News - Part 30

Mechanical Ventilation for Pneumocystis сarinii Pneumonia in Patients With the Acquired Immunodeficiency Syndrome: TreatmentFourteen patients were initially hospitalized in ICUs (3 survivors and 11 nonsurvivors). The 19 others (3 survivors and 16 nonsurvivors) were hospitalized for 6.9 ±6.3 days (range, 1 to 22 days) before they were transferred to ICUs. The antiparasitic treatment had been started in 14 patients 7 ±5.6 days before their transfer (range, 3 to 22 days) and in almost all of them, the steroids were associated to cotrimoxazole four times.
Three patient groups were defined according to the period during which TMP-SMZ and steroids were given before the beginning of MV, as follows: group 1 (n = 10) less than 5 days of TMP-SMZ with (n = 9) or without (n = 1) steroids; group 2 (n = 4) 5 days or more of TMP-SMZ and less than 5 days of steroids; group 3 (n = 19) 5 days or more of TMP-SMZ and steroids. This latter group represented the treatment failures (Table 2). canadianneighborpharmacy.com

The overall mortality rate was 81.8 percent (27/33 patients). Death associated with ARF occurred 20 ±9.8 days after the beginning of treatment (range, 6 to 54 days) and after 11.4 ±9.9 days of MV (range, 1 to 46 days). The mortality rate among patients placed on a regimen of M V after failure of medical treatment (group 3) was 94.7 percent, compared with 50 percent in group 1 (p = 0.02).
Among the survivors (Table 3), five were in group 1 and one was in group 3. There was no significant difference between the survivors and nonsurvivors in terms of duration of symptoms before admission, age, simplified acute physiology score, P&02, lactate dehydrogenase activity or the CD4 lymphocyte count at admission (Table 4).

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Twenty-nine men and four women required tracheal intubation and MV for ARF secondary to PCP (Table 1). Pneumocystis carinii pneumonia was the presenting illness in nine cases. The other patients, known as HIV infected, were not being seen regularly by a physician (n = 6), were asymptomatic (n = 7), or were suffering from clinical manifestations (n= 11): AIDS-related complex (n=l), Kaposi’s sarcoma (n = 4), recurrent cutaneous herpes or shingles (n = 2), herpetic esophagitis (n = l), pulmonary tuberculosis (n = l), pulmonary aspergillosis (n = l), HIV encephalitis (n = 1), cryptosporidiosis (n = 1), or oral hairy leuko-plasia (n = 1). Five patients were receiving zidovudine when PCP was diagnosed.
It was the first episode of PCP in all patients but one. Three received primary prophylaxis, either with monthly pentamidine aerosols (n = 2) or with daily cotrimoxazole (n = l). One patient presented with a second episode of PCP 6 months after the first and despite monthly pentamidine aerosols by way of secondary prophylaxis.
The clinical signs of PCP were as follows: dyspnea (n = 33), dry cough (n = 21), temperature above 38°C (n = 28), weight loss (n = 7), fatigue (n = 7), and anorexia (n = 4). Pulmonary radiographs showed diffuse interstitial and alveolar opacities in every case. canadian pharmacy mall

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Mechanