Atypical erythema annulare centrifugum in a child with celiac disease

Herpetiformis dermatitis is the best characterized extraintestinal manifestation of celiac disease (CD). However, other chronic heterogeneous skin lesions have been associated with CD and should be considered in the differential diagnosis.     

Chronic mucocutaneous anogenital herpes: series of ten cases and literature review

Anogenital herpes is one of the most prevalent sexually transmitted infections worldwide. It has several clinical manifestations, from cases of primary herpes infection to recurrent forms, among them chronic mucocutaneous herpes. This presentation is rare, characterized by a duration of more than four weeks, usually associated with immunosuppression and resistance to classic anti-herpetic treatment. The present study presents a series of ten cases of chronic mucocutaneous herpes with a discussion about its clinical, laboratory, and therapeutic aspects.     

Ventilator-dependent survivors of catastrophic illness transferred to 23 long-term care hospitals for weaning from prolonged mechanical ventilation

STUDY OBJECTIVES: This multicenter study was undertaken to characterize the population of ventilator-dependent patients admitted to long-term care hospitals (LTCHs) for weaning from mechanical ventilation. DESIGN: Observational study with concurrent data collection. Characteristics of the LTCHs were also surveyed. SETTING: Twenty-three LTCHs in the United States. PATIENTS: Consecutive ventilator-dependent patients admitted over a 1-year period: March 1, 2002, to February 28, 2003. RESULTS: A total of 1,419 patients were enrolled in the Ventilation Outcomes Study. Median age of the patients was 71.8 years old (range, 18 to 97.7 years), with an equal gender distribution. The premorbid domicile was home or assisted living in 86.5%; "good" premorbid functional status (Zubrod score 0-2) was assessed in 77%. There was a history of smoking in 59% (mean, 57 +/- 42 pack-years [+/- SD]); premorbid diagnoses averaged 2.6 per patient. Patients came to the LTCH after mean of 33.8 +/- 29 days at the transferring hospital; mean time to tracheotomy was 15.0 +/- 10 days. A medical illness led to ventilator dependency in 60.8% of patients; a surgical procedure led to ventilatory dependency in 39.2%. On admission to the LTCH, the median acute physiology score of APACHE (acute physiology and chronic health evaluation) III was 35 (range, 4 to 115); > 90% of patients had at least three penetrating indwelling tubes/catheters; 42% of patients had stage 2 or higher pressure ulceration. CONCLUSIONS: This is the first multicenter study to characterize ventilator-dependent survivors of catastrophic illness admitted to the post-ICU venue of LTCHs for weaning from prolonged mechanical ventilation (PMV). Overall, our findings suggest that ventilator-dependent patients admitted to LTCHs for weaning will continue to require considerable medical interventions and treatments, owing to the burden of acute-on-chronic diseases resulting in PMV.     

Circulatory hypokinesis and functional electric stimulation during standing in persons with spinal cord injury.

OBJECTIVE: To evaluate the effects of functional electric stimulation (FES) of lower limb muscles during 30 minutes of upright standing on the central and peripheral hemodynamic response in persons with spinal cord injury (SCI). DESIGN: A repeated-measure design. Subjects were used as their own control and underwent 2 testing protocols of FES-augmented standing (active standing) and non-FES standing (passive standing). SETTING: Rehabilitation hospital. PARTICIPANTS: Fourteen individuals with SCI (7 with tetraplegia, 7 with paraplegia). INTERVENTIONS: During active standing, FES was administered to 4 muscle groups of each leg in an overlapping fashion to produce a pumping mechanism during standing. During passive standing, subjects stood for 30 minutes using a standing frame with no FES intervention. MAIN OUTCOME MEASURES: Central hemodynamic responses of stroke volume, cardiac output, heart rate, arterial blood pressure, total peripheral resistance (TPR), and rate pressure product (RPP) were evaluated by impedance cardiography. All measurements were performed during supine and sitting positions before and after standing, and during 30 minutes of upright standing. RESULTS: Comparisons between the groups with paraplegia and tetraplegia showed a significant increase in heart rate in the paraplegics after 30 minutes of active standing. During active standing, paraplegics' heart rate increased by 18.2% (p = .015); during passive standing, it increased by 6% (p = .041). TPR in the tetraplegics significantly (p = .003) increased by 54% when compared with the paraplegics during passive standing. Overall, the tetraplegic group had a significantly lower systolic blood pressure (p = .013) and mean arterial pressure (p = .048) than the paraplegics during passive standing. These differences were not detected during active standing. When data were pooled from both groups and the overall groups response to active and passive standing were compared, the results showed that cardiac output, stroke volume, and blood pressure significantly decreased (p < .05) during 30 minutes of passive standing, whereas TPR significantly increased (p < .05). All of the hemodynamic variables were maintained during 30 minutes of active standing, and there were increases in RPP and heart rate after 30 minutes of active standing. CONCLUSION: FES of the lower extremity could be used by persons with SCI as an adjunct during standing to prevent orthostatic hypotension and circulatory hypokinesis. This effect may be more beneficial to those with tetraplegia who have a compromised autonomic nervous system and may not be able to adjust their hemodynamics to the change in position.     

