bluuebunny/crossref_metadata_2025 huggingface dataset:
Severity of Child Sexual Abuse and Revictimization: The Mediating Role of Coping and Trauma Symptoms
Authors: Fortier Michelle A. , DiLillo David , Messman-Moore Terri L. , Peugh James , DeNardi Kathleen A. , Gaffey Kathryn J.
Published: November 2015

Child sexual abuse (CSA) has consistently been associated with the use of avoidant coping; these coping methods have been associated with increased trauma symptoms, which have, in turn, been linked to increased risk for adult sexual revictimization. Given these previous findings, the purpose of the current study was to test a model that conceptualized the relationships among these variables. Specifically, CSA severity was conceptualized as leading to the use of avoidant coping, which was proposed to lead to maintenance of trauma symptoms, which would, in turn, impact severity of revictimization indirectly. This comprehensive model was tested in a cross-sectional study of a large, geographically diverse sample of college women. Participants were 99 female undergraduates classified as having experienced CSA who completed measures of abuse history, coping style, current levels of trauma symptoms, and adult sexual revictimization. Multivariate path analysis indicated that the data fit the hypothesized model for verbally coercive, but not physically aggressive, revictimization. Specifically, increased CSA severity was associated with the use of avoidant coping, which, in turn, predicted greater levels of trauma symptomatology and severity of sexual coercion in adulthood. Although cross-sectional in nature, findings from this study suggest that coping strategies and trauma symptoms may represent modifiable factors that place women at increased risk for verbally coercive sexual revictimization.
Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy
Authors: Seng Chusheng , Mohan P. Chandra , Koh Suang Bee Joyce , Howe Tet Sen , Lim Yee Gen , Lee Brian P. , Morrey Bernard F.
Published: November 2015

Background:

A previously published study found positive outcomes for a novel technique for ultrasound-guided percutaneous ultrasonic tenotomy, showing good tolerability, safety, and early efficacy within an office setting.

Purpose:

In this follow-up study, all 20 members of the original cohort were contacted after 3 years to explore the sustainability of symptomatic relief, functional improvement, and sonographic soft tissue response for percutaneous ultrasonic tenotomy.

Study Design:

Case series; Level of evidence, 4.

Methods:

All 20 subjects of the clinical trial that was performed from June to November 2011 were further assessed at 36 months after the procedure in terms of visual analog scale for pain, Disabilities of the Arm, Shoulder and Hand (DASH)–Compulsory/Work scores, need for adjunct procedures, and overall satisfaction. Importantly, all 20 were reassessed with ultrasound imaging at 36 months, and evidence of the common extensor tendon response was assessed in terms of tendon hypervascularity, tendon thickness, and the progress of the hypoechoic scar tissue.

Results:

A 100% clinical follow-up was achieved, inclusive of ultrasonographic assessment. None of the subjects required further treatment procedures, and 100% expressed satisfaction. Previous improvements in visual analog scale (current median ± SD, 0 ± 0.9; range, 0-3) and DASH-Work scores (current median, 0 ± 0) were sustained with conformity to a linear pattern on polynomial measures. There was further reduction in DASH-Compulsory scores to a median of 0 ± 0.644 (range, 0-2) with a significant decrease on repeated measures ( P = .008). Tendon hypervascularity was resolved in 94% of patients, and 100% had reduction in tendon thickness. Overall reduction in the hypoechoic scar tissue was observed in all subjects, with a 90% response achieved by 6 months. Between 6 and 36 months, further reduction in the scar was observed in around 60% of patients, with 20% of patients having complete resolution of the hypoechoic scar.

Conclusion:

Minimally invasive percutaneous ultrasonic tenotomy provided sustained pain relief and functional improvement for recalcitrant tennis elbow at 3-year follow-up. It is one of the few procedures to demonstrate positive sonographic evidence of tissue-healing response and is an attractive alternative to surgical intervention for definitive treatment of recalcitrant elbow tendinopathy.
Confidence to Manage Learning: The Self-Efficacy for Self-Regulated Learning of Early Adolescents with Learning Disabilities
Authors: Klassen Robert M.
Published: November 2015

This study examined the self-efficacy for self-regulated learning of 146 early adolescents with and without learning disabilities (LD). Results from the study showed that a 7-item self-regulatory efficacy measure demonstrated factorial invariance for the adolescent sample and also for a validation sample of 208 undergraduates with and without LD. Adolescents with LD rated their self-regulatory efficacy and reading self-efficacy lower than their NLD peers. Hierarchical multiple regression showed that self-regulatory efficacy made a significant contribution to end-of-term English grade after controlling for sex, SES, reading self-efficacy, and reading score. Finally, students with LD who scored low on self-regulatory efficacy were significantly more likely than their higher-scoring LD peers to have a low end-of-term English grade, although there was no difference on a reading performance score. Several suggestions for teachers working with adolescents with LD are provided, along with directions for future research.
The Conundrum of Reform: A Comparative Analysis
Authors: Ingraham Patricia W. , Peters B. Guy
Published: November 2015

