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Biomedical subjects

D R Gracey

Publications and source records attributed to D R Gracey.

At least 19 recordsLinked to original sources
PubMed1992

Outcomes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital.

The outcomes in 61 patients admitted to a chronic ventilator-dependent unit (CVDU) at Saint Marys Hospital in Rochester, Minnesota, during an 18-month period are summarized. This unit was designed for patients who could not be weaned from mechanical ventilators after repeated attempts. Most patients had been ventilator dependent for more than 21 days, but some patients were admitted to the CVDU after briefer periods if special circumstances suggested that weaning from mechanical ventilation would be difficult. The unit was organized to provide a multidisciplinary approach to the general medical and respiratory management of these patients, including a physiologic evaluation of the respiratory system to determine the actual cause of ventilator dependence and complete medical, nursing, and psychosocial assessments to help adopt a plan of care and weaning from the ventilator. Of the numerous causes for ventilator dependence in this study group, chronic obstructive pulmonary disease was the most frequent underlying diagnosis. Of the 61 patients admitted to the CVDU, 58 survived, and 53 were liberated from the mechanical ventilator. Ultimately, 35 patients were dismissed directly home from the CVDU. Five of these patients required nocturnal mechanical ventilation. An additional eight patients were dismissed home after rehabilitation. After being weaned from mechanical ventilation, 11 patients were eventually transferred to nursing homes, and 3 additional patients were transferred to a local hospital or physical medicine unit. One patient remains in the CVDU. Thus, the CVDU has successfully liberated patients from ventilator dependence. In addition, because of a decreased need for nursing care, the unit has been cost-effective.

Adult↗
PubMed1992

Hospital and posthospital survival in patients mechanically ventilated for more than 29 days.

Experience with prolonged mechanical ventilation has improved over recent years. Retrospective analysis of the records of 104 patients older than 16 years of age who were mechanically ventilated for more than 29 days over a 29-month period from May 1986 to October 1988 revealed the following findings. The mean patient age was 66.3 +/- 15.7 years (SD). The mean number of in-hospital ventilator days was 59.9 +/- 36.7 days (range, 29 to 247 days). The mean number of days of oral or nasal endotracheal intubation prior to tracheostomy (96 patients) was 21.5 +/- 14.2 days. The mean length of hospital stay for the 104 patients was 79.9 +/- 45.4 days. The majority of the 104 patients (82.6 percent) were surgical patients. Nine patients left the hospital receiving extended mechanical ventilation. Mortality was highest in multiple organ system failure and lowest among the trauma patients. The total days of mechanical ventilation did not appear to be related to mortality if patients older than 16 years survived for seven days. Postdischarge survival of the 53 of 60 patients who survived and whom we were able to contact was 67 percent at one year and 56 percent at three years.

Adolescent↗
PubMed1990

Assessment of prediction of mortality by using the APACHE II scoring system in intensive-care units;.

Some investigators have suggested that information on quality of care in intensive-care units (ICUs) may be inferred from mortality rates. Specifically, the ratio of actual to predicted hospital mortality (A/P) has been proposed as a valid measure for comparing ICU outcomes when predicted mortality has been derived from data collected during the first 24 hours of ICU therapy with use of a severity scoring tool, APACHE II (acute physiology and chronic health evaluation). We present a comparison of mortality ratios (A/P) in four ICUs under common management, in two hospitals within a single institution. Significant differences in A/P were detected for nonoperative patients (0.99 versus 0.67;P = 0.014) between the two hospitals. This variation was traced to uneven representation of a subset of patients who had chronic health problems related to diseases that necessitated admission to the hematology-oncology or hepatology service. No differences in A/P were seen between the two hospitals for operative patients or for nonoperative patients on services other than hematology-oncology or hepatology. Thus, differences in A/P detected by using the APACHE II system not only may reside in operational factors within the ICU organization but also may be related to weaknesses in the APACHE II model to measure factors intrinsic to the disease process in some patients. We suggest that case-mix must be examined in detail before concluding that differences in A/P are caused by differences in quality of care.

Diagnosis-Related Groups↗
PubMed1988

Benign lymphocytic angiitis and granulomatosis: experience with three cases.

Of three patients with lung-biopsy-proven benign lymphocytic angiitis and granulomatosis, two experienced complete resolution of their disease from therapy with chlorambucil and one underwent spontaneous remission with no drug therapy after lung biopsy and removal of a benign spindle cell thymoma. Clinically, it is difficult to determine whether benign lymphocytic angiitis is a low-grade (prelymphomatous) lymphoma or a vasculitis. Its position in this spectrum of diseases is uncertain. Nonetheless, benign lymphocytic angiitis and granulomatosis corresponding to a low-grade angiocentric immunoproliferative lesion is a clinicopathologically useful concept.

Aged↗
PubMed1988

Tuberculosis in the world today.

Tuberculosis remains a major public health problem throughout the world. Although the disease was previously well controlled in the United States, several factors now present a potential for the reemergence of tuberculosis as a significant public health concern. Physicians who will be responsible for the care of these patients must be trained to respond appropriately.

Acquired Immunodeficiency Syndrome↗
PubMed1988

Outcome of respiratory failure in hematologic malignancy.

