bluuebunny/crossref_metadata_2025 huggingface dataset:
Responses to Suburban Highway Congestion: An Overview
Authors: Ross Catherine
Published: November 2015

The dramatic increase in the growth of suburban-to-suburban travel as a result of the suburbanization of both jobs and people has ushered in another crisis. The congestion level in suburbs of American cities is the foremost topic of discussion and everywhere there is concern that we develop solutions that are both immediate and effective. Unfortunately, or perhaps fortunately, this need arises at a time when local areas are financially stressed and the federal government is reducing funding for transportation services.

It is obvious that in addition to the identification of nontraditional funding sources there is need for careful consideration of the fundamental policies that underlay service provision. These papers present approaches that focus on coordinated land use planning and ridesharing that challenge conventional methods.
Drug Dosing in Critically Ill Patients with Renal Failure: A Pharmacokinetic Approach
Authors: DeBellis Ronald J. , Smith Brian S. , Cawley Pauline A. , Burniske Gail M.
Published: November 2015

Accurate pharmacotherapy management in the intensive care unit (ICU) patient is crucial to minimize adverse drug events. Pharmacokinetic principles including absorption, distribution, metabolism, and excretion (ADME) all play an important role in determining the fate of medications used in the critical care setting. Renal failure in this setting further alters pharmacokinetic parameters, resulting in drug dosing changes. This article highlights and applies principles of drug dosing in normal patients and in the pharmacokinetically challenging environment of critically ill patients with renal failure. Specific drug dosing tables serve as a guide for the clinician to renally adjust medication doses in the critically ill patient with renal failure.
Predicting the Need for Medical Intensive Care Monitoring in Drug-Overdosed Patients
Authors: Hamad Abdullah E. , Al-Ghadban Adnan , Carvounis Christos P. , Soliman Emad , Coritsidis George N.
Published: November 2015

Drug overdose (OD) is one of the most common single diagnoses admitted to medical intensive care units (MICUs). The diagnosis results in relatively little morbidity or mortality, suggesting a need to improve the methods utilized in deciding on MICU admission. Our objective in this study was to develop a quantitative system whereby the emergency room (ER) physician, with reasonable safety and ease, would be able to discriminate between the need for an ICU and a nonmonitored bed. We reviewed the charts of 216 consecutive MICU admissions for intentional OD involving 199 patients between the years 1995 and 1998. Clinical histories, vital signs, laboratory data inclusive of toxicologic analysis, and both APACHE II and Glasgow coma scores (GCS) were assessed from the ER and on transfer to the MICU 4–6 hours later. These scores, as well as individual components of the APACHE II score, were evaluated for significance. Of 216 admissions reviewed, 75 (35%) had MICU-requiring morbidity: intubation 61%, pneumonia 20%, arrhythmia or EKG changes 20%, and hypotension 3%. Mortality was 2.7%. The remaining admissions were for ICU monitoring due to lethargy, irritability, laboratory abnormalities, or simply based on the diagnosis of drug overdose. Urine examinations for drugs were positive in only 53%, with the most common agent identified being benzodiazepines (39%). Age, Apache II score, and GCS were significantly different between those patients who developed MICU-requiring morbidity and those who did not, as well as when comparing the morbidity with the mortality group. Receiver operator control (ROC) curves reveal that both the APACHE and GCS are excellent and equal predictors of morbidity, with a GCS of ≤ 12 having 88% sensitivity and 92% specificity in predicting MICU-requiring morbidity. We conclude that ER evaluation of GCS can be used to accurately assess and predict the need for MICU monitoring in drug overdose. OD patients with a persistent GCS of greater than 12 or who do not demonstrate any hemodynamic, infectious, or electrocardiographic complications in the ER do not require MICU admission.
Outcome and Predictors of Mortality in Pediatric Oncology Patients Requiring Intensive Care
Authors: Parsons Simon J. , Tomas Katarina , Wensley David F.
Published: November 2015

Children with malignancies admitted to pediatric intensive care units (PICUs) for complications of their treatment regimes have a high mortality. There are seven previous publications addressing the outcome of this group of patients. We retrospectively analyzed data from 171 admissions (134 patients) to the PICU for predictors of outcome. The most frequent underlying diagnosis was acute lymphoblastic leukemia (ALL) (n = 23, 17%) followed by post-bone marrow transplant (DMT) (n = 12, 9%), but a wide variety of tumors were represented. Sixty-three children were admitted with suspected sepsis, 58 with positive cultures. This represents the largest series published. Mortality for sepsis was 53% and for systemic inflammatory response syndrome (SIRS) (negative cultures), 80%. Logistic regression analysis revealed the number of organs failed, day 1 PRISM score, and the dose and type of inotropes required to be independent predictors of mortality. The need for ventilation alone was not an independent predictor of death. Twenty-six percent of all ventilated children with sepsis survived, with a mean number of failed organs in the survivors of 1.8. Children with respiratory failure without multiple organ dysfunction syndrome (MODS) have a significant chance of survival. Mortality was 100% for four or more failed organs and was 92% for children in renal failure. Survival if ventilation and inotropes were required was 9.4%, higher than expected.
A Fatal Hyperthermic Syndrome in a Patient with Myokymia
Authors: Ashida Hiromi , Shime Nobuaki , Hiramatsu Noriko , Kageyama Kyoko , Hashimoto Satoru
Published: November 2015

