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Biomedical subjects

R M Rodriguez

Publications and source records attributed to R M Rodriguez.

At least 37 records · Page 2Linked to original sources
PubMed1999

[Angioplasty in chronic coronary occlusion].

In the last few years, coronary angioplasty has been the object of real progress in the treatment of total chronic coronary occlusion; The primary success rate of the procedure regularly exceeds 70% with the use of improved equipment; however, these procedures are not without risk with a reported complication rate close to that of angioplasty of non-occlusive stenosis. The use of stents has significantly reduced the restenosis rate, mainly by decreasing the risk of reocclusion. The indications of angioplasty for chronic occlusion remain controversial: the procedure is justified in patients with angina; in asymptomatic patients, angioplasty may improve global and regional left ventricular function in those with documented myocardial viability and limit ventricular remodelling but the results of a randomised trial of systematic angioplasty versus medical treatment in this type of indication are not yet available.

Angioplasty, Balloon, Coronary↗
PubMed1998

Management of parapneumonic effusions.

When a patient with a parapneumonic pleural effusion is first evaluated, a therapeutic thoracentesis should be performed if more than a minimal amount of pleural fluid is present. Fluid obtained at the therapeutic thoracentesis should be gram-stained and cultured and analyzed for glucose, pH, LDH, white blood cells, and differential cell count. If the fluid cannot be drained because of loculations, a chest tube should be inserted and thrombolytic agents administered. If the pleural fluid recurs after the initial therapeutic thoracentesis but the patient is doing well clinically and the initial pleural fluid glucose was greater than 60 mg/dL; the pH, greater than 7.2; the LDH, less than three times the upper normal limit for serum and the cultures are negative; he or she can be observed. If one or more of the aforementioned criteria are not met, a second therapeutic thoracentesis should be performed, with repeat diagnostic evaluations of the pleural fluid. If the fluid recurs a second time, a small chest tube should be placed if the pleural fluid glucose and pH were lower and the LDH higher on the second thoracentesis than on the first thoracentesis. Patients with loculated-parapneumonic effusions should be treated with tube thoracostomy and thrombolytic agents. If drainage is incomplete, thoracoscopy, with breakdown of adhesions and debridement of the pleural space, is indicated. If thoracoscopy is unsuccessful, then thoracotomy, with decortication, is indicated unless the patient is too debilitated.

Anti-Bacterial Agents↗
PubMed1998

Comparison of pleural fluid pH values obtained using blood gas machine, pH meter, and pH indicator strip.

STUDY PURPOSE: The purpose of this study was to compare the pleural fluid pH values obtained with a blood gas machine (pHbg), with a pH meter (pHmet), and with a pH indicator strip (pHstrip), to determine if the pleural fluid pH measured by a pH meter or a pH indicator strip was sufficiently accurate for clinical decisions. METHODS: The pleural fluid pH was determined, within 20 min after being collected anaerobically, by a blood gas machine (CIBA-Corning model 288), pH meter (Corning pH meter 610A), and pH indicator strip (Baxter Diagnostic) following routine laboratory procedures in 50 pleural fluids. Pleural fluid pH was determined in seven additional samples with the blood gas machine and a pH meter at 25 and 37 degrees C respectively, initially, and after 30 min. RESULTS: The mean pHbg (7.42+/-0.01) was significantly less than the mean pHmet (7.58+/-0.02) or the mean pHstrip (8.23+/-0.06). There were significant differences between the pHbg and the pHmet (p < 0.001), and between the pHbg and the pHstrip (p < 0.001). Analysis of the additional seven samples demonstrated that when the blood gas machine was set at 25 degrees C, the pHbg (pHbg = 7.54+/-0.02) and the pHmet (7.53+/-0.01) were almost identical. CONCLUSION: When the pleural fluid pH is going to be used for decision making, only the pH values provided by the blood gas machine are sufficiently accurate.

Blood Gas Analysis↗
PubMed1997

Prediction of poor outcome of intensive care unit patients admitted from the emergency department.

