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Biomedical subjects

M Hersch

Publications and source records attributed to M Hersch.

At least 19 recordsLinked to original sources
PubMed2006

The impact of regional culture on intensive care end of life decision making: an Israeli perspective from the ETHICUS study.

BACKGROUND: Decisions of patients, families, and health care providers about medical care at the end of life depend on many factors, including the societal culture. A pan-European study was conducted to determine the frequency and types of end of life practices in European intensive care units (ICUs), including those in Israel. Several results of the Israeli subsample were different to those of the overall sample. OBJECTIVE: The objective of this article was to explore these differences and provide a possible explanation based on the impact of culture on end of life decision making. METHOD: All adult patients admitted consecutively to three Israeli ICUs (n = 2778) who died or underwent any limitation of life saving interventions between 1 January 1999 and 30 June 2000 were studied prospectively (n = 363). These patients were compared with a similar sample taken from the larger study (ethics in European intensive care units: ETHICUS) carried out in 37 European ICUs. Patients were followed until discharge, death, or 2 months from the decision to limit therapy. End of life decisions were prospectively organised into one of five mutually exclusive categories: cardiopulmonary resuscitation (CPR), brain death, withholding treatment, withdrawing treatment, and active shortening of the dying process (SDP). The data also included patient characteristics (gender, age, ICU admission diagnosis, chronic disorders, date of hospital admission, date and time of decision to limit therapy, date of hospital discharge, date and time of death in hospital), specific therapies limited, and the method of SDP. RESULTS: The majority of patients (n = 252, 69%) had treatment withheld, none underwent SDP, 62 received CPR (17%), 31 had brain death (9%), and 18 underwent withdrawal of treatment (5%). The primary reason given for limiting treatment was that the patient was unresponsive to therapy (n = 187). End of life discussions were held with 132 families (36%), the vast majority of which revolved around withholding treatment (91% of the discussions) and the remainder concerned withdrawing treatment (n = 11, 9%). There was a statistically significant association (chi2 = 830.93, df = 12, p < 0.0001) between the type of end of life decision and region-that is, the northern region of Europe, the central region, the southern region, and Israel. CONCLUSIONS: Regional culture plays an important part in end of life decision making. Differences relating to end of life decision making exist between regions and these differences can often be attributed to cultural factors. Such cultures not only affect patients and their families but also the health care workers who make and carry out such decisions.

Adult↗
PubMed2003

Dural arteriovenous fistulae causing pseudotumour cerebri syndrome in an elderly man.

The clinical presentation of dural arteriovenous fistulae (DAVF) is dependent on their location and the nature of their venous drainage. The latter plays a critical part in determining whether or not the fistula gives rise to intracranial hypertension, which is present in only a minority of cases. We present a case of the pseudotumour cerebri syndrome in an elderly man with bilateral intracranial DAVF supplied by the occipital arteries. Cerebral angiography was required for definitive diagnosis, and to characterise the abnormal venous drainage. The pathophysiology of intracranial hypertension in DAVF is discussed.

Aged↗
PubMed2003

Biomechanics, diagnosis, and treatment outcome in inflammatory myopathy presenting as oropharyngeal dysphagia.

AIMS: In patients with inflammatory myopathy and dysphagia, our aims were to determine: (1) the diagnostic utility of clinical and laboratory indicators; (2) the biomechanical properties of the pharyngo-oesophageal segment; (3) the usefulness of pharyngeal videomanometry in distinguishing neuropathic from myopathic dysphagia; and (4) clinical outcome. METHODS: Clinical, laboratory, and videomanometric assessment was performed in 13 patients with myositis and dysphagia, in 17 disease controls with dysphagia (due to proven CNS disease), and in 22 healthy age matched controls. The diagnostic accuracy of creatine kinase (CPK), erythrocyte sedimentation rate, antinuclear antibody, and electromyography (EMG) were compared with the gold standard muscle biopsy. The biomechanical properties of the pharyngo-oesophageal segment were assessed by videomanometry. RESULTS: Mean time from dysphagia onset to the diagnosis of myositis was 55 months (range 1-180). One third had no extrapharyngeal muscle weakness; 25% had normal CPK, and EMG was unhelpful in 28%. Compared with neurogenic controls, myositis patients had more prevalent cricopharyngeal restrictive disorders (69% v 14%; p=0.0003), reduced upper oesophageal sphincter (UOS) opening (p=0.01), and elevated hypopharyngeal intrabolus pressures (p=0.001). Videomanometric features favouring a myopathic over a neuropathic aetiology were: preserved pharyngeal swallow response, complete UOS relaxation, and normal swallow coordination. The 12 month mortality was 31%. CONCLUSIONS: The notable lack of supportive clinical signs and significant false negative rates for laboratory tests contribute to the marked delay in diagnosis. The myopathic process is strongly associated with restricted sphincter opening suggesting that cricopharyngeal disruption is a useful adjunct to immunosuppressive therapy. The condition has a poor prognosis.