Despite obvious cross-national political and cultural differences, civil service reform policies exhibit strong similarities. An examination of reform efforts in the United States, the United Kingdom and Australia emphasizes the centrality of politics and political processes to administrative reform. This is true for mechanical or procedural reform, structural reform and what we termed “relational reforms,” or, reforms aimed at restructuring the relationship between politicians and career civil servants. The overriding influence of politics reduces policy design considerations and often results in solutions that do not match the problems being addressed. The outcomes are new bureaucratic problems and the need for additional reforms.
Cities of the Future: Implications for the Rise and Relative Decline of the Cities of the West
Authors: Jones Barclay G. , Shepherd William F.
Published: November 2015

The prospect for enormous urban growth in many regions of the world outside of Europe and North America is examined. Huge urban centers that must be built in the next generation will be in these regions and will be vastly larger than anything that ever has been built in the West.
The Poor, the Periphery, and the State in Metropolitan Rio de Janeiro
Authors: Gondim Linda
Published: November 2015

This paper analyzes the socio-economic and political factors accounting for the spatial structure of Metropolitan Rio de Janeiro. Urban services and facilities, as well as upper- and middle-class housing are concentrated in the core. The most poor are segregated to poorly equipped peripheral areas. To the extent that access to urban services is considered a component of real income, spatial segregation reinforces income concentration, a feature of the region's process of economic development.

The paper analyzes how state intervention has contributed to this pattern by concentrating investments in the core and immediate periphery, and relocating squatter settlers to suburbs. The state has adopted a laissez-faire attitude towards the periphery, where speculative land subdivision had provided a viable, yet inequitable, housing alternative for the poor. Low-income groups have fought to improve their lot, pressuring against favela removal and for urban improvements in their neighborhoods. They have also used the system to their advantage by becoming petty landlords or land speculators. Although these may be viewed merely as “coping strategies,” their conservative or revolutionary potential is a matter to be assessed empirically.

Likewise, whether state policies will be repressive, distributive, or even redistributive cannot be stated beforehand. These policies are shaped not only by structural forces, but also by the political context and the views of government employees.
Misconceptions about the Urban Poor and the Dynamics of Housing Policy Evolution
Authors: Perlman Janice E.
Published: November 2015

This paper identifies five common misconceptions about the urban poor in Third World cities and traces their affect on housing policy. Prospects for a successful housing strategy are suggested.
Urban Cultivation Amidst Modernization: How Should We Interpret It?
Authors: Sanyal Bishwapriya
Published: November 2015

Many African cities are currently marked by the decline of the formal urban economy and the simultaneous upsurge of household cultivation by the urban poor. This has generated two types of critical responses, though for very different reasons. The modernization proponents view urban cultivation as a manifestation of rural habits, predominantly relied upon by recent migrants lacking integration into the urban economy and culture. The New-Marxist critics, on the other hand, blame such activities for contributing to the “double exploitation of labor” and for maintaining the status quo of capitalist social relations of production. This paper, based on a survey of 250 low-income households in Zambia, attempts to respond to both criticisms. First, it demonstrates that the modernization proponents' assumption regarding who cultivates and why are basically incorrect. The paper then provides evidence that urban cultivation is an innovative response from below which was initially strongly resisted by capitalist countries. The paper also argues that urban cultivation by the poor reduces their vulnerability to the fluctuations of fortune that currently beset the economies of African cities.
Ridesharing, Firm Size, and Urban Form
Authors: Ferguson Erik
Published: November 2015

Ridesharing, firm size, and urban form are analyzed using 1980 Census data. It was hypothesized that the propensity of employees to carpool should increase with firm size at the regional level of analysis. A few outlier observations at the county and SMSA levels of analysis seemed to corroborate this hypothesis. In general, however, no relationship, or a weakly negative one, was found between firm size and the propensity of employees to carpool at the regional level. Firm size is therefore probably not a direct cause of higher levels of employee ridesharing. Other factors, including the interrelated location decisions of firms and their employees, must also be involved.
Increasing news content and diversity improves revenue
Authors: Li You , Thorson Esther
Published: November 2015

A time-series analysis of 10 years of a newspaper’s content and financial data confirms the positive content and revenue relationship in cross-sectional data also exists in longitudinal data. Publishing more news content, particularly in shorter article length and more diverse topic areas, boosts the newspaper’s circulation and ad revenue over time.
Venous Thromboembolism in Pregnancy
Authors: Shapiro Dr Janet M.
Published: November 2015

The risk of venous thromboembolism (VTE) is increased in pregnancy and puerperium. Thrombophilia has been identified in pregnancy-related VTE. Venous ultrasound and ventilation-perfusion lung scanning are the initial tests; pulmonary angiography should be performed if necessary for the definitive diagnosis. Anticoagulation is achieved with heparin antepartum and warfarin postpartum. Low molecular weight heparin has been effective and safe in pregnancy. Thrombolytic therapy has been administered to pregnant patients.
Pancreatitis in the Pediatric ICU Patient
Authors: Wankum Patricia , Tobias Joseph D.
Published: November 2015

