Serial levels of CA 19-9 and CEA in colonic cancer.

The use of serial carbohydrate antigen (CA) 19-9 assays was assessed by comparison with serial carcino-embryonic antigen (CEA) levels on the plasmas of 53 patients with colorectal carcinoma. The patients had all undergone resection for their primary tumors and in six instances subsequent resections for hepatic metastases. Initial CA 19-9 levels were greater than or equal to 37 U/mL in 22 of the 53 patients (41%) and in 68% of the patients with metastatic disease. Similar trends of serial CA 19-9 and CEA levels were found in 79% of the 53 patients. One patient with initially normal CEA levels had elevated CA 19-9 levels from the start. In ten of the 53 patients (19%), serial CA 19-9 levels remained low despite tumor recurrence or progression, and despite increasing CEA levels above 5 ng/mL. The increasing serial CEA trends predicted recurrence in 88% and increasing CA 19-9 trends in 50% of cases, which was increased to 70% by including trends of CA 19-9 levels below 37 U/mL. Following hepatic lobectomy, both serial CEA and CA 19-9 levels decreased rapidly. Used alone, serial CA 19-9 levels did not appear to be as sensitive as standard CEA in this retrospective study of selected patients.

Relatively low proportion of dystrophin gene deletions in Israeli Duchenne and Becker muscular dystrophy patients.

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are allelic disorders caused by mutations in the X-linked dystrophin gene. The most common mutations in western populations are deletions that are spread non-randomly throughout the gene. Molecular analysis of the dystrophin gene structure by hybridization of the full length cDNA to Southern blots and by PCR in 62 unrelated Israeli male DMD/BMD patients showed deletions in 23 (37%). This proportion is significantly lower than that found in European and North American populations (55-65%). Seventy-eight percent of the deletions were confined to exons 44-52, half of these to exons 44-45, and the remaining 22% to exons 1 and 19. There was no correlation between the size of the deletion and the severity of the disease. All the deletions causing frameshift resulted in the DMD phenotypes.

Predicting eventual success or failure to wean in patients receiving long-term mechanical ventilation.

PURPOSE: To determine if the ultimate ability of a long-term ventilated patient to wean can be predicted at the time of his or her admission to a long-term ventilator unit. DESIGN: Two-phased prospective study. SETTING: Long-term ventilator facility, university-affiliated. SUBJECTS: Adults ventilated for an average of 3 weeks, who did not have sepsis and who did not have chest tubes or progressive neurologic impairment. INTERVENTIONS: On admission to the long-term ventilator unit, historic factors, ventilator history, and the following laboratory and metabolic tests were obtained: electrolytes, serum calcium, magnesium, and phosphorus, WBC, hemoglobin, albumin, total protein, transferrin, oxygen consumption, carbon dioxide production, respiratory quotient, and dead space/tidal volume. The patients were then placed in a weaning protocol utilizing increasing duration of pressure support ventilation during the day with complete rest at night. Forty-two days after enrollment in the study, representing three times the duration of the weaning protocol, the patients who successfully weaned were compared to those who remained ventilator dependent (n = 20). Patients who died or were transferred to another institution were excluded from this phase of the study, because we were trying to develop parameters that would be predictive of successful weaning. A parameter was considered to be predictive, and retained for the scoring system, if it produced at most 15% false-positives and false-negatives. A score of 0 was then assigned to the threshold value that produced no false-positives; 2 to the threshold value that produced no false-negatives and 1 to the intermediate values. The scoring system was then applied to a new prospective group of patients (n = 72). MEASUREMENTS AND MAIN RESULTS: Of all the parameters evaluated, only the following satisfied the false-positive and false-negative requirements; static compliance, airway resistance, dead space to tidal volume ratio, PaCO2, and frequency/tidal volume. Applying these, in the scoring system, to the initial group of patients, demonstrated that a score greater than 3 was associated with failure to wean; a score less than 3 was associated with successful weaning, and a score of 3 was not predictive. Using these thresholds, the data were applied to the new prospective group of patients, which again demonstrated that a score of greater than 3 was associated with failure to wean in all cases. A score less than 3 was again associated with successful weaning but there were two false-positives. The sensitivity, specificity, and positive predictive and negative predictive values for the scoring system were 1.0, 0.91, 0.83, and 1.0, respectively. None of the individual parameters included in the scoring system demonstrated equivalent statistical results. All but two of the patients who died prior to finishing the weaning period had weaning scores, which suggested that they would not be successfully weaned. CONCLUSIONS: Parameters that are generally available, when combined into a scoring system, can predict at the time of admission to a long-term ventilator unit, in most cases, whether a patient will eventually wean. The scoring system resulted in no false-negatives and an acceptable number of false-positives. None of the individual parameters were as reliable as the scoring system as a whole.

