bluuebunny/crossref_metadata_2025 huggingface dataset:
Outer Table Graft in Middle Fossa Surgery
Authors: Linstrom Christopher J. , Krajewski Marek J. , Shapiro Aaron L. , Caruana Salvatore
Published: November 2015

We describe a surgical technique in which the middle fossa craniotomy ordinarily used for facial nerve decompression and related surgery is extended superiorly to allow the harvest of a split‐thickness calvarial graft. This graft allows the tegmen defect in middle fossa surgery to be repaired without shortening the original craniotomy plate. Avoiding the usual temporoparietal depression after middle cranial fossa surgery is both a structural and cosmetic benefit for the patient.
Exposure of the Lateral Extremity of the Internal Auditory Canal through the Retrosigmoid Approach: A Radioanatomic Study
Authors: Blevins Nikolas H. , Jackler Robert K.
Published: November 2015

The recent trend toward earlier diagnosis of acoustic neuroma has substantially increased the number of candidates suitable for surgery with an attempt at hearing preservation. Although the retrosigmoid approach affords the possibility of saving hearing in selected cases, it is associated with a somewhat greater morbidity that other approaches, in terms of persistent headache, cerebrospinal fluid leakage, and cerebellar dysfunction. For this reason, it is best used selectively, when the probability of success in hearing conservation is high. Only a portion of the internal auditory canal can be exposed through the retrosigmoid approach without violating the inner ear, a maneuver that greatly reduces the chance of preserving residual hearing. Substantial variability exists between individuals as to just how far laterally the internal auditory canal may be opened without compromising labyrinthine integrity. To assess the magnitude of this variability, measurements were obtained from 60 high‐resolution temporal bone computed tomography scans with a schema intended to model the surgical angle of view used during the retrosigmoid procedure. Intraoperative measurements in a series of cases established that the actual surgical point of view is situated along a line that passes approximately 1.5 cm behind the sigmoid sinus. In this typical surgical position, these data predict that an average of 3.0 mm (32% of the internal auditory canal length) must be left unexposed to avoid labyrinthine injury, with a range between 1.1 mm and 5.3 mm (9% to 58% of the internal auditory canal). Each additional 1‐cm retraction on the cerebellum beyond that customarily used affords approximately 1 mm (10% of the internal auditory canal) further exposure of the canal. When considering the retrosigmoid approach to an acoustic neuroma, the clinician is urged to evaluate each patient individually to estimate the amount of internal auditory canal accessible without the removal of a portion of the inner ear. This can be ascertained from an axially oriented, gadolinium‐enhanced magnetic resonance imaging scan in the internal auditory canal plane by drawing a line that originates 1.5 cm behind the posterior margin of the sigmoid sinus and passes tangential to the most medial extent of the labyrinth. If this line intersects the posterior margin of the internal auditory canal at least 2 mm lateral to the deepest point of tumor penetration, then adequate exposure with preservation of the labyrinth is likely an achievable goal.
Head and Neck Manifestations of Erythema Multiforme in Children
Authors: Stewart Michael G. , Duncan Newton O. , Franklin Daniel J. , Friedman Ellen M. , Sulek Marcelle
Published: November 2015

Erythema multiforme, Stevens‐Johnson syndrome, and toxic epidermal necrolysis are related disorders of skin and mucous membranes, which are typically associated with antecedent medication use or infection. We review 108 cases of erythema multiforme, Stevens‐Johnson syndrome, and toxic epidermal necrolysis from Texas Children's Hospital, Houston, Texas, from 1981 to 1991, and illustrate the characteristic skin and mucosal lesions. In addition, we describe in detail two unusual cases requiring intensive airway management. Head and neck manifestations were present in 4 of 79 patients (5%) with erythema multiforme and 26 of 28 patients (93%) with Stevens‐Johnson syndrome. In Stevens‐Johnson syndrome, mucosal involvement of the lip (93%), conjunctiva (82%), oral cavity (79%), and nose (36%) were most common. Antecedent medication use was identified in 59% of erythema multiforme patients and 68% of Stevens‐Johnson syndrome patients. We note a striking increase in the number of cases in our series caused by cephalosporins. Fifty percent of Stevens‐Johnson syndrome patients required supplemental hydration or alimentation because of the severity of the oral cavity involvement. The head and neck mucosal manifestations largely respond to local care, and the routine use of prophylactic antibiotics or systemic steroids is not recommended.
Book Review: Profiting from Public Research
Authors: Senker Jacqueline
Published: November 2015

Profiting from Public Research. Review of “The Story of Taxol. Nature and Politics in the Pursuit of an Anti-Cancer Drug” by Jordan Goodman and Vivien Walsh. Cambridge University Press: £18.95
Employment changes in knowledge-based industries in large urban areas of Spain: Impact of the economic crisis and austerity policies
Authors: Méndez Ricardo , Sánchez-Moral Simón , Malfeito-Gaviro Jorge
Published: November 2015