Several factors may be involved in the etiology of pancreatitis, including traumatic injury, drugs, toxins, infectious agents, and biliary disease. As opposed to the general pediatric population, the diagnosis in the pediatric intensive care unit (PICU) population may be masked by the inability of the patient to communicate due to associated disease processes, use of sedative/analgesic agents, or altered cognitive function. Due to these issues, a high index of suspicion is necessary to arrive at a timely diagnosis. This issue is of significant importance, as the compromised ICU patient may be unable to tolerate the added stress of a secondary illness such as pancreatitis. The authors present five cases, review the possible etiologies of pancreatitis in the PICU patient, and discuss its presentation in this unique patient population. The incidence in our PICU of five cases in approximately 1,200 admissions over an 18-month period suggests that this problem is of a greater magnitude than we would have previously thought.
Inhibitory Effects of Pentobarbital and Phenobarbital on Human Neutrophil Functions
Authors: Mikawa Katsuya , Akamatsu Hirohiko , Nishina Kahoru , Shiga Makoto , Obara Hidefumi , Niwa Yukie
Published: November 2015

Neutrophils are important components of the immune system which protects the host from bacterial invasion. Phenobarbital and pentobarbital are used to treat seizures/convulsions in critically ill patients who are sometimes immunocompromised hosts. In the current study we examined the effect of pentobarbital and phenobarbital at clinically relevant concentrations and at 10 and 100 times these concentrations on several aspects of human neutrophil functions using ex vivo system. The two barbiturates impaired neutrophil chemotaxis but failed to suppress phagocytosis. Pentobarbital and phenobarbital also inhibited production of superoxide (O2), hydrogen peroxide (H2O2), and hydroxyl radical (OH·) by neutrophils in a dose-dependent manner. These drugs did not scavenge the reactive oxygen species (ROS) generated by the xanthine-xanthine oxidase system. Elevation of intracellular calcium concentrations ([Ca2+]i) in neutrophils by a stimulant was dose-dependently attenuated with pentobarbital and phenobarbital. The two anesthetics also decreased protein kinase C (PKC) activity. These effects on [Ca2+]i and PKC activity may represent a part of mechanisms responsible for inhibition of neutrophil functions. Further studies using in vivo systems are required to elucidate inhibitory effects of pentobarbital or phenobarbital on ROS production and chemotaxis in clinical settings.
Upper Gastrointestinal Bleeding of Nonvariceal Origin in the ICU Setting
Authors: Wassef Wahid , Obando Jorge , Sharma Ashish
Published: November 2015

Upper gastrointestinal bleeding (UGI) is a common medical emergency in the intensive care unit (ICU). Although it can be caused by a number of gastrointestinal disorders, its management usually follows a few simple management rules. Prior to endoscopy, the key to management is to resuscitate the patient, to determine the need for airway protection, and to assess the need for transfusions according to the American Society of Gastrointestinal Endoscopy guidelines. During endoscopy, the key to management is to recognize the cause of the bleeding and to achieve hemostasis. Following endoscopy, the key to management is to determine the need for medical therapy and to determine a proper disposition for the patient given his potential risk for rebleeding. Stress-related erosions syndrome (SRES) is a disease that usually develops in the ICU setting and is known to be associated with a high degree of morbidity and mortality. Although it is approached in the same fashion as other causes of UGI bleeding, patients tend to do better if they are recognized early and treated prophylactically. Criteria for proper patient selection and the recommended prophylactic therapy are reviewed.
Management of Brain Edema Complicating Stroke
Authors: Rosand Jonathan , Schwamm Lee H.
Published: November 2015

Ischemic brain edema, the accumulation of fluid within the brain parenchyma following stroke, is a predictable consequence of both ischemic and hemorrhagic strokes. Its development is the result of injury to both brain parenchyma and the blood vessels supplying the parenchyma. Ischemic stroke produces both cytotoxic (intracellular) edema, which develops when cells are damaged, and vasogenic (extracellular) edema, which arises from injury to structures essential to blood-brain barrier integrity. An understanding of the distinction between cytotoxic and vasogenic edema is essential in preventing secondary brain injury, since the treatments for the two entities differ. The development of new brain imaging technologies has advanced our understanding of brain edema. Both computed tomography (CT) and magnetic resonance imaging (MRI) can detect edema. Specific MRI sequences such as diffusion-weighted imaging can distinguish cytotoxic and vasogenic subtypes, and thereby detect ischemic cell injury within minutes of the onset of symptoms.

