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Biomedical subjects

Alejandro C Arroliga

Publications and source records attributed to Alejandro C Arroliga.

52 records · Page 3Linked to original sources
PubMed2003

A prospective observational study of the effect of penicillin skin testing on antibiotic use in the intensive care unit.

BACKGROUND: Patients with penicillin allergy admitted to the intensive care unit (ICU) frequently receive non-beta-lactam antimicrobials for the treatment of infection. The use of these antimicrobials, more commonly vancomycin and fluoroquinolones, is associated with the emergence of multidrug-resistant infections. The penicillin skin test (PST) can help detect patients at risk of developing an immediate allergic reaction to penicillin and those patients with a negative PST may be able to use a penicillin antibiotic safely. METHODS: We determined the incidence of true penicillin allergy, the percentage of patients changed to a beta-lactam antimicrobial when the test was negative, the safety of the test, and the safety of administration of beta-lactam antimicrobials in patients with a negative test. Skin testing was performed using standard methodology. RESULTS: One hundred patients admitted to 4 ICUs were prospectively studied; 58 of them were male. The mean age was 63 years. Ninety-six patients had the PST: one was positive (1.04%), 10 (10.4%) were nondiagnostic, and 85 (88.5%) were negative. Of the 38 patients who received antimicrobials for therapeutic reasons, 31(81.5%) had the antibiotic changed to a beta-lactam antimicrobial after a negative reading versus 7 patients of the 57 (12%) who had received a prophylactic antimicrobial (P < .001). No adverse effects were reported after the PST or after antimicrobial administration. CONCLUSIONS: The PST is a safe, reliable, and effective strategy to reduce the use of non-beta-lactam antimicrobials in patients who are labeled as penicillin allergic and admitted to the ICU.

Anti-Bacterial Agents↗
PubMed2003

Endocrine paraneoplastic syndromes in lung cancer.

Lung tumors are capable of synthesizing and secreting peptide proteins (hormones) that lead to a variety of endocrine paraneoplastic syndromes. Knowledge about the clinical manifestations, pathophysiology, and treatment of these syndromes has evolved over time. This article provides an up-to-date overview of this knowledge.

Adrenocorticotropic Hormone↗
PubMed2003

Respiratory failure and sepsis are the major causes of ICU admissions and mortality in survivors of lung transplants.

STUDY OBJECTIVE: To identify outcome predictors and prognostic factors in long-term survivors (> 30 days post-transplant) of single-lung and double-lung transplants on readmission to the medical ICU (MICU). DESIGN: Retrospective study. SETTING: MICU of the Cleveland Clinic Foundation, a lung transplantation center. PATIENTS: As of August 2000, 210 lung transplantations have been performed at our institution. The records of 33 lung transplant recipients who required readmission to the MICU after the initial 30-day post-transplant period over a 4-year period from August 16, 1996 to August 15, 2000 were reviewed. RESULTS: Thirty-three patients had a total of 46 MICU readmissions. Twenty-seven MICU admissions (59%) were due to respiratory deterioration with mechanical ventilation (10 deaths), and 16 MICU admissions (35%) were due to the systemic inflammatory response syndrome (SIRS; 8 deaths). The MICU mortality rate was 37% per admission in our group of patients. A preadmission diagnosis of bronchiolitis obliterans syndrome was observed in 7 of 14 nonsurvivors (50%) and in 5 of 25 patients (20%) surviving to hospital discharge. CONCLUSIONS: Respiratory failure and SIRS are the predominant causes of MICU readmissions and are frequent causes of death. APACHE (acute physiology and chronic health evaluation) III scores, nonpulmonary organ system dysfunction, initial serum albumin level, and duration of mechanical ventilation are important prognostic factors.

APACHE↗
PubMed2003

Treatments and strategies to optimize the comprehensive management of patients with pulmonary arterial hypertension.

The management of pulmonary arterial hypertension (PAH) should aim to provide vasodilation of the pulmonary arteries, treat right ventricular failure, improve functional capacity and quality of life, and improve survival, if possible. Data from right heart catheterization and an estimation of vasoresponsiveness together guide treatment for PAH. The judicious use of calcium channel blockers, prostacyclin analogues, anticoagulation, and endothelin receptor antagonists forms the current basis of therapy. Three drugs-the prostacyclin analogues epoprostenol and treprostinil and the endothelin receptor antagonist bosentan-are currently approved for the primary treatment of PAH and have been clinically shown to improve outcomes. Coumarin derivatives, epoprostenol, and, in selected patients, calcium channel blockers are the only drugs associated with improved survival, and only epoprostenol has been shown to improve survival in a prospective randomized trial. Knowledge of the supportive therapies, indications for surgical intervention, and emerging drug therapies should provide the working armamentarium for clinicians treating this rare but devastating disease.