A fatal hyperthermic syndrome occurred in a patient with myokymia. The patient suffered acute circulatory collapse and severe rhabdomyolysis associated with hyperthermia. Although these symptoms, were similar to neuroleptic malignant syndrome or malignant hyperthermia, he did not have a history of antipsychotic medication or anesthesia. Continuous muscular contraction due to myokymia likely led to the development of hyperthermic syndrome.
Advances in Fetal Surgery
Authors: Mackenzie Tippi C. , Adzick N. Scott
Published: November 2015

Advances in prenatal screening and diagnosis, combined with an understanding of the pathophysiology of congenital anomalies, have brought incredible impetus to the field of fetal surgery. Identification of fetal anomalies can lead to counseling of the affected family so that informed decisions can be made on how to proceed with the pregnancy. Counseling may lead to pregnancy termination, changes in the timing or mode of delivery, and, in select cases, prenatal intervention. Open fetal surgery may be considered in severe cases of congenital diaphragmatic hernia, congenital chest lesions, sacrococcygeal teratoma, urinary tract obstruction, and myelomeningocele. The ex utero intrapartum treatment procedure may be lifesaving for fetuses with giant neck masses. Finally, fetoscopic surgery may be offered for select cases of twin-twin transfusion syndrome and twin reversed arterial perfusion sequence. Fetal intervention in all of these cases depends on a team approach to the patient and on the objective comparison of outcomes with and without fetal therapy. In the future, further understanding of the genetic basis of congenital diseases may enable minimally invasive treatments such as stem cell transplantation or gene therapy.
A 15-Year-Old with Sepsis and Cavitary Lung Lesions
Authors: Kogan Inna , Wolf Lucas , Celli Bartolome R.
Published: November 2015

We report the case of a critically ill patient with Lemierre syndrome. Lemierre syndrome is characterized by septic thrombophlebitis of the internal jugular vein and metastatic abscesses in different organs, most frequently in the lungs. The disease usually occurs in young, previously healthy individuals. Most cases are caused by Fusobacterium necrophorum, an anaerobic gram-negative rod. Oropharyngeal infection occurring 2–3 weeks prior to septicemia is a harbinger of the syndrome. Frequently oropharyngeal symptoms and local signs are absent at the time of presentation. Computed tomography (CT) scan of the neck with contrast is the most helpful diagnostic study to identify internal jugular vein thrombosis. Treatment involves a prolonged course of intravenous antibiotics with anaerobic coverage. It is important for an intensivist to keep this syndrome in mind, especially when dealing with a young, otherwise healthy patient with sepsis. Mortality is high if the disease is not diagnosed and treated promptly. The syndrome is rare in the antibiotic era, therefore a high index of suspicion is essential.
Anesthesia for Bedside Procedures
Authors: Landow Laurence
Published: November 2015

Within the past 10 years, numerous short-acting anesthetic drugs have been introduced for use in the operating room. This review article will discuss the role of these agents in critically ill patients undergoing bedside procedures.

After a brief historical update, the first part of the review will focus on issues related to the pathophysiology and pharmacology of critically ill patients in general, and of specific organ dysfunction in particular. In-appropriate dosing and improper selection of agents will be highlighted. The second part of the article will discuss specific classes of drugs, with reference to their advantages and disadvantages in the ICU population.

The article will conclude by emphasizing the potency, safety, and efficacy of these drugs in significantly reducing the pain and suffering experienced by patients with critical illness.
Cardiac Transplantation: A Review for the Intensivists
Authors: Mark G. Perlroth
Published: November 2015

Cardiac transplantation has now become accepted therapy for the treatment of end-stage heart disease in both children and adults, and literally thousands of patients are bearers of cardiac grafts. Because of these patients' susceptibility to infections, rejection, coronary disease, and malignancy, as well as to serious illnesses unrelated to their transplantation, they will often be encountered at hospital centers both close to their homes and distant from the site of their surgery. The intensive care unit physician's role will be a demanding one when caring for these patients because of the broad differential diagnosis of infections, frequency of drug interactions and altered immunosuppression, and continuous uncertainty regarding the possibility of rejection, particularly during the first year after transplantation.
Critical Care Management of Lung Transplant Recipients
Authors: Bierman Morris I. , Stein Keith L. , Stuart R. Scott , Dauber James H.
Published: November 2015

In the last 10 years, lung transplantation has become an increasingly common procedure for patients with end-stage respiratory disease. Although long-term survival can be achieved, there is still significant morbidity within the first year. Early postoperative problems that may be anticipated include respiratory insufficiency, airway anastomotic problems, hemorrhage, infection, and episodes of acute rejection. These problems and others make the immediate perioperative period particularly challenging. With aggressive management, however, the probability of a successful outcome can be enhanced.
Incidence of Clinically Important Bleeding in Mechanically Ventilated Patients
Authors: Cook Deborah J. , Pearl Ronald G. , Cook Richard J. , Guyatt Gordon H.
Published: November 2015