Brain edema causes neurologic deterioration predominantly through its mass effect, which leads to distortion of the intracranial contents and impairment of both regional and global cerebral blood flow (CBF). Edema may also cause local tissue dysfunction. Management of the intracranial hypertension and tissue shifts caused by ischemic brain swelling is based on the fundamental relationship between pressure, flow, and resistance. Interventions are directed at preserving CBF and preventing secondary brain injury. Strategies include reducing intracranial blood volume with hypocapnia, reducing brain volume with osmotic agents, reducing cerebral metabolism with hypothermia and barbiturates, reducing resistance with rheologic agents, increasing blood pressure with vasoconstrictors, and expanding the cranial vault with decompressive surgery. All individual therapies must be used as part of a structured approach that involves frequent serial neurologic assessments, quantitative measures of pressure, flow, and resistance, and prespecified protocols for intervention.
Continuous pH and pCO2 Monitoring Using the Paratrend Inserted Through a Pulmonary Artery or Central Venous Catheter
Authors: Tobias Joseph D.
Published: November 2015

The Paratrend continuous blood gas monitoring system was placed through a pulmonary artery or central venous catheter as a means of continuously monitoring pH, pCO2, and mixed venous oxygen saturation in three neonates at risk for cardiorespiratory dysfunction, two following surgery for congenital heart disease and one with septic shock. After calibration with an arterial/mixed venous blood gas value, the Paratrend monitor provided a clinically useful continuous measurement of pH and pCO2. The difference between the Paratrend and the arterial values for pH and pCO2 were 0.02 ± 0.009 and 2.4 ± 0.8 mmHg, respectively. There was a significant discrepancy between the oxygen saturation reading from the Paratrend and the actual measured mixed venous value (9 ± 5%). The possible applications of the Paratrend placed through a pulmonary artery or central venous catheter are discussed.
Critical Care Medicine: Major Changes in Dogma of the Past Decade
Authors: Joffe Ari Robin
Published: November 2015

Critical care medicine is a young specialty that has experienced an expansion of research efforts in the last decade. Many physiologic and therapeutic principles or “dogmas” have been challenged, resulting in major “shifts” and minor “drifts” in thinking. This article reviews the available literature about some of these important and sometimes controversial changes, with emphasis on the practical implications of the concepts. Specific areas discussed include supply-dependent oxygen consumption in critical illness, manipulation of the cytokine cascade in sepsis, ventilation in the acute respiratory distress syndrome (ARDS), blood transfusion in the critically ill, the concept of the multiple organ dysfunction syndrome (MODS), the need for nutritional support in the critically ill, and others. Many of the changes discussed involve the recognition that the host response to a severe insult is exceedingly complex, and the understanding of this response and the effects of it at a tissue and cellular level are incomplete. As a result, the ability to impact the outcome of sepsis and MODS has thus far been disappointing, with the possible exception of “lung-protective” ventilation. The final challenge in critical care medicine is to gain information that will allow the practitioner to better understand, prevent, and treat the complex events that result in organ and cellular dysfunction. Future changes in dogma are welcome if they help achieve these goals.
Variceal Bleeding: Prophylaxis, Treatment, and Prevention
Authors: Do Khoa , Wassef Wahid , Bhattacharya Kanishka
Published: November 2015

Variceal bleeding leads to significant morbidity and mortality in patients with portal hypertension. Mortality can be greater than 50% with the initial bleed and many patients develop recurrent bleeding with equal or greater mortality. Currently cirrhosis is the leading cause of portal hypertension, which is defined as a hepatic vein-portal vein gradient greater than 5 mmHg. Portal hypertension may arise from increased splanchnic blood flow due to systemic vasodilation that occurs in the hyperdynamic circulation of cirrhosis or from increased vascular resistance in intrahepatic and/or portocollateral vessels; by decreasing splanchnic blood flow, portal inflow decreases and so does portal pressure. Pharmacologic therapy consisting of nonselective β-blockers, vasopressin, and octreotide act by decreasing splanchnic blood flow, and long-acting nitrates may cause direct vasodilation of portocollateral vessels and/or decreased splanchnic blood flow. Nonselective β-blockers are the cornerstone of treatment for primary prophylaxis of bleeding, whereas vasopressin and octreotide are used for acute hemorrhaging. Two endoscopic modalities are available for control of acute bleeding and prevention of recurrent bleeding: sclerotherapy and endoscopic variceal ligation. After standard airway control and adequate fluid resuscitation, endoscopy helps localize the area of bleeding, and often in conjunction with vasopressin or octreotide can help control bleeding. Empiric antibiotics (fluoroquinolones or third-generation cephalosporins) should be started prior to endoscopy and early in the course of treatment. Sclerotherapy and band ligation along with nonselective β-blockers can help prevent recurrences of bleeding. For patients with bleeding gastric varices or uncontrollably bleeding esophageal varices, interventional radiologic procedures such as the transjugular intrahepatic portosystemic shunt (TIPS) can be used, and depending on the clinical condition and Child's classification of the patient, a surgically created portosystemic shunt may be appropriate treatment. Hopefully with emerging, new techniques and more widespread, prudent use of prophylactic drugs and endoscopy, the mortality and morbidity of variceal bleeding can be reduced.
Tissue Plasminogen Activator as Adjunctive Therapy of Empyema in a Child
Authors: Stevens Amy , Tobias Joseph D.
Published: November 2015

Pleural effusions and empyemas may complicate 20–57% of bacterial pneumonias. Clinical experience supports the use of fibrinolytic agents as a means of dissolving fibrin, releasing loculations and adhesions, thereby allowing for free drainage via thoracostomy tubes. Currently available thrombolytic agents include urokinase, tissue plasminogen activator (TPA), and streptokinase. Due to manufacturer-related issues, the supply of urokinase has become somewhat limited while streptokinase has the potential for allergic reactions in pediatric patients. The authors report the use of TPA as an adjunct to other therapies for treatment of empyema in a 6-year-old boy with pneumococcal pneumonia.
Anaphylaxis
Authors: Hollingsworth Helen M. , Giansiracusa David F. , Upchurch Katherine S.
Published: November 2015

