolus or continuous infusion. Frequently cited indications for sedatives were anxiety, fear, and amnesia and facilitation of intubation and maintenance of mechanical ventilation for NMBA. Only 13.4% indicated using written protocols for sedatives and 26.1% for NMBA. Decisions regarding the choice of agent were usually based on clinician preference and experience and the duration of action of the agent. Respondents most often reported using clinical assessment (57%) or the Glasgow Coma Scale (47.3%) to monitor the depth or adequacy of sedation. Over 80% of those surveyed use a peripheral nerve stimulator to monitor NMBA activity. CONCLUSION: Clinicians continue to use the opioids and benzodiazepines most often for sedation in the pediatric intensive care units, but newer agents are being used more often and warrant further investigation. The use of written protocols is very low, possibly because of the lack of guidelines in the literature on pediatric intensive care unit sedation and neuromuscular blockade. Development and implementation of protocols for the selection, use, and monitoring of sedatives and NMBA through a multidisciplinary team approach may be a beneficial way to provide safe and cost-effective therapy to critically ill pediatric patients.
66 citations
TL;DR: It is found that the cost of outpatient therapy was substantial, although nonuniform, across payer types, and alternative outpatient therapies associated with lower risks for adverse events and lower costs should be considered.
Abstract: Intravenous antimicrobial therapy often continues after a patient is discharged from the hospital or it begins in the outpatient setting. Reimbursement for this therapy varies by payer. The United States Outpatient Parenteral Antibiotic Therapy (OPAT) Outcomes Registry is a valuable resource for quantifying cost by payer, as well as for describing practice patterns and adverse events related to intravenous antimicrobial therapy. To describe the reimbursement structure and cost of intravenous vancomycin home care therapy for four different types of payers, a survey of home infusion companies was done. Also surveyed were infusion programs participating in the OPAT Outcomes Registry, representing four different types of payers, to determine the cost of outpatient intravenous therapy. A retrospective cohort study of these infusion programs was conducted to describe practice patterns and to identify adverse events that resulted from intravenous vancomycin. We found that the cost of outpatient therapy was substantial, although nonuniform, across payer types. Alternative outpatient therapies associated with lower risks for adverse events and lower costs should be considered.
49 citations
TL;DR: The lack of consensus with regards to appropriate stress ulcer prophylaxis is apparent in this survey of Level I trauma centers, and for those institutions with a preferred agent, histamine-2-blockers were most common.
Abstract: Introduction
A number of issues concerning stress ulcer prophylaxis remain unresolved despite numerous randomized, controlled trials and several meta-analyses. The role of stress ulcer prophylaxis, particularly in trauma patients, is further complicated by the lack of trials utilizing clinically important bleeding as an endpoint. Given the lack of consensus regarding stress ulcer prophylaxis in trauma patients, prescribing practices at Level I trauma centers in the United States were assessed.
TL;DR: During emergency trauma surgery, the PETCO and its derived values help to predict outcome and may be used to identify patients needing more aggressive resuscitation.
Abstract: Background The purpose of this study was to determine whether end-tidal carbon dioxide (PETCO2) derived variables assist in evaluating the adequacy of resuscitation during emergency surgery for trauma.Methods This was a prospective study of end-tidal derived variables and outcome in 106 trauma patie
TL;DR: Clinical exam and other published CT criteria are better indicators of injury severity and outcome.
Abstract: Computed tomography (CT) mixed density of traumatic extra-axial hemorrhages (TEH) or the 'swirl sign' has been reported to correlate with active bleeding found at craniotomy and poor outcome. This study was done to test the hypothesis that mixed density of TEH detected by third or fourth generation CT correlated with the type of bleeding or clinical outcome. All cases of TEH operated at Detroit Receiving Hospital from 1991-1997 were reviewed for type of bleeding (active vs. not active; arterial vs. venous); Glasgow Coma Scale (severe 1-8, not severe 9-15); and Glasgow Outcome Score (1-3 poor; 4,5 good). CT density (CTD) of 51 cases with specific written documentation of bleeding type were then independently reviewed (SKS and MHR) and classified into TEH with mixed or high density. Data was analyzed using corrected Chi Square analysis, Fischer's Exact Test and Pearson's Correlation (SPSS 6.0). The Pearson Chi Square probability for correlation follows: CTD vs. active bleeding, 0.21; CTD vs. arterial, 0.41; CTD vs. severity, 0.57; and CTD vs. outcome, 0.81. No other statistical analysis identified a significant correlation, thus the null hypothesis could not be rejected. CT mixed density was not found to be correlated by more than chance with bleeding type, injury severity or outcome. Surgeon inaccuracy in documentation of bleeding type and use of later generation CT may account for the discrepancy between this and previous studies. Nevertheless, we conclude clinical exam and other published CT criteria are better indicators of injury severity and outcome.