Antihypertensive Agents↗
PubMed2003

Diagnosis and evaluation of pulmonary hypertension.

The diagnosis of pulmonary hypertension (PH) relies on a high index of suspicion. In patients with symptoms or chest radiographic findings suggestive of PH, a detailed history and physical examination followed by early assessment with a transthoracic echocardiogram, ventilation-perfusion scanning, chest computed tomography, pulmonary function testing, and nocturnal oximetry screening can provide valuable information about etiology and severity. Right heart catheterization should follow in patients who are symptomatic or who demonstrate moderate to severe PH by echocardiography and are candidates for treatment. Patients at risk for developing PH should undergo serial echocardiography and pulmonary function testing to assess for disease development and progression. Genetic testing is not currently recommended in the routine evaluation of patients with a diagnosis of primary pulmonary hypertension.

Cardiac Catheterization↗
PubMed2003

Weekly versus daily changes of in-line suction catheters: impact on rates of ventilator-associated pneumonia and associated costs.

BACKGROUND: An earlier randomized, controlled trial showed that weekly or as-needed (as opposed to daily) changes of in-line suction catheters were associated with substantial cost savings, without a higher rate of ventilator-associated pneumonia (VAP). To examine the impact of decreasing the frequency of in-line suction catheter changes in our medical intensive care unit, we conducted an observational study, comparing the catheter costs and frequency of VAP during (1) a control period, during which in-line suction catheters were changed daily, and (2) a treatment period, during which the catheters were changed every 7 days or sooner if needed, for mechanical failure or soilage. METHODS: All adult patients admitted to our 18-bed medical intensive care unit were evaluated for the 3-month interval 1 year prior to the practice change (May through July 1998) and for the 3 months after implementing the new policy (May through July 1999). To avoid bias related to usual seasonal variation in VAP frequency, we also determined (via medical records) the VAP rate during May through July 1997. The occurrence of VAP was ascertained by an infection control practitioner, using criteria established by the Centers for Disease Control and applied in a standard fashion. The VAP rate was calculated as the mean number of VAPs per 100 ventilator-days for each 3-month interval. Use of ventilators, humidifiers, and non-heated-wire, disposable circuits was uniform during the study, as were policies regarding humidity, temperature settings, and frequency of routine ventilator circuit changes. RESULTS: During the control period 146 patients accounted for 1,075 ventilator-days and there were 2 VAPs (0.19 VAPs per 100 ventilator-days). During the treatment period 143 patients accounted for 1,167 ventilator-days and there were no VAPs. The mean +/- SD duration of in-line suction catheter use during the treatment period was 3.8 +/- 0.8 days, and 51% of the patients had the same catheter in place for > 3 days (range 4-9 days). The actual cost of catheters used during the treatment period was lower than during the control period ($1,330 vs $6,026), predicting annual catheter cost savings of $18,782. CONCLUSIONS: We conclude that (1) a policy of weekly (vs daily) change of in-line suction catheter is associated with substantial cost savings, with no significant increase in the frequency of VAP, and (2) to the extent that these findings confirm the results of prior studies they support a policy of changing in-line suction catheters weekly rather than daily.

Catheterization↗
PubMed2002

The prostacyclin analogue treprostinil blocks NFkappaB nuclear translocation in human alveolar macrophages.

Primary pulmonary hypertension (PPH) is characterized by increased pulmonary arterial pressure and vascular resistance. We and others have observed that inflammatory cytokines and infiltrates are present in the lung tissue, but the significance is uncertain. Treprostinil (TRE), a prostacyclin analogue with extended half-life and chemical stability, has shown promise in the treatment of PPH. We hypothesize that TRE might exert beneficial effects in PPH by antagonizing inflammatory cytokine production in the lung. Here we show that TRE dose-dependently inhibits inflammatory cytokine (tumor necrosis factor-alpha, interleukin-1beta, interleukin-6, and granulocyte macrophage colony-stimulating factor) secretion and gene expression by human alveolar macrophages. TRE blocks NFkappaB activation, but IkappaB-alpha phosphorylation and degradation are unaffected. Moreover, TRE does not affect the formation of the NFkappaB.DNA complex but blocks nuclear translocation of p65. These results are the first to illustrate the anti-cytokine actions of TRE in down-regulating NFkappaB, not through its inhibitory component or by direct binding but by blocking nuclear translocation. These data indicate that inflammatory mechanisms may be important in the pathogenesis of PPH and cytokine antagonism by blocking NFkappaB may contribute to the efficacy of TRE therapy in PPH.

Active Transport, Cell Nucleus↗
PubMed2002

Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study.

