Management of tracheomediastinal fistulas using self-expanding metallic stents.
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Aged↗
Biomedical subjects
Marie M Budev
Publications and source records attributed to Marie M Budev.
Extended use of extracorporeal membrane oxygenation after lung transplantation.
OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) for severe graft failure after lung transplantation is accepted immediately postoperatively; extending its use is controversial. We evaluated our post-lung transplant ECMO experience, which included extended indication, to (1) determine its prevalence, risk factors, indications, and timing, (2) compare complications and outcomes of these patients with those not requiring it, and (3) identify risk factors, including indications, for mortality. METHODS: From February 1990 to October 2005, 474 patients underwent lung transplantation; postoperative ECMO support was instituted for severe graft failure 23 times in 22 patients (4.0%). Indications for ECMO and its timing were obtained by reviewing medical records and survival by systematic follow-up. RESULTS: No factor evaluated predicted severe graft failure leading to ECMO. The most common indication for ECMO was early graft failure (13 patients); however, it was also used for pneumonia or sepsis (6) and acute rejection (4). ECMO was initiated at a median arterial oxygen tension/inspired oxygen fraction of 59 at a median of 2 days postoperatively and was maintained for a median of 4 days. The most common complications were renal failure (57%) and bleeding (43%). ECMO was effective in salvaging patients with rejection and early graft failure (survival at 1, 3, 6, and 12 months: 62%, 54%, 49%, and 41%), but ineffective for pneumonia or sepsis (survival at these intervals: 9%, 4%, 4%, and 3%). CONCLUSIONS: ECMO can be extended beyond early severe graft failure to acute rejection and can be considered after the immediate postoperative period. Survival after ECMO in patients with pneumonia or sepsis is poor.
Extracorporeal Membrane Oxygenation↗
Acanthosis nigricans following single lung transplantation: a case report.
Acanthosis nigricans was observed 3 months after single lung transplantation in a 51-year-old African American woman with idiopathic pulmonary fibrosis. The patient had no endocrinological abnormalities and was not taking any medications known to cause acanthosis nigricans; extensive investigation did not reveal an underlying malignant process. Because acanthosis nigricans may occur as a paraneoplastic phenomenon, it is important to rule out an underlying malignancy. This is especially important in solid-organ transplant recipients receiving chronic immunosuppressive therapy.
Acanthosis Nigricans↗
Cystic fibrosis in adults: an overview for the internist.
The care of patients with cystic fibrosis (CF) has improved over the past 30 years, and most patients now survive well into adulthood. As a result, clinicians other than pediatricians are more likely than in the past to see CF patients and manage their respiratory, gastrointestinal, pancreatic, and reproductive complications.
Adrenergic beta-Antagonists↗
Exacerbation of underlying pulmonary disease in pregnancy.
OBJECTIVE: The presence of underlying pulmonary disease in women of childbearing potential can present a significant challenge during pregnancy and the postpartum period. Management of the underlying disease, recognizing and preventing disease progression, and, most important, managing and minimizing toxic side effects of various therapies require the expertise of an interdisciplinary team. This team must involve close collaboration between intensive care physicians, pulmonary physicians, and high-risk obstetricians familiar with these disease states in an effort to minimize fetal and maternal morbidity and mortality. We will review the impact of the pregnant state in lung transplant recipients, patients with pulmonary arterial hypertension, and patients with underlying cystic fibrosis. DESIGN: Review of the literature in regards to pregnancy outcomes and issues for patients with cystic fibrosis, pulmonary hypertension, and lung transplants. METHODS: A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and outcomes for pregnant patients with underlying pulmonary diseases. CONCLUSIONS: Safety of pregnancy in the female lung transplant recipient concerns three outcomes: maternal outcome, fetal outcome, and transplanted graft outcome.
Critical Care↗
Ovarian hyperstimulation syndrome.
OBJECTIVE: Ovarian hyperstimulation syndrome (OHSS) is a rare iatrogenic complication of ovarian stimulation usually occurring during the luteal phase or during the early part of pregnancy. OHSS is a potential complication of ovarian induction by almost every agent used for ovarian stimulation. Today, due to aggressive treatment protocols including the development of in vitro fertilization and cryopreservation with the goal of obtaining sufficient numbers of oocytes and embryos, an increased risk of developing OHSS is present. OHSS is now becoming increasingly more recognized due to the higher number of women undergoing assisted reproductive techniques. DESIGN: Review of the literature regarding ovarian hyperstimulation syndrome. METHODS: A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and treatment and prevention of OHSS. CONCLUSION: OHSS can be thought of as the loss of control over the hyperstimulation of the ovaries. Although the prevalence of the severe form of OHSS is small, it is important to remember that OHSS is usually an iatrogenic complication of a nonvital treatment that has the potential for a fatal outcome. Therefore, critical care physicians play an integral part in the care of these patients and therefore should be familiar with and recognize the various clinical manifestations and potential outcomes of this entity.