Inhaled sodium pyruvate improved FEV1 and decreased expired breath levels of nitric oxide in patients with chronic obstructive pulmonary disease

Exogenously administered sodium pyruvate has a variety of biological effects including antioxidant/anti-inflammatory effects. Chronic obstructive pulmonary disease (COPD) is an inflammatory disease of the airways mediated in part by reactive oxygen species (ROS) and reactive nitrogen species (RNS). The current therapies for COPD have limited efficacy. This study was designed to test the safety and therapeutic efficacy of inhaled pyruvate in COPD patients. Subjects were randomized to receive either sodium pyruvate or placebo three times per day over a 6-week period. Long-term efficacy was evaluated by spirometry and expired breath nitric oxide (NO) levels taken at baseline, 3 days, 1 week, 2 weeks, 4 weeks, and 6 weeks. In addition, acute assessments (1 h pre- and 1 h postinhalation of compound) were made at day 0 and at 4 weeks. Subjects receiving inhaled pyruvate showed significant (p < 0.02) improvement of approximately 11% in forced expiratory volume in 1 sec (FEV(1)) at 6 weeks, whereas subjects receiving placebo did not. The inhalation of pyruvate or placebo had no significant effect on expired breath NO levels at any of the long-term outcome time points; measurements were made 12 h after the last inhalation of the compound. In contrast, acute assessments (1 h pre-and 1 h postinhalation of compound) of expired breath NO made at 4 weeks demonstrated that inhalation of pyruvate resulted in a significant (p 相似文献   

Weaning from long-term mechanical ventilation

As many as 5% of patients who need mechanical ventilation will require prolonged mechanical ventilation (PMV). The cost of their care and its associated morbidity is alarming; however, good outcomes can be achieved when their care is specialized and delivered in a programmatic manner. In this article, we review some of the common and potentially reversible reasons why patients fail successfully liberation from mechanical ventilation. We examine the outcomes of patients requiring PMV and present evidence that supports the development of specialized units where patients can be cohorted and may produce better outcomes than would be likely if these patients remained in the ICU.     

Post-ICU mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study

STUDY OBJECTIVES: This multicenter study was undertaken to characterize the population of ventilator-dependent patients admitted to long-term care hospitals (LTCHs) with weaning programs, and to report treatments, complications, weaning outcome, discharge disposition, and survival in these patients. DESIGN: Observational study with concurrent data collection. SETTING: Twenty-three LTCHs in the United States. PATIENTS: Consecutive ventilator-dependent patients admitted over a 1-year period: March 1, 2002, to February 28, 2003. RESULTS: A total of 1,419 patients were enrolled in the Ventilation Outcomes Study. Median age of patients was 71.8 years (range, 18 to 97.7 years). Patients averaged 6.9 procedures and treatments during the LTCH hospitalization; median length of stay was 40 days (range, 1 to 365 days). Seven of the 10 most frequent complications treated at the LTCH were infections; congestive heart failure and diabetes mellitus were the most common comorbidities requiring treatment. Outcomes of weaning attempts, scored at LTCH discharge, were 54.1% weaned, 20.9% ventilator dependent, and 25.0% deceased. Median time to wean (n = 766) was 15 days (range, 7 to 30 days). Discharge disposition included 28.8% to home, 49.2% to rehabilitation and extended-care facilities, and 19.5% to short-stay acute hospitals. Nearly one third of patients were known to be alive 12 months after admission to the LTCH. CONCLUSIONS: Patients admitted to LTCHs for weaning attempts were elderly, with acute-on-chronic diseases, and continued to require considerable medical interventions and treatments. The frequency and type of complications were not surprising following prolonged and aggressive ICU interventions. In the continuum of critical care medicine, more than half of ventilator-dependent survivors of catastrophic illness transferred from the ICU were successfully weaned from prolonged mechanical ventilation in the setting of an LTCH.     

Management of the severely anemic patient who refuses transfusion: lessons learned during the care of a Jehovah's Witness.

OBJECTIVE: To present the case of a Jehovah's Witness with severe anemia and to review the religious philosophy of such patients, the ethical and medicolegal aspects of their care, and the therapeutic options available to clinicians. DATA SOURCES: A MEDLINE literature search (1980 to 1992) identified most studies. Other studies were selected from the bibliographies of identified articles. STUDY SELECTION: Selection of articles was limited to the history, philosophy, medicolegal and ethical issues, and clinical management of anemic Jehovah's Witnesses; a recent article on recommendations for red cell transfusion was also reviewed. CONCLUSIONS: A clear understanding of the philosophy of the Jehovah's Witnesses regarding blood transfusion and of the medicolegal and ethical aspects of their care is essential to clinicians who care for such patients. One must also be aware of the many alternative therapeutic options that can maximize oxygen delivery and minimize oxygen consumption. The insights gained from this review are applicable to any severely anemic patient who refuses blood transfusion.