bluuebunny/crossref_metadata_2025 huggingface dataset:
Endocrine and Metabolic Manifestations of HIV Infection and AIDS
Authors: Rosenfeld Cheryl R. , Reddy S. Sethu K.
Published: November 2015

Since the first descriptions of acquired immune deficiency syndrome (AIDS) and human immunodeficiency virus (HIV), a great deal of knowledge has been accumulated on how these entities interact with the endocrine system. Recently new information has been received on autoimmune dysregulation causing thyroid abnormalities after highly active antiretroviral therapy (HAART), as well as metabolic dysregulation occurring in the setting of protease inhibitors. We review the pathophysiologic abnormalities of the endocrine systems due to HIV infection as well as the endocrine effects of drugs commonly used in HIV management. The spectrum of endocrine dysfunction associated with HIV is growing and the intensive care physician must be aware of these potentially reversible abnormalities.
Neurogenic Pulmonary Edema Following Catastrophic Subarachnoid Hemorrhage: A Case Report and Pathophysiologic Review
Authors: Venkatesan Aradhana M. , Karmpaliotis Dimitri , Silverman Eric S.
Published: November 2015

Neurogenic pulmonary edema (NPE) is an increase in interstitial and alveolar lung fluid that occurs as a direct consequence of acute or subacute central nervous system (CNS) injury. In this review we describe a patient who developed hypoxemic respiratory failure as a result of NPE following catastrophic subarachnoid hemorrhage (SAH). The patient displayed many of the characteristic symptoms, signs, and physiologic aberrations associated with NPE, including an altered level of consciousness, dyspnea, cyanosis, crackles, hypoxemia, and diffuse pulmonary infiltrates. These clinical features can be mistaken for other causes of pulmonary edema and may lead to confusion in the diagnosis and therapeutic approach of hypoxemic respiratory failure in the setting of CNS injury. Although NPE is thought to be due to a combination of pulmonary capillary leakage and elevated intravascular pressures, many questions about its pathophysiology remain unanswered. Data from animal models using therapeutic trials of antiadrenergic agents suggest a significant role for sympathetic nervous system activation and massive catecholamine release in the pathogenesis of this disorder. The most common causes of NPE include head trauma, seizures, cerebral hemorrhages, subarachnoid bleeds, and increased intracranial pressure of any etiology. As is generally observed with this disorder, conservative and supportive management of our patient's respiratory failure led to complete resolution of the NPE within 96 hours. Although NPE is an infrequent phenomenon, it should be considered in the differential diagnosis of all patients who develop respiratory complications soon after CNS injury.
The Vessel Dilator for Central Venous Catheter Placement: Forerunner for Success or Vascular Misadventure?
Authors: Scott Walter Louis , Collier Paul
Published: November 2015

During placement of a central venous catheter (CVC), the vessel dilator and/or combination dilator/sheath-introducer are recognized as potential causative agents in numerous traumatic complications that may be erroneously ascribed to the catheter, placement needle, or guidewire. A review of the literature and device-user survey are offered in support of the need for additional training in safe dilator use, as well as the need to address device labeling and device design.
Controversies in Weaning from Mechanical Ventilation
Authors: Epstein Scott K.
Published: November 2015

Invasive mechanical ventilation can successfully support the patient with acute respiratory failure, but it is associated with considerable risks. Numerous complications of invasive mechanical ventilation have been identified, and these may contribute to increased mortality. Therefore after clinical improvement has occurred, considerable emphasis is placed on expeditiously freeing the patient from the ventilator. This process of getting a patient off mechanical ventilation has been variably termed weaning, liberation, or discontinuation (terms which may be used interchangeably), and can be further divided into “readiness testing” and “progressive withdrawal.” Over the last decade, new developments in our understanding of the process of weaning have provided investigators with the tools to address a number of key questions: How should readiness for weaning (and trials of spontaneous breathing) be determined? What is the role of weaning parameters in deciding when to initiate the weaning process? What is the best mode for conducting a spontaneous breathing trial and how should the patient be monitored? What are the mechanisms for weaning (and spontaneous breathing trial) failure? What is the best technique to facilitate progressive withdrawal? What other factors can facilitate liberation from mechanical ventilation? What are the risks of extubation failure and how can extubation outcome best be predicted? What is the role for protocols in facilitating weaning from mechanical ventilation?.
Serum Cortisol: A Predictor of Mortality in Sepsis?
Authors: Cook Deborah J. , Guyatt Gordon H. , McIlroy William , Reeve Brenda K. , Willan Andrew , Pearl Ronald G.
Published: November 2015

To evaluate the pattern and predictive value of serum cortisol levels in severe septic shock, we studied 20 consecutive critically ill patients with severe sepsis. Serum cortisol levels were measured at time of diagnosis, at 12 and 24 hours, and daily for 5 days. Underlying diagnoses included pneumonia (n = 9), urosepsis (n = 5), peritonitis (n = 4), and cellulitis (n = 2). Two patterns of cortisol secretion were identified. In Group A, serum cortisol levels were greater than 400 nmol/L and gradually decreased (n = 14). In Group B, levels were less than 400 nmol/L and remained below normal (n = 6). In Group A, 2 patients died (14.3%), whereas in Group B, 5 died (83.3%) (p < 0.05). The Simplified Acute Physiology Score (SAPS) was higher, intitial serum cortisol levels were lower, and serum lactate levels were higher in the nonsurvivors. In a logistical regression model, SAPS was the only independent predictor of death; when this variable was removed from the model, decreased initial serum cortisol was also predictive. Increased serum lactate was strongly associated with mortality. There appears to be an association between decreased initial serum cortisol and mortality in patients with severe septic shock.
Occult Tuberculosis in the Intensive Care Unit
Authors: Eveloff Scott E. , Donat Walter E. , Braman Sidney S.
Published: November 2015

Mycobacterium (TB) is often a subtle disease. Unrecognized TB may occur in hospitalized patients and contribute to increased patient morbidity and even mortality. To determine the magnitude of this problem in the critical care unit, we retrospectively reviewed the records of all patients with cultures positive for TB who were admitted to the critical care units of the Rhode Island Hospital between 1981 and 1991. Fourteen such patients (mean age, 59; range, 31-84 years) wsere identified from a total of 100 cases of proven TB among all hospitalized patients during this 11-year period. Thirteen of 14 patients had risk factors known to predispose to TB, including alcoholism, malnutrition, and immunosuppression. No patient was known to have TB at the time of ICU admission. The median time from admission to definitive diagnosis or death was 25 days; TB was the primary or contributing cause of death in 9 of 14 patients. Reasons for the marked delay in diagnosis and subsequent high mortality include (1) a low yield of initial diagnostic tests for TB, (2) nonspecific radiographic studies, (3) willingness of critical care staff to attribute overwhelming illness to more common conditions seen in the ICU, and (4) empiric antibiotic or immunosuppressive therapy directed at nontuberculous processes. In all patients, TB was a strong diagnostic consideration but was dismissed when initial noninvasive and invasive studies were unrevealing. IN critically ill patients with unexplained fever and hypoxic respiratory failure, TB should be strongly considered despite negative diagnostic studies.
A Prediction Rule For Mortality in the Medical Intensive Care Unit Based on Early Acute Organ-System Failure
Authors: Gordan Victor , Pitman Roger K. , Stukel Thérese A. , Teres Daniel , Gillie Edward
Published: November 2015

We evaluated early acute organ-system failure (AOSF) as a predictor of mortality in medical intensive care unit (MICU) patients. Prospective data were obtained on 825 men admitted to a Veterans Administraion (VA) Medical Center MICU. Clinical criteria were used to diagnose the presence of 7 types of AOSF. Of the 2,364 AOSFs detected, 1,847 (78%) were “early” (i.e., detected within the first 48 hours of MICU stay). A random sample of 550 patients was selected for derivation of a prediction rule for MICU mortality based on age and number of early AOSFs. For each additional early AOSF, the adjusted odds of mortality increased by 3.3 (95% confidence interval: 2.7, 4.0; p < 0.0001). When applied to the cross-validation sample of 275 patients, this rule yielded a sensitivity of 77%, a specificity of 86%, and an overall correct classification rate of 82%. These results suggest that a simple rule based on number of AOSFs detected in the early portion of a patient's MICU stay may be a useful predictor of mortality.
Pancreas-Kidney Transplantation for Intensivists: Perioperative Care and Complications
Authors: Fabrega Alfredo J. , Rivas Pedro A. , Pollak Raymond
Published: November 2015

Simultaneous pancreas-kidney transplantation is a therapeutic option for type I diabetics with end-stage renal disease. It aims to correct the uremic state, to normalize glucose hemeostasis, and to ameliorate diabetic complications. Careful donor-recipient selection and meticulous intra-operative and postoperative care will substantially impact recipient morbidity. An understanding of the technical aspects of the surgical procedure and its metabolic and immunological consequences is necessary to successfully manage a pancreas-kidney transplant recipient, many of whom are nursed in intensive care units. A successful outcome is predicted in early recognition of technical complications and aggressive management of rejection to achieve the current 1-year graft survival rates of 75% for pancreas transplants and 84% for kidney transplants.
Clinical Electrocardiography. Pretest Self-Assessment and Review
Authors: Okin Peter M.
Published: November 2015

By Franklin H. Zimmerman McGraw-Hill, 1994 illustrated
Gastric Tonometry: A New Monitoring Modality in the Intensive Care Unit
Authors: Gutierrez Guillermo , Brown Steven D.
Published: November 2015

