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Dr. Rade B. Vukmir MD JD FCCP FACEP 《European journal of trauma and emergency surgery》2008,34(3):261-266
Abstract
Background: This work attempted to define the care and course of those most severely affected patients in the setting of blunt chest trauma,
who had hypotension refractory to routine fluid resuscitation.
Methods: Twenty-three critically ill blunt trauma ICU patients were resuscitated and enrolled with ongoing hypotension required placement
of a pulmonary artery catheter. The REF?Explorer (Baxter, Edwards, Anaheim, CA) catheter was placed in the right heart measuring pressure, volume and oxygen utilization
information, as well as recording Injury Severity Score, EKG, CXR, CPK/MB and echocardiography over the initial 72-h time
period.
Results: There were an approximately 2,300 Level I trauma patients admitted annually over a 4-year period with an overall mortality
rate of 4.3% (100) patients with 3.4% (79) patients “ruling in” with elevated cardiac enzymes, associated with an increased
mortality rate of 6.7% (p < 0.05). The 23 patients were male (17, 74%), mean age 41.2 years, with no past medical history
(19, 83%), in a motor vehicle accident (21, 91%), with pulmonary injury (9, 39%), undergoing celiotomy in (10, 44%). They
presented with moderate to severe trauma acuity defined as mean GCS of 8.6, TS of 11.3, and ISS of 34 with an increased mean
hospital stay of 15 days versus 6 days in the ICU; and a 26 days versus 10 days overall stay for those with myocardial contusion
(p < 0.05). Analysis of diagnostic variables found an abnormal EKG in (21, 91%), CXR in (20, 87%) and echocardiogram in (8,
37%). The total CPK was found to be elevated, mean 2,219 (204–8,278 U/l), while the MB fraction was normal 2.3 ± 1.3%. Invasive
cardiac monitoring found an increase in CO of 1.6 l/min from 5.9 to 7.8 l/min during the first 24 h of recovery. Survival
was worsened with increased ISS (29 vs. 43) p < 0.02, but improved with longer ICU (17 vs. 8) p < 0.03 and hospital (39 vs.
7) p < 0.05 stay in days. The analysis of commonly used diagnostic modalities – EKG, CXR, ECHO, or CO, did not correlate with
survival, but the total CPK was increased in survivors (2,715 vs. 1,432 U/l) p < 0.009.
Conclusion: There is worsened morbidity with a 2-fold increase in ICU LOS and hospital stay, and a 1.5-fold increase in mortality in the
severe myocardial contusion group. The diagnostic dilemma posed by lack of definitive testing continues unresolved after analysis
of routinemodalities – EKG, CXR, ECHO, CPK or CO – failing to yield a “best test”. 相似文献
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166.
Jeanne M. Clark MD Donna R. H. Cryer JD Michelle Morton MSN Jay H. Shubrook DO 《Diabetes, obesity & metabolism》2023,25(6):1421-1433
Nonalcoholic fatty liver disease (NAFLD) affects up to one-third of the US population. Approximately one-fifth of patients with NAFLD have nonalcoholic steatohepatitis (NASH), characterized by hepatocyte damage and inflammation with or without fibrosis. NASH leads to greater risk of liver-related complications and liver-related mortality, with the poorest outcomes seen in patients with advanced fibrosis. NASH is also associated with other metabolic comorbidities and conveys an increased risk of adverse cardiovascular outcomes and extrahepatic cancers. Despite its high prevalence, NAFLD is frequently underdiagnosed. This is a significant concern, given that early diagnosis of NAFLD is a key step in preventing progression to NASH. In this review, we describe the clinical impact of NASH from the perspective of both the clinician and the patient. In addition, we provide practical guidance on the diagnosis and management of NASH for primary care providers, who play a pivotal role in the frontline care of patients with NASH, and we use case studies to illustrate real-world scenarios encountered in the primary care setting. 相似文献
167.
Joaquin E. Cigarroa MD Curtis Rooney JD James Blankenship MD Peter L. Duffy MD Andrew M. Goldsweig MD Sandeep Krishnan MD Kusum Lata MD Deepali Tukaye MD Lyndon Box MD 《Catheterization and cardiovascular interventions》2023,101(6):1081-1087
Practice environments for interventional cardiologists have evolved dramatically and now include small independent practices, large cardiology groups, multispecialty groups, and large integrated health systems. Increasingly, cardiologists are employed by hospitals or health systems. Data from MedAxiom and the American College of Cardiology (ACC) demonstrate an exponential increase in the percentage of cardiologists in employed positions from 10% in 2009 to 87% in 2020. This white paper explores these profound changes, considers their impact on interventional cardiologists, and offers guidance on how interventional cardiologists can best navigate this challenging environment. Finally, the paper offers a potential model to improve the employed physician experience through greater physician involvement in decision making, which may increase jobs satisfaction. 相似文献
168.
Jack M. Guralnik MD MPH PhD Peggy M. Cawthon PhD MPH Shalender Bhasin MD Roger Fielding PhD Jay Magaziner PhD MSHyg Alfonso J. Cruz-Jentoft MD Bruno Vellas MD Lindsay Clarke JD Laura Lattimer BA William Evans PhD 《Journal of the American Geriatrics Society》2023,71(5):1595-1602
Background
Sarcopenia, a reduction in skeletal muscle mass and function, is a condition that contributes to functional decline and disability in older adults. Although research on this geriatric condition has developed rapidly in recent years, little work has been done to document whether practicing physicians are incorporating sarcopenia into their clinical practice.Methods
An online survey of 253 practicing U.S. physicians assessed knowledge of sarcopenia, use of the term in practice, motivation for screening patients, and diagnostic and treatment approaches. They were board certified in four practice areas: internal medicine (n = 69), family medicine (n = 69), geriatrics (n = 40), or physical medicine and rehabilitation (PM&R) (n = 75).Results
Less than 20% of internists and family medicine physicians reported being very familiar with the term sarcopenia, with substantially higher familiarity at this level reported among geriatricians (70%) and among PM&R specialists (41%). Two additional findings pointed to deficiencies in sarcopenia knowledge and practice: participants substantially overestimated the prevalence of sarcopenia in older adults (44% of participants reported an expected prevalence of >25%) compared to findings from published studies (indicating 10% of older adults experience sarcopenia); over 75% reported not typically using specific diagnostic criteria or being unsure if their approach utilized any specific criteria. When asked what terminology they use in a medical chart for a patient presenting with significant loss of muscle mass and strength, only 8% said sarcopenia.Conclusions
Sarcopenia, a condition that can have a major impact on older adults as they age, has not been fully incorporated into the knowledge base and practices of active physicians. The survey data suggest that improving physician familiarity with sarcopenia and having universal agreement on criteria for diagnosis may increase the screening for and treatment of sarcopenia. 相似文献169.
Roca O Gómez-Ollés S Cruz MJ Muñoz X Griffiths MJ Masclans JR 《Critical care (London, England)》2008,12(3):R72
Introduction
The benefits of β-adrenergic stimulation have been described in acute lung injury (ALI), but there is still no evidence of its anti-inflammatory effect in these patients. Biomarkers in exhaled breath condensate (EBC) were used to study the effects of salbutamol on lung inflammation in mechanically ventilated patients with ALI. 相似文献170.