Operative Nd:YAG laser plus postoperative hyperbaric oxygen reduces surgical morbidity after radical head and neck cancer surgery and complex reconstruction.

Unlabelled: Complications after radical head and neck cancer surgery in irradiated patients are frequent and life-threatening. Hemorrhage, salivary fistulas, wound infections that expose the carotid sheath, among others, make these patients difficult management challenges in the ICU. We studied the effects of Nd:YAG laser surgery plus hyperbaric oxygen (HBO2) therapy on radical head and neck resections and complex reconstruction as a means of reducing postoperative morbidity and mortality.

A prospective multicenter cohort study of the association between global tissue hypoxia and coagulation abnormalities during early sepsis resuscitation.

Objective: Coagulation activation is an integral part of sepsis pathogenesis. Experimental data suggest that endothelial exposure to hypoxia activates coagulation. We aimed to test the hypothesis that the quantity of exposure to global tissue hypoxia is associated with the degree of coagulation activation during early sepsis resuscitation.

New and improved strategies for the treatment of gout.

The Western world appears to be in the midst of the third great gout epidemic of all time. In this century, gout is increasing in prevalence despite an increased understanding of its risk factors and pathophysiology, and the availability of reasonably effective treatment. The main cultural factors responsible for this appear to be diet, obesity, ethanol use and medications.

Point-of-care assessment of microvascular blood flow in critically ill patients.

Objective: Sublingual microvascular videomicroscopy can assess tissue perfusion in critically ill patients; however, data analysis is currently limited to delayed off-line evaluation. We hypothesized that a real-time point-of-care (POC) determination of the microcirculatory flow index (MFI), an established metric for assessing microcirculatory perfusion, agrees well with the conventional off-line analysis.

Design: Prospective observational study.

Multicenter study of early lactate clearance as a determinant of survival in patients with presumed sepsis.

We sought to determine (a) if early lactate clearance is associated with improved survival in emergency department patients with severe sepsis and (b) the concordance between central venous oxygen saturation (ScvO2) optimization and lactate clearance during early sepsis resuscitation. Within a multicenter shock research network that uses quantitative resuscitation for severe sepsis, we analyzed prospectively collected registries of consecutive emergency department patients diagnosed with severe sepsis at three urban hospitals. Inclusion criteria are as follows: (a) age older than 17 years, (b) two or more systemic inflammation criteria, (c) systolic blood pressure 90 mmHg or less after fluid challenge or initial lactate of 4 mmol/L or greater, and (d ) initial and repeat lactate measurement within 6 h of resuscitation initiation.

Continuous cardiac index monitoring: A prospective observational study of agreement between a pulmonary artery catheter and a calibrated minimally invasive technique.

Introduction: Continuous cardiac index (CCI) monitoring can provide information to assist in hemodynamic support. However, pulmonary artery catheters (PAC) pose logistic challenges in acute care settings. We hypothesized that CCI measured with a calibrated minimally invasive technique (LiDCO/PulseCO, UK) would have good agreement with the PAC.

Outcome measures utilized in clinical trials of interventions for post-cardiac arrest syndrome: a systematic review.

Background: The post-cardiac arrest syndrome (period of critical illness following return of spontaneous circulation [ROSC]) is a promising window of opportunity for clinical trials of therapeutic interventions to improve outcome from cardiac arrest. However, the methodological rigor of post-ROSC trials and the ability to compare or pool data on treatment effects across studies requires consistent and appropriate outcome measures. We aimed to determine the current degree of uniformity of outcome measures in clinical trials of post-ROSC interventions.

Early arterial hypotension is common in the post-cardiac arrest syndrome and associated with increased in-hospital mortality.

Aim: After return of spontaneous circulation (ROSC) from cardiac arrest, profound myocardial stunning and systemic inflammation may cause hemodynamic alterations; however, the prevalence of post-ROSC hemodynamic instability and the strength of association with outcome have not been established. We tested the hypothesis that exposure to arterial hypotension after ROSC occurs commonly (>50%) and is an independent predictor of death.

Methods: Single-center retrospective cohort study of all post-cardiac arrest patients over 1 year.

Early increases in microcirculatory perfusion during protocol-directed resuscitation are associated with reduced multi-organ failure at 24 h in patients with sepsis.

Objective: Sepsis mortality is closely linked to multi-organ failure, and impaired microcirculatory blood flow is thought to be pivotal in the pathogenesis of sepsis-induced organ failure. We hypothesized that changes in microcirculatory flow during resuscitation are associated with changes in organ failure over the first 24 h of sepsis therapy.

Design: Prospective observational study.

Resuscitating the microcirculation in sepsis: the central role of nitric oxide, emerging concepts for novel therapies, and challenges for clinical trials.

Microcirculatory dysfunction is a critical element of the pathogenesis of severe sepsis and septic shock. In this Bench-to-Bedside review, we present: 1) the central role of the microcirculation in the pathophysiology of sepsis; 2) new translational research techniques of in vivo video microscopy for assessment of microcirculatory flow in human subjects; 3) clinical investigations that reported associations between microcirculatory dysfunction and outcome in septic patients; 4) the potential role of novel agents to "rescue" the microcirculation in sepsis; 5) current challenges facing this emerging field of clinical investigation; and 6) a framework for the design of future clinical trials aimed to determine the impact of novel agents on microcirculatory flow and organ failure in patients with sepsis. We specifically focus this review on the central role and vital importance of the nitric oxide (NO) molecule in maintaining microcirculatory homeostasis and patency, especially when the microcirculation sustains an insult (as with sepsis).

Dynamic visualization of lung sounds with a vibration response device: a case series.

Background: The field of computer-assisted mapping of lung sounds is constantly evolving and several devices have been developed in this field.

Objectives: Our objective was to evaluate a new computer-assisted lung sound imaging system, 'vibration response imaging' (VRI), that records and creates a dynamic image of breath sounds. We postulated that the VRI display format would qualitatively and quantitatively reveal breath sound distribution throughout the breathing cycle.

Serum lactate as a predictor of mortality in patients with infection.

Objective: To determine the utility of an initial serum lactate measurement for identifying high risk of death in patients with infection.

Design And Setting: Post-hoc analysis of a prospectively compiled registry in an urban academic hospital.

Participants: Patients with (a) a primary or secondary diagnosis of infection and (b) lactate measurement who were admitted over the 18 months following hospital-wide implementation of the Surviving Sepsis Campaign guideline for lactate measurement in patients with infection and possible severe sepsis.

Henoch-Schönlein purpura after etanercept therapy for psoriasis.

Etanercept is a recombinant dimeric fusion protein consisting of a tumor necrosis factor-alpha receptor ligand-binding region linked to the Fc portion of human IgG. It is approved for use in the treatment of rheumatoid arthritis, ankylosing spondylitis, juvenile rheumatoid arthritis, psoriasis, and psoriatic arthritis. Since 1998, there have been reports of vasculitic adverse events, including necrotizing vasculitis and leukocytoclastic vasculitis.

Multi-day low dose ketamine infusion for the treatment of complex regional pain syndrome.

Background: Complex regional pain syndrome (CRPS) is characterized by pain that is out of proportion to the injury and is regional in distribution. A large body of literature supports a dynamic change in the physiology and structure of central pain projecting neurons mediated through the N-methyl-D-aspartate (NMDA) receptor. A critical factor in central sensitization seems to be the release of the magnesium block on the NMDA receptor with influx of calcium and initiation of intracellular cascades.

Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department.

Objective: Early goal-directed therapy (EGDT) has been shown to decrease mortality in patients with severe sepsis and septic shock. Consensus guidelines now advocate EGDT for the first 6 h of sepsis resuscitation. However, EGDT has not yet been widely adopted in practice.

Clinical manifestations of disordered microcirculatory perfusion in severe sepsis.

Microcirculatory dysfunction plays a pivotal role in the development of the clinical manifestations of severe sepsis. Prior to the advent of new imaging technologies, clinicians had been limited in their ability to assess the microcirculation at the bedside. Clinical evidence of microcirculatory perfusion has historically been limited to physical examination findings or surrogates that could be derived from global parameters of oxygen transport.

Inclusion criteria for clinical trials in sepsis: did the American College of Chest Physicians/Society of Critical Care Medicine consensus conference definitions of sepsis have an impact?

Background: Over the last 25 years, a growing number of clinical trials have evaluated novel sepsis therapies. To promote uniformity in inclusion criteria for patient enrollment, the American College of Chest Physicians and Society of Critical Care Medicine first published consensus conference definitions for sepsis in 1992.

Study Objectives: To characterize (1) the utilization of specific criteria for patient enrollment in sepsis clinical trials and (2) the impact that the consensus conference definitions have had on these criteria.

Other supportive therapies in sepsis: an evidence-based review.

Objective: In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for other supportive therapies in sepsis that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.

Design: The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

Methods: The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum.

Thyroid disease and the skin.

Cutaneous manifestations of thyroid disease are protean in nature and can be divided into specific lesions such as the thyroglossal duct cyst and cutaneous metastases from thyroid malignancy, nonspecific signs secondary to thyroid hormone imbalance, and associated dermatologic and systemic disorders. This review represents a summary and update of thyroid disease and the skin.

Beyond easy answers: the plastic surgeon and prenatal diagnosis.

Objective: To explore how plastic surgeons handle the issue of prenatal diagnosis of cleft lip and palate.

Design: Mail survey.

Participants: The plastic surgeon listed as team contact in the team directory of the American Cleft Palate-Craniofacial Association was identified.

Use of the skeletal survey in the evaluation of child maltreatment.

The radiologic skeletal survey is an important tool for evaluating occult trauma in suspected child abuse. The purposes of this study were: (1) to determine the incidence of clinically unsuspected fractures detected by skeletal survey, and (2) to identify high-risk groups of children who would benefit from skeletal surveys. We retrospectively reviewed the medical records of 203 children admitted over a 30-month period to Children's National Medical Center for alleged physical abuse.

Diltiazem-induced drug eruption sparing seborrheic keratoses.

A case of a diltiazem-induced morbilliform drug eruption, which spared the circumferential margin of seborrheic keratoses, is presented. Hypotheses regarding the pathogenesis of this novel exanthem are discussed. The potential mechanisms may be immunologic involving cytokines, or due to diminished levels of prostaglandin E2, altered optical properties of the skin, mechanical pressure phenomena, or altered local vasoconstriction secondary to diltiazem itself.

Acral steatocystoma multiplex.

Steatocystoma multiplex (SM) is characterized by multiple, widespread cutaneous cystic lesions. These lesions can appear virtually anywhere on the body but are more common in areas where the pilosebaceous apparatus is well developed, such as the trunk (especially the presternal area), neck, axilla, inguinal region, scalp, and proximal extremities. We present a case of a woman with predominantly acrally located SM.

Phase II study of mifepristone (RU486) in refractory ovarian cancer.

Objective: A phase II study of Mifepristone (RU486) was conducted in patients with ovarian cancer whose tumors were resistant to cisplatin and paclitaxel, alone or in combination.

Patients And Methods: Forty-four patients were accrued into this study. All had ovarian cancer that had become resistant to cisplatin and paclitaxel.