Helium-oxygen mixtures in intubated patients with status asthmaticus and respiratory acidosis.

Seven patients with status asthmaticus intubated for respiratory failure who had elevated airway pressures and persistent respiratory acidosis were successfully ventilated using a mixture of 60 percent helium and 40 percent oxygen. All patients experienced a rapid reduction in airway pressures, CO2 retention, and resolution of acidosis while breathing a helium-oxygen mixture. There were no untoward effects. Helium-oxygen mixtures improve ventilation by reducing the Reynolds number and reducing density dependent resistance. Helium's beneficial effects are due to its high kinematic viscosity, high binary diffusion coefficient for CO2, and high diffusivity. Helium-oxygen mixtures should be considered for use in mechanically ventilated asthmatics with respiratory acidosis who fail conventional therapy.

Use of ultrahigh frequency ventilation in patients with ARDS. A preliminary report.

STUDY OBJECTIVE: Our objective was to compare the efficacy of ultrahigh frequency ventilation (UHFV) (frequencies > 3 Hz) with respect to oxygenation, airway pressures, and hemodynamic parameters in patients with adult respiratory distress syndrome (ARDS) who were not responding to conventional ventilation. DESIGN: We used a prospective, multicenter, nonrandomized study design in which each patient served as his own control. SETTING: Three university-affiliated, tertiary-care medical centers participated. PATIENTS: Persons aged 16 to 79 years old with ARDS and unresponsive to conventional ventilation, as defined by a Food and Drug Administration (FDA) approved protocol, were included. INTERVENTIONS: Ninety patients who were not responding to conventional ventilation were changed to UHFV using a microcomputer-controlled device. MEASUREMENTS AND RESULTS: The patient's blood gas, hemodynamic, and airway pressure variables were measured just before, and at 1 and 24 h after the switch to UHFV. We demonstrated clinically significant improvements in arterial oxygen tension (PaO2) and reductions in peak and mean inspiratory pressures. CONCLUSIONS: In a multicenter study, UHFV improved respiratory gas exchange and reduced airway pressure variables at both 1 h and 24 h after the onset of UHFV when compared with conventional ventilation just prior to the change and without hemodynamic deterioration, in patients with severe ARDS.

Analysis of indications for intensive care unit admission. Clinical efficacy assessment project: American College of Physicians.

OBJECTIVE: To formulate recommendations for the development of intensive care unit (ICU) admission policies. DESIGN: Literature review of published reports over the period 1966 to 1991 pertaining to admission criteria for intensive care or coronary care units (CCUs). PATIENTS: Studies identifying patients least likely to benefit from ICU or CCU admission were analyzed. Patient populations of interest included adults (> or = 18 years of age) with medical conditions possibly requiring intensive care; trauma patients were excluded. MEASUREMENTS AND MAIN RESULTS: Of 970 articles identified as being pertinent to intensive care, only two case-control studies used the direct method of measuring the effect of ICU intervention on mortality. No studies were found that compared outcomes of low-risk patients treated in a CCU vs those treated in alternative hospital locations, and none identified patients with a very high probability of a bad outcome. CONCLUSIONS: The use of decision-making models for ICU and CCU admissions must be tested in prospective, randomized clinical trials. Critical care units and ICUs should be studied separately. Existing studies of early discharge from CCUs need to be summarized and evaluated. The triaging of ICU patients to alternative hospital locations needs to be evaluated, as do existing predictive models for early triage decision-making.

Analysis of indications for early discharge from the intensive care unit. Clinical efficacy assessment project: American College of Physicians.

OBJECTIVE: To formulate recommendations for the development of early intensive care unit (ICU) discharge criteria for low-risk monitor patients. DESIGN: Literature review of published reports over the period 1966 to 1991 pertaining to ICU discharge criteria. PATIENTS: Studies identifying patients admitted to ICUs who could be characterized as low risk. Patient populations of interest included adults (> or = 18 years of age) with low-risk medical or mixed medical/surgical conditions; cardiac care unit and burn patients were excluded. MEASUREMENTS AND MAIN RESULTS: Of 1,492 articles identified as being pertinent to ICU discharge, only 2 studies (by the same group of investigators) were found that distinguished low-risk populations among medical and mixed medical/surgical ICU patients. The physiologic component of the Acute Physiology and Chronic Health Evaluation (APACHE) was used in both of these studies to ascertain the degree of risk. No studies were found that compared outcomes of low-risk patients remaining in the ICU after 24 h with those transferred to other hospital locations. CONCLUSIONS: Objective methods (such as APACHE III) should be used to identify low-risk patients at 24 h post-ICU admission. A multicenter study should be conducted to compare outcomes on patients identified as low risk who are randomly assigned to alternative hospital locations for treatment versus those assigned to continued ICU treatment until routine ICU discharge. Mortality and quality of life data should be used as outcome measures (prior to ICU admission and 6 months post-ICU discharge).

Drug-induced left ventricular failure in patients with pulmonary disease. Endomyocardial biopsy demonstration of catecholamine myocarditis.

Three patients with severe chronic lung disease had left ventricular failure develop with marked impairment of cardiac function. Ejection fractions by radioactive blood pool ventriculography were 0.17, 0.24, and 0.20. Right ventricular endomyocardial biopsy specimens showed interstitial hemorrhage and foci of interstitial polymorphonuclear leukocytes, strongly suggestive of catecholamine myocarditis. These patients had used beta-adrenergic agonist inhalants and methylxanthines. One of them clearly abused the inhalant and had elevated levels of urinary catecholamines. Progressive deterioration of pulmonary and cardiac function occurred in two patients, with death within three months of the initial myocardial biopsy. Concomitant use of beta-adrenergic agonists and methylxanthines may cause myocarditis with left ventricular failure in susceptible patients.

Preoperative angiography of the superior mesenteric and portal vein with prostaglandin F2 alpha in portal hypertension.

In a comparative study, we showed that a gain in diagnostic reliability justifies the routine use of PGF in indirect superior mesenteric venograms of patients with portal hypertension. Three radiologists without knowledge of patients' data and treatment analyzed 30 angiograms with and 30 examinations without PGF. Complicating factors, such as presence of varices and dose of contrast medium (CM), were taken into account by a Mantel and Haenszel procedure. When PGF was used, intrahepatic portal branches could be outlined beyond their second ramification more frequently. The superior mesenteric and portal veins, but not the confluence, were visualized significantly more often using this agent, so that patency, constriction, partial thrombosis or occlusion could be reliably diagnosed. Independent of the use of PGF, visualization of the confluence was improved by high CM doses in combination with high flow rates.

Ultra-high-frequency jet ventilation in a bronchopleural fistula model.

High-frequency ventilation techniques have been demonstrated to be useful in decreasing gas loss from bronchopleural fistulas. We performed the present study to evaluate the impact of a new jet ventilator design and ventilatory frequency on hemodynamics, gas exchange, and bronchialstump gas flow in an animal model of bronchopleural fistula. Ten pigs underwent a right-sided thoracotomy and right-sided upper pulmonary lobectomy with cannulation of the upper lobe bronchus for measurement of bronchial fistula flow rate. Animals underwent a random sequence of conventional ventilation (12 to 20 breaths per minute), conventional high-frequency jet ventilation (120 breaths per minute), and ultra-high-frequency jet ventilation (UHFJV; 450 breaths per minute). Hemodynamic measurements were similar in the three ventilatory modes, but oxygenation was best with UHFJV. Bronchial fistula flow was lowest with UHFJV and greatest with conventional ventilation. Ultra-high-frequency jet ventilation demonstrated superior oxygen loading, adequate carbon dioxide elimination, and the least flow through the fistula, suggesting that both ventilator design and frequency are important therapeutic variables in the management of major airway disruption.

An experimental study of feeding, vigilance and predator avoidance in a single bird.

In an aviary experiment with captive Goldfinches (Carduelis carduelis L.) vigilance and foraging behaviour were recorded before and after the appearance of a predator. When foraging, individual Goldfinches had a low head jerk rate during the first minute, but each scan was of relatively expanded duration; the scanning rate increased with a shorter duration of each scan up to the time the predator, a Merlin (Falco columbarius), appeared. Thereafter the birds showed a low head jerk rate, which returned to the former level after ten minutes. The time spent feeding was low if head jerk rate was low and high if head jerk rate was high. There were significantly more scans of long duration after the predator was visible compared with undisturbed feeding. The intake loss of individuals due to increased vigilance after the appearance of the predator during the following minutes is calculated to be 53%. A linear, negative regression function is formulated relating the number of scans per time unit and total time spent scanning: [Formula: see text] With increased number of scans the total time spent vigilant is decreased. From this is concluded that if birds ingest relatively large sized seeds and therefore only a few per time unit they gain a higher security against predators compared to feeding on small sized seeds and ingesting relatively more, because time not spent vigilant is increased with increased pecking rate.

[Value of vascular morphology for the selection of catheters in selective celiacography and mesentericography]. / Bedeutung der Gefässmorphologie für die Katheterwahl bei der selektiven Zöliako- und Mesenterikographie.

By means of 192 lateral aortograms the vascular morphology of the coeliac and superior mesenteric artery were correlated to age, sex and body weight. Independently of these parameters 90% of the exit angles of the coeliac artery were situated between 15 degrees and 90 degrees with a median of 45 degrees. In persons with less than 65 kg body weight the median origin angle of the superior mesenteric artery corresponded to 45 degrees, too, whereas in heavier patients they were bigger (60 degrees). The vascular diameter and the further course of the superior mesenteric artery significantly depended on the constitutional type. In 40.5% we saw a cranial eccentric stenosis of the coeliac artery. Frequency and intensity were not influenced by age, sex or body weight, but accompanied by smaller origin angles of the coeliac artery and bigger ones of the superior mesenteric artery. In conclusion different catheter shapes in dependence of the constitutional type are recommended for combined coeliac and mesenteric angiography.

Investigation of the significance of heavy metal contents of blackbird feathers.

The lead, cadmium and zinc in untreated blackbird (Turdus merula L.) feathers is predominantly of exogenous origin. The endogenous concentration is of minor importance. The degree of surface metal pollution depends on exposure time. The exogenous fraction of heavy metals cannot be completely removed by washing procedures. The difference between washed and unwashed feathers is demonstrated by SEM micrographs.

[Documentation of surgical performance--does more really help more? Comparison of the effects of maximum and limited documentation depth of clinical patient data on theoretical revenue volume of a surgical clinic after introduction of the DRG-based reimbursement system]. / Chirurgische Leistungsdokumentation--Hilft viel wirklich viel? Vergleich der Auswirkung von maximaler und geringer Dokumentationstiefe klinischer Patientendaten auf das theoretische Ertragsvolumen einer chirurgischen Klinik nach Einführung des DRG-basierten Entgeltsystems.

INTRODUCTION: The forthcoming introduction of a DRG-based account system in Germany aims at higher transparency and economic efficiency, particularly in the sector of in-patient health care. The availability of documentation of the highest quality, taking into account all potentially relevant diagnoses, appears to be the best method for achieving maximum revenue in individual surgical units. The aim of the study was to determine the relevance of various degrees of documentation depth on calculated DRG-based revenue. Furthermore, we evaluated whether improvements in the quality of documentation can be realized in current hospital organization. METHODS: In a prospective study, clinical data from 402 in-patients were collected and revenues were calculated based on the Australian-Refined DRG system. Various qualities of documentation were defined. In order to find the medical sectors most sensitive to "under-documentation", homogenous cases were classified into 23 treating groups, according to diagnosis. RESULTS: In 267 cases, maximum revenue was determined only by one main diagnosis, while better results could be achieved in 137 cases (34%) by extended documentation quality. Half of this gain could only be achieved by an independent medical documentation specialist. An upper limit of documentation intensity (number of diagnoses) could be defined. Maximum gain did not require maximum number of diagnoses. CONCLUSIONS: Documentation depth has an important influence on the calculated revenue of surgical therapy based on AR-DRG system. The quality and depth of the documentation is not, in itself, sufficient. In order to be really effective, it requires the highest degree of professionalism from hospital staff.

The use of helium-oxygen mixtures in the support of patients with status asthmaticus and respiratory acidosis.

Ten patients with status asthmaticus and respiratory or combined respiratory and metabolic acidosis were treated with a mixture of helium-oxygen (He-O2) in addition to the usual bronchodilator therapy and corticosteroids. A significant reversal of the acidosis was noted within the first 20 minutes, and no patient required subsequent intubation. The He-O2 mixture was started after the aerosolized and subcutaneous bronchodilators, but before intravenous corticosteroids and aminophylline had reached their peak effects. There were no untoward reactions and most of the patients sensed an immediate reduction in their dyspnea with the onset of He-O2 therapy. We conclude that He-O2 may be a useful adjunct to the usual medications employed in the treatment of status asthmaticus and may allow some patients to avoid intubation and mechanical ventilation.

A controlled trial of methylprednisolone in the emergency treatment of acute asthma.

Ninety-seven acutely ill patients with bronchial asthma were enrolled in a double-blind, placebo-controlled, randomized trial of intravenous methylprednisolone (125 mg), given on presentation in the emergency room in addition to standard emergency treatments for asthma. Subjective and spirometric indexes of the severity of the asthma were similar on entry into the study in all patients, but only 9 of 48 patients (19 percent) treated with methylprednisolone required hospital admission, as compared with 23 of 49 patients (47 percent) in the control group (P less than 0.003). Our results suggest that prompt use of glucocorticoids in the emergency treatment of severe asthma can prevent significant morbidity, reduce the number of hospitalizations, and effect substantial savings in health care costs.

A clinical librarian program in the intensive care unit.

OBJECTIVES: Clinical decision-making in the intensive care setting frequently requires the physician to obtain additional resource information. Physicians typically consult with colleagues, use personal medical books or files, or use library materials. Clinical librarians may also be used. This study evaluates the effectiveness of an ongoing clinical librarian program in the intensive care setting. DESIGN/SETTING: During a 3-month period, house officers in the medical and coronary ICUs in a major teaching hospital asked the clinical librarian 66 patient-care questions. Attached to the information selected by the clinical librarian was a questionnaire asking how the information was applied. MAIN RESULTS: There was an overall response rate of 65.1%. House officers indicated that the information: a) aided in diagnosis (37.2%), b) contributed to a better understanding of the therapy (51.2%), and c) resulted in improved patient management (30.2%). In some instances, the information was multibeneficial. The clinical librarian spent an average of 47 mins/question, and accumulated an average computer charge of $3.59. Personnel and on-line charges over the 3-month study period averaged $45/question. CONCLUSIONS: Clinical librarian programs may deliver patient-specific information in a timely, cost-effective manner. This information has an impact in the intensive care setting.

Morphological and functional changes of the liver following small intestinal bypass for obesity.

Liver biopsies of 6 patients were obtained at time of jejuno-ileal bypass and compared with liver biopsies obtained at 6, 12, and 18 months after the operation. The extent of fatty changes, cellular infiltration, connective tissue infiltration, and parenchymal cell damage was recorded. In biopsies taken 6 and 12 months postoperatively a considerable increase was observed in steatosis and cell damage, biopsies obtained at 18 months after the operation showing reduction or clearing of fat. Transient increase in periportal cell infiltration was observed, and in one patient a manifest cirrhosis developed, necessitating partial reversal of the shunt. An attempt was made to correlate the histological changes with alterations in standard liver function tests. The tests were of limited value in predicting the histological changes unless the morphological changes were very serious and the liver in a state of insufficiency. The importance of liver biopsies in the follow-up of bypass patients is stressed.