Anaphylactic reactions are acute medical emergencies characterized by the abrupt onset of hemodynamic instability, respiratory distress from bronchoconstriction or laryngeal edema, urticaria, and angioedema. These clinical manifestations may occur singly or in any combination. Inciting stimuli are diverse, ranging from penicillin, Hymenoptera venom, and radiographic contrast media to exercise. The pathogenesis usually involves interaction of an antigen with specific immunoglobulin E (IgE) antibodies on the surface of mast cells or basophils, which then results in the release of chemical mediators from intracytoplasmic granules and the generation of arachidonic acid metabolites, including prostaglandin D2, and leukotrienes B4, C4, D4, and E4, at the cell membrane. Mediator release from mast cells and basophils may also be stimulated by non-IgE mechanisms, such as complement activation or direct mast cell/basophil activation. Mast cell and basophil—derived mediators have a panoply of effects, including vasodilatation, increased vascular permeability, smooth muscle contraction, airway mucous gland hypersecretion, and chemotaxis of neutrophils and eosinophils. These cellular events result in the observed clinical features. Effective treatment depends on prompt recognition of the clinical syndrome of anaphylaxis, interruption of antigen exposure and absorption when feasible, and administration of appropriate medication. Epinephrine is the drug of first choice for all of the manifestations of anaphylaxis. Adjunctive therapy with oxygen, fluid, H1 and H2 antihistamines, bronchodilators, corticosteroids, and other vasopressors is frequently necessary. Prevention of recurrence is vital. The roles of patient education, skin testing, pretreatment, and desensitization are reviewed.
A Randomized Control Trial of Right-Heart Catheterization in Critically Ill Patients
Authors: Guyatt Gordon
Published: November 2015

We investigated the impact of right-heart catheterization (RHC) on physiological status and stay in the intensive care unit. Thirty three of 148 potentially eligible patients were randomized. Fifty-two otherwise eligible patients were excluded because the attending physician felt that RHC was ethically mandated. Ten of 16 (63%) patients randomized to RHC, and 9 of 17 (53%) to no RHC, died (difference: −10%; 95% confidence interval {CI}, −43% to 24%). Mean number of days in the intensive care unit were 10.3 for RHC and 8.1 for no RHC (difference, −2.2; CI, −10.2 to 5.8). The lowest modified APACHE score achieved after randomization was 10.8 for RHC and 8.1 for no RHC (difference, −3.8; CL, −7.0 to −0.6), and the mean modified APACHE score was 14.4 for RHC and 11.1 for no RHC (difference, −3.3; CI, −6.47 to −0.2). Physiological measures in this trial showed statistically significantly differences in favor of patients not receiving RHC. Confidence intervals around other outcomes include clinically important differnces in favor of both RHC and control groups. Although other controlled trials of RHC are ccrucial, investigators face major practical difficulties.
Musculoskeletal Manifestations of Human Immunodeficiency Virus Infection
Authors: Silveira Luis H. , Jara Luis J. , Martínez-Osuna Píndaro , Espinoza Luis R. , Seleznick Mitchel J.
Published: November 2015

Human immunodeficiency virus (HIV) causes an infection characterized by a wide spectrum of clinical manifestations, including musculoskeletal conditions that have been recognized with increasing frequency in recent years. Arthralgia, usually of moderate intensity, intermittent, and oligoarticular, is the most frequent rheumatic manifestation of HIV; it occurs in approximately 35% of the cases. Knees, shoulders, and elbows are the most frequently involved joints. A “painful articular syndrome,” characterized by severe articular or bone pain of short duration and absence of inflammation, can be observed in up to 10% of cases. Reiter's syndrome was the first rheumatological disorder recognized in association with HIV infection. The reported frequency has ranged from 0.5 to 9-9%. Most of the patients with this syndrome develop the incomplete form, and they usually are positive for human lymphocyte antigen B27. HIV-associated arthropathy has been observed by several groups. It is characterized by absence of recognizable rheumatic disease or syndrome, an oligoarticular pattern, and a subacute course. Psoriasis and psoriatic arthritis may flare up or develop in the course of an HIV infection and have been reported with increased prevalence in HIV patients. Psoriatic arthritis usually has a polyarticular and asymmetrical pattern. Several forms of myopathy have also been reported. Myalgia and a myopathy similar to polymyositis are the most frequent patterns observed. Two forms of the latter have been recognized, one attributed to HIV infection itself and the other to the use of zidovudine. Septic conditions in joint, bursa, bone, and muscle have rarely been described despite the immunodeficiency state. A Sjogren's syndrome-like disorder, termed “diffuse infiltrative lymphocyte syndrome,” may be seen in HIV patients, and it has many features that distinguish it from primary Sjögren's syndrome. Several types of vasculitis have been described; the necrotizing type is the most frequent type found. Fibromyalgia, hypertrophie osteo-arthropathy, and soft-tissue lesions have also been described. The pathogenetic mechanisms underlying the rheumatic manifestations of HIV infection are not well known. Their treatment is not well defined, but includes conventional antirheumatic therapy. Methotrexate and other immunosuppressive drugs should be used cautiously because they can precipitate the acquired immunodeficiency syndrome in an HIV-positive patient.
Management of Monoamine Oxidase Inhibitor-treated Patients in the Emergency and Critical Care Setting
Authors: Lipson Rachel Elizabeth , Stern Theodore A.
Published: November 2015