The purpose of this study was to determine the incidence of clinically important gastrointestinal hemorrhage in mechanically ventilated patients, and to determine the risk factors for overt bleeding in this population. One hundred consecutive critically ill medical and surgical patients requiring mechanical ventilation for more than 48 hours were prospectively evaluated in a university-based tertiary care, medical/surgical intensive care unit. Seventyfour patients received stress ulcer prophylaxis. Overt bleeding occurred in nine paticnts (9.0%; 95% confidence interval [CI], 3.4-14.6%); eight of the nine patients had a coagulopathy. Clinically important bleeding occurred in two additional patients (2.0%; 95% CI, 0-6.2%). Multiple logistical regression analysis revcaled that only the presence of a coagulopathy (odds ratio 12.5; 95% CI, 3.4-46.5) and the presence of occult bleeding for six or more days (odds ratio 5.5; 95% CI, 1.2-25.4) were independently predictive of overt gastrointestinal hemorrhage. Sixteen patients died, two of whom had overt bleeding and one of whom had clinically important gastrointestinal bleeding. Clinically important gastrointestinal bleeding is uncommon in ventilated patients receiving stress ulcer prophylaxis. In the two patients who bled, both had peptic ulcer disease; one of these had stress ulceration. The presence of a coagulopathy is a powerful independent risk factor for overt bleeding in this population. The risk of overt bleeding also increases with the number of days of positive occult bleeding.
Role of Doppler Echocardiography in Coronary Artery Disease
Authors: Kaul Sanjiv
Published: November 2015

Doppler echocardiography can have a major role in the evaluation of patients with coronary artery disease. This review deals with the imaging planes in relation to coronary vascular territories and the role of Doppler echocardiography in evaluating patients with acute and chronic ischemic syndromes.
Effect of Bronchoalveolar Lavage on Gas Exchange in Patients with Diffuse Lung Disease and Respiratory Failure
Authors: Shapiro Janet M. , Pedersen Kathleen L. , Cole Randolph P.
Published: November 2015

The effect of fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) on arterial oxygenation was examined in 22 patients with acute respiratory failure requiring mechanical ventilatory support. Arterial blood gases were determined immediately prior to BAL and at 15, 60, 120, and 360 minutes following BAL. PaO2/FIO2 decreased at 15 minutes and continued to decrease to approximately 33% below the baseline value at 2 hours. PaO2/FIO2 then remained constant over the remainder of the 6-hour study period. No substantial changes in FIO2, level of positive end-expiratory pressure, or intravenous pressor requirements occurred during the period of observation. Patients with lower pre-BAL PaO2/FIO2 ratios showed the least reduction in PaO2/FiO2 following BAL The BAL was diagnostic in 9 of 22 (41%) patients ( Pneumocystis carinii pneumonia in 5, bacterial pneumonitis in 2, and neoplastic involvement of the lung in 2). BAL was associated with mild deterioration of gas exchange but did not require significant changes in ventilatory or hemodynamic support for the 6-hour interval studied.
Ethylene Glycol Intoxication
Authors: Kruse James A.
Published: November 2015

Commonly available as automotive antifreeze, ethylene glycol can cause toxicity and death if ingested. It is metabolized to several aldehyde and acid intermediates that can cause severe metabolic acidosis, central nervous system derangements, cardiorespiratory failure, and acute renal failure. A presumptive diagnosis can often be made by assessment of the anion gap and the osmol gap and the finding of metabolic acidosis. Corroborating findings include oxalate crystalluria and urine that fluoresces on exposure to ultraviolet light. Recognition is important because there are specific treatment methods available. Therapy consists of administering sodium bicarbonate to counter the acidosis, ethanol to slow the generation of toxic metabolites, and vitamin cofactors, which may speed detoxification of these intermediates. Hemodialysis is employed to remove both ethylene glycol and its metabolites, to correct the acidbase disturbances, and as treatment for acute renal failure.
Pulmonary Manifestations of Neurological Disease
Authors: Colice Gene L.
Published: November 2015

Breathing is a complicated act that requires sophisticated control mechanisms. The nervous system coordinates 3 fundamentally important components of respiration. The central nervous system has a central pattern generator that, along with appropriate feedback mechanisms, establishes both the resiratory rate and the depth of respirations. The peripheral nervous system facilitates transmission of these respiratory commands to the ventilatory muscles. The nervous system also contributes to the control of airway size. Laryngeal function is coordinated with inspiration, and local nerves in the lung have a major role in determining bronchial patency. Finally, the nervous system acts in incompletely understood ways to regulate perfusion of the lungs and to match local pulmonary blood flow with ventilation. Failure of the nervous system to adequately control these 3 different aspects of respiration may result in lifethreatening illness. Understanding how the nervous system affects control of ventilation, airway patency, and pulmonary perfusion therefore will enable intensivists to recognize and manage the pulmonary complications of neurological disease.
Clinical Pharmacology in Aged Intensive Care Unit Patients
Authors: Zawada Edward T. , Boice John L.
Published: November 2015