In many critically ill patients, systemic measures of hemodynamic and O2 transport variables may not be sufficiently sensitive to portray the complex interaction between energy requirements and energy supply in all tissues. Gastric or intestinal tonometry has been proposed as a relative noninvasive index of the adequacy of aerobic metabolism in the gut mucosa, a tissue that is particularly vulnerable to alterations in perfusion and oxygenation. The gut mucosa lacks some of the microvascular control mechanisms that allow other tissues, such as the heart, skeletal muscle, and the brain, to increase tissue perfusion during times of stress, and, just like the canary, it will display metabolic changes indicative of dysoxia earlier than those more “vital” tissues. The tonometric measurement of mucosal PCO2 rests on the premise that equilibrium exists between mucosal and luminal PCO2. Increases in mucosal PCO2, or conversely, decreases in mucosal pH (pHi), are associated with the development of intestinal mucosa ischemia. The clinical utility of pHi to detect intestinal mucosal ischemia has been demonstrated in patients undergoing abdominal aortic surgery. Further, a low gastric mucosal pHi on admission to the ICU appears to be predictive of mortality and pHi-guided resuscitation may improve outcome in a subpopulation of patients admitted to the ICU with normal pHi, perhaps by preventing splanchnic ischemia and the development of a systemic oxygen deficit.
Medical Therapy of Acute Myocardial Infarction: Part I. Role of Thrombolytic and Antithrombotic Therapy
Authors: Jafri Syed M. , Walters Bradford L. , Borzak Steven
Published: November 2015

Thrombolytic therapy has been established as a safe and effective therapeutic strategy in acute myocardial infarction (MD. Its efficacy is improved with early administration, although modest benefits can be demonstrated for up to 12 hours. Tissue plasminogen activator (TPA) appears to offer benefits over streptokinase when administered to patients who present within 4 hours, those with an anterior MI, and who are less than 75 years old. Age alone is not a contraindication for thrombolysis because the risk of bleeding complications in the elderly is outweighed by a significant improvement in mortality. One of the major limitations of thrombolytic therapy in acute MI is reocclusion. Use of adjunctive antithrombotic therapy can reduce the rate of reocclusion following successful thrombolysis. The beneficial role of aspirin is well established. Use of intravenous heparin in conjunction with streptokinase offers no clinical benefit. The efficacy of heparin when administered with other thrombolytic agents remains to be established. These issues and the role of newer antiplatelet and antithrombin agents are being examined in ongoing clinical trials. The objective of this review is to provide the information needed for careful and appropriate judgment in the use of thrombolytic agents and antithrombotic therapy. General principles are emphasized, and specific recommendations are included as guidelines.
Bone Marrow Necrosis
Authors: Conrad Marcel E.
Published: November 2015

Bone marrow necrosis is regarded as an uncommon entity that is associated with a poor prognosis. However, organized studies using either bone marrow biopsy specimens or autopsy material showed that bone marrow necrosis can be demonstrated in approximately one third of specimens. It is found in a large number of both malignant and nonmalignant disorders, in addition to occurring following large exposures to radiation or high dose cancer chemotherapy. In the absence of radiation or cancer chemotherapy, it probably eventuates from either vascular occlusion or blood stasis in small blood vessels. When bone marrow necrosis is prolonged, it may be associated with the development of bone marrow fibrosis, and it may serve as a predisposing etiology for idiopathic myelofibrosis. Most patients discovered with bone marrow necrosis have few symptoms, and they are eventually lost to follow-up without evident progression or development of a clinical illness. In acute disorders and in those who undergo effective therapy, recovery appears to occur without complications. This frequently overlooked finding is the subject of many case reports in the medical literature, but it has only been rarely systematically investigated. The latter is probably warranted because of the potential role of bone marrow necrosis in the pathophysiology of a number of disorders and the paucity of information for treatment of this pathological finding.
Should Critical Care Medicine be a Formal Part of the Undergraduate Curriculum?
Authors: Tewari Krishnansu , Steiger Ralph , Monk Bradley , Scannell Gianna , Tominaga Gail , Waxman Kenneth
Published: November 2015

Medical students were surveyed shortly after completing the third year of medical school. The survey was designed to identify those areas of critical care medicine students had been exposed to and expressed interest in learning more about. In addition, the surveys sought to discern the level of confidence students felt with respect to different critical illnesses and intensive care unit (ICU) therapeutic modalities. Finally, the students were asked their opinion regarding the possibility or need for critical care medicine as part of their medical school curriculum. The three most common topics of interest among medical students who had recently finished their third year in medical school were shock, hemodynamic monitoring, and mechanical ventilation. Less than 30% of the students surveyed felt “better-than-average” confidence on any one of a number of critical care topics and treatment modalities. Of the 80% of students (n = 70) who completed the survey, 91% (n = 64) felt that critical care medicine should be made a part of the medical school curriculum, 6% (n = 4) felt it should not, and 3% (n = 2) were undecided. The survey results and the finding that most of the relevant literature acknowledges the need for critical care medicine in medical school has led us to conclude that a national core clerkship or a didactic lecture series in critical care medicine should be carefully designed and implemented into the undergraduate curriculum.
Mechanical Circulatory Assist Devices
Authors: Boujoukos Arthur J. , Martich G. Daniel
Published: November 2015

A ventricular assist device (VAD) is a heterotopic mechanical pump that augments or replaces the output of a failing ventricle. In the past decade, investigation and use of these devices has greatly improved our understanding of their potential roles and limitations. Successful univentricular and biventricular support has allowed for myocardial recovery and survival in several settings of intractable cardiogenic shock. The development of long-term VADs has allowed for successful bridging of patients to heart transplantation, and it has laid the groundwork for a permanent implantable replacement ventricle. In this review, we address indications, complications, management, and results of mechanical support in postcardiotomy, bridge to recovery, and bridge to transplantation settings. The tools to achieve ventricular support in the United States, and the VADs themselves, are described, with emphasis on unique features, indications, and limitations.
Temporary Cardiac Pacing in the Intensive Care Unit
Authors: Le Khoi , Goldschlager Nora
Published: November 2015