We reviewed records of patients with hematologic malignancy requiring mechanical ventilation (MV) from 1976 to 1985 (excluding postoperative MV less than 48 hours). There were 119 episodes in 116 patients. In-hospital mortality was 82 percent. Of 21 (18 percent) episodes survived, median duration of survival was 12 months. Survivors did not differ from nonsurvivors in age, leukocyte count, or duration of MV. Survival for chronic lymphocytic leukemia was 42 percent, for other leukemias 16 percent, Hodgkin's disease 29 percent, and non-Hodgkin's lymphomas, 6 percent. Bronchoscopy was performed in 28 patients, resulting in a diagnosis of infection, hemorrhage, or malignancy in 19 cases. Open lung biopsy (OLB) was obtained in 23 patients, yielding a diagnosis of interstitial inflammation or fibrosis (13 cases), drug effect (three), malignancy (two), hemorrhage (one), Pneumocystis (seven), aspergillosis (two), and Legionella (one). Only two patients survived following OLB. Despite intensive management and adequate diagnosis, respiratory failure in patients with hematologic malignancy carries a high mortality. Although these data may help identify groups with a limited prognosis for long-term recovery, patient care must be individualized.

Female↗
PubMed1987

Respiratory failure in Lambert-Eaton myasthenic syndrome.

Five patients with the Lambert-Eaton myasthenic syndrome who required more than 48 hours of mechanical ventilation for respiratory failure are described. All five had small cell bronchogenic carcinoma. In one patient with associated chronic bronchitis, one with interstitial pulmonary fibrosis, and one other, respiratory failure requiring mechanical ventilation developed as a result of the Lambert-Eaton myasthenic syndrome. The two other patients had received muscle relaxant drugs, but the acute respiratory failure episode in one of the two was not clearly related to their administration. One patient had an initial response to plasmapheresis, which allowed assisted mechanical ventilation to be discontinued. This improvement was not sustained, and the patient subsequently died in respiratory failure. Three patients survived to be dismissed from the hospital after they were weaned from mechanical ventilation.

Aged↗
PubMed1984

Differential mechanical ventilation in respiratory failure due to severe unilateral lung disease.

Severe unilateral lung disease that produces respiratory failure may necessitate mechanical ventilatory support to sustain gas exchange. This article describes the successful use of differential lung ventilation in the management of one patient with diffuse unilateral pneumonia and another with a postoperative bronchopleural fistula after standard methods of mechanical ventilation failed to provide adequate gas exchange for these patients.

Adult↗
PubMed1984

Plasmapheresis in the treatment of ventilator-dependent myasthenia gravis patients. Report of four cases.

During a 42-month period, we used plasmapheresis to treat four cases of myasthenia gravis with refractory respiratory failure. All four patients were ventilator dependent for prolonged periods and were not responding to management with cholinesterase inhibitors and corticosteroids. All four patients rapidly responded to the plasmapheresis; respiratory muscle strength returned sufficiently to allow discontinuation of assisted mechanical ventilation and removal of the artificial airway. In our experience, plasmapheresis is indicated in the treatment of the myasthenia gravis patient with respiratory failure which is refractory to conventional drug therapy.

Adult↗
PubMed1984

Postoperative respiratory care after transsternal thymectomy in myasthenia gravis. A 3-year experience in 53 patients.

During a three-year period, 53 patients with myasthenia gravis underwent transsternal thymectomy by a partial sternum-splitting technique at our institution. This procedure was carried out (1) because an x-ray film or a computed tomography scan had suggested the presence of a thymoma or (2) to manage symptoms of myasthenia gravis. In 41 patients the endotracheal tube was removed in the post-anesthesia recovery room. The remaining 12 patients were extubated in the Respiratory Care Unit--in five, after prolonged mechanical ventilation. From our experience, the only factor useful for predicting the probable need for prolonged postoperative mechanical ventilation is the degree of bulbar involvement. Patients in Osserman classification groups 3 and 4 have an extremely high incidence of postoperative respiratory failure. Consideration should be given to the use of preoperative plasmapheresis in myasthenia gravis patients who have significant bulbar symptoms.

Adolescent↗
PubMed1983

Mechanical ventilation for respiratory failure in myasthenia gravis. Two-year experience with 22 patients.

We evaluated a 2-year experience involving 22 patients who required prolonged mechanical ventilation for respiratory failure associated with myasthenia gravis. The most frequent cause of respiratory failure was operation, and the most common type of procedure was thymectomy. Next in frequency as exacerbating factors were myasthenic crisis and cholinergic crisis. Of the 22 patients, 21 survived and were weaned from the ventilator after 1 to 32 days of respiratory support.

Adolescent↗
PubMed1982

Unexplained diaphragmatic paralysis: a harbinger of malignant disease?

The records of 103 male and 39 female patients with unexplained diaphragmatic paralysis were reviewed. A probable cause of the paralysis was not revealed by the initial history, physical examination, or review of plain chest roentgenograms. Paralysis occurred on the left in 82 patients (58%), on the right in 58 (41%), and bilaterally in two (1%). Initially, 64 patients (45%) had symptoms; dyspnea, cough, and chest wall pain were the most common. Long-term follow-up showed the best prognosis to be for patients with chest wall pain and cough (improvement in 82% and 78%, respectively); dyspnea improved in only 34% of patients with this complaint. Intrathoracic malignant lesions with phrenic nerve involvement were subsequently diagnosed in five patients (3.5%) and progressive neurogenic atrophy in one (0.7%). Roentgenographic follow-up showed return of normal diaphragmatic position in only 12 instances (9.2%). Patients with unexplained diaphragmatic paralysis are unlikely to have an underlying occult malignant or neurologic process, but recovery of diaphragmatic function is also unlikely and subsidence of related symptoms is variable.

Adolescent↗