Elderly patients are presenting themselves for advanced critical care services in ever-increasing numbers due to changing population demographics coupled with advances in medical technology and pharmacology. Medical management of the elderly in critical care settings is complicated by pre-existing multisystem chronic disease, polypharmacy, and age-related changes in pharmacokinetics and pharmacodynamics. Three principles in the management of the elderly in an intensive care unit (ICU) setting are discussed: (1) the protection of renal function from common nephrotic drugs; (2) the necessity of altered drug dosing due to changes in pharmacokinetics and pharmacodynamics; and (3) the necessity of avoiding polypharmacy. Strategies for the prevention of acute renal failure in ICU contrast studies are described. A review of pharmacodynamics and pharmacokinetics in the elderly is presented with examples of commonly seen ICU medication problems.
Trauma Radiology: Part I. Computerized Tomographic Imaging of Abdominal Trauma
Authors: Mirvis Stuart E. , Shanmuganathan K.
Published: November 2015

The value of computerized tomography (CT) scanning for identification of injuries sustained primarily from blunt trauma to the abdomen and pelvis is well established. During the 1980s, numerous articles appeared comparing the value of CT versus diagnostic peritoneal lavage (DPL) as a screening test for intraperitoneal injury. A consensus emerged recognizing the complimentary and different kinds of information provided by each study. CT is indicated in hemodynamically stable patients; to assess the retroperitoneum; after indeterminant DPL results; potentially in patients with positive DPL results by cell count; whenever PDL is contraindicated; in patients with persistent abdominal pain despite a negative DPL; for penetrating flank trauma; for mild abdominal tenderness in alert patients; and arguably for patients with unreliable physical examination. The accuracy of CT is dependent on speed and quality of the scanner, attention to technique to provide optimal oral and intravenous contrast enhancement, and experience of the image interpreter. In general, the accuracy of CT for detection of solid visceral injuries (including in the liver, the spleen, and the kidneys) and for evaluation of the retroperitoneum is well established. Recent studies indicate that CT also offers important information regarding pancreatic and hollow viscous injuries. Fast scanning with a power-injected intravenous contrast bolus can provide localization of active bleeding sites, with important implications for management by surgery or interventional angiography. We review the CT imaging findings typically observed with a variety of abdominal/pelvic injuries.
Cardiac Transplantation: A Review for Critical Care Nurses
Authors: Ohler Linda , Morris Kay Hoopes , McCauley Mary F. , Disanto Patricia
Published: November 2015

Advances in immunology, immunosuppressive therapy, and preservation techniques have contributed to making cardiac transplantation an accepted therpay for end-stage heart discase. One-year survival rates now exceed 90% at some transplant centers. coronary artery disease, and malignancies, continue to plague long-term survival rates in this infection and rejection requires the special experitise of experienced cardiologists and immunologists. An improved understanding of the immune system promises to increase long-term survival rates of cardiac transplant recipients. Critical care nurses require special assessment skill to meet the demanding challenges of cardiac transplant recipients in the immediate postoperative period. The impact of cardiac denervation, immunosupression, and the risk for acute rejection add a different perspective for nursing interventions in the critical care environment. With mortality rates remaining at 8 to 10% for the first month following cardiac transplanation, the skill of critical care nurses is crucial to decreasing morbidity and increasing survival during the acute perioperative period.
Hydrothorax After Inadvertent Placement of a Central Venous Catheter in the Left Pericardiophrenic Vein
Authors: Trujillo Maximo H. , Arai Kaduo
Published: November 2015

Angiography has a central role In both diagnosis and therapy of traumatic vascular injuries from blunt and penetrating mechanisms. Angiography is considered the “gold standard” for establishing the presence of vascular injury, but precise indications and appropriate timing of angiography in certain clinical situations, such as proximity injury to the extremities or penetrating neck injuries, remain controversial. We consider the role of angiography in the diagnosis of major arterial injury in the thorax, selective use of diagnostic and therapeutic angiography for intraabdominal trauma, identification and control of pelvic hemorrhage, and detection of vascular injury of the head, neck, and extremities.
Combined Modalities in the Treatment of an Unresponsive Patient with Adult Status Asthmaticus
Authors: Toor Sabena , Borenstein Jeff , Mohsenifar Zab
Published: November 2015

We present a 42-year-old woman with status asthmaticus who required mechanical ventilation and a combination of maneuvers, including barbiturate coma, general anesthesia, high-dose steroids, bronchoscopic pulmonary toilet, and helium-oxygen ventilation, resulting in successful extubation and eventual hospital discharge. This case report illustrates the possible role of combination therapy in the management of severe asthma exacerbation.
Current Approach to the Management of Neutropenia
Authors: Liles W. Conrad , Dale David C.
Published: November 2015