Aged↗
PubMed2000

Loss of ability to sneeze in lateral medullary syndrome.

Four consecutive patients with lateral medullary syndrome reported reversible inability to complete a reflex sneeze, despite retaining the urge to do so and the ability to mimic the motor act. This previously undescribed feature of a relatively common syndrome is in keeping with the known location of a "sneeze center" in the lateral medulla of cat. In man, unilateral brainstem lesion is sufficient to abolish the sneeze reflex temporarily.

Adult↗
PubMed2000

The use of the arterial line as a source for blood cultures.

OBJECTIVE: To determine the reliability of blood cultures obtained through indwelling arterial lines as compared to that of blood cultures obtained by venipuncture. DESIGN: A prospective observational study. SETTING: Six-bed mixed medical surgical intensive care unit (ICU) of a 550-bed university-affiliated medical center. MEASUREMENTS: During a 3-month period blood culture sets, when clinically indicated, were drawn in parallel from indwelling arterial catheters and one-time venipuncture and the results compared. Each blood sample consisted of 15 ml and was distributed equally between three blood culture bottles: aerobic, anaerobic and one aerobic resin-containing bottle. Blood culture results from the two sources were compared according to preset definitions. MAIN RESULTS: During the study period 90 parallel blood culture sets (540 bottles) were obtained from 36 patients. Forty-three (16%) venipuncture bottles were positive versus 88 (32%) arterial line culture bottles (p < 0.001). Of the parallel sets, 83% yielded equivalent results - either both sterile or both growing the same organism. Amongst the discordant sets, the arterial line cultures grew 37 gram-positive and 18 gram-negative isolates not found in venipuncture sets (i.e. 50% of 109 arterial line isolates), while only two gram-positive isolates were solely grown in venipuncture cultures (4% of all 55 venipuncture isolates, p < 0.001). On clinical correlation, all the gram-positive organisms in the discordant cultures were found not to reflect bacteremia, while five of the 18 gram-negative isolates (28%) grown only in arterial line cultures probably did reflect ongoing bacteremia. CONCLUSION: The results of blood cultures taken from the arterial line are frequently equivalent to those taken from venipuncture. When discordant, the growth of gram-positive bacteria almost certainly reflects contamination or arterial line colonization, whereas the growth of gram-negative bacteria may have to be considered as reflecting bacteremia.

Bacteremia↗
PubMed1998

Selective gut microcirculatory control (SGMC) in septic rats: a novel approach with a locally applied vasoactive drug.

Gut mucosal hypoperfusion plays a major role in the pathogenesis of ongoing sepsis and multiple organ dysfunction syndrome. Traditionally, therapy included increasing systemic flow, thus secondarily augmenting blood flow to the gut. Direct manipulation of the gut mucosal microcirculation avoiding systemic effects, i.e., selective gut microcirculatory control (SGMC), has not been tested with a clinically available vasodilating drug. We hypothesized that a topically applied vasoactive drug would affect gut mucosal microcirculation without systemic effects. Twelve Sprague-Dawley rats were randomly assigned to cecal ligation and perforation (CLP), or sham (SC) laparotomy. Twenty-four hours after surgery, mucosal arterioles of a 3-4 cm exteriorized ileal segment were studied using intravital microscopy while suffused with saline followed by sodium nitroprusside (SNP, 100 microg/mL, 3.4 mM). SNP normalized (to SC saline values, 14.5 +/- .6 microm) the CLP arteriolar diameters, from 11 +/- 6 to 14.6 +/- .3 microm (p < .05), while mean arterial pressure (MAP) was stable. Flowmotion patterns were also normalized by SNP, and intercapillary areas (i.e., diffusion distance) were decreased. We conclude that SNP exerted beneficial effects on gut mucosal microcirculation without affecting MAP; therefore, SGMC may be a novel way to affect the course of sepsis.