The aim of this article is to analyse the impact of the economic crisis and austerity measures on knowledge-intensive industries in seven large urban areas in Spain. We will attempt to respond to three key questions: How have these activities evolved since the crisis? How have the fiscal austerity measures in force in the Eurozone since 2010 affected them? And finally, have large urban areas followed different development paths in recent years based on the extent of their exposure to the crisis? The analysis of employment tendencies confirms that both common trends and disparities exist, with knowledge-based industries displaying a resilient and countercyclical behaviour. Moreover, the implementation of fiscal austerity policies has had a very negative impact on these activities, but the individual consequences in each case depend on the strengths and weaknesses accumulated by each urban area over time.
Validation and internal consistency of the Swedish version of the Valued Life Activities scale
Authors: Björk Mathilda , Thyberg Mikael , Valtersson Eva , Katz Patricia
Published: November 2015

Objective:

The objective was to create a linguistically and culturally validated Swedish version of the Valued Life Activities scale. The aim was also to describe its content and concurrent validity and its internal consistency in persons with rheumatoid arthritis.

Methods:

The Valued Life Activities scale was translated to Swedish and culturally adapted. In order to describe the content validity, both the Swedish and original Valued Life Activities scale were linked to the International Classification of Functioning, Disability and Health. The concurrent validity and internal consistency were evaluated in 737 patients with rheumatoid arthritis. To establish concurrent validity, the scale was correlated to disease activity, activity limitations, and life satisfaction. Internal consistency was assessed with Cronbach’s alpha.

Results:

The equivalence of meaning between the Swedish and the original Valued Life Activities scale was ensured by harmonization review. Content validity was high when linked to the International Classification of Functioning, Disability and Health. Concurrent validity showed a strong correlation with the activity limitations (r = 0.87), moderate with life satisfaction (r = –0.61), and weak with disease activity (r = 0.38). Internal consistency was excellent (Cronbach’s alpha = 0.97).

Conclusions:

The Swedish Valued Life Activities scale has been tested in a large and well-characterized sample and found to be a linguistically valid and culturally adapted self-reported measure of participation. Content validity of the Valued Life Activities scale was excellent, concurrent validity strong, and the internal consistency excellent. Since both individual preferences and International Classification of Functioning, Disability and Health concepts of disability are taken into account, the Swedish Valued Life Activities scale appears to be a promising new scale addressing important aspects of participation.
Is There a Research Paradigm for Palliative Care?
Authors: Corner Jessica
Published: November 2015

The question of whether a coherent tradition in research and research methods (or paradigm) exists in palliative care is explored in this paper through an examination of the discussion and debate surrounding palliative care; attempts at achieving consensus for research through priority setting exercises; and a crititical review of published research in palliative care accessed through a systematic review of studies. The findings of this systematic review of 384 published studies are reported. It appeared from the review that both the subjects employed for study and methods used are disparate, and that research to date has been preoccupied with describing activities and problems in palliative care, reflecting an emergent and new field of work, rather than actively evaluating existing and new approaches to care. More creativity in palliative care research is needed, and the future of palliative care research needs to be determined strategically. A model on which such a strategy might be based is presented.
Medical Education — Addressing the Needs of the Dying Child
Authors: Charlton Rodger
Published: November 2015

This paper reviews the formulation of attitudes, the acquisition of knowledge and the development of skills which together enable medical practitioners to provide comprehensive palliative care for terminally ill children. Ideally, these should be developed to such an extent that a ‘good death’ can be achieved. Current medical education does not address these areas and the associated issues, including the breaking of bad news, understanding the grief reaction to serious illness and children's perceptions of death. Neither does training include how to take management decisions concerning informed consent, the transition from active treatment to palliative care, symptom control and choosing the place for care. These, and the unintentional attitude that regards the dying child as a ‘medical failure’, are discussed, together with the need to meet the needs of the parents and siblings, and the effects of bereavement. Finally, recommendations are made for undergraduate curricula and the need to emphasize the relationship of caring for the family unit, and not just the patient.
Ketamine Injection Used Orally
Authors: Broadley KE , Kurowska A , Tookman A
Published: November 2015

Ketamine has been used parenterally for pain unresponsive to opioids, including neuropathic pain, and has also been used as an alternative analgesic agent after surgery. Although oral administration of ketamine has been used for some time as a single dose, it has not been given by this route on a regular basis.

The use of ketamine administered orally is described for two patients with severe neuropathic pain who were intolerant of, or whose pain was unrelieved by, more commonly used agents. Pain relief was achieved without significant side effects.
Compensation of Non-Material Damage in Civil and Criminal Law in the Netherlands
Authors: Malsch Marijke
Published: November 2015

In cases of war, large-scale accidents, and crime, victims may suffer serious non-material damage. This article focuses on the compensation of non-material damage in both civil and criminal cases. Compared to other countries, Dutch courts do not honour such claims on a wide scale. The article discusses court decisions concerning claims for non-material damage, both in the Netherlands and in other countries. The functions that compensation for non-material damage may have for the victim are explained. Theories about the goals of punishment and archetypal models of a criminal justice system form the background of this description. It is concluded that in the absence of more sophisticated methods of compensation or redress, a monetary compensation is to be made available for victims suffering from non-material damage.
Early Onset of Disk Degeneration and Spondylosis in Sand Rats (Psammomys Obesus)
Authors: Adler J.H. , Schoenbaum M. , Silberberg R.
Published: November 2015