OBJECTIVE: To assess whether physicians can identify very low likelihood of survival and very low likelihood of favorable functional outcome in adult nontrauma patients before admission to the intensive care unit (ICU) from the emergency department (ED). DESIGN: Prospective survey. SETTING: University hospital ED and ICU. PARTICIPANTS AND PATIENTS: Critical care fellows and ED physicians and all adult nontrauma patients admitted to the ICU from the ED over 1 yr. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The survey compared predictions of poor outcome from three sources: critical care fellows, ED physicians, and the admission Mortality Probability Model (MPM0). All patients were followed until hospital death or hospital discharge. Six-month follow-up data were obtained for patients predicted to have a < 2% chance of surviving with favorable functional outcome. In the ED, critical care fellows and ED physicians predicted likelihood of patient survival and likelihood of favorable functional outcome. MPM0 estimates of mortality were determined. The sensitivities, specificities, and positive predictive values were calculated for the predictions of < 2% survival and the predictions of < 2% chance of favorable functional outcome made by each prediction group. Complete data were obtained on 236 (96%) of 243 eligible patients. With regard to hospital mortality rate, fellows' predictions had a sensitivity of 27%, a specificity of 99%, and a positive predictive value of 88%; ED physicians' predictions had a sensitivity of 24%, a specificity of 98%, and a positive predictive value of 81%; and MPM0 predictions had a sensitivity of 2%, a specificity of 100%, and a positive predictive value of 100%. With regard to mortality rate combined with poor functional outcome, fellows' predictions had a sensitivity of 35%, a specificity of 99%, and a positive predictive value of 96%; ED physicians' predictions had a sensitivity of 37%, a specificity of 99%, and a positive predictive value of 96%. CONCLUSIONS: If a cutoff point of < 2% predicted survival is used in the triage of patients away from the ICU, the MPM0 has too low a sensitivity to be used as an effective screen. The low sensitivities and relatively low positive predictive values with wide confidence intervals of physician predictions of < 2% survival also preclude their use in triage. The addition of functional outcome as an end point improves the sensitivity, specificity, and positive predictive value of subjective predictions, making triage of patients away from the ICU at the time of ED evaluation a realistic possibility.

Adult↗
PubMed1995

Need and desire for preventive care measures in emergency department patients.

STUDY OBJECTIVE: To determine the need and desire for selected preventive care measures in an adult emergency department population, comparing patients with and without primary physicians. DESIGN: Written survey. SETTING: Urban university ED. PARTICIPANTS: English-speaking patients 18 years of age or older who did not arrive by ambulance, did not have a critical illness, and did not have a psychiatric complaint. RESULTS: The main outcome measures were past preventive care and desire to initiate preventive care measures as part of ED care. Nine hundred fifty-three surveys were distributed; 647 were completed and returned. Twenty-seven percent of patients knew their cholesterol level. Forty-three percent of men aged 40 years or older reported having had a prostate examination in the past year, and 39% of men aged 50 years or older reported having had an examination of stool for blood in the past year. Twenty-one percent of women reported taking calcium, and 67% of women aged 40 years or older had had a mammogram in the past 2 years. Sixty-three percent of patients had a primary physician; these patients were more likely to have received each of the preventive care measures studied (P < .025). Fifty-three percent of women not taking calcium requested information about osteoporosis prevention, and 30% requested prescriptions for calcium supplements. Sixty-two percent of women who did not have a current mammogram requested mammography information, and 60% requested referrals for mammography. Fifty-four percent of patients requested cholesterol and diet information. Patients requesting information, referrals, and prescriptions were given them. CONCLUSION: In a selected ED population, there was both need and desire for preventive health care measures to be initiated or provided as part of ED care, especially among patients who did not have primary physicians.

Adult↗
PubMed1993

Emergency department immunization of the elderly with pneumococcal and influenza vaccines.