Monoamine oxidase inhibitors (MAOIs) are the most effective treatment for some forms of depression. Unfortunately, these agents cause many adverse reactions and interact with a number of other drugs. We review the pharmacology, side effects, and interactions of MAOIs, and focus on how MAOI-treated patients can be safely managed in critical care settings.
Anesthesia for Cardiac Surgery in Newborns with Congenital Heart Disease
Authors: Kern Frank H. , Hickey Paul R.
Published: November 2015

The repair of complex congenital heart disease in the neonatal period is an evolving practice that began a decade ago and has resulted in improved survival and reduced long term morbidity. Surgical techniques and anesthetic, management hare evolved to care for these uniquely challenging infants. Optimal anesthetic care requires a sound basis in normal and pathologic neonatal and dedopmental physiology, cardiac and pediatric anesthesia, and cardiopulmonary bypass management. Typical concerns in neonatal congenital heart patients include a reduced myocardial compliance and poorly

developed calcium transport systems. This limits stroke volume and increases calcium requirements in the post-bypass patient. Additionally, abnormal blood flow patterns are common and may be adversely affected by inotropes, inspired oxygen concentration, carbon dioxide tension, and mechanical ventilation. The impact of cardiopulmonary bypass on the neonate is extreme. Infants are commonly cooled to 15°C, their blood volume is hemodiluted by 3-4 fold, and periods of total circulatory arrest for up to 60 min are routine. The physiologic impact of these biologic extremes on organ function must be anticipated. Bypass management must assure optimal distribution of pump flow to minimize any impediment to organ protection. High dose narcotics combined with a benzodiazepine have become an integral part of anesthetic management for the neonate with congenital heart disease. Combined intravenous drug therapy provides a complete anesthetic (sedation amnesia and analgesia), hemodgnamic stability, reduced stress hormone release, and control of pulmonary vascular reactivity. Thii reduces the need for multiple inotropic therapy aimed at decreasing pulmonary vascular resistance and improving myocardial contractility. This manuscript provides an in-depth understanding of the anesthetic management of the neonate with complex congenital heart disease. The overall goal of anesthetic management is to deliver a patient to the ICU with stable hemodynamics and a clear management plan based on intraoperative observations and interventions.
Blood-borne Infections Associated with Transfusion
Authors: Ulrich Paul P. , Vyas Girish N.
Published: November 2015

The epidemic of acquired immunodeficiency syndrome (AIDS) and the realization that transmission of human immunodeficiency virus is caused by homologous blood transfusion have changed the way physicians and their patients view the safety of hemotherapy. Considering that nearly four million patients receive the lifesaving benefits of blood transfusions every year in the United States, we need to recognize and reduce the inherent biological complications of this therapy. Currently, a major concern is the transmission of blood-borne infectious agents and the establishment of persistent infection in transfusion recipients, which is apparently facilitated by suppression of the recipient's hematopoietic and immune systems. Education of blood donors, patients, and attending physicians regarding infectious complications of transfusion is essential and remains the most effective procedure for making rational decisions. Before giving blood transfusions, astute physicians should calculate a risk/benefit ratio and communicate it to the patient or family. Potential recipients of transfusions can be assured that the blood supply is safer now than at any time in the past, although there is still a very small risk for the transmission of infectious agents that cause chronic diseases, such as hepatitis, AIDS, neuropathies, and leukemias. It is essential that everyone understands that the goal of a zero-risk blood supply is not attainable. Recent developments in molecular biology and biotechnology, however, provide opportunities for further reduction of infectious complications of blood transfusions.
Medical and Neuropsychiatric Complications Associated with Use of the Intraaortic Balloon Pump
Authors: Sanders Kathy M. , Stern Theodore A. , O'Gara Patrick T. , Field Terry S. , Rauch Scott L. , Lipson Rachel E. , Eagle Kim A.
Published: November 2015