The sand rat is a desert animal which feeds mainly on salt bush, a shrub with a high salt content in its leaves. Sand rats have been used for the study of renal function, and since they may develop diabetes if kept on a laboratory diet without a supplement of salt bush, they have been used for investigation of diabetes-related disorders as well. Older diabetic and non-diabetics and rats are prone to develop severe degeneration of the intervertebral disks, disk herniation, and subsequent hyperostotic spondylosis. This report is concerned with the relation of these processes to aging. The vertebral columns of 25 sand rats which were fed a standard laboratory diet and a supplement of salt bush ad libitum were examined. The sand rats ranged from 12 to 18 months of age. The vertebral columns were dissected, prepared for microscopic examination, and the findings were compared with those obtained previously in sand rats from 1 ½ to 2 ½ years of age. Both disk degeneration and spondylosis were comparable in course and frequency to the changes found in the older sand rats. It was concluded that factors other than age are involved in the pathogenesis of disk degeneration in the sand rat.
Prevalence, Lesions, and Differential Diagnosis of Ollulanus Tricuspis Infection in Cats
Authors: Hargis A.M. , Prieur D.J. , Blanchard J.L.
Published: November 2015

Ollulanus tricuspis were found in the stomachs of 26 of 201 cats which were mainly from Washington and Idaho. Twenty-four of the cats were from research or commercial breeding colonies (catteries) and two were pets. Twenty-seven percent of colony cats were infected with O. tricuspis, whereas only 2% of the pet cats were infected. No consistent clinical signs were seen. Histologically there was a significant increase in fibrous connective tissue in the lamina propria and in the number of lymphoid follicles and globule leukocytes in the gastric mucosa of infected cats.

Histologic examination revealed no parasites in 13 of the 26 infected cats. The 26 infected cats were identified by examination of stomach washings. An additional 21 cats had larvae of other nematodes in their stomachs. These nematode larvae need to be differentiated from O. tricuspis.
Chlamydial Infection of the Gastric Mucosa in Twelve Cats
Authors: Hargis A. M. , Prieur D. J. , Gaillard E. T.
Published: November 2015

Twelve cats, all from research or commercial breeding colonies, had unidentified, intracellular organisms in the gastric mucosa. Histochemical staining and ultrastructural features provided the basis for identification of the organism as a Chlamydia sp. Ultrastructural observations were restricted to one of the 12 infected cats. There was no consistent association of gastric chlamydial infection and clinical disease. The infection was present in apparently healthy cats as well as those with a variety of clinical signs and lesions, especially weight loss of undetermined origin. None of the cats with gastric chlamydial infection had lesions compatible with feline pneumonitis. The significance of gastric chlamydial infection has yet to be established.
An Immunopathologic Study of the Bovine Prepuce
Authors: Flower P. J. , Ladds P. W. , Thomas A. D. , Watson D. L.
Published: November 2015

The prepuces of 83 bulls with macroscopically normal reproductive tracts were obtained at slaughter and microbiological, immunological, and histologic studies were done and the findings were correlated. Some bulls had been vaccinated on several occasions against Campylobacter fetus.

Mean concentrations of intrapreputial immunoglobulins (Ig) in 27 bulls were IgG1 — 1.8 ± 5.2; IgA — 0.16 ± 0.15; and IgM — 0.24 ± 0.24 mg/ml. High concentrations of IgG2 in some bulls precluded precise estimation but mean concentration was in excess of 11.0 mg/ml (range 0 to 20+ mg/ml). Differences between these concentrations were significant (P < 0.005).

Mean prevalences of class specific, immunoperoxidase-labeled plasma cells in the preputial dermis of 35 bulls were IgG — 39.0 ± 9.3; IgA — 16.6 ± 6.6; and IgM — 2.2 ± 1.8 labeled cells/100 nuclei (P < 0.001). The prevalence of IgG labeled cells in the preputial dermis was, however, negatively correlated with the concentration of intrapreputial IgG (IgG1 + IgG2) (r = −0.4; P < 0.05).

Except for an apparently lower intrapreputial Ig concentration in Trichomonas foetus-infected bulls than in negative ones, there were no significant correlations between intrapreputial immunoglobulin concentration, histologic findings, and age, infection, or vaccination status of the bulls.
Osteosarcoma in a Phthisical Feline Eye
Authors: Woog J. , Albert D. M. , Gonder J. R. , Carpenter J. J.
Published: November 2015

Eight years ago a cat sustained injury to the left globe and phthisis bulbi ensued. Two months prior to presentation, a firm intraorbital and periorbital mass developed and enucleation was done; histologic examination revealed osteogenic sarcoma. This is the first histologically documented report of osteosarcoma occurring in association with phthisis bulbi.
Four Cases of Hodgkin's Disease in Striped Skunks (Mephitis Mephitis)
Authors: Smith D. A. , Barker I. K.
Published: November 2015