Neutrophils have a critical role in host defense. Reduction in the absolute neutrophil count to below 1,000/μL is associated with increased susceptibility to infection. The pattern of infections depends on the severity and the duration of neutropenia and other associated defects in host defense mechanisms and exposure to antibiotics and other drugs, particularly corticosteroids and immunosuppressive agents. Breaks in the integrity of the skin or the gastrointestinal mucosal surfaces serve as the portals of entry for the majority of infecting organisms. Empiric antibiotic therapy and hospitalization are almost always required for the management of fever (temperature >38.2°C) in a neutropenic patient. A single antibiotic (e.g., ceftazidime or imipenem) or a combination of antibiotics with activity against both gram-positive and gram-negative organisms usually provides effective antimicrobial therapy. In low-risk patients, trials of out-patient therapy are ongoing. When febrile neutropenia does not respond to empiric broad-spectrum antibacterial therapy, fungal infections, particularly Candida and Aspergillus, should be considered, and antifungal therapy should be initiated. Recently, availability of the hematopoietic growth factors, particularly G-CSF and GM-CSF, have changed the approach to prevention and treatment of neutropenia. Randomized controlled studies have established that these growth factors accelerate hematopoietic recovery following chemotherapy and bone marrow transplantation. By shortening the duration of neutropenia, many of the heretofore inevitable problems with fever and infection can be avoided. The only major factor limiting the use of these agents is their cost. Despite the use of these growth factors, some patients will still experience slow hematopoietic recovery. For these patients, use of neutrophil transfusions, possibly from G-CSF-stimulated normal donors, may prove to be a useful adjunctive therapy.
Clinical Applications of Therapeutic Hemapheresis
Authors: Rososhansky Sarah , Szymanski Irma O.
Published: November 2015

Therapeutic hemapheresis may be a life-saving treatment for patients with some diseases, such as thrombotic thrombocytopenic purpura (TTF), Goodpasture's syndrome, and leukemia-induced leukocytosis, among others. Although plasma exchange has been applied for treatment of many conditions, during the last decade a consensus has been reached about the specific but limited number of diseases for which it is of definitive benefit. Some patients are severely ill during the course of the disease, and they require prompt treatment in the intensive care unit. Therapy of these patients is discussed in this review in detail, in addition to technical aspects, indications, contraindications, and complications of therapeutic hemapheresis.
Principles and Practice of Venovenous Extracorporeal Membrane Oxygenation
Authors: Cornish J. Devn , Clark Reese H.
Published: November 2015

Over the past several years, the use of venovenous extracorporeal membrane oxygenation (ECMO) has increased. The primary advantage of venovenous (VV) over venoarterial (VA) ECMO is preservation of the carotid artery. Its primary disadvantage is that it does not provide circulatory support. While VV ECMO is technically similar to VA ECMO, clinical application of VV ECMO is quite different from VA ECMO. Recent clinical data show that VV ECMO is safe and effective. The purpose of this review is to discuss these differences between VV and VA ECMO, to review the various forms of VV ECMO, and finally to offer recommendations on the safe clinical use of VV ECMO.
Dialytic Support in Patients with Acute Renal Failure with Implantable Left Ventricular Assist Devices
Authors: Moreno Luz , Leblanc Martine , Gurley Melisa , Mccarthy Patrick , Paganini Emil P.
Published: November 2015

The left ventricular assist device (LVAD), used thus far as a bridge to heart transplantation, may offer an alternative to heart transplantation. Because patients receiving LVADs are in cardiogenic shock, many experience acute ischemic renal failure in the peri-implantation period. We describe 10 patients who underwent dialysis after receiving LVADs for end-stage heart disease. Among 37 patients who received an LVAD, 10 required dialytic support (8 men, 2 women; mean age, 47.3 ± 11.3 yr; mean APACHE II score at ICU admission, 18.0 ± 4.7). Renal replacement therapy was started for fluid removal within 48 hours of LVAD implantation in 8 patients. Continuous renal replacement therapy (CRRT) was the first-line modality for 9 patients, including 3 slow continuous ultrafiltrations (SCUF), 4 continuous venovenous hemofiltrations (CWH), 5 continuous venovenous hemodiafiltrations (CWHD), 2 continuous arteriovenous hemofiltrations (CAVH), and 1 continuous arteriovenous hemodiafiltration (CAVHD). Patients remained on CRRT for a mean of 14.4 ± 6.1 days, and 5 were eventually changed to intermittent hemodialysis. The mean time on renal replacement therapy was 27.8 ± 19.7 days. During CRRT, despite daily average ultrafiltration of 3,445 ± 623 mL, net fluid loss was only 358 ± 507 mL/day. Metabolic control achieved with CRRT, expressed as mean ± SD, was: BUN 75.5 ± 13.0 mg/dL (26.9 ± mmol/L), serum creatinine 4.0 ± 0.7 mg/dL (354 ± 62 mmol/L), carbon dioxide content (bicarbonate plus dissolved CO2) 21.5 ± 1.7 mEq/L, and serum electrolytes within normal limits. Survival for patients with LVADs who did not require dialysis was 93% compared with 40% for the group with combined LVADs and dialytic support. The 4 patients who survived in the dialysis group all recovered renal function, and their need for dialysis ceased within 18 to 33 days. Mean serum creatinine levels at follow-up after transplantation were 2.0 ± 1.0 mg/dL (177 ± 88 mmol/L). In conclusion, CRRT provides good metabolic control and allows large ultrafiltration volume in patients supported by an implantable LVAD. We observed a 40% survival rate in patients with combined LVADS and dialytic support, and the survivors all recovered renal function.
Use of Hematopoietic Growth Factors in the Neonatal Intensive Care Unit
Authors: Sola Martha , Christensen Robert D.
Published: November 2015