Critical Care↗
Referral for lung transplantation: a moving target.
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Guidelines as Topic↗
Do as we say, not as we do: healthcare workers and hand hygiene.
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Cross Infection↗
Overview of treprostinil sodium for the treatment of pulmonary arterial hypertension.
Pulmonary arterial hypertension is a life-threatening disorder that refers to a group of diseases characterized by an abnormal elevation of the blood pressure within the pulmonary circulation due to a vasculopathy of the pulmonary microcirculation (1). If left untreated, the overall prognosis of pulmonary arterial hypertension is poor, with a 5-year survival rate of 34%. The most common cause of death is progressive right-sided heart failure (2). There is no pharmacologic cure for pulmonary arterial hypertension, and a team approach is required for the proper care of these patients (3). Treatment is directed at improving clinical symptoms, increasing exercise tolerance and extending survival. Until just a few years ago, standard treatment options for the treatment of pulmonary arterial hypertension were limited and included coumarin derivatives, calcium channel blockers, diuretics, digoxin and oxygen supplementation (4). In the last decade, the therapeutic options for pulmonary arterial hypertension have made considerable advances. In at least three major randomized controlled trials, the continuous intravenous infusion of epoprostenol, a synthetic salt of prostacyclin with potent vasodilatory ability, has been shown to improve exercise tolerance, hemodynamics, survival and quality of life in patients with New York Heart Association (NYHA) functional classes III and IV with either primary pulmonary hypertension or pulmonary arterial hypertension associated with scleroderma (5-9). Epoprostenol has now become a mainstay therapy in the long-term treatment of primary pulmonary hypertension or pulmonary arterial hypertension associated with scleroderma. Nevertheless, epoprostenol is far from an ideal form of therapy. Issues such as the short half-life of the drug, need for continuous central intravenous access and significant side effects have led to the development of more stable prostacyclin analogues as alternative therapies for primary pulmonary hypertension. These alternative therapies include iloprost (inhaled delivery) and treprostinil (subcutaneous delivery). As a result, the Food and Drug Administration (FDA) recently approved treprostinil for the treatment of pulmonary arterial hypertension in patients with NYHA classes II-IV. This review will offer a discussion of the basic pharmacology of treprostinil, its similarities to and differences from epoprostenol, the animal studies as well as the initial investigational studies leading to its FDA approval, and clinical uses of the drug alone or in combination with newer therapies directed at pulmonary arterial hypertension developed over the last decade.
Antihypertensive Agents↗
Estrogen-containing oral contraceptives are allowable in young women with factor V Leiden heterozygosity without a history of thrombosis.
An 18-year-old woman without significant past medical and surgical history presents to discuss the safety and efficacy of oral contraceptives. She is sexually active and currently relying on condoms alone for birth control. Her cousin had a deep venous thrombosis (DVT) following a pregnancy. As part of the family screening, this patient was identified as a factor V Leiden heterozygote. The risks and benefits of initiating oral contraceptives are discussed.
Adolescent↗
Cor pulmonale: an overview.
Chronic cor pulmonale involves the enlargement of the right ventricle as a result of pulmonary hypertension due to pulmonary disorders involving the lung parenchyma, bellows function, or ventilatory drive. The right ventricular hypertrophy that occurs in chronic cor pulmonale is a direct result of chronic hypoxic pulmonary vasoconstriction and subsequent pulmonary artery hypertension, leading to increased right ventricular work and stress. We discuss methods by which hypoxic vasoconstriction and reduction in the pulmonary vascular bed lead to the development of pulmonary artery hypertension. This article reviews the interaction of the pulmonary vasculature and right ventricle in the non-diseased state as well as during disease exacerbations. Ventricular dependence and its contribution to the pathophysiology of right ventricular failure are also reviewed. In addition, we provide an overview of specific disease states that can result in the development of chronic cor pulmonale including chronic obstructive pulmonary disease (COPD), interstitial lung disease, sleep apnea, alveolar hypoventilation disorders, and primary pulmonary hypertension. We also review the current diagnostic studies used to evaluate and study cor pulmonale.
Journal Article↗
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↗