Twelve of 152 striped skunks ( Mephitis mephitis) necropsied at the Ontario Veterinary College between 1970 and 1980 had neoplasms. Tumors occurred in one of 86 wild skunks, and 11 of 66 captive skunks. Captive skunks were primarily from one source and were older animals. Tumors in four skunks resembled those found in Hodgkin's disease of man. This diagnosis was based on the presence of Sternberg-Reed cells, the cellular pattern, and the malignant behavior of the neoplasms. In two of these skunks, a second neoplasm also was present. Other tumors diagnosed included pulmonary adenocarcinoma, pulmonary adenomatosis, undifferentiated adenocarcinoma, renal adenocarcinoma, thyroid adenoma, interstitial cell tumor, pheochromocytoma, pinealoma, squamous cell carcinoma, and spindle cell sarcoma.
Postdependency? The Third World in an Era of Globalism and Late-Capitalism
Authors: James Paul
Published: November 2015

Each year 14 million children—about 10 per cent of the number born annually—die of hunger.
International Ethics and European Integration: Federal State or Network Horizon?
Authors: Diez Thomas
Published: November 2015

Practical problems of international politics are often described in terms of building a bigger and better state—a European Union or an Atlantic Community or an Arab Union, without seeing that such an achievement would leave the problems of inter-state politics precisely where they were.
Slow Cortical Potentials in Migraine: A Comparison of Adults and Children
Authors: Kropp P , Kirbach U , Detlefsen J-O , Siniatchkin M , Gerber W-D , Stephani U
Published: November 2015

Amplitudes of contingent negative variation (CNV) in 40 migraine patients were studied during the pain-free period and compared with healthy controls ( n = 24). The early component (initial CNV) is especially more negative in migraine patients. Within the migraine group, 14 children with migraine without aura (mean age 13.6 years) were compared with 11 healthy children (mean age 12.4 years). Migraine children differ from healthy children in the same manner that adult migraine patients differ from healthy adults. The CNV of five healthy children did not differ from the CNV of their siblings suffering from migraine. We suggest that there is a family-related cortical hypersensitivity which does not necessarily lead to the development of migraine.
Spelling-Related Teacher Knowledge: The Impact of Professional Development on Identifying Appropriate Instructional Activities
Authors: Carreker Suzanne , Joshi R. Malatesha , Boulware-Gooden Regina
Published: November 2015

Informed instruction that adjusts content, materials, or intensity to student needs is critical for students with learning disabilities. Informed literacy instruction requires teachers to have thorough knowledge of literacy-related content, which includes phonemes, syllables, and morphemes. The current study investigated whether teachers who possess this knowledge are better able to identify student needs and appropriate instructional spelling activities than teachers who do not possess this knowledge. In Study 1, 36 preservice teachers and 38 inservice teachers completed measures to evaluate their literacy-related content knowledge and ability to identify appropriate spelling activities. Overall, the inservice teachers demonstrated greater knowledge and were better able to identify appropriate instructional activities than the preservice teachers. In Study 2, the knowledge of 196 inservice teachers completing varying numbers of hours of professional development was analyzed to determine the effects of professional development on literacy-related content knowledge and ability to identify appropriate activities. Generally, greater teacher knowledge and identification of appropiate activities were related to the number of hours of professional development completed.
Conceptualizing RTI in 21st-Century Secondary Science Classrooms: Video Games' Potential to Provide Tiered Support and Progress Monitoring for Students with Learning Disabilities
Authors: Marino Matthew T. , Beecher Constance C.
Published: November 2015

Secondary schools across the United States are adopting response to intervention (RTI) as a means to identify students with learning disabilities (LD) and provide tiered instructional interventions that benefit all students. The majority of current RTI research focuses on students with reading difficulties in elementary school classrooms. Recommendations for practice that stem from this empirical work are not generalizable to high school classrooms, where adolescents with LD experience unique learning challenges. This is especially true in secondary science classes, where an emphasis on complex vocabulary and sophisticated phenomenological investigations places added cognitive requirements on these students.

This article presents a foundation for conceptualizing the role of technology in RTI implementation at the secondary level. We examine how video games can enhance RTI instructional practices by providing multiple tiers of academic supports and realtime progress monitoring in secondary science classrooms. The article illustrates how evidence-based practices can be included in the games in a manner that increases intervention fidelity and assessment reliability. While this article focuses on science video games, we contend that there is considerable conceptual overlap among high school science, technology, engineering, and mathematics (STEM) courses that will allow for further expansion of this discussion. The article concludes with recommendations for future research.
The Effects of Strategic Morphological Analysis Instruction on the Vocabulary Performance of Secondary Students with and without Disabilities
Authors: Harris Monica L. , Schumaker Jean B. , Deshler Donald D.
Published: November 2015

This study tested the effects of teaching high school students with learning disabilities (LD) and other students enrolled in general education classes a morphemic analysis strategy for analyzing and predicting the meaning of words. A comparison-group design was used with random assignment of three intact classes to each of two conditions: (a) the Word Mapping condition, where students learned the morphological analysis strategy; and (b) the Vocabulary LINCing condition, where students learned a mnemonic strategy. Three other classes were used to establish a norm for knowledge of targeted words. Students in both strategy groups and students with and without disabilities learned their respective strategy and the meaning of taught words. Word Mapping students with and without disabilities earned higher scores on a test of morphological analysis than students in the other groups. Thus, students were able to learn generative and non-generative vocabulary strategies and could apply a generative strategy to analyze and create meaning for unknown words, an important skill while reading assignments and taking reading tests.
Civil Servant Attitudes Toward Administrative Rules and Procedures: A Comparative Analysis of Brazil and the United States
Authors: Steel Brent S.
Published: November 2015

