The Yale journal of biology and medicine
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Review Comparative Study
Transesophageal two-dimensional echocardiography in the critically ill--is the Swan-Ganz catheter redundant?
Swan-Ganz catheterization can facilitate intra-operative management of critically ill patients. The derived data lacks specificity, however, and, as such, is frequently misleading. This disadvantage, combined with recent advances in echocardiography imaging techniques, has resulted in increasing application of transesophageal (TE) two-dimensional echocardiography (2D-echo) to supplement and, in instances, to supplant conventional cardiac monitoring. ⋯ In contrast, corresponding estimates of LV ejection fraction correlate closely with overall performance, at least in cases without asynergy. Finally, the capacity of TE 2D-echo to detect LV regional wall-motion abnormalities can be particularly useful. Such abnormalities commonly represent early manifestations of ischemia and can, in addition, be predictive of subsequent outcome.
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Historical Article
Research on smoking and lung cancer: a landmark in the history of chronic disease epidemiology.
This paper describes the history of the epidemiologic research on lung cancer prior to 1970 and its effect on chronic disease epidemiology. In the 1930s, epidemiology was largely concerned with acute infectious diseases. As the evidence grew that the incidence of lung cancer was increasing among men, however, epidemiologists undertook research into the etiology of the disease. ⋯ A controversy developed over the credibility of this finding and was increased in 1954 when a cohort study by Doll and Hill and another by Hammond and Horn each gave estimates that the risk of lung cancer was greatly increased among smokers relative to the risk among comparable non-smokers. An account is given of the disputes surrounding these and related studies. The controversy had a stimulating effect in fostering the developing discipline of chronic disease and epidemiology.
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Cryoprecipitate is frequently administered as treatment for hemostatic defects in patients with uremia. The only published data supporting this approach however, involves seven patients described by Janson and colleagues in whom bleeding times were shortened and bleeding complications reduced after cryoprecipitate infusion. We retrospectively reviewed our institution's experience with cryoprecipitate in this setting. ⋯ Three patients failed to shorten their bleeding time after cryoprecipitate infusion or, in one case, multiple infusions. One of these latter patients had correction of his abnormal bleeding time after subsequent administration of deamino-8-D-arginine vasopressin (DDAVP). We conclude that the hemostatic response to cryoprecipitate therapy is variable, and that cryoprecipitate therapy does not achieve restoration of normal hemostasis in some patients with uremic bleeding.
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Acquired immune deficiency syndrome (AIDS), a devastating disease with numerous masks (e.g., a primary neurosymptomatic disease), has now been reported in over one hundred countries of the world. Projections by the Public Health Service of the numbers of cases and fatal illnesses in the United States by 1991 stagger the imagination, and we are told that these projections may be understated. The Veterans Administration (VA) has not been immune to this disorder, over 2,000 cases of frank AIDS (as defined by the Centers for Disease Control [CDC] having been reported to VA's Central Office by 111 of the VA's 172 medical centers. ⋯ The VA has developed an action plan, one of whose features is the development of a direct discussion and collaboration with other federal health care agencies, including the military. Emphasis is to be placed on the exchange of information among these various executive branches and, most important, on the smooth transfer of patients with AIDS or ARC from the uniformed services into the VA's health care system. In addition to the primary goal of providing timely, compassionate care to these patients, the VA also has a commitment to the dissemination of information to our patients, their families, and our employees.
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The adult respiratory distress syndrome (ARDS) represents a common denominator of acute lung injury leading to alveolar flooding, decreased lung compliance, and altered gas transport. In the absence of specific etiology and therapy, the management of ARDS remains largely supportive. Ubiquitous use of intermittent positive-pressure ventilation with positive end-expiratory pressure (PEEP) improves arterial oxygenation but with some risk of pulmonary barotrauma and decreased cardiac output. The recent understanding of lung inflation as a modulator of right heart afterload and the effect of the right ventricle on global cardiac performance continues to redefine optimal patterns of ventilatory and hemodynamic intervention in ARDS.