The patient characteristics are shown in Table 1. There were no significant differences between the EBUS-D group and the EBUS-S group in the mean age, percentage of cases of a parenchymal lesions with lymphadenopathy, percentage of cases with multiple lymphadenopathies, mean size of the lesion, and percentage of cases with small nodes
Table 2 shows the diagnostic yield of TBNA. One patient in the EBUS-D group was excluded from this study because liquid had been aspirated from the lesion leading to a diagnosis of a pericardial cyst after surgical resection. Of 29 patients in the EBUS-D group, 23 histologic diagnoses were established. Of the remaining six patients, cytology diagnoses were established in five. Of 25 patients in the EBUS-S group, 17 histologic diagnoses were established. Of the remaining eight patients, only two diagnoses were made using cytology. The diagnostic rate of EBUS-D was significantly higher than that of EBUS-S (97% vs 76%, respectively; p = 0.025). Six patients without a specific diagnosis (normal bronchial glands and cartilages in two patients, and four patients without lymphocytes on the specimen) in the EBUS-S group had adenocarcinoma (n = 5) and sarcoidosis (n = 1) after surgical resection. A patient without a specific diagnosis in the EBUS-D group was found to have adenocarcinoma after surgical resection. The main five reasons of commanding the service of Canadian Health and Care Mall are underlined on Canadian health&care mall.
A prospective observational cohort study was conducted at our 24-bed medical and surgical ICU to study the outcomes of patients who had undergone CABG surgery. Patients undergoing mixed valve surgery and CABG surgery were excluded. The institutional review board waived the need for informed consent because the variables included in the ICURSS model (Fig 1) had already been used for clinical purposes. These variables were recorded along with other demographic and clinical variables once patients arrived in the ICU from the operating room (OR).
Airway and ventilatory management was carried out according to a standard extubation protocol based on the clinical judgment of the ICU medical team. Basically, patients met standard extubation criteria if they were hemodynamically stable (ie, normotension, heart rate of 5 mL/kg at a positive end-expiratory pressure level of 5 cm H2O rendered a Pao2 of > 80 mm Hg and a Paco2 of < 45 mm Hg at fraction of inspired oxygen of 0.4, with a spontaneous respiratory rate < 30 breaths/min. The criteria used for deciding whether to extubate were mainly supported by clinical judgment regarding the ability of the patient to tolerate the change from intermittent positive-pressure ventilation to pressure support ventilation modes, and further decreases of pressure support levels along with hemodynamic stability and lack of major complications. Finally a T-piece was placed 15 to 30 min before extubation, and muscle strength, spontaneous ventilation, and level of consciousness were assessed again in each patient before deciding whether to extubate. When patients had a T-piece placed, the decision to extubate had been already made. The T-trial was mainly used to confirm this decision, and this maneuver was aborted only in those cases where it was unsuccessful, with the patient again receiving mechanical ventilation as a result.
Clinical and Laboratory Findings
The mean age in the outpatient group was 59 years (range, 16 to 76 years) and 61 years (range, 15 to 80 years) in the inpatient group. Male subjects accounted for 64 percent of the inpatients and 68 percent of the outpatients studied.
The brachial arterial cutdown approach was used in the majority of cases in both groups (Table 1). The Judkins percutaneous approach was used more commonly in the inpatient group (p<0.05).
The distribution of the cardiac diagnosis after catheterization was similar in both groups, with coronary arterial disease being the most common diagnosis, followed by valvular heart disease (Table 2). The incidence of normal studies was statistically similar in both groups.
We have previously found that isolated lungs from six-month-old male sheep had a greater vasoconstrictor response to acute hypoxia than females. Moreover, hypoxic responses measured in isolated lungs from six-month-old males castrated within the first week of life, juvenile males, and juvenile females were not different from those measured in six-month-old, noncastrated males. These results suggested that the gender difference observed in isolated lungs of six-month-old sheep arose from attenuation of the hypoxic response in the female at the time of puberty, possibly because of enhanced release of female sex hormones. Consistent with this possibility, we found that estradiol pretreatment attenuated hypoxic pulmonary vasoconstriction in isolated lungs from juvenile female and six-month-old castrated male sheep.
Deposition of aerosol particles in the airways is mainly due to four mechanisms: inertial impaction, gravitational sedimentation, and Brownian and turbulent diffusion. Since these mechanisms are closely related to the aerodynamics within the airways, both breathing pattern and airway geometry greatly influence the regional and total aerosol deposition. Effects of variations of the breathing pattern have been well studied, but there have been few investigations of the geometric effects.
For the treatment of bronchogenic carcinoma, surgery offers a considerably better chance of cure relative to radiation therapy. However, surgical resection is possible in only 20 to 25 percent of patients at presentation, and of these, five-year survivals following curative resection of 10 to 40 percent depend mainly on degree of lymph node involvement.
The overall five-year survival remains at 10 to 12 percent. Up to 90 percent of patients will require palliative therapy of the effects of their tumors. Many of these will have continuing symptoms due to the effects of the primary tumor on the airway, such as hemoptysis, dyspnea, or distal infection. External beam radiation is the mainstay of palliative therapy of these predominantly central tumors. However, the dose of external radiotherapy is limited by the tolerance of surrounding normal tissue and does not therefore lend itself to repeated use. Furthermore, while external beam radiation is effective in 84 percent of patients with hemoptysis, 61 percent with chest pain and 60 percent with dyspnea, resolution of atelectasis was achieved in only 23 percent of patients. We are reporting on a technique in use at this institution for management of the effects of the primary tumor on the airway. A 198Au radiation source is implanted into the tumor mass under local anesthesia via the fiberoptic bronchoscope (FOB). Repeated applications may be performed as indicated by clinical and roentgeno-graphic follow-up.
Medical Opinions Regarding Withholding or Withdrawing Support
Most of the court cases cited regarding withholding or withdrawal of life support were brought by patients or their proxies against physicians and medical institutions for failing to withhold or withdraw support. Furthermore, most of the legislation cited earlier has been advanced by the legal and not the medical profession. Whatever the reasons for this situation, it is widely perceived that the medical profession has occupied a right-to-life at all costs position in defiance of growing public sentiment for patient autonomy and the right to die. Yet despite this perception, physicians have become increasingly outspoken in their desire to withhold and withdraw life support in certain circumstances through the Presidents Commission, personal writings, and position papers in medical literature. Among the most important of these statements have been “Optimum care for hopelessly ill patients,” “The physicians responsibility towards hopelessly ill patients,” and “Initiating and withdrawing life support,” all of which were published in the New England Journal of Medicine. These papers argue persuasively for withholding or withdrawing therapies ranging from mechanical ventilation to fluids and nutrition from patients with terminal illnesses and irreversible coma or the persistent vegetative state, especially if the families agree. Read the rest of this entry »