This study represents an empirical investigation of civil servant orientations toward the regulation of bureaucratic conduct and discretion in a developing country—Brazil—and in an advanced capitalist country—the United States. Survey findings suggest that Brazilian civil servants are far more cautious and more likely to oppose the use of discretion than a comparable sample of American civil servants. Factors such as personal/background characteristics and value orientations were also investigated for their impact upon orientations toward the use of discretion, producing evidence of both common associations and some nation—specific effects.
Community counts: The social reintegration of ex-combatants in Colombia
Authors: Kaplan Oliver , Nussio Enzo
Published: November 2015

What explains the social reintegration of ex-combatants from armed conflicts? Community-level programs to reintegrate ex-combatants into society are based on the theory that the participation of ex-combatants in their communities can promote reconciliation and minimize recidivism to illegal activities. We evaluate community and security-related opportunities for and constraints on social reintegration using a survey of ex-combatants from Colombia. We find that ex-combatants in more participatory communities tend to have an easier time with social reintegration and feel less of a need to organize among themselves. These findings suggest that to help ex-combatants, reintegration processes should also work to improve the social vibrancy of receptor communities.
Providing Continuity for Part-Time Graduate Students
Authors: Siembieda William J.
Published: November 2015

Enrollment of part-time students is on the rise, and this is especially true for planning programs in regional universities which offer the Master's as a terminal degree. This change in student tenure requires rethinking of the delivery of educational services and the manner in which faculty respond to this changing environment. A series of program adaptations are presented, including the time schedule, course content, exiting requirements, advising, faculty productivity, and interpersonal relationships. But the need to provide continuity for the part-time student may be the central program issue.
The Effect of Blind-Protected Specimen Brush Sampling on Antibiotic Use in Patients with Suspected Ventilator-Associated Pneumonia
Authors: Marik Paul E. , Lynott Joseph , Croxton Michele , Palmer Edward , Miller Larry , Zaloga Gary P.
Published: November 2015

The diagnosis of pneumonia in ventilated patients is exceedingly difficult. Although culture of tracheal aspirates have poor diagnostic value they are frequently used to diagnose ventilator-associated pneumonia (VAP). Recently a number of studies have reported on the diagnostic value of “blind” protected specimen brush (B-PSB) sampling in the diagnosis of VAP. B-PSB sampling can readily and safely be performed by respiratory care practitioners (RCPs). The aim of this study was to determine the cost-effectiveness of B-PSB sampling performed by respiratory therapists in patients with suspected VAP. During a 3-month run-in period, patients in our medical intensive care unit (MICU) with suspected VAP were treated based on clinical criteria and tracheal aspirate culture. Following this run-in period the house staff, nurses, and RCPs were prevented from sending tracheal aspirates for culture. All patients suspected of having VAP underwent B-PSB sampling with quantitative culture. The B-PSB sampling was performed by RCPs who had been trained to perform the technique. A PSB with a potential bacterial pathogen concentration greater than 500 CFU/ml was regarded as positive. During the 3-month run-in period 172 patients received mechanical ventilation with an average of 4.9 ±3.1 ventilator days/patient. During this period 79 patients were treated for VAP. During the 3-month study period 160 patients received mechanical ventilation, with an average of 5.1 ± 2.9 ventilator days/patient (NS). Fifty-eight B-PSB samplings were performed in 50 patients for suspected VAP. No complications related to the procedure were reported. No tracheal aspirates were cultured during this time period. Eight patients had positive PSB cultures. Antibiotics were changed in three of these patients based on the PSB results. Thirty-eight courses of antibiotics (in 36 patients) were stopped based on negative PSB results. Twelve cases of VAP were suspected in six patients receiving antibiotics for other reasons. No change in antibiotics were made in these cases based on the negative PSB results. The length of mechanical ventilation was 5.4 ± 3.2 days in the 38 culture-negative patients in whom antibiotics were stopped compared to 8.2 ± 4.7 days in the 8 patients with PSB-positive VAP (NS; p = 0.14). The direct cost savings as a result of discontinuing antibiotics was $9,500. There were additional cost savings due to the reduced number of culture specimens sent to the laboratory (approximately $3,000; taking the $23 cost of the PSB brush into account), with a projected annual cost savings of $50,000. B-PSB sampling is a simple and cost-efficient diagnostic test that can safely be performed by adequately trained RCPs. Furthermore, this study confirms that antibiotics may be safely discontinued in patients with negative quantitative culture results.
Transcutaneous Carbon Dioxide Measurement During Apnea Testing in Pediatric Patients
Authors: Tobias Joseph D.
Published: November 2015