Indications for temporary cardiac pacing have increased substantially in the last several years. Although most temporary cardiac pacing is still carried out to treat symptomatic bradycardia due to atrioventricular conduction system disease or atrial bradycardia (i.e., sinus node dysfunction), temporary pacing is currently used to induce and to terminate some supraventricular tachyarrhythmias, prevent pause-dependent ventricular tachycardia (usually torsades de pointes), and vagally mediated atrial fibrillation, to allow the maintenance of hemodynamic competence in postoperative cardiac patients and to evaluate selected patients with hypertrophic and dilated cardiomyopathies who might benefit hemodynamically from cardiac pacing. The roles of transcutaneous and esophageal pacing have also expanded; transcutaneous pacing is now commonly used in patients at high risk for the development of atrioventricular block, such as those with acute myocardial infarction and bifascicular block. We review available types of temporary pacing leads and pulse generators, the methods by which temporary pacing is accomplished, complications of pacing system insertion, and current indications for this therapy. Guidelines for troubleshooting normal and abnormal pacemaker function in the intensive care unit setting are provided.
Nonoperative Management of Solid Abdominal Visceral Injury: Part II. Liver and Kidney
Authors: Knudson M. Margaret , Bermudez Kenneth
Published: November 2015

Only in recent years has it been recognized that the injured liver is not only capable of spontaneous hemostasis, but also that it can heal itself remarkably well without surgical intervention. Currently, the approach to stable patients with blunt liver trauma should be nonoperative, regardless of the age of the patient, the degree of liver injury, or the amount of blood in the peritoneal cavity. However, success with this method of management is highly dependent on selection of patients whose liver has ceased bleeding and who do not have an associated intra-abdominal injury in need of operative repair. Similarly, a nonoperative approach is appropriate in patients with blunt renal trauma if the injury is properly staged and if major urinary extravasation and vascular injuries are not present.
Sedation during Artificial Ventilation by Continuous Intravenous Infusion of Midazolam: Effects of Hepatocellular or Renal Damage
Authors: Nishiyama Tomoki
Published: November 2015

To evaluate the effects of hepatocellular or renal damage on therapeutic doses of midazolam and emergence time after withdrawal of the drug, 87 patients under continuous sedation with midazolam on artificial ventilation were prospectively studied. They needed continuous sedation for 12 hours or more. They included 55 patients with normal hepatocellular and renal functions (C group), 21 patients with hepatocellular damage (II group), and 11 patients with hepatocellular and renal damage (HR group). Midazolam was initiated with an intravenous dose of 0.1 mg/kg followed by 0.05 mg/kg/hr. Dosage was regulated to maintain a state in which patients responded to verbal command and had bucking responses to endotracheal suctioning. The three groups were compared with respect to midazolam dosage, emergence time, aspartate aminotransferase (AST), alanine aminotransferase (ALT), blood urea nitrogen (BUN), and creatinine (Cr) levels and urine volume. The mean doses of midazolam in the C, H, and HR groups were 0.083 ± 0.038 mg/kg/hr, (mean ± standard deviation) 0.073 ± 0.037 mg/kg/hr, and 0.088 ± 0.048 mg/kg/hr, respectively, showing no differences among these groups. Emergence time was significantly longer in the H group (333 ± 263 min; p < 0.005) and the HR group (305 ± 225 min; p < 0.025) than in the C group (171 ± 106 min). No effect of midazolam administration was seen on AST, ALT, BUN, Cr, and urine volume in all groups. In conclusion, presence of hepatocellular or renal damage did not alter required dosage of midazolam. Hepatocellular damage prolonged emergence time, but renal damage had no more additive effect. There was no evidence of hepatocellular and renal damages during treatment.
Neuromuscular Blockade in the Pediatric Intensive Care Unit: Pancuronium, Vecuronium, Rocuronium, or Atracurium
Authors: Tobias Joseph D.
Published: November 2015

Certain conditions may necessitate use of neuromuscular blocking agents (NMBAs) in children in the pediatric intensive care unit (PICU). Despite information concerning individual agents, there are limited studies comparing agents. I compare 4 of the more commonly used NMBAs: pancuronium, vecuronium, rocuronium, and atracurium. All agents were administered by bolus followed by a continuous infusion with the rate adjusted by use of a peripheral nerve stimulator to maintain one twitch of the train-of-four. Ten patients with normal hepatic and renal function were included in each group. The study period included the first 72 hours of neuromuscular blockade. All 4 agents were easily titrated by continuous infusion to maintain the desired level of blockade. Pancuronium infusion requirements varied from 0.03 to 0.12 mg/kg/hr, vecuronium requirements from 0.05 to 0.2 mg/kg/hr, rocuronium requirements from 0.5 to 1.9 mg/kg/hr, and atracurium requirements from 0.8 to 2.2 mg/kg/hr. No significant advantage of one agent over another was noted. The wide range of infusion requirements further stresses the need for close monitoring of the degree of neuromuscular blockade with a peripheral nerve stimulator. An additional 10 patients with abnormal hepatic/renal function received atracurium. The dose requirements were the same as in patients with normal end-organ function, ranging from 0.6 to 2.0 mg/kg/hr. In patients with abnormal hepatic or renal function, atracurium may be used without the need to alter the dose.
Stress and Critical Illness: The Integrated Immune/Hypothalamic-Pituitary-Adrenal Axis Response
Authors: Torpy David J. , Md George P. Chrousos
Published: November 2015

