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Lewis Rubinson

Publications and source records attributed to Lewis Rubinson.

11 recordsLinked to original sources
PubMed2007

Mass casualty respiratory failure.

PURPOSE OF REVIEW: The severe acute respiratory syndrome epidemic of 2002-2003, recent natural catastrophes, burgeoning concerns regarding intentional catastrophes, and the looming threat of an influenza pandemic have focused attention on large-scale, survivable respiratory failure. In this article, we review appropriate medical equipment, treatment space, and strategies to augment health professional staff in response to a massive increase in need for sustained critical care. RECENT FINDINGS: There is insufficient modern healthcare experience with mass casualty respiratory failure to develop evidence-based preparedness efforts. For this reason, initial efforts to augment critical care capability in response to disasters have relied on extrapolation from the routine critical care knowledge base, military medicine, critical care transport, and expert opinion. We review recently published documents on augmenting supplies of positive pressure ventilation equipment, ongoing projects for increasing health professional staff, and infection control issues during epidemics. SUMMARY: Mass casualty respiratory failure remains a largely unstudied field, but we believe informed decisions about equipment stockpiling and use, the development of creative operational concepts to increase staffing, and the careful implementation of rational infection control practices can lay a foundation for an appropriate response until additional data become available.

Acute Disease↗
PubMed2006

Positive-pressure ventilation equipment for mass casualty respiratory failure.

In the event of an influenza pandemic, patients with severe acute respiratory failure (ARF) due to influenza will require positive-pressure ventilation (PPV) in order to survive. In countries with widely available critical care services, PPV is delivered almost exclusively through use of full-feature mechanical ventilators in intensive care units (ICUs) or specialized hospital wards. But the supply of these ventilators is limited even during the normal course of hospital functioning. Purchasing and maintaining additional full-feature mechanical ventilators to be held in reserve and used only during mass casualty events is too expensive to allow the stockpiling of such equipment. Consequently, planning and preparedness efforts to respond to a severe influenza pandemic have stimulated consideration of limited-feature, less-expensive ventilation devices to augment traditional PPV capacity. This article offers guidance to authorities charged with preparing for mass casualty PPV in deciding which PPV equipment would be adequate for ventilating patients for days, weeks, or even months during a medical catastrophe.

Anesthesia↗
PubMed2005

Critical care during epidemics.

We recommend several actions that could improve hospitals' abilities to deliver critical care during epidemics involving large numbers of victims. In the absence of careful pre-event planning, demand for critical care services may quickly exceed available intensive care unit (ICU) staff, beds and equipment, leaving the bulk of the infected populace without benefit of potentially lifesaving critical care. The toll of death may be inversely proportional to the ability to augment critical care capacity, so critical care health care professionals must take the lead for planning and preparing to care for numbers of seriously ill patients that far exceed available ICU beds.

Bioterrorism↗
PubMed2005

Why is it that internists do not follow guidelines for preventing intravascular catheter infections?

BACKGROUND AND OBJECTIVE: High morbidity of CVC-related infections has led to national guidelines for their prevention. Despite recommendations for the use of maximal barrier precautions (mask, sterile gloves, gown, and large drape) and skin antisepsis with 2% chlorhexidine gluconate during CVC insertion, internists in the United States are not implementing these practices frequently. This study sought to identify and characterize the obstacles to and potential opportunities for improving adherence. DESIGN: Cross-sectional survey. PARTICIPANTS: One thousand randomly selected physician-members of the American College of Physicians-American Society of Internal Medicine. METHODS: Several potential determinants of adherence to maximal barrier precautions were assessed, including awareness of, agreement with, and ability to implement the recommendation, as well as the practice and training characteristics of the respondents. Factors influencing antiseptic selection were also recorded. RESULTS: Of 526 respondents, 178 (34%) had recently inserted CVCs. Clinician experience and subspecialty, awareness of CDC guidelines, and external influences (eg, time to collect equipment) did not affect maximal barrier precautions adherence. The only independent predictor of adherence was high outcome expectancy for the use of large sterile drapes (OR, 5.3; CI95, 2.2-12.6). Availability had the greatest influence on internists' selection of specific antiseptic agents, whereas cost was the least important determinant. CONCLUSIONS: Despite established efficacy, use of maximal barrier precautions and chlorhexidine gluconate is low among internists. Because improved adherence to these practices will require increased outcome expectancy for maximal barrier precautions and availability of chlorhexidine gluconate, targeting these areas through focused education and systems modifications is essential.

Anti-Infective Agents, Local↗
PubMed2005

Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations of the Working Group on Emergency Mass Critical Care.