CONTEXT: The outcome of patients receiving mechanical ventilation for particular indications has been studied, but the outcome in a large number of unselected, heterogeneous patients has not been reported. OBJECTIVE: To determine the survival of patients receiving mechanical ventilation and the relative importance of factors influencing survival. DESIGN, SETTING, AND SUBJECTS: Prospective cohort of consecutive adult patients admitted to 361 intensive care units who received mechanical ventilation for more than 12 hours between March 1, 1998, and March 31, 1998. Data were collected on each patient at initiation of mechanical ventilation and daily throughout the course of mechanical ventilation for up to 28 days. MAIN OUTCOME MEASURE: All-cause mortality during intensive care unit stay. RESULTS: Of the 15 757 patients admitted, a total of 5183 (33%) received mechanical ventilation for a mean (SD) duration of 5.9 (7.2) days. The mean (SD) length of stay in the intensive care unit was 11.2 (13.7) days. Overall mortality rate in the intensive care unit was 30.7% (1590 patients) for the entire population, 52% (120) in patients who received ventilation because of acute respiratory distress syndrome, and 22% (115) in patients who received ventilation for an exacerbation of chronic obstructive pulmonary disease. Survival of unselected patients receiving mechanical ventilation for more than 12 hours was 69%. The main conditions independently associated with increased mortality were (1) factors present at the start of mechanical ventilation (odds ratio [OR], 2.98; 95% confidence interval [CI], 2.44-3.63; P<.001 for coma), (2) factors related to patient management (OR, 3.67; 95% CI, 2.02-6.66; P<.001 for plateau airway pressure >35 cm H(2)O), and (3) developments occurring over the course of mechanical ventilation (OR, 8.71; 95% CI, 5.44-13.94; P<.001 for ratio of PaO(2) to fraction of inspired oxygen <100). CONCLUSION: Survival among mechanically ventilated patients depends not only on the factors present at the start of mechanical ventilation, but also on the development of complications and patient management in the intensive care unit.

Adult↗
PubMed2002

Circulating monocytes from patients with primary pulmonary hypertension are hyporesponsive.

Primary pulmonary hypertension (PPH) is a rare disease of unknown etiology characterized by arterial thickening and remodeling. The transcription factor NF-kappaB is responsible for the activation of several cytokines and growth factor genes reported to be associated with PPH. Our previous study showed NF-kappaB activation in alveolar macrophages from PPH patients, suggesting the presence of a localized pulmonary inflammatory response. In PPH, circulating monocyte activity has not been previously examined. The present study was undertaken to determine whether circulating monocytes also showed evidence of activation, which could suggest a systemic response to PPH injury. Results indicated that NF-kappaB activation in monocytes from PPH patients did not differ from that of healthy controls. However, mRNA expression was decreased compared to controls for NF-kappaB-regulated genes, granulocyte macrophage colony-stimulating factor, interleukin-6, macrophage inflammatory protein-1alpha (MIP-1alpha), and vascular endothelial growth factor. MIP-1alpha protein secretion from PPH monocytes was also lower than that of controls cultured with and without endotoxin. Expression of the surface activation markers HLA-DR and CD-14 were significantly reduced on monocytes from PPH patients compared to healthy controls. Toll-like receptor-4 (TLR-4) expression was significantly increased on monocytes from PPH patients while TLR-2 remained unchanged. Thus, our data are the first to show that monocytes in PPH have decreased activation and are hyporesponsive to lipopolysaccharide (LPS) stimulation. The monocyte LPS hyporesponsiveness may in part be the result of decreased CD-14 expression, since LPS responsiveness is dependent on the physical association of LPS/CD-14 complexes with TLR-4, and without this association signal transduction does not occur. These data indicate that although PPH is a localized pulmonary disorder, there are alterations in the systemic compartment. What remains unknown is how the reduced activation of monocytes in PPH is related to the pulmonary vascular lesion.

Adult↗
PubMed2002

Bronchoscopy and needle biopsy techniques for diagnosis and staging of lung cancer.

Lung cancer is the leading cause of cancer deaths in the United States. The individual therapeutic approach and prognosis depends on accurate diagnosis and staging. Flexible bronchoscopy (FB) and transthoracic needle biopsy (TNB) are the most widely used techniques for this purpose. This article provides a critical overview of indications, diagnostic yield, and limitations of bronchoscopy and TNB in the diagnosis of lung cancer.

Biopsy, Needle↗
PubMed2002

Paraneoplastic syndromes associated with bronchogenic carcinoma.

Paraneoplastic syndromes associated with lung cancer are diverse in their presentation, pathophysiology, and implications. They can be seen as a diagnostic and therapeutic challenge or as an opportunity to detect an otherwise asymptomatic malignancy. Unraveling the mechanisms that produce these syndromes will lead to insight into tumor biology that will be translated into novel approaches for early detection and therapy.

