Withholding and Withdrawal of Life Support from Critically Ill PatientsWithholding and withdrawal of life support are the processes by which various medical interventions either are not given to or are removed from patients with the expectation that they probably will die without such interventions. These processes are possible because technologic advances have allowed life to be supported in the first place. Because life support is often extended to critically ill patients, the question of whether to withhold or withdraw such support comes up frequently in the intensive care unit (ICU). This article examines withholding and withdrawal of life support from an ICU perspective. It begins with a historic review that specifically relates withholding and withdrawal of life support to critically ill patients. We then discuss the evolving concepts of life and death in American society, legal opinions regarding withholding or withdrawing support, the use of advance directives in such patients, medical opinions regarding withholding or withdrawing support, and how such support actually is withheld or withdrawn. Read the rest of this entry »

HLA-DQw Alloantigens and Pulmonary Dysfunction in Rheumatoid Arthritis: ConclusionIn a previous report, we found an association between HLA-DR4 and secondary Sjogrens syndrome with abnormal pulmonary function in patients with rheumatoid arthritis. This same association had been supported by other investigators. Radoux et al found that 80 percent of rheumatoid patients with airway dysfunction were HLA-DR4 positive and that a generalized abnormality of exocrine glands was present. Clinically defined pulmonary manifestations have also been reported to be more common in HLA-DR4-positive patients with rheumatoid arthritis. The present study suggests that this DR4 association may be of only secondary importance, since the variability of pulmonary function in this group can be adequately accounted for by the associated subtypes at the DQ locus. At the genomic level, studies have found one a and three P chain genes at the HLA-DR loci and two a and two P genes encoding for HLA-DQ molecules. Read the rest of this entry »

Methods
The main modification of the setup in the present study compared with that previously reported is the design of the additional resistor. The new resistor (Fig 1) was made of three layers of stainless steel screen, two layers of No. 400 mesh and one layer of No. 300 mesh. The screens were sandwiched between two thin pieces of plastic, which were then glued together (total thickness, 0.36 mm). A circular area of mesh, with a diameter of 1 inch and an area of5.067 sq cm, was exposed to the subjects air flow. The rest of the apparatus consisted of a rotary solenoid valve in which the resistor was mounted, a heated Fleisch-type pneumotachograph (HP 21071), a differential pressure transducer (Validyne MP45-14-871 ±2 cm HaO), a stimulator (Grass SD9) to standardize the duration of the addition of Rk (0.1 s), and a polygraph to record flow (Grass 79D). Though a single channel pen recorder may be all that is required to record the necessary data, for this study we digitized the flow signal and used a microcomputer to calculate R„. Read the rest of this entry »

The main finding in this study is that patients with rheumatoid arthritis who are HLA-DQwl positive have a significant reduction in pulmonary function compared to DQwl-negative individuals. The findings of a reduced FEVj, FVC, and D are consistent with an abnormal pattern of interstitial pulmonary disease in patients with rheumatoid arthritis who manifest the DQwl allele. The TLC was well preserved in this group, a finding in other cohorts of patients with rheumatoid arthritis with abnormal pulmonary function. DQw3-positive subjects showed evidence of airflow obstruction associated with an increased prevalence of keratoconjunctivitis sicca and HLA-DR4. Analysis of subgroups showed that the majority of these subjects with airflow obstruction were heterozygotes for DQwl and DQw3. Read the rest of this entry »

HLA-DQw Alloantigens and Pulmonary Dysfunction in Rheumatoid Arthritis: Pulmonary FunctionPulmonary Function
Table 4 demonstrates the data on pulmonary function classified by the major DQw phenotypes. DQwl-positive patients had evidence of a restrictive ventilatory defect with a lower percentage of predicted FEVX, FVC, and D than DQwl-negative patients. DQw3-positive patients had evidence of an obstructive ventilatory defect with a lower FEVj/FVC than DQw3-negative patients. The TLC, functional residual capacity (FRC), and RV were not significantly different between any HLA-DQw allelic subgroup. The presence of DQw2 seemed to be “protective” in that the percent predicted FEVi and FVC were significantly higher in the population of DQw2-positive patients. Read the rest of this entry »

Clinical Data
The clinical characteristics of the 47 patients grouped by major HLA-DQw status are shown on Tables 1, 2, and 3. DQwl-positive subjects included the phenotypes, DQwl/DQw-, DQwl/DQw2, and DQwl/DQw3. DQwl-negative subjects included the phenotypes DQw2/DQw-, DQw3/DQw-, and DQw2/ DQw3. Similar subclassifications were made for the presence of DQw2 and DQw3 alleles. There were no significant differences in age, race, and sex distribution, duration of disease, or functional class among patients with different DQw alleles. Laboratory data and clinical measures of disease activity were also not statistically different, except for a lower geometric mean titer of rheumatoid factor in DQwl-positive patients (p<0.05) and a lower frequency of keratoconjunctivitis sicca in DQw2-positive patients (p<0.05). buy glucophage Read the rest of this entry »

HLA-DQw Alloantigens and Pulmonary Dysfunction in Rheumatoid Arthritis: Laboratory DataLaboratory Data
Laboratory studies included complete blood cell count, platelet count, Westergrens erythrocyte sedimentation rate (ESR), rheumatoid factor by latex fixation, and antinuclear antibody. Chest roentgenograms were performed in all patients and were rated for the presence or absence of the following characteristics: hyperinflation; increased interstitial markings; pleural abnormalities; or localized scarring or atelectasis. Chest roentgenograms were classified as normal if there was no abnormality other than localized disease. read more Read the rest of this entry »

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