Administration, Topical↗
PubMed1997

Routine surveillance blood cultures: their place in the management of critically ill patients.

The use of surveillance blood cultures has been advocated as a means to allow earlier detection of septic episodes amongst intensive care patients, and therefore earlier institution of appropriate antibiotic therapy. We compared the results of surveillance cultures and clinically indicated blood cultures for bacterial isolates grown and the influence of culture results on patient management. Blood cultures were obtained from all intensive care unit (ICU) patients over the course of 3 months at a set surveillance time (surveillance group) or according to clinical indications (clinical group). Bacteriological results were compared and real-time chart review performed to assess the influence of the surveillance cultures on patient management, with particular reference to antibiotic therapy. Two hundred and forty-nine blood culture sets were collected over 3 months, 99 in the surveillance group and 150 in the clinical group. A total of 256 bacterial isolates were grown, 95 in the surveillance group and 161 in the clinical group. For the surveillance group 36%, 20%, and 44% of the isolates represented bacteraemia, line colonization and culture contamination, respectively. For the clinical group the distibution was 69%, 7%, and 24% respectively (P<0.001, P<0.01, and P<0.0027 for comparisons of percentages within each classification). On only one occasion was antibiotic therapy started based on the result of a surveillance culture, and on only one occasion was a septic episode detected earlier by a surveillance culture; however, this culture result did not lead to a change in patient management. Surveillance blood cultures are expensive and add very little to the management of patients in the intensive care environment.

Adult↗
PubMed1996

Impact of the resin blood culture medium on the treatment of critically ill patients.

OBJECTIVE: To assess the relevance, both clinical and bacteriologic, of the use of resin-containing blood culture media in blood cultures taken from critically ill patients receiving antibiotics. DESIGN: A prospective, open clinical trial. SETTING: The mixed medical surgical intensive care unit (ICU) of a 550-bed urban hospital. PATIENTS: All ICU patients admitted during a 3-month period (n = 49) with suspected sepsis requiring blood cultures as part of their laboratory investigations. INTERVENTIONS: The use of an aerobic resin-containing blood culture medium, in addition to the regular aerobic and anaerobic media for all blood cultures taken. MEASUREMENTS AND MAIN RESULTS: Each blood culture result was classified as to its clinical significance. Changes in patient management were recorded. Culture sets in which the resin-containing bottle provided the information central to the change in patient management were identified. Bacteriologically, the results from the resin-containing medium were compared with the results from the aerobic and anaerobic media. Of 266 blood culture sets, 103 (39%) were positive, growing 278 bacterial and fungal isolates. Clinically, the resin-containing medium alone provided relevant data leading to changes in patient management on three occasions. On two of these occasions, cultures from the regular media provided the same data within 72 hrs. Bacteriologically, 77 (29%) aerobic bottles, 55 (21%) anaerobic bottles, and 89 (33%) resin-containing bottles were positive (statistical comparison of percentages: aerobic vs. resin-containing bottles, nonsignificant; aerobic vs anaerobic bottles, p < .046; anaerobic vs. resin-containing bottles, p < .0027). A similar proportion of pathogens was isolated from the resin-containing bottles only (9%) and aerobic bottles only (6%). A higher proportion of contaminants was isolated from the resin-containing bottles only than the aerobic bottles only in the various sets (17% vs. 7%, p < .046). The resin-containing bottle showed a trend toward increased detection of Staphylococcus aureus and Pseudomonas aeruginosa bacteremia. CONCLUSIONS: The resin-containing medium offers little clinical benefit to the majority of ICU patients. Bacteriologically, it seems to have a similar overall sensitivity as the regular aerobic medium (with the possible exception of a higher sensitivity for the isolation of S. aureus and P. aeruginosa), but a lower specificity. The wide-spread use of the resin-containing bottle cannot be recommended.