Several variables affect the rate at which PaCO2 increases during apnea testing in the determination of brain death. In many cases, arterial blood gases (ABGs) are obtained at predetermined times in an attempt to demonstrate a PaCO2 value greater than 60 mmHg. This practice may result in the need to obtain multiple ABGs, terminating the apnea test before the PaCO2 is 60 mmHg, or waiting too long with a resultant compromise of hemodynamic status or arterial desaturation. We have found that transcutaneous CO2 (TC-CO2) monitoring can be used to guide the time to obtain ABGs during apnea testing. TC-CO2 monitoring was used during apnea testing in eight patients ranging in age from 1 to 16 years. In patients 1 and 2, when an ABG was obtained when the TC-CO2 value equaled 60 mmHg, the PaCO2 was less than 60 mmHg in all four cases (one ABG drawn for each apnea test in the two patients). When an ABG was obtained with the TC-CO2 value equal to 70 mmHg (n = 16), the TC-CO2 to PaCO2 difference was 2–11 mmHg (5.8 ± 2.7 mmHg) and the PaCO2 ranged from 59 to 72 mmHg (64.4 ± 3.2 mmHg). When an ABG was obtained with the TC-CO2 value equal to 80 mmHg (n = 14), the TC-CO2 to PaCO2 difference was 2–8 mmHg (5.4 ±1.9 mmHg) and the PaCO2 ranged from 72 to 83 mmHg (75.4 ± 32 mmHg). TC-CO2 monitoring can be used to help judge the timing of ABG analysis during apnea testing in children. When the TC-CO2 value reached 70 mmHg, we noted that the PaCO2 was greater than 60 mmHg in 15 of 16 cases.
Bedside Graphical Display of Lung Mechanics: A Clinical Experience of Use in the NICU
Authors: Cheema I. U. , Ahluwalia J. S.
Published: November 2015

Pulmonary function analysis by graphical display is becoming increasingly available to clinicians caring for newborn infants. Many of the currently available infant ventilators are able to provide this information in one form or another. Interpretation of these graphics in a ventilated newborn infant who is also making spontaneous effort can be challenging. There is a relative dearth of information that is directly applicable to the often bizarre appearances seen in tiny premature infants breathing out of synchrony with the ventilator. This is an area where there is a need for sharing of experience and dissemination of information for better education for all involved in providing care for newborn infants. We present our observational experience of analyses of pulmonary graphics displayed by infants on a tertiary intensive care unit (ICU). We highlight what we believe are significant differences in the graphical displays between pediatric and adult patients and newborn infants. We also present some clinical situations, commonly faced in the neonatal ICU (NICU), where we have found the use of pulmonary graphics particularly useful.
Concepts of the Strong Ion Difference Applied to Large Volume Resuscitation
Authors: Powner David J. , Kellum John A. , Darby Joseph M.
Published: November 2015

The occurrence of acidosis following trauma or other clinical conditions that require large volumes of resuscitation fluid may be modified by manipulation of the physical chemistry properties of substances within plasma. These include the strong ion difference, modification of hydrogen ion production through control of alveolar ventilation, and protection/provision of protein and phosphate-based weak acids. An understanding of these principles as an alternative method to analyze/anticipate acid-base abnormalities is important during resuscitation. Loss of protein-based weak acids may often occur after trauma or other conditions requiring large-volume resuscitation. These losses may potentially be replaced with albumin-based colloid solutions. Large quantities of normal saline should be avoided so as to avoid hyperchloremia-induced metabolic acidosis. Ringer's lactate solution is preferred. Alveolar ventilation must be adjusted so as to eliminate further hydrogen ion production caused by hypercarbia. The serum base excess and/or hyperlactemia have only limited value in diagnosing acidosis and guiding resuscitation. Current experimental data and reviews of this topic were obtained from a Medline literature search. In addition, the personal experience and investigations of the authors in critically ill and injured patients were used to formulate recommendations.
Rapid Reduction of Oxygenation Index by Employment of a Recruitment Technique in Patients with Severe ARDS
Authors: Richards Guy , White Hayden , Hopley Mark
Published: November 2015

Mechanical ventilation of patients with acute respiratory distress syndrome (ARDS) may contribute to pulmonary injury and systemic inflammation. The objective of this study was to examine the safety and efficacy of a recruitment maneuver that rapidly improves atelectasis and oxygenation, and in so doing may reduce the potential for ventilator-induced lung injury. Nineteen patients with severe ARDS (defined as PaO2: FiO2 ≤ 150) from diverse etiologies were turned prone and a positive pressure of 40 cmH2O was applied for a period of 90 seconds. This pressure was increased in 5 cmH2O increments in subsequent maneuvers to a maximum of 50 cmH2O if there was an inadequate initial response. Subsequently pressure-limited mechanical ventilation with a PEEP of 15 cmH2O was instituted to prevent derecruitment. Peak pressures were maintained at ≤35 cmH2O. Outcome measures were oxygenation index, PaO2: FiO2 ratio, and alveolar-arterial oxygen difference. The oxygenation index decreased from a median of 31 cmH2O/mmHg to 14 cmH2O/mmHg immediately after recruitment and to 11 cmH2O/mmHg (p < 0.0001) 24 hours later. The A-aDO2 improved from 454 mmHg to 128 mmHg (p < 0.0001) and the PaO2:FiO2 ratio from 75 to 218 (p < 0.0001) 24 hours later. Twenty-five percent of patients had PaO2:FiO2 ratios of more than 300 mmHg at 24 hours. Mean airway pressure increased by 3 cmH2O initially, from 23 cmH2O to 26 cmH2O as a consequence of the increase in PEEP, but this had decreased to 25 cmH2O after 24 hours. There were no significant complications. Rapid reductions in FiO2 can be achieved safely by the implementation of a relatively simple recruitment technique.
Transcranial Doppler Sonographic Monitoring in the Intensive Care Unit
Authors: Babikian Viken L. , Pochay Val , Burdette David E. , Brass Lawrence M.
Published: November 2015