The Working Group on Emergency Mass Critical Care was convened by the Center for Biosecurity of the University of Pittsburgh Medical Center and the Society of Critical Care Medicine to provide recommendations to hospital and clinical leaders regarding the delivery of critical care services in the wake of a bioterrorist attack resulting in hundreds or thousands of critically ill patients. In these conditions, traditional hospital and clinical care standards in general, and critical care standards in particular, likely could no longer be maintained, and clinical guidelines for U.S. hospitals facing these situations have not been developed. The Working Group offers recommendations for this situation.

Bioterrorism↗
PubMed2004

Low caloric intake is associated with nosocomial bloodstream infections in patients in the medical intensive care unit.

OBJECTIVE: To determine whether caloric intake is associated with risk of nosocomial bloodstream infection in critically ill medical patients. DESIGN: Prospective cohort study. SETTING: Urban, academic medical intensive care unit. PATIENTS: Patients were 138 adult patients who did not take food by mouth for > or =96 hrs after medical intensive care unit admission. MEASUREMENTS: Daily caloric intake was recorded for each patient. Participants subsequently were grouped into one of four categories of caloric intake: <25%, 25-49%, 50-74%, and > or =75% of average daily recommended calories based on the American College of Chest Physicians guidelines. Simplified Acute Physiology Score II and serum albumin were measured on medical intensive care unit admission. Serum glucose (average value and maximum value each day) and route of feeding (enteral, parenteral, or both) were collected daily. Nosocomial bloodstream infections were identified by infection control surveillance methods. MAIN RESULTS: The overall mean (+/-sd) daily caloric intake for all study participants was 49.4 +/- 29.3% of American College of Chest Physicians guidelines. Nosocomial bloodstream infection occurred in 31 (22.4%) participants. Bivariate Cox analysis revealed that receiving > or =25% of recommended calories compared with <25% was associated with significantly lower risk of bloodstream infection (relative hazard, 0.24; 95% confidence interval, 0.10-0.60). Simplified Acute Physiology Score II also was associated with risk of nosocomial bloodstream infection (relative hazard, 1.27; 95% confidence interval, 1.01-1.60). Average daily serum glucose, admission serum albumin, time to initiating nutritional support, and route of nutrition did not affect risk of bloodstream infection. After adjustment for Simplified Acute Physiology Score II in a multivariable analysis, receiving > or =25% of recommended calories was associated with a significantly lower risk of bloodstream infection (relative hazard, 0.27; 95% confidence interval, 0.11-0.68). CONCLUSIONS: In the context of reducing risk of nosocomial bloodstream infections, failing to provide > or =25% of the recommended calories may be harmful. Higher caloric goals may be necessary to achieve other clinically important outcomes.

Cohort Studies↗
PubMed2003

Prognostic importance of promoter hypermethylation of multiple genes in esophageal adenocarcinoma.

PURPOSE: We investigated aberrant methylation patterns in esophageal adenocarcinoma and correlated the findings to patient survival and tumor recurrence. EXPERIMENTAL DESIGN: Gene promoter methylation was performed in 82 samples from 41 esophagectomy patients consisting of 41 adenocarcinoma samples, each with its adjacent nonmalignant tissue, which included one sample with Barretts metaplasia. The methylation status of seven genes was determined. Epigenetic silencing was confirmed using immunohistochemical staining. Kaplan-Meier plots were constructed using disease-specific survival as the primary end point and the interval from surgery to tumor recurrence as the secondary end point. The association of clinicopathological and biomolecular risk factors to survival and recurrence was performed using the Log-rank test and Cox proportional hazards model for multivariate analysis. RESULTS: Methylation frequencies of the genes analyzed were APC, 68%; E-cadherin, 66%; O(6)-methylguanine DNA methyltransferase, 56%; ER, 51%; p16, 39%; DAP-kinase, 19%; and TIMP3, 19%. DNA methylation of some genes individually showed only trends toward diminished survival, whereas patients whose tumors had >50% of their gene profile methylated had both significantly poorer survival (P = 0.04) and earlier tumor recurrence (P = 0.05) than those without positive methylation. By multivariate analysis, the hazard ratios (HRs) with positive methylation status were more powerful predictors of survival [HR 2.7 (1.14-6.45; 95% confidence interval)] and tumor recurrence [HR 2.5 (1.11-5.6)] than age (HR 2.03 and 1.96, respectively) or stage (HR 1.48 and 1.67, respectively). CONCLUSIONS: Our data suggest that positive methylation status for multiple genes in esophageal adenocarcinoma is a predictor of poor prognosis.

Adenocarcinoma↗