Recombinant hematopoietic growth factors have emerged as valuable treatments for a variety of medical conditions. Recently, their applications have reached the neonatal intensive care unit, where they offer new therapeutic options for problems as common as anemia of prematurity, or as catastrophic as neonatal sepsis. When facing bacterial infection, it is known that newborn infants are capable of increasing their serum G-CSF concentrations. However, their response does not reach the concentrations that adults are able to achieve, and frequently neutropenia complicates the picture of neonatal sepsis. Although Phase III clinical trials are still in progress, published animal studies, case reports, and Phase I trials suggest that neonates with a variety of neutropenias experience a rapid elevation in their blood neutrophil concentration following administration of rG-CSF, without significant adverse effects. Although many factors contribute to the development of the “anemia of prematurity,” one of the major factors is the inability of preterm infants to generate an erythropoietin (Epo) response appropriate to their degree of anemia. On the basis of this fact, administration of rEpo to preterm neonates to treat or to prevent the anemia of prematurity has been the subject of multiple clinical studies, and it is now clear that rEpo administration to this population can indeed result in lower transfusion requirements, with only occasional and mild adverse effects. Neonatal thrombocytopenia is also a frequent clinical problem, which in most patients develops without a clear underlying cause. Recent studies, quantifying circulating megakaryocyte progenitors in the peripheral blood of thrombocytopenic neonates, suggest that impaired megakaryocytopoiesis may be the main underlying mechanism of many cases of thrombocytopenia. On the basis of this finding, it is tempting to speculate that recombinant thrombopoietin, the newly discovered physiological stimulator of platelet production, will be of clinical relevance in the treatment of thrombocytopenic neonates.
Neuromuscular Blockade Does Not Decrease Oxygen Consumption or Energy Expenditure Beyond Sedation in the Mechanically Ventilated Child
Authors: Sheridan Robert L. , Prelack Kathy , Szyfelbein Stanislaw K.
Published: November 2015

Minimizing the high oxygen consumption and energy expenditure of the critically ill is an important therapeutic goal. This study was done to determine if neuromuscular blockade decreases oxygen consumption or energy expenditure more than sedation alone in the mechanically ventilated child. Twelve burned children, with an average age of 5.1- 1.6 yrs, average weight of 22.8 − 6.5 kg, and average burn size of 28.3 − 5.8% of the body surface, scheduled for a planned surgical procedure under general anesthesia were enrolled in this prospective self-controlled study. In conjunction with planned operative procedures and using an intravenous anesthetic technique, the children underwent expired gas collection before and after neuromuscular blockade was induced. Expired gas was collected and analyzed for the fractional concentration of oxygen and carbon dioxide. Oxygen consumption (VO2), carbon dioxide production (VCO2), energy expenditure (EE), and respiratory quotient (RQ) were calculated. We found no significant difference in EE, VO2, VCO2, or RQ between the well-sedated and mechanically ventilated and the well-sedated, mechanically ventilated and paralyzed states. We therefore concluded that neuromuscular blockade does not decrease energy expenditure in the otherwise well-sedated burned child.
Airway Management in the Pediatric Trauma Patient
Authors: Tobias Joseph D.
Published: November 2015

The most immediate concern in the management of any pediatric emergency, including trauma, is airway assessment with assisted or controlled ventilation as needed. In the trauma setting, several factors may increase the risks associated with airway management including cardiorespiratory instability, associated maxillofacial injuries, cervical spine injuries, and the risk of acid aspiration. The author reviews the techniques used to manage the airway in the pediatric trauma patient including the evaluation of the cemcal spine and techniques to protect the cenical spine during endotracheal intubation. Airway management techniques including standard oral endotracheal intubation with sedation and neuromuscular blockade, the approach to the recognized difficult airway, and the techniques used in the “cannot intubate/cannot ventilation” scenario are discussed.
Infection in the Immobile Host: A Practical Review for the Intensive Care Physician
Authors: Gradon Jeremy D. , Adamson Carrie
Published: November 2015

Immobility in the critically ill patient is a significant risk factor for infection, independent of the patient's underlying critical illness. Specific causes of infection related to immobility in the intensive care setting are explored. The pathogenesis, treatment, complications, and prevention of pressure ulcers, pneumonia, and urinary tract infections in the immobile patient are emphasized. Featured topics include the differentiation of colonization versus infection in pressure ulcers and the urinary tract, the significance and optimal treatment of positive fungal cultures, as well as a rational clinical approach to the immobile patient with a fever and no obvious source of infection. The clinical relevance of anaerobic infections in this population is emphasized because it influences empiric antibiotic therapy and differential diagnosis.
Bilevel Positive Airway Pressure (BiPAP) by Nasal Mask for the Treatment of Respiratory Insufficiency Following Cardiac Surgery in Children
Authors: Tobias Joseph D. , Wilson William
Published: November 2015