Transcranial Doppler sonography noninvasively measures flow velocities within the basal cerebral arteries. It has been used for the management of patients with ischemic cerebrovascular disease and subarachnoid hemor-rhage, as well as in the determination of brain death. Its role and technical limitations in the intensive care unit are reviewed.
Moral, Ethical, and Legal Issues in the Intensive Care Unit
Authors: Paris John J. , Reardon Frank E.
Published: November 2015

The United States Supreme Court's recent ruling in Cruzan and Congress' passage of the Patient Self-Determination Act of 1990 are part of the expanding legal and ethical concerns affecting medicine. These changes force us to examine not only issues in termination of treatment and advanced directives, but questions of medical futility and the quandary of how to pay for beneficial but costly new technologies. These problems indicate the need for more vigorous intensive care unit admission and discharge criteria and for policies on appropriate care of patients. We review these developments and propose approaches to such issues as do not resuscitate orders, requests for “futile” treatments, brain death, organ retrieval, advanced directives, and decision making for competent and incompetent patients.
Phrenic Nerve Injury Following Cardiac Surgery, with Emphasis on the Role of Topical Hypothermia
Authors: DeLisser Horace M. , Grippi Michael A.
Published: November 2015

Phrenic nerve dysfunction that develops after cardiac surgery has generally been attributed to the topical hypothermia used for myocardial preservation and protection. Although studies relying on postoperative radiographic findings to establish the diagnosis reveal an incidence as high as 73%, investigations employing electrophysiological assessment indicate a 10% incidence. Most patients who sustain phrenic injury during cardiac surgery do not suffer major respiratory morbidity; those who do generally recover. In addition to the role of topical hypothermia as a major etiological factor, physical trauma or compromise of the vascular supply to the phrenic nerve and diaphragm may also be important factors. Although a number of measures have been advocated to lower the incidence of the problem, none have been evaluated in a prospective, randomized study using electrophysiological techniques. This review focuses on the incidence, underlying mechanisms, and clinical and electrophysiological recognition of phrenic nerve dysfunction following cardiac surgery.
The Inflammatory Response
Authors: Williams John G. , Maier Ronald V.
Published: November 2015

Inflammation is a critical component of the normal healing process. In the patient with extensive injury or infection, however, this same process may lead to organ dysfunction and failure as seen in adult respiratory distress syndrome and multiple organ failure syndrome. In this article we review: (1) the evolution of current concepts of inflammation; (2) individual elements of the host response to inflammatory stimuli; and (3) current strategies for the prevention and treatment of adult respiratory distress syndrome and multiple organ failure syndrome.

From the Department of Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, WA.
Septic Shock
Authors: Parker Margaret M. , Fink Mitchell P.
Published: November 2015

The incidence of sepsis and septic shock has been increasing dramatically over the past 10 years. Despite advances in antimicrobial therapy, the mortality of septic shock remains very high. We review the clinical manifestations of sepsis and septic shock and describe the cardiovascular manifestations. Pathophysiology of the cardiovascular changes is discussed, and mediators believed to be involved in the pathogenesis are reviewed. Management of septic shock is also discussed, including antimicrobial therapy, supportive care, and adjunctive treatment aimed at affecting the mediators involved in producing the sepsis syndrome.
Life-threatening Candida Infections in the Intensive Care Unit
Authors: Franklin Cory , Metry Michael
Published: November 2015

In the past decade there has been a dramatic increase in the incidence of life-threatening Candida infections in patients in intensive care units (ICUs). Once considered a minor pathogen, Candida is now among the most commonly cultured pathogens in the ICU. This phenomenon is in part attributable to greater numbers of immunocompromised patients being hospitalized and the more frequent use of surgery, instrumentation, and broadspectrum antibiotics. Serious Candida infections can present as generalized sepsis, as focal involvement of virtually any organ, or as part of the syndrome of multiple system organ failure. Once established, these infections can be difficult to detect until their late stages and consequently are responsible for significant morbidity and mortality in ICU patients. For treatment to be successful it must be instituted promptly and, on occasion, empirically. As a result, new diagnostic techniques, treatments, and prophylactic strategies to minimize the occurrence of Candida infections are the subjects of ongoing research. This article is intended to provide practitioners with an understanding of why serious Candida infections are increasing, as well as information on pathogenesis, diagnosis, treatment, and some measures that can be taken to prevent such infections in critically ill patients.
Use of Hypertonic-Hyperoncotic Fluids for Resuscitation of Trauma Patients
Authors: Vassar Mary J. , Holcroft James W.
Published: November 2015