Critical illness leads to a coordinated reaction that is categorized as the stress response; activation of the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system leads to metabolic and cardiovascular changes that are generally directed toward maintenance of homeostasis. The HPA axis and the sympathetic nervous system are linked via reciprocally activating brainstem pathways. The immune system acts via cytokines, which are hormones, to activate the HPA axis. Glucocorticoid secretion suppresses immune activity, thus completing an immune-HPA feedback loop. Restraint of immune activity may be a major function of glucocorticoids during stress, thus averting the potential for immune-mediated damage to healthy tissues. Cortisol also acts to produce adaptive metabolic, cardiovascular, and cognitive changes. Activation of the stress system is also associated with inhibition of thyroid, gonadal, and growth axes through neuroendocrine and peripheral mechanisms; such effects can be seen as directed toward conservation of energy. There is growing evidence that hyperfunction and hypofunction of the integrated stress system may lead to a variety of previously unexplained disorders. Recently, a more detailed understanding of the stress system combined with astute clinical observation of critically ill patients has led to promising new avenues for therapeutic investigation.
Changes in Cisatracurium Infusion Requirements During Induced Hypothermia to Treat Increased Intracranial Pressure in a Child
Authors: Tobias Joseph D.
Published: November 2015

Several factors may affect the dosing requirements of neuromuscular blocking agents in pediatric intensive care unit patients. I present a 4 year, 2 month old child who received neuromuscular blockade with cisatracurium and induced hypothermia to control increased intracranial pressure. Induction of hypothermia led to a reduction in cisatracurium infusion requirements. The infusion requirements promptly returned to baseline once the patient's body temperature was allowed to normalize. Priorto induction of hypothermia, the infusion requirements for cisatracurium averaged 3.2 μg/kg/min. During the 48 hours of deliberate hypothermia (core body temperature, 34°C) to control intracranial pressure, cisatracurium infusion requirements averaged 1.7 μg/kg/min. Infusion requirements promptly increased to 3.4 μg/kg/min once body temperature was allowed to return to normal.
Heterogeneous Distribution of Pulmonary Ventilation in Intensive Care Patients Detected by Functional Electrical Impedance Tomography
Authors: Frerichs Inéz , Golisch Wolfgang , Hahn Günter , Michael Kurpitz , Burchardi Hilmar , Hellige Gerhard
Published: November 2015

Electrical impedance tomography (EIT) is a new noninvasive imaging technique which utilizes the different electrical properties of biological tissues to produce cross-sectional images of selected parts of the body. When applied on the thorax, the cyclic fluctuations of electrical impedance of the lung tissue, associated with different air contents of the lungs in the course of the respiratory cycle, can be used to generate derived EIT tomograms which represent the spatial distribution of ventilation in the chosen transverse plane. The corresponding evaluation technique, the functional EIT, was used for the first time to follow the regional ventilation in three intensive care patients. The method was shown (1) to identify the redistribution of inspired air in the lungs associated with controlled ventilation in a patient undergoing elective laparotomy, (2) to follow the improvement of locally impaired lung ventilation in the course of severe pneumonia, and (3) to detect regional reduction of ventilation due to lobar atelectasis with stasis pneumonia in a patient with bronchial carcinoma.
Heart Rate Variability in Intensive Care
Authors: Goldstein Brahm , Buchman Timothy G.
Published: November 2015

Clinicians have long been aware that the normal oscillations in a heart beat are lost during fetal distress, during the early stages of heart failure, with advanced aging, and with critical illness and injury. However, these oscillations, or variability in heart rate and other cardiovascular signals, have largely been ignored or discounted as variances from the mean or average values. It is becoming increasingly clear that these oscillations reflect the dynamic interactions of many physiologic processes, including neuroautonomic regulation of heart rate and blood pressure. We present a synthesis and review of the current literature concerning heart rate variability with special reference to intensive care. This article describes the background of time series analysis of heart rate variability including time and frequency domain and nonlinear measurements. The implications and potential for time series analysis of variability in cardiovascular signals in clinical diagnosis and management of critically ill and injured patients are discussed.
Digital Imaging and PACS: An Update
Authors: Esch Oliver , Burdick Thomas , Van Sonnenberg Eric
Published: November 2015