The authors present their experience with the use of bilevel positive airway pressure (BiPAP) administered via a nasal mask to treat respiratory failure in three children following surgery for congenital heart disease. The three children developed progressive atelectasis, hypoxemia, and impending respiratory failure following tracheal extubation in the postoperative period. The use of BiPAP by nasal mask resulted in a decrease in the patients' respiratory rate, an increase in oxygen saturation and PaO2, a decrease in transcutaneous CO2, and resolution of atelectasis. The applications of this technique and the equipment required are reviewed.
Imaging Evaluation of Pediatric Extremity Trauma, Part III: Lower Extremity and Soft Tissues
Authors: John Susan D. , Phillips William A.
Published: November 2015

Lower extremity injuries are slightly less common than upper extremity injuries in children, and the structures below the knee are more often involved. Impaction injuries are often associated with twisting forces which can result in subtle buckle and hairline types of fractures, particularly in young children. Epiphyseal-metaphyseal injuries are especially common at the ankle. A variety of avulsion fractures also occur in the lower extremities, often associated with injury to nearby cartilaginous and ligamentous structures. This article reviews the important plain radiograph findings of lower extremity injuries in children as well as indications for special imaging such as ultrasound and MRI.
Borders Up in Smoke: Marijuana Enforcement in Nebraska After Colorado’s Legalization of Medicinal Marijuana
Authors: Ellison Jared M. , Spohn Ryan E.
Published: November 2015

With the passage of Amendments 20 (2000) and 64 (2012), Colorado legalized the medicinal and recreational use of marijuana. Nebraskan law enforcement in border counties subsequently reported increases in arrests and reductions in jail space. In response, the Nebraska state legislature passed LR-520 to study the potential increased costs incurred by criminal justice agencies in border counties. To investigate this situation, we compare trends in drug arrests and jail occupancy across three areas: border counties, those that contain Interstate 80 (I-80) as a major transportation route, and the remaining counties in the state of Nebraska from 2000 through 2013. We found that border counties, but not necessarily those along the I-80 corridor, experienced significant growth in marijuana-related arrests and jail admissions after the expansion of the medical marijuana program in Colorado. Implications for research and policy are discussed.
Contract Clinical Research: A Rapidly Changing Marketplace
Authors: Krichbaum Daniel , Rosenthal Alan
Published: November 2015

Drug development in the United States has undergone considerable change over the past decade. The outsourcing of clinical research activities to Contract Research Organizations (CROs) continues to escalate in an attempt to speed drugs to market faster. The increasing use of business strategies at the investigational site level has fostered the emergence of specialty networks and Site Management Organizations (SMOs). SMOs offer pharmaceutical and biotechnology sponsors the ability to work with a tightly managed network of experienced professional multispecialty research centers that can enroll large numbers of patients and provide high quality data. While these organizations have fundamentally changed the way drugs are developed, they have also contributed to an acceleration of the process and an improvement in the scientific integrity and quality of the data.
The Fundamentals of Institutional Review Board Operations
Authors: Mertl Sue Lyon
Published: November 2015

The Institutional Review Board (IRB) is one component of the human subjects protection system. Established in response to various catastrophes and atrocities involving human subjects, the IRB is a unique combination of individuals. Guided by state and federal regulations, local institutional policies and ethical standards, the IRB is the ideal advocate for human subjects participating in research studies. This review will address the fundamental issues relating to the evolution of the human subjects protection system, the principles of IRB organization and the elements of an IRB review.
The Pharmacist's Role in Developing Critical Paths
Authors: Andrusko-Furphy Kathryn T.
Published: November 2015

The use of various terms for critical paths (i.e., care plans, care mapping) creates problems for practitioners trying to understand the concept. It is important for pharmacists to understand their role in this process. Once pharmacists understand their role, they may take responsibility for their involvement in implementing and managing critical paths. Once responsibility is understood, the importance of documenting their role needs to be understood. Once the full process is understood, the pharmacist can participate in the development of critical paths and the necessary documentation. This article is intended to augment the process, as well as provide information on the outcomes of care provided.
An Integrated “Care Path” Approach: Useful for Implementation and Coordination of New Care Guidelines for Treatment of HIV Infections
Authors: Klotz Roger S.
Published: November 2015

Recently, the 1997 revised guidelines were published for the treatment of HIV-infected patients. These guidelines, while having a dramatic effect on the morbidity and mortality associated with HIV infection, will require the implementation of a coordinate interdisciplinary “Care Path” for each patient. This review presents updated information on the HIV life cycle and the latest approach to antiretroviral therapy. The new approach to therapy is to utilize combination antiretroviral therapy including two retroviral inhibitors with a protease inhibitor. Further, the importance of viral load has become a primary indicator of prognosis and therapy efficacy. The CD4 cell count is important, but it is of secondary significance in treatment effectiveness measurement and indication of disease progress. The complexity of the new guidelines increases the need for a well-planned interdisciplinary “Critical Path” which is then utilized for development of a patient-specific “Care Path.”
The Science of Biotechnology
Authors: Tami Joseph A.
Published: November 2015

The quest to understand how genetic information is passed from one generation to the next reached a major milestone in the 1950s with the discovery of the complementary double-helix structure of DNA by Watson and Crick and the demonstration by Kornberg that DNA was capable of self-replication. These breakthroughs provided the stimulus for a flurry of research that culminated in a basic understanding of the genetic code and a statement of the central dogma of molecular biology: DNA goes to RNA goes to protein. In expressing a gene, RNA is formed from the DNA template in a process called transcription. The process of RNA forming protein is known as translation. During translation, amino acids are linked to form protein. The primary structure of proteins is thus determined by the sequence of amino acids. Using x-ray crystallography and computer imaging, it has been possible to determine the three-dimensional structure of many proteins and to design small molecule peptides which can either mimic or block the function of the protein and thus be useful therapeutic agents.
Multisystem Director: A Product of Managed Care in Today'S Health System
Authors: Vohra Saifi
Published: November 2015

The reform of the health care system in this country has led to a restructuring of hospitals into large networks. Hospital administrators in new affiliates face the problem of coordinating services while reducing costs. One solution is the unification of congruent departments in nearby affiliates into multisystem departments under the lead of one director. This paper summarizes the experiences of a newly-appointed multisystem hospital pharmacy director, emphasizing his approaches to leadership, employee motivation, organization, and time management.
A Review of the Three Types of Biomedical Literature and the Systematic Approach to Answer a Drug Information Request
Authors: Wright Stephanie Gooch , Lecroy Rhonda Lea , Kendrach Michael G.
Published: November 2015

The pharmacist is relied upon to provide drug information on a daily basis for patients and health care professionals. Performing drug information tasks requires the ability to efficiently search, critically analyze, and objectively evaluate the biomedical literature. Pharmacists and pharmacy students need to understand the biomedical literature and an organized method to answer drug information questions. Therefore, the tertiary, secondary, and primary literature resources are defined and examples are presented. In addition, the modified systematic approach to answer a drug information request is reviewed. Understanding the different types of literature and applying the systematic approach assists practitioners in efficiently supplying drug information. The purpose of this article is to assist the pharmacist and pharmacy student in determining the strengths and limitations of the various types of literature and applying the systematic approach to a drug information inquiry.
Drug Information Technology and Internet Resources
Authors: Malone Patrick M.
Published: November 2015

The Internet poses many challenges and opportunities for pharmacists. This article discusses what is needed to access the Internet, including hardware and software. Afterwards, a discussion of the various capabilities that pharmacists can take advantage of and integrate into their practice philosophy is presented. Specific items covered include web searching, web site establishment, electronic mail, USENET News, collaboration software, listservers, and push technology. Furthermore, some likely future areas for pharmacists to evaluate are discussed.
Meta-Analysis: Methodology, Utility, and Limitations
Authors: Mancano Michael A. , Bullano Michael F.
Published: November 2015

Meta-analyses are statistical methods to evaluate large numbers of clinical trial data sets to answer specific clinical questions. Meta-analyses can be performed when large clinical trials are not available or prior to their availability. It is essential for pharmacists to effectively evaluate potential methodological problems and be aware of the current controversies surrounding meta-analysis. This article will focus on the components of a properly performed meta-analysis and the many sources of bias inherent in a literature review of this magnitude. A suggested reading list of in-depth references concerning the many aspects of meta-analysis is provided for the interested reader.
Management of Chronic Nonmalignant Pain
Authors: O'Donnell James T. , Richie Moriah B. , Nesbitt Lori A.
Published: November 2015

Although advances in knowledge about the pathophysiology of pain have been impressive in recent years, high-quality clinical research in patients with chronic pain has not been abundant. Because chronic pain often leads to profound changes in psychologic state, level of functioning, and interpersonal relationships, treatment requires attention not only to the pathophysiologic cause of the pain (if one can be found) but also to the psychologic and social consequences (and antecedents).
Diabetic Autonomic Neuropathy
Authors: Parish Roy C.
Published: November 2015

Diabetic autonomic neuropathy (DAN) occurs in approximately half of Caucasian patients with diabetes and perhaps three-fourths of black diabetic patients. This may be asymptomatic for several years, but the majority of patients with DAN eventually exhibit symptoms of diarrhea, cardiac arrhythmias, sexual dysfunction, and abnormal sweating. Prolonged hyperglycemia results in damage to the autonomic nervous system (ANS), particularly the vagus nerve and other parts of the parasympathetic division. DAN is associated with increased risk of sudden death, high-risk cardiac arrhythmias, myocardial infarction, and death from other causes. Objective testing of autonomic nervous system function yields specific information that affects treatment decisions. Drug therapy can effect improvements in ANS function and reduce these risks.

Complications of diabetes that result from ANS dysfunction can be partly reversed or their progress can be slowed by appropriate drug therapy. Features, implications, and therapy of the most common complications resulting from DAN are reviewed, and suggestions for pharmacist involvement in the care of these difficult patients are offered.