Hypertonic sodium chloride solutions in concentrations ranging from 1.5% to 24% have been studied for use in the resuscitation of burn and hemorrhagic shock victims for many years. In animal studies, in the setting of small volume resuscitation, hypertonic sodium chloride is superior to standard isotonic crystalloid resuscitation for restoration of hemodynamic stability. The combination of hypertonic sodium chloride with a hyperoncotic colloid solution sustains hemodynamic improvements for an additional hour. Hypertonic-hyperoncotic solutions restore vascular volume primarily by drawing water out of the cell and then selectively partitioning some of the newly recruited fluid within the plasma space. The hyperosmolar state also augments microcirculatory flow, reduces cerebral edema formation, and perhaps increases myocardial contractility. The ability to increase cardiac output with small volume hypertonic-hyperoncotic resuscitation may solve some of the problems related to fluid resuscitation in the prehospital setting when transport times are prolonged or mass casualties need to be treated. Decreasing the volume of fluid required during resuscitation may also prove beneficial in the setting of craniocerebral trauma where the administration of large volumes of crystalloid can increase intracranial pressure. The largest clinical experiences have been reported with the administration of 4 mL/kg of 7.5% sodium chloride combined with 6% dextran 70. These studies have shown that this solution is safe to administer and effective for reversal of hypotension. Whether or not the ability to reverse hypotension will translate into improved survival remains undetermined at present and will require larger multi-institutional trials.
Diabetic Ketoacidosis: Pathophysiology, Management and Complications
Authors: Bratton Susan L. , Krane Elliot J.
Published: November 2015

Diabetic ketoacidosis (DKA) is a common and potentially life-threatening complication of diabetes mellitus, the second most common chronic childhood disease [1]. Prior to the introduction of insulin to clinical medicine by Banting and Best in 1922, DKA had a mortality rate greater than 60% [2]. As insulin was introduced into clinical practice, there was a gradual decrease in mortality associated with DKA over the subsequent 30 years. Recent epidemiological data reveal current mortality varies from 0 to 19% [3,4]. DKA continues to be the most common cause of death in patients younger than 24 years of age; it accounts for as many as 50% of deaths of young diabetic patients [5–7]. In elderly diabetics who have coexisting diseases, DKA carries a high mortality [8]. Despite many advances in the care of diabetic patients, the prevalence of DKA is not declining; it accounts for 14% of all diabetes-related hospital admissions [3, 4, 9].

The incidence of insulin-dependent diabetes mellitus continues to increase worldwide and has roughly doubled in each recent decade [10–13]. Because insulin-dependent diabetes mellitus is increasing, and preventative measures to avoid DKA in diabetic patients have not been successful, the incidence of DKA can also be expected to increase in coming years. Prevention of DKA is the ultimate goal (80% of hospital admissions for DKA occur in treated diabetics) [3,8]. It is necessary for clinicians to understand the pathophysiology and treatment of DKA to care for this increasing diabetic population. We discuss the pathophysiology of diabetic ketoacidosis, its management, and its complications.
Myopathy in Status Asthmaticus: Relation to Neuromuscular Blockade and Corticosteroid Administration
Authors: Shapiro Janet M. , Condos Rany , Cole Randolph P.
Published: November 2015

Myopathy is a rare complication that arises during management of status asthmaticus that may be related to administration of corticosteroids and neuromuscular blocking agents. We present 4 patients with myopathy and a review of the 31 previously reported patients in the literature. All patients received corticosteroids, and 33 of the 35 patients received neuromuscular blocking agents. Muscle weakness was often diffuse and, in several patients, involved the muscles of respiration. Creatine kinase values ranged from normal to markedly elevated. Diagnosis was obtained by electromyogram and muscle biopsy in most patients. Resolution of the muscle weakness occurred over a period of days to months. Patients in whom myopathy developed required mechanical ventilation for longer periods than patients intubated for status asthmaticus without myopathy.
Tension Pneumothorax: Etiology, Diagnosis, Pathophysiology, and Management
Authors: Gilbert Timothy B. , McGrath Brian J.
Published: November 2015

The normally air-free pleural cavity exists at subatmospheric pressure to promote pleural apposition and proper lung excursion. Owing to its unique bilayer structure, air introduced into this space either from within the thoracic cavity or from an extrathoracic source causes pleural separation and simple pneumothorax (PTX). Most simple pneumothoracies of a small or static volume in healthy patients do not appreciably impair cardiopulmonary function despite variable collapse of the lung. If increasing pressure develops within this pleural air collection, however, a cascade of pathophysiological changes can result from altered anatomical positions of heart, lung, and great vessels. The development of increasing pressure within the pleural space, with resultant ipsilateral lung collapse and hemithoracic expansion into the mediastinum and the contralateral lung, is termed tension pneumothorax (TPTX). The exact incidence of TPTX is unknown, but it is reported in up to 2 to 3% of all pneumothoracies. Certain medical and surgical disease states—many found within the critical care environment—place patients at higher risk for development of TPTX and also limit physiological tolerance to TPTX once it occurs. Although physical examination and chest radiography generally confirm the occurrence of TPTX, physiological monitoring may herald the development of increasing intrapleural pressure. Expeditious recognition and pleural decompression are necessary to prevent the untoward hemodynamic and respiratory consequences of TPTX. Significant morbidity and mortality may arise from TPTX if treatment is unduly delayed, particularly in mechanically ventilated patients.