We conducted a retrospective chart review of 195 consecutive patients who had an intraaortic balloon pump (IABP) placed at the Massachusetts General Hospital during the calendar year 1988 to determine the incidence of complications associated with IABP treatment. Demographics, medical and psychiatric history, hospital course, medical and neuropsychiatric complications observed while on the IABP, pharmacological management, and outcome were recorded. Patients ranged in age from 26 to 81 years, with a mean of 62 years. Women comprised only 25% of the sample but had a mortality (40%) twice that of men (20%; p = 0.008). An IABP was inserted for cardiogenic shock in 52% of patients, for refractory angina in 36%, and intraoperatively in 12%. Patients were treated with an IABP for a mean of 4.4 days (range, several hours to 36 days). Complications included delirium (34%), mortality (25%), peripheral vascular insufficiency (17%), bleeding (14%), acute renal failure (14%), infection (8%), and stroke (4.6%). Delirium was associated only with a history of seizures and with development of a residual organic brain syndrome. Mortality was associated with female sex, cardiogenic shock, and number of complications present per patient. Vascular insufficiency was associated with female sex, history of peripheral vascular disease, valve replacement surgery, and mortality. Residual organic brain syndromes were more common in patients in whom delirium developed. A review of the literature on complications associated with IABP therapy is provided. This study highlights the common but previously unrecognized complication of delirium in IABP patients.
Intraventricular Hemorrhage: An Update
Authors: Kuban Karl C.K. , Volpe Joseph J.
Published: November 2015

Although the incidence of intraventricular hemorrhage (IVH) has decreased in recent years, the increasing survival rates for the smallest premature infants indicate that the lesion will continue to be a major problem in neonatal intensive care facilities. We review prenatal, perinatal, and postnatal variables that have been associated with enhanced risk of IVH and address some of the methodological limitations of previously reported studies. The neuropa-thology is characterized by bleeding into the subependymal germinal matrix, with subsequent rupture into the lateral ventricle. The pathogenesis of IVH relates to intravascular, vascular, and extravascular factors. Intravas-cular factors are those that relate primarily to control of blood flow and pressure in the microcirculation of the germinal matrix. Vascular factors relate to the microcirculation of the matrix, the site of initial bleeding. A maturation-dependent alteration of vascular integrity and a vulnerability of matrix vessels to injury appear important. Extravascular factors include those relevant to mesenchy-mal and glial support for matrix vessels and to local fibrino-lytic activity in the germinal matrix. Prognosis in the setting of IVH relates to the mechanisms of brain injury, the most important of which is pcriventricular hemorrhagic infarction, often inappropriately called grade IV IVH and often associated with subsequent motor and cognitive deficits. Prevention of IVH remains the most important goal. Prenatal interventions include prevention of premature birth, transportation of premature infants to a tertiary facility in utero rather than after birth, possibly prenatal administration of phenobarbital or vitamin K, and optimal management of labor and deliver. Postnatal interventions include careful newborn resuscitation, correction or prevention of major hemodynamic disturbances, and correction of abnormalities of coagulation. Postnatal pharmacological interventions that have been studied in detail include phenobarbital, indomethacin, ethamsylate, and vitamin E. No single agent among this group has been shown consistently to lead to a decrease in incidence and severity of IVH.
Diagnosis, Management, and Complications of Nonpenetrating Cardiac Trauma: A Perspective for Practicing Clinicians
Authors: Voyce Stephen J. , Becker Richard B.
Published: November 2015

We provide a state-of-the-art review for practicing clincians concerning diagnosis and treatment of patients with non-penetrating cardiac trauma. Internists, cardiologists, and intensivists are becoming increasingly involved in the diagnosis and management of patients with nonpenetrating cardiac injuries. Electrocardiography and cardiac isoenzyme determinations are the least expensive and most common laboratory tests used to diagnose this condition. Despite widespread use, however, these tests have significant limitations in diagnostic sensitivity and specificy. Two-dimensional echocardiography is advocated by some to improve diagnostic accuracy and to identify patients at increased risk of cardiovascular complications. Patients identified as low risk may be suitable for limited monitoring and early hospital discharge. Transesophageal echocardiography is a useful diagnostic tool that offers many advantages over standard transthoracic imaging. Nuclear medicine techniques, including radionuclide-labeled antimyosin scanning, also represent exciting new developments in this area. Invasive techniques such as cardiac catheterization and pumonary artery catheterization should be reserved for patients with hemodynamic instability and overt mechanical complications. Appropriate selection of diagnostic tests can assist clinicians in rapid traging of patients with nonpenetrating cardiac trauma. Identification of patients at low risk for cardiovascular complications may lead to more appropriate use of hospital resources.
Blood Conservation and Blood Salvage
Authors: Goodnough Lawrence T. , Bodner Mathew S. , Martin Jeffrey W.
Published: November 2015

Autologus blood transfusion has been recommended as the blood of choice for surgical patients. Procurement of autologus blood can be accomplished by utilizing one or more conservation interventions: preoperative autologous blood donation, acute preoperative hemodilution, and perioperative autologous salvage. Recent estimates of cost-effectiveness emphasize that blood conservation interventions need to be held accountable with regards to their costs as well as their benefits. Despite recent advances in blood safety, patients need to be informed of the relative risks of blood transfusion and blood conservation, so that a careful balance of the need for blood conservation along with an acknowledgment of the life-saving properties of blood can be maintained.
Critical Care of Intrathoracic Complications of Lung Cancer
Authors: Schultz Michelle Z. , Murren John R.
Published: November 2015

Lung cancer is the most common underlying malignancy in cancer patients admitted to intensive care units. Because of the proximity to vital organs in the mediastinum, lung cancer frequently causes complications requiring critical care, including cardiac tamponade, central airway obstruction, massive hemopytsis, and superior vena cava syndrome. In addition, radiation and chemotherapeutic agents used to treat lung cancer may cause life-threatening pneumonitis in a minority of patients. There are several management options available for each complication. Educated decisions must be made based on individual patient circumstances. Technological advances have allowed for successful treatment of the majority of patients with such complications. For example, photoresection with the NdYAG laser can relieve dyspnea in 18% of patients with airway obstruction; hemorrhage can be controlled 80% of the time with bronchial artery embolization; and symptoms of superior vena cava syndrome may be relieved in more than 90% of patients. Although the median survival of cancer patients admitted to the intensive care unit is relatively short, such interventions can effectively palliate symptoms and may prolong survival.
The Polyneuropathy of Critical Illness
Authors: Bolton Charles F.
Published: November 2015

Polyneuropathy occurs in 70% of patients who have sepsis and multiple organ failure. It presents as limb weakness and difficulty in weaning from the ventilator. Clinical signs are often unreliable, and electrophysiological studies are necessary to establish the diagnosis. These studies show a primary axonal degeneration of predominantly motor fibers. Creatinine phosphokinase levels are normal or mildly elevated. Muscle biopsy shows predominantly denervation atrophy. Recovery occurs, except in the most severe cases, if sepsis and multiple organ failure can be successfully treated. Other neuromuscular conditions that may be associated with sepsis are disuse atrophy and, rarely, acute myositis or pyomyositis. Measurements of creatinine phosphokinase levels and muscle biopsy, in addition to electrophysiological studies, are necessary to establish the correct diagnosis in these conditions. Recent reports in the literature implicate use of neuromuscular blocking agents or steroids as a possible further mechanism for causing either an axonal polyneuropathy or a primary myopathy; however, the precise role of these drugs in this type of toxicity has not been established. Nonetheless, comprehensive investigation of these patients is worthwhile to aid respiratory and rehabilitation management and to establish a long-term prognosis.
Pseudoaneurysm Formation Subsequent to Pulmonary Artery Catheter-Induced Hemorrhage
Authors: Hasnain Jawad U.
Published: November 2015

Pulmonary artery (PA) rupture and hemorrhage is the most dreaded (and potentially fatal) complication of PA catheters. The reported mortality from this complication is 50% [1]. There is very little information available regarding followup and management subsequent to the initial successful control of bleeding. We report a case of pulmonary artery rupture resulting in massive hemorrhage and subsequent development of a PA aneurysm. This aneurysm formation can result in delayed pulmonary hemorrhage with potentially fatal consequences. This case emphasizes the need for follow-up after the successful management of the initial PA rupture.
Acute Acalculous Cholecystitis
Authors: Walden David T. , Urrutia Fernando , Soloway Roger D.
Published: November 2015

Acute acalculous cholecystitis (AAC) is a dangerous complication of medical and surgical illnesses, and it is most commonly encountered in the intensive care setting. Although uncommon, recent reports have indicated an increasing incidence. AAC occurs most often following major trauma or nonbiliary surgical procedures, but it may be seen in conjunction with avariety ofmedical illnessesaswell. Transfusion, narcotics, mechanical ventilation, total parented nutrition, and sepsis have been associated with AAC, but it is likely that ischemic injury to the gallbladder is the most important pathogenetic factor. Primary infection of the biliary tract is not an important factor in the development of AAC, except in the acquired immunodeficiency syndrome. The incidence of gangrene and perforation is high in AAC in contrast to acute calculous choleqstitis. The clinical presentation may be highly variable; thus, a high index of suspicion is required for diagnosis. Fever, leukocytosis, and right upper quadrant tenderness are the most common findings. Early ultrasonography is appropriate when AAC is suspected, although computed tomography and cholescintigraphy may be useful in selected patients. Delay in diagnosis longer than 48 hours is associated with a perforation rate of 40%. Urgent cholecystectomy is the preferred treatment, but percutaneous cholecystostomy is an acceptable alternative in patients unable to withstand surgery.
Treatment of Hypothermia in Trauma Victims: Thermodynamic Considerations
Authors: Gentilello Larry M. , Moujaes Samir
Published: November 2015

The relatively high specific heat of the human body makes hypothermia very difficult to treat. Although there are many treatment methods available, most evaluations of rewarming techniques are based on clinically observed rewarming rates, and they do not take into account initial core temperature, ambient temperature, the patient's own heat production, the effects of anesthesia, paralytic agents, and other variables. A heat transfer model is proposed that simulates the flow of heat through the body of a hypothermic patient. The model uses first principles involved in heat transfer and thermodynamics to describe the effects of currently available rewarming techniques.

A commercially available routine is used to solve the equations, which also include any heat exchange between the patient's body and the environment, as well as metabolic heat generation as a function of time and core temperature. This thermodynamic analysis of rewarming, based on computer modeling of heat transfer, provides a scientific basis on which to establish guidelines for appropriate selection of treatment strategies for hypothermia, and it indicates that direct blood warming or infusion of warm intravenous fluids are the most effective rewarming techniques.