Carcinoma, Bronchogenic↗
PubMed2002

Central nervous system vasculitis in the intensive care unit.

Intensivists are sometimes faced with unexplained neurologic defects in ICU patients. A subacute presentation over weeks or months characterized by headache and mental status change with focal deficits in the absence of evidence of secondary vasculitis or other diseases mentioned in the differential diagnosis should arouse suspicion of PACNS. Delay in diagnosis of this rare condition may lead to additional morbidity and prolong ICU stay. There is also a risk of permanent cognitive dysfunction with untreated PACNS. A reactive CSF picture, ischemic changes on MR imaging, and alterations in vessel caliber on cerebral angiography are not diagnostic but strengthen the evidence for PACNS. A brain biopsy may be required to confirm the diagnosis. High-dose steroid therapy with a prolonged course and gradual taper controls the disease in most cases. Additional immunosuppressive therapy is needed in some patients.

Communicable Diseases↗
PubMed2002

Incidence of ARDS in an adult population of northeast Ohio.

STUDY OBJECTIVES: To assess the incidence of the ARDS in a well-defined adult population. DESIGN: Kaiser Permanente of northeast Ohio, a health maintenance organization, uses the Cleveland Clinic Foundation as its only tertiary care center. In an ongoing prospective assessment in the Cleveland Clinic ICUs, we identified adult Kaiser Permanente patients with ARDS between 1996 and 1999. ARDS was defined according to the 1994 American-European Consensus Conference criteria. The denominator in the incidence calculation was the adult members of Kaiser Permanente of each year of the study period, and the numerator was the new adult ARDS patients in this particular year. The cause of ARDS, the mortality, and the cause of death were retrospectively identified, as well as other characteristics of the study population. RESULTS: ARDS was diagnosed in 66 patients during the 3-year study period. The incidence per 100,000 population was 11.4 in 1996, 19.8 in 1997, and 14.4 in 1998; the overall incidence was 15.3/100,000/yr. The mean PaO(2)/fraction of inspired oxygen (+/- SD) was 110.8 +/- 37.8, the mean APACHE II was 23.4 +/- 6.9, and the mean ICU stay was 12.0 +/- 9.5 days. The most common cause of ARDS was direct lung injury (75.8%), and the most common cause of death was septic shock (53.8%). CONCLUSION: The incidence of ARDS in an adult population in northeast Ohio was 15.3/100,000/yr, a number that is slightly higher but comparable to recent estimates reported by other researchers.

Female↗
PubMed2002

Role of transbronchial needle aspiration in patients receiving mechanical ventilation.

STUDY OBJECTIVE: s: To evaluate the diagnostic accuracy and safety of transbronchial needle aspiration (TBNA) in patients receiving mechanical ventilation in the ICU. METHODS: Retrospective review of all patients in the medical and surgical ICUs from February 1999 to July 2001 who underwent TBNA while receiving mechanical ventilation. RESULTS: A total of eight histology (19 gauge) and eight cytology (22 gauge) TBNAs were performed on eight patients (four men and four women). TBNA yielded a definitive pathologic diagnosis in five of eight patients (62.5%). Diagnoses were posttransplantation lymphoproliferative disorder, large cell carcinoma, poorly differentiated non-small cell carcinoma, squamous cell carcinoma, and adenocarcinoma. Among patients with negative TBNA results (n = 3), two patients underwent mediastinoscopy. Results of mediastinoscopy were non-small cell carcinoma and inflamed tissue. TBNA led to management changes in five of these patients. Excluding one patient in whom a negative TBNA result could not be further confirmed, TBNA yielded a sensitivity of 83%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 50%. The overall accuracy of the procedure was 75%. There were no complications following any of the TBNAs. CONCLUSIONS: In this small group of patients, TBNA was safe and had a high diagnostic accuracy in selected patients receiving mechanical ventilation in the ICU.

Adult↗
PubMed2002

Intensive care update: seven studies that should change your practice.

Seven recent studies in intensive care found that: *The need for intravenous sedation should continually be reassessed * Low-dose dopamine does not offer significant renal protection * Higher doses of continuous venovenous hemofiltration may improve survival * Subclavian central venous catheterization is associated with fewer complications than the femoral route * We have little evidence to support the use of ranitidine and sucralfate as prophylaxis for stress ulcers * Many young patients with suspected bacterial meningitis can undergo lumbar puncture without a CT scan if they have no abnormalities on a quick history and physical examination * Intensive insulin therapy to control blood glucose lowers the mortality rate.

Clinical Trials as Topic↗