STUDY OBJECTIVE: To determine the feasibility of immunizing unvaccinated elderly patients with influenza and pneumococcal vaccines in the emergency department. PARTICIPANTS AND SETTING: A convenience sample of elderly patients presenting to an urban university-affiliated ED. DESIGN AND INTERVENTIONS: Elderly ED patients were asked about prior influenza and pneumococcal immunization. Nonimmunized patients were given information sheets, were informed of the changes for vaccination, and were asked if they desired immunization as part of their ED care. Those desiring immunization who lacked contraindications were immunized. RESULTS: One hundred thirty-three patients were enrolled. Eighty-two percent had not been immunized with pneumococcal vaccine; 62% of these nonimmunized patients stated they desired pneumococcal vaccination, and 58% were immunized. Sixty-three percent of the 133 patients had not received current influenza vaccine; 54% of these nonimmunized patients stated they desired influenza vaccine, and 50% were immunized. CONCLUSION: The majority of elderly ED patients are not immunized adequately with influenza and pneumococcal vaccines as recommended by the Centers for Disease Control and Prevention. Most elderly patients will accept immunization with these vaccines as part of their ED care. These vaccines can be delivered effectively to elderly patients in the ED.

Aged↗
PubMed1992

T lymphocyte adhesion to fibronectin (FN): a possible mechanism for T cell accumulation in the rheumatoid joint.

The accumulation of T cells within the joint is responsible for the perpetuation of synovitis. This process is partly regulated by selective binding to endothelium. However, adhesion to extra-cellular matrix proteins, like FN, may also be important. FN binding is mediated by certain members of the VLA (beta 1 integrin) family of proteins. To investigate the role of Tc-FN interactions in synovitis the binding of synovial fluid (SF) and peripheral blood (PB) T cells to FN-coated wells, and the expression of cell surface VLA molecules on these cells by double label immunofluorescence, were studied. SF T cells bound better to FN than PB T cells. VLA alpha 4 and VLA beta 1 but not VLA alpha 5 were up-regulated on SF compared with PB T cells. Anti-VLA alpha 4, VLA beta 1 and VLA alpha 5 MoAbs inhibited the binding of SF T cells to FN. The increased binding of SF T cells to FN could have been related to activation and/or to their predominantly memory phenotype. Purified resting memory or naive T cells bound poorly to FN. In contrast, compared with SF T cells, concanavalin A-activated T cells showed a very similar level of binding to FN, comparable expression of VLA molecules and the same pattern of inhibition of binding to FN by MoAbs. Thus, VLA molecules may play an important role in the retention of T cells in the joint and since T cells can be activated via VLA-FN interactions, this mechanism may perpetuate chronic inflammation.

Arthritis, Rheumatoid↗
PubMed1986

Avascular necrosis of bone: a manifestation of Cushing's disease.

Cushing's disease is endogenous hypercortisolism due to a pituitary adenoma. Although exogenous hypercortisolism is a well known cause of avascular necrosis and although there have been many reports of avascular necrosis associated with endogenous Cushing's syndrome, there has only been a single well documented case report associating avascular necrosis of bone with Cushing's disease. We report four new cases of avascular necrosis of bone in patients with well documented Cushing's disease.

Adult↗
PubMed1986

Involuntary breath-stacking. An alternative method for vital capacity estimation in poorly cooperative subjects.

Performed correctly, the vital capacity (VC) is a useful indicator of the mechanical properties of the thorax and of neuromuscular performance. Unfortunately, its use is often limited by impaired comprehension, altered mental status, or inability to sustain forceful effort. Our purpose was to develop a measure of VC independent of subject cooperation. We estimated the subcomponents of VC (inspiratory capacity (IC) and expiratory reserve volume (ERV], using one-way valving of an external circuit to enforce cumulation or elimination of the tidal breaths stimulated by endogenous ventilatory drive. When configured to measure IC, gas entered the chest incrementally, until tidal effort became insufficient to overcome thoracic recoil. Valve rearrangement permitted analogous estimation of ERV. We tested the validity of this method in cooperative but naive subjects by comparing the VC measured in standard fashion (VCC) to the breath-stacked estimate (VCS). Thirty normal subjects and 20 ambulatory patients with diverse causes for respiratory impairment were studied. Peak and mean values of VCS correlated strongly with the corresponding values of VCC (r greater than or equal to 0.91). The coefficient of variation for sequential V VCS determinations (approximately equal to 5.5%) was comparable to that observed for VCC (approximately equal to 3.5%) in both subject groups, indicating acceptable reproducibility of the involuntary VCS measurement. VCS maneuvers were quickly completed and well tolerated. Involuntary breath-stacking may provide a useful estimate of VC in clinical settings where conventional methodology cannot be confidently applied.

Adult↗
PubMed1986

The inspiratory workload of patient-initiated mechanical ventilation.

We quantified inspiratory effort during patient-triggered ventilator cycles in 20 critically ill patients receiving assisted mechanical ventilation (AMV). An index of the patient's work per liter of ventilation (WP) was defined as the difference in the mechanical work done by the ventilator during controlled and assisted breathing cycles at similar settings of tidal volume and flow. WP was estimated graphically from plots of airway pressure against inflation volume for peak flow settings of 60 L/min and 100 L/min. During patient-initiated cycles, effort did not cease with the onset of gas delivery. Values for WP varied widely but at both flow settings frequently equalled or exceeded the total workload expected for a spontaneously breathing normal subject. Furthermore, the patient's component of the mechanical workload during AMV was often a large percentage of the work performed during spontaneous breathing 30 s after discontinuing ventilator support (at 60 L/min: mean 62.6%; range 30.3 to 116.3%). The addition of deadspace to the external circuit increased VE and WP significantly. Both the maximally negative pressure generated against an occluded airway and the deflection of esophageal pressure in the first 100 ms after the onset of inspiratory effort were highly correlated with WP, suggesting the importance of strength and ventilatory drive as determinants of patient effort. WP correlated poorly with measures of chest mechanics, and there was no separation of WP values for the two flow rates we studied, perhaps because both settings exceeded the patient's spontaneous demand for airflow (FD).(ABSTRACT TRUNCATED AT 250 WORDS)

Carbon Dioxide↗
PubMed1986

Bedside estimation of the inspiratory work of breathing during mechanical ventilation.

The work of chest inflation, WI, is a primary determinant of the need for ventilatory support and an integrative index of elastic and resistive impedance. Although the mechanical work performed by a ventilator in moving gas into the passive chest (WI = integral of PV dt) can be determined by measuring the area enclosed by a display of airway pressure (P) against delivered volume (V), the instrumentation required is not routinely available at the bedside. Under conditions of constant flow, however, inspiratory time represents an analog of delivered volume, and airway pressure can be recorded easily by equipment normally employed to monitor pulmonary vascular pressures. We reasoned that the area beneath the airway pressure vs time tracing should accurately reflect WI for unassisted breaths delivered by the ventilator at constant flow. We computed estimates of WI from simultaneous pressure-volume (PV) and pressure-time (PT) plots during square-wave inflation in 20 acutely ill patients. Ventilator settings were varied over the usual clinical range for tidal volume (10 to 15 ml/kg) and inspiratory flow (40 to 80 L/min). PV and PT estimates agreed closely; across the four setting combinations tested, the difference between PV and PT estimates averaged 2.4 +/- 5.6 percent (means +/- SD, r = 0.99). Furthermore, the reproducible geometric configuration of the curves generated allowed accurate estimation of WI from routine beside observations of tidal volume and peak dynamic and static inflation pressures, without the need for specialized equipment or area measurement. Such simplified estimates could serve in clinical practice to gauge the ventilatory workload and to monitor changes in respiratory impedance.

Adult↗
PubMed1985

Magnesium toxicity as a cause of hypotension and hypoventilation. Occurrence in patients with normal renal function.

Symptomatic hypermagnesemia usually requires both increased intake of the ion and abnormal renal function; however, we treated two patients with iatrogenic hypermagnesemia (10.4 and 13.2 mEg/L) who had normal renal function. One received ureteral irrigation with hemiacidrin (Renacidin) to dissolve a stone, and the other was treated for ingestion of an unknown toxin with large doses of magnesium sulfate. Therapy included ventilatory support, intravenous calcium, and fluids. Dialysis was not required, and recovery was complete.

Adult↗