TL;DR: The complications of injection drug use (IDU) can lead to a wide variety of clinical problems that range from complications localized to the injection site to more disseminated disease as discussed by the authors.
TL;DR: Barriers to optimal end of life care in the ICU are described and strategies for making improvements are recommended.
TL;DR: To compare dosing requirements over time among patients receiving continuous cisatracurium versus pancuronium therapy, and to identify factors that may account for changes in Pancuronium versus cisatacurium infusion requirementsover time, is compared.
Abstract: Study Objectives. To compare dosing requirements over time among patients receiving continuous cisatracurium versus pancuronium therapy, and to identify factors that may account for changes in pancuronium versus cisatracurium infusion requirements over time.
Design. Retrospective, comparative cohort analysis.
Setting. A tertiary level 1 trauma center.
Patients. Forty-five consecutive adult patients who were admitted to intensive care units at our institution from January 1998–August 2000 and received continuous cisatracurium or pancuronium therapy for at least 48 hours.
Measurements and Main Results. Dosing requirements of patients treated with pancuronium or cisatracurium were recorded over time throughout the treatment period. Factors that could affect dosing requirements of a neuromuscular blocking agent (NMBA) were stratified as time invariant (admitting service, acute physiology and chronic health evaluation II score, duration of mechanical ventilation, pressure control ventilation, baseline hepatic or renal insufficiency, thermal injury, train-of-four assessment, and concurrent drug administration or disorders affecting neuromuscular transmission) or time variant (concurrent sedation and narcotic analgesia therapy; serum magnesium, potassium, and creatinine concentrations; arterial pH level; temperature; peak airway pressure; and partial pressure of oxygen:fraction of inspired oxygen ratio). Hierarchical linear modeling was used to compare the dosing requirements and to identify confounders affecting the relationship. The infusion rate escalation for the cisatracurium group was greater (0.39 μg/kg/min; 95% confidence interval [CI] 0.22–0.56; 23 patients) than for the pancuronium group (−0.06 μg/kg/min; 95% CI −0.24-0.12; 22 patients; p<0.001) and was associated with an average daily cost/patient significantly higher (p<0.001) with cisatracurium ($258 ± $114) than pancuronium ($11 ± $5). Confounder analysis revealed that only the admitting service and the number of times the NMBA infusion was suspended because no twitch was detected differed between groups. Neither of these confounders significantly affected the temporal relationship between cisatracurium and pancuronium infusion rates.
Conclusion. Dosing requirements increase over time at a significantly greater rate for cisatracurium than pancuronium infusions. Tachyphylaxis with cisatracurium is associated with substantial drug-related costs and is not accounted for by various disease-, patient-, and therapy-related factors. Further investigation is required to elucidate the mechanisms and risk factors underlying this phenomenon.
TL;DR: The purpose of the present report is to describe the difficulties in obtaining accurate determinations of analyte concentrations in which there are creations of pseudo-hypo-findings along with the corrective actions that can be taken including a novel clearing mechanism when excess triglycerides create a problem such as a spectrophotometric perturbation.
TL;DR: This review will highlight the immune mechanisms and clinical data reported with glatiramer acetate in multiple sclerosis over the past three decades, providing remarkable evidence of efficacy and safety.
Abstract: The ‘Decade of the Brain’ (1990–2000) saw unprecedented advances in neurosciences including multiple sclerosis. It could have not been more aptly named, as it produced a shift in the paradigm of multiple sclerosis management, making multiple sclerosis a treatable disorder with the availability of several therapeutic options. For a chronic progressive neurological disorder like multiple sclerosis, this change in the understanding and treatment touched the lives of hundreds of thousands of patients worldwide and many more who provided care and counsel as family and friends. Of the four agents available for the treatment of the most common type of multiple sclerosis – relapsing–remitting – three are β-interferons and one is a noninterferon polypeptide of four amino acids (glatiramer acetate) with a distinct immunomodulating profile. Glatiramer acetate is now approved and available in North America, Europe and many other countries. It has been tested in pivotal trials as well as long term extension trials for...