Anti-Bacterial Agents↗
PubMed1992

Interaction of sepsis and sepsis plus sympathomimetics on myocardial oxygen availability.

The ability to regulate myocardial blood flows (Q) in accord with changing myocardial O2 needs may be depressed in sepsis. This could be an important concern when sympathomimetics are used to augment systemic oxygen delivery (QO2) in this syndrome as increased myocardial O2 needs may accompany an infusion of this class of drugs. Therefore after measuring the effect of sepsis on myocardial O2 metabolism, we then infused various sympathomimetics to evaluate the sepsis+sympathomimetic interaction on myocardial QO2. We measured Q to the left (LV) and right (RV) ventricles by the radioactive microsphere technique in 36 unanesthetized mature sheep, before and during the infusion of dopamine, dobutamine, dopexamine, norepinephrine, salbutamol, or placebo. Randomly selected for infusion, these drugs were titrated to augment the thermodilution-derived cardiac index (CI) by greater than 20%. This study was repeated 24-48 h after cecal ligation and perforation had resulted in a hyperdynamic septic state [change (delta) in CI = sepsis - baseline = +54%; P less than 0.01]. During the septic study, both Q-LV (delta = +80%; P less than 0.01) and Q-RV (delta = +84%; P less than 0.01) were increased above baseline values; the augmented Q to both LV and RV was directly correlated with the arterial perfusion pressure (PA) x CI product and the mean pulmonary artery pressure (PPA) x CI product, respectively. Only 23% of study animals demonstrated net transmyocardial lactate production during the septic study. When the infusion of sympathomimetics was accompanied by an increase in the PPA x CI and PA x CI products, a further increase in both Q-RV and Q-LV, respectively, occurred. Also, neither the ventricular endocardial-to-epicardial flow ratios nor transmyocardial lactate extraction were modified by the sympathomimetics infusion. We conclude that the septic response to infection in this animal model was not accompanied by significant abnormalities in the metabolic regulation of myocardial QO2 (R. E. Cunnion, G. L. Scher, and M. M. Parker, Circulation 73: 637-644, 1986).

Animals↗
PubMed1992

The effect of various sympathomimetics on the regional circulations in hyperdynamic sepsis.

Because sepsis is characterized by a depression in vascular reactivity, we hypothesized that changes in organ blood flows (Q) would differ between the nonseptic and septic state during the infusion of sympathomimetics. Therefore we examined the (sepsis x organ Q) interaction during the infusion of five sympathomimetics in 36 mature, awake sheep before and after cecal ligation and perforation produced hyperdynamic sepsis. A 3-hour infusion of dobutamine, norepinephrine, dopamine, dopexamine, or salbutamol was compared with that of placebo during both nonseptic and septic studies; drug infusion was titrated to an increase in cardiac index of greater than 20%. Increased plateau infusion doses of norepinephrine (+305%), salbutamol (+275%), dopamine (+70%), and dobutamine (+49%) were required to achieve predefined treatment guidelines during the septic versus nonseptic study. Few differences in the regional effects of individual sympathomimetics were found in the nonseptic study, although infusion of sympathomimetics was accompanied by a redistribution of systemic Q toward the heart and away from the brain, kidney, small intestine, liver, and pancreas. In the septic study, however, the sympathomimetic infusions were not accompanied by the redistribution of Q away from small intestine and liver that was demonstrated in the nonseptic study. Therefore (1) the depressed vascular reactivity in hyperdynamic sepsis altered the dose profile of exogenous sympathomimetics required to augment systemic Q, and (2) the (sepsis x sympathomimetic) interaction was characterized by a depression in the anticipated redistribution of organ Q from "nonvital" to "vital" circulations.

Animals↗