Pharmacologic management of constipation in the critically ill patient

STUDY OBJECTIVE: To compare the effectiveness of common laxatives in producing a bowel movement in patients admitted to a medical intensive care unit (MICU). DESIGN: Retrospective medical record review. SETTING: MICU of an academic medical center. PATIENTS: Ninety-five patients admitted to the MICU from July 1-October 31, 2004. MEASUREMENTS AND MAIN RESULTS: Fifty patients satisfied the inclusion criteria. Patient-specific data such as age, weight, sex, length of MICU stay, Acute Physiology and Chronic Health Evaluation (APACHE) II score, dietary intake, opioid intake, laxative intake, and bowel movements were recorded during the first 96 hours of admission. Logistic regression analysis was used to compare patients who did and did not have a bowel movement. Of the 50 patients, 25 did not have a bowel movement during the first 96 hours of MICU admission. Patients given a stimulant laxative (senna, bisacodyl) and/or an osmotic laxative (lactulose, milk of magnesia) were more likely to have a bowel movement (odds ratio [OR] 26.6, 95% confidence interval [CI] 3.2-221, p=0.002). Opioid intake, expressed as logarithmic morphine equivalents, was negatively associated with occurrence of a bowel movement (OR 0.76, 95% CI 0.59-0.97, p=0.027). Disease severity, as determined by APACHE II score, was also negatively associated with a bowel movement (OR 0.84, 95% CI 0.7-0.99, p=0.04). CONCLUSION: Critically ill patients have a high frequency of constipation, and opioid therapy is a significant risk factor. Routine administration of stimulant or osmotic laxatives should be considered for this patient population.     

T1N0M0 bronchogenic carcinoma: assessment by CT

We reviewed medical records and conventional chest radiographs that showed a solitary T1N0M0 nodule in 23 patients who had non-oat-cell bronchogenic carcinoma. No patient had evidence of metastases, either on the chest radiograph or clinically. All patients underwent computed tomography (CT) examination of the thorax, including the adrenal glands. Only one patient (4%) had mediastinal lymph nodes greater than 1 cm in diameter accessible to mediastinotomy; anterior mediastinotomy confirmed metastatic spread in this patient, which precluded curative resection. Three patients each had a mildly enlarged (2 cm or less) adrenal gland; however, follow-up study suggested that metastasis was not the cause of adrenal enlargement in these patients. This study reinforces concern over whether CT is warranted in the preoperative assessment of T1N0M0 bronchogenic carcinoma.     

Chronic pancreatitis: ultrasonic features

A retrospective analysis of 84 ultrasound examinations (in 77 patients) was performed to assess the frequency of sonographic findings in chronic pancreatitis. The findings included: inhomogeneously increased echogenicity in 53% of these examinations, focal or diffuse enlargement in 41%, focal dense echoes in 40%, pseudocyst formation in 21%, and a hypoechoic head mass in 7%. Thirteen per cent of our patients had a normal sonogram. Several presentations of chronic pancreatitis not previously described in the sonographic literature included: pancreatic or common bile duct enlargement or pseudocyst formation with otherwise normal-appearing glands. There was no direct relationship between the presence of focal high-intensity echoes within the pancreatic parenchyma and the presence of radiographic calcification. There was no difference in the frequency of ultrasonic abnormalities between patients with and without clinical evidence of pancreatic insufficiency. These results indicate that the sonographic findings in chronic pancreatitis are significantly more varied than previous reports would indicate.     

Retrospective evaluation of inhaled prostaglandins in patients with acute respiratory distress syndrome

STUDY OBJECTIVES: To determine whether use of inhaled alprostadil (PGE 1 ) or epoprostenol (PGI 2 ) significantly improved oxygenation in patients with acute respiratory distress syndrome (ARDS), and to determine whether differences between the two drugs exist with regard to oxygenation, duration of mechanical ventilation and hospitalization, adverse effects, and survival. DESIGN: Retrospective chart review. SETTING: A 360-bed tertiary care teaching facility with medical and surgical intensive care units. PATIENTS: Twenty-seven patients admitted to the hospital who received either PGI 2 or PGE 1 for a primary or secondary diagnosis of ARDS. MEASUREMENTS AND MAIN RESULTS: Seventeen patients received inhaled PGE 1 and 10 received inhaled PGI 2 . There were no significant changes in the ratio of arterial partial pressure of oxygen (PaO 2 ):fraction of inspired oxygen (FiO 2 ) and in the PaO 2 , from baseline to any time point that was analyzed during treatment, for patients receiving either PGE 1 (p=0.2120 and 0.3399, respectively) or PGI 2 (p=0.1655 and 0.0784, respectively). CONCLUSION: No statistically significant improvement in oxygenation was observed in patients receiving either PGE 1 or PGI 2 . In addition, no significant differences were found between the two prostaglandins for the variables studied. Until positive results from large, prospective studies are available, we recommend that these inhaled prostaglandins not be used to treat ARDS.     

The Dental Caries Pandemic and Disparities Problem

Understanding caries etiology and distribution is central to understanding potential opportunities for and likely impact of new biotechnologies and biomaterials to reduce the caries burden worldwide. This review asserts the appropriateness of characterizing caries as a "pandemic" and considers static and temporal trend reports of worldwide caries distribution. Oral health disparities within and between countries are related to sugar consumption, fluoride usage, dental care, and social determinants of health. Findings of international and U.S. studies are considered in promoting World Health Organization's and others' recommendations for science-based preventive and disease management interventions at the individual, clinical, public health, and public policy levels.     

Estimation of creatinine clearance in end-stage liver disease

BACKGROUND: Estimation of renal function in patients with end-stage liver disease (ESLD) is complicated by several factors. OBJECTIVE: To develop a practical and relatively inexpensive method for estimating creatinine production and clearance in patients with ESLD. METHODS: Serum creatinine concentrations and urinary excretion of creatinine were measured in 27 patients with moderate-to-severe liver disease with the goal of developing equations to predict creatinine clearance from serum creatinine. Subjects were studied during an initial evaluation for a liver transplant program. Two 24 hour urine specimens were collected along with 3 serum samples over a 2 day evaluation period. Serum and urine creatinine concentrations were determined using both a modified Jaffé (autoanalyzer) method and an HPLC method. The data were analyzed using nonlinear mixed-effects modeling. RESULTS: Considering both statistical criteria and physiological conventions through allometric scaling theory, creatinine clearance (mL/min) in males can be estimated as (80/serum creatinine) x (actual body weight/70)0.75. For females, the same equation is valid, but the result is multiplied by 0.661. A simplified equation without the exponent is presented, along with equations that are appropriate when an HPLC assay is used for greater specificity. CONCLUSIONS: These equations offer potential for improved estimation of creatinine clearance in patients with liver impairment; however, they need further validation using an independent group of subjects.