The instant and simultaneous availability of radiologic examinations has long been of interest to referring clinicians, and certainly to radiologists, within and outside of the hospital. In daily clinical routine, the term “film management problem” has been used to describe a lack of access to this essential part of clinical information. Comprehensive picture archiving and communication systems (PACSs) have been proposed and implemented only within few institutions. This article discusses some of the most important standards, and technical and practical aspects of digital imaging and PACS.
Alcohol Abuse in Later Life
Authors: Cargiulo Thomas P.
Published: November 2015

Alcohol abuse and dependence are problems that have no prejudice when it comes to age. These are problems that are often overlooked by health care providers even though they are major causes of many adverse health effects in the elderly. Pharmacists can play a major role in the detection and treatment of alcohol dependence. This can be done by knowing the signs and symptoms of dependence that are unique to the elderly, determining the stage of the disease the elderly patient is in, and making an appropriate intervention.
The Development of Critical Pathways in Home Infusion
Authors: Wright Brenda
Published: November 2015

Critical paths have been used successfully in the acute care facility to manage resources with satisfactory patient outcomes since 1985. Clinical pathways exhibiting significant impact in length of stay and cost savings have included home care. Organizations are also beginning to implement clinical pathways in home health agencies. Many include pathways for home infusion. This article reviews the evolution of clinical pathways in the acute care facility, home care, and home infusion. The benefits and barriers in each environment are included. Recommendations on the developing critical pathways are, detailed.
The Principle of Intention to Treat Analysis in Clinical Studies: Its Use and Controversies
Authors: Hardin J. Michael
Published: November 2015

The principle of intention-to-treat (ITT) has become the standard policy for comparing treatment and control groups in clinical studies. Yet, ITT is not without its critics, controversies, and misunderstandings. To properly judge results reported from clinical studies, it is imperative that pharmacists be able to assess the underlying assumptions and the methodological issues associated with ITT. This article will provide an exposition of the history, assumptions, definitions, methodology, and controversies of ITT.
Treatment of Neuropathic Pain
Authors: Mendizabal Jorge E. , Zweifler Richard M.
Published: November 2015

Neuropathic pain is generated by disruption of normal nerve connections and/or abnormal hyperactivity at some level of the pain sensory system. Neuropathic pain syndromes due to peripheral nervous system injury are commonly encountered in clinical practice and often adversely affect patients’ quality of life. Pharmacotherapy is the mainstay of neuropathic pain management, with the majority of clinical data supporting the use of three main drug classes: (1) tricyclic antidepressants; (2) anticonvulsants; and (3) anesthetic-antiarrhythmics. Clonidine, opioids, capsaicin, nonsteroidal anti-inflammatory drugs, immunosuppressants, and the novel antidepressants may also have a role in some patient populations.
Psychiatric Side Effects of Herbal Medicinals
Authors: Spollen Iii John J. , Spollen Shelly M. , Markowitz John S.
Published: November 2015

The use of herbal medicinals has grown tremendously in the last several years. Unfortunately, there is little knowledge about the safety of these products. There have been several reports of psychiatric side effects associated with the use of herbal medicinals. Manic symptoms have been reported with the use of St. John's wort, yohimbe, ginseng, and ma huang or its synthetically produced alkaloids. Ma huang or its alkaloids have also been associated with psychotic symptoms. Worsening anxiety and panic attacks have been reported with yohimbe. Recommendations for the use of these phytomedicinals and for future research are included.
Gout and Hyperuricemia
Authors: Stanaszek Mary Beth
Published: November 2015

Gout is recognized by sudden onsets of joint pain and swelling caused by imbalances in production and excretion of uric acid. Hyperuricemia is a risk factor for gout, however, not all patients with hyperuricemia will develop gout. Other risk factors include hypertension, renal insufficiency, obesity, excessive alcohol consumption, high purine diets, and medications such as thiazide diuretics and low dose aspirin. Management of gout and hyperuricemia can be achieved through inhibiting urate synthesis, enhancing urate excretion, or both. Medications to treat gout include NSAIDs, colchicine, and glucocorticosteroids. Chronic therapy with uricosuric agents or xanthine oxidase inhibitors may be necessary for those with recurrent attacks.
Evaluation of Novel New NSAIDs: A Review of COX-2 Inhibitors, with an Emphasis on Gastrointestinal Toxicity
Authors: Kirk Julienne K. , Hamilton Jennifer M. , Phelps Kathy C.
Published: November 2015

Identification of two isoforms of cyclooxygenase, COX-1 and COX-2, has initiated a revolution in the approach to pharmacologie pain management. It has been further determined that inhibition of COX-2 reduces inflammation, and inhibition of COX-1 compromises gastrointestinal mucosal integrity. As traditional nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit both COX-1 and COX-2, gastrointestinal ulceration can develop in association with the use of these agents to control pain and inflammation. An ideal NSAID would, therefore, inhibit COX-2 to provide anti-inflammatory effects while leaving COX-1, and, therefore, gastrointestinal mucosa, unaffected.

Two selective COX-2 inhibitors have recently been approved in the United States. Celecoxib (Celebrex, G.D. Searle & Co.) and rofecoxib (Vioxxj, Merck & Co., Inc.) are indicated for the treatment of osteoarthritis. Also, celecoxib is approved for rheumatoid arthritis. Rofecoxib is also approved for the treatment of acute pain and dysmenorrhea. Both agents have displayed similar efficacy to traditional NSAIDs. In addition, endoscopically detected gastrointestinal ulceration is reduced versus older NSAIDs. Further evaluation of selective COX-2 inhibitors will elucidate long-term efficacy, safety, and potential reduction of health care dollars spent on hospitalization and treatment for NSAID-induced gastrointestinal toxicity.
Irritable Bowel Syndrome
Authors: Marsh T. Donald
Published: November 2015

Irritable Bowel Syndrome (IBS) is a common gastrointestinal disorder. Abdominal pain or discomfort relieved by bowel movements and worsened by stress suggest a brain/gut disorder. Associated factors include a history of affective disorders, sexual or physical abuse, low fiber intake, certain foods, and drugs. Diagnosis is one of exclusion and is based on the Rome Criteria. Symptom control is a reasonable treatment goal using fiber-containing foods, bulk laxatives, antidiarrheals, and antispasmodics. Tricyclic antidepressants may relieve unremitting pain and improve daily functioning. Other measures include patient education and reassurance, behavioral therapy, reduction of stress, and inclusion of the patient and family in the treatment plan.
The Elements of Crashworthiness: Scope and Actuality
Authors: Johnson W
Published: November 2015

An across-the board survey of several aspects of crashworthiness is attempted, being in part an update and an improvement to the balance of an early monograph on the subject of The crashworthiness of vehicles of which the writer was co-author (1). Attention is given to perceiving this subject as three interconnected disciplines—materials engineering and design, combustion and fire, and medical engineering or biomechanics—but only after discussing some general guiding principles and the engineer's responsibility for the vehicles he or she produces.

The latter subjects, together with short separate sections on head injury, fire fundamentals with broad allusions to vehicle fire situations and studies of kinetic energy absorption systems, comprise Part 1 of the paper.

Part 2 reviews some types of collision concentrating on those involving road vehicles but with some attention to the other main types identified. Some useful and provocative conclusions are finally drawn.

The author has tried to provide a useful list of references, the needs of students and non-specialists being kept in mind throughout.
UNION BUDGET FOR 1997-98: AN EVALUATION
Authors: Thimmaiah G.
Published: November 2015

Chidambaram's Budget for 1997-98 has received well-deserved acclaim. Some economists have started indulging in nit picking while others have gone to the other extreme of calling it an agenda for 21st century. The author finds that the truth lies in between. The paper brings out how the Budget tries to satisfy everybody except those who are enjoying good life without paying tax. Only they will be asked to pay a little more tax and enjoy the best things of life.
MANAGEMENT: AN AGENDA FOR 21ST CENTURY
Authors: Shankar Uma
Published: November 2015

There is a perceptible decline of status-driven hierarchical management. The workforce's attitudes and behaviours are changing fast and so are their expectations and career patterns. The attitude towards leadership is also becoming of a more participative style in which personal relationships are highly significant. In this backdrop, the paper suggests that the psychological instruments may be used, to assess the strengths of individual potential. It can also help organisations maximise the application of human potential for organisational effectiveness.
INFRASTRUCTURE DEVELOPMENT IN MAJOR INDIAN STATES
Authors: Rajeev P.V.
Published: November 2015

Infrastructure bottlenecks may impose severe constraints on the process of economic development in India. The pattern of infrastructure development has not been uniform in different parts of the country. In this paper an attempt is made to study the extent of disparities that exist in infrastructure development in major states in India. It has been found that States with higher per capita income are also the ones where better progress has been achieved in infrastructure development.
Strategic Learning: A Key to Competitive Strategy
Authors: Shah DR A.M.
Published: November 2015

Despite strategic teaming being an important management technique by which companies can achieve excellence in business performance, many organisations Jail to keep learning and are unable to use learning as a competitive weapon. In order to outperform and outmanoeuvre their competitor's, organisations need to learn co1ztinuously and quickly. This article provides guidance to Indian organisations for enhancing the effectiveness of their strategic learning processes. It is argued that the success of strategic learning depends upon developing and sharing knowledge throughout the organisation, creating a suitable teaming culture and speeding up the learning processes for learning and utilizing the new knowledge faster than competitors. However, this calls for commitment, enthusiasm and initiative at the individual, team and corporate level.
Role of Technology in Manufacturing Units
Authors: Agrawal Ankur
Published: November 2015

Technology is defined as the know-how to transform concepts into products and services for the satisfaction of consumers/customers. Technology, according to the Indian philosophy is like ‘god’ and can produce anything and everything on earth provided it is ordained by the creator to the inventor/ builder god ‘Vishwakarma’. Technology as created by Vishwakarma, can convert the impossible into possible.

Technology in its forms would include know-how. know-why, designs , drawings, specifications, manufacturing process, management information system, training, retraining, etc.

Pt. Nehru stated that the creation and adoption of new scientific techniques can, in fact, make up for deficiency in natural resources and reduce the demands of capital. Now-a-days, it has become a readymade instrument to solve labour problems which were considered in the Marxian age as indomitable.
Operational Risk: Measurement and Management Techniques
Authors: Ghosh T P
Published: November 2015

In the recent period, there is a dramatic change in the management approach to operational risks. Capturing past event loss is an important hurdle in the implementation phase. It is, of course, possible to use industry data for operational loss event and loss impact can be modified to fit into the size of an organisation. However, using standard industry data may not be justified because of specific inefficiency and advantages of a particular organisation as compared to the industry standard.

However, a manufacturing organisation can easily use this method to identify loss provision and risk capital need as well as impact of catastrophic loss. This is in particular applicable to after sale services and product warranty agreement and in transactions with dealers. Non-financial service industry like hotel, transportation can also apply this model.
Management of Productivity in the Manufacturing Sector: An Analysis
Authors: Sangmi Mohi-ud-Din
Published: November 2015

The analysis and measurement of prodllctivity at the enterprise and plant level has proved to be very useful for the planners, management, and employees of a company. The successful management of productivity has contributed to cost reduction , profit maximisation and the shareholder value-addition . Thus, a micro-level study on productivity would go a long way to highlight the bottlenecks and causes which act as impediments for higher productivity. In this paper, an attempt has been made to make a plant level study in a manufacturing company with the objective of analysing the factors which act as deterrent for better productivity and , therefore , hinder the future growth of the enterprise.
Knowledge Economy: A Strategic Economic Transformation
Authors: Agarwal Nikhil , Sherry AM
Published: November 2015

The origin of trade is as old as human race. People started trading goods to meet their daily needs. Slowly money came into picture and the entire scenario was transformed. The 19th and 20th century saw world transformation through industrial revolution. Whole new methods evolved to do business. The turn of 20th century has witnessed a new breed of companies coming up, doing business in a totally new manner. Redefining old models, creation of new markets and doing business at the speed of thought. This age has been termed as Knowledge age.
Quadratic Programming Approach to Portfolio Selection
Authors: Sharma J.K. , Bhargava A.K.
Published: November 2015

In this paper, an attempt has been made to evaluate the various diversification techniques to reduce the risk of loss by using quadratic programming concepts. Selecting the Markowitz diversification and Sharpe’s diagonal model, an attempt is made to arrive at the optimal portfolio. Seven companies have been selected representing different industrial sectors to arrive at an optimal portfolio. Selection of these is based on their active trading and availability of historic data for the past five years. The data pertaining to their dividends, prices, etc. has been taken from the Bombay Stock Exchange Directory. The return on market has been calculated on the basis of RBI share price index.
Corporate Social Responsibility: Assessment of Global and Indian Trends and Prospects
Authors: Kumar Pushpam
Published: November 2015

The genesis of the awareness and evolution of whole range of issues related to corporate social responsibility including corporate environmental management goes back to the issues of changing course of business in 1980s and 1990s, where eco-efficiency was presented as a managerial approach to improve competitiveness and ecological efficiency. The Present paper discusses the important drivers of corporate social responsibility. It also throws light on the socially responsibile practices of the firms at the global level as well as in India.
Global Competitiveness With Core Competence: A Case Study of HCL
Authors: Kak Anjana
Published: November 2015

The most effective way to exist in global market has not been explored by most of the companies. During last decade, the CEOs were judged on their ability to redesign and making organisations flatter. But now the trend is different, they will be judged on the front of core competence. The global leadership is determined by core competencies and companies must gear themselves up to build these competencies. A global competitive advantage exists in when a company can differentiate itself from its competitors, thereby succeeding not by making profits but also creating share of mind among global customers. There can be numerous sources of a company’s global competitive advantage, how sustainable is the competitive advantage is the main issue. Innovation can give a company a competitive advantage and profits, it is imitated with add on features or lower prices and does not last forever. Learning is the only sustainable source of advantage and managers must device actions for growing core competencies that lie at the heart of competitive advantage at the global level.

This article examines the conditions under which core competence can be a long lasting source of a company’s global competitive advantage. It also identifies the mode of technology acquisition best suited to the organization with respect to the people involved, inherent strength, existing facilities and managerial actions that can improve the odds of success with technology development. It links the development of technology to the company’s competitive strategy, the need for executive level information for technology assimilation, accessing the technology implementation process and linking core competence perspective to the company’s competitive strategy. A case study of HCL has been presented to analyze that core competence is the sustainable source of competitive advantage at global level.
Conflicts: Types, Causes And Resolution Strategies
Authors: Subramoniam Suresh
Published: November 2015

Conflicts can be viewed as a dynamic process which generates energy for the organization to deal with uncertain situations. The dynamics of conflict change from time to time based on the way in which behaviour of one party influences that of the other and the strategies used in the past for the settlement of the between-groups and within group conflicts. The fundamental cause of any organizational conflict described above can be again classified as one which arises out of personal differences, value differences, perceptual differences, differences in objectives, competition for limited resources, interdependence of people or departments, role pressures and denial of status. Win-lose, compromise and win-win are the major conflict resolution strategies which are commonly used. The paper also discusses the major reasons for interdepartmental conflicts and that of project scenario. Effectiveness of the conflict management technique used mainly depends on how successfully the deleterious effects of conflicts were alleviated. It has become necessary to identify the appropriate cause of any conflict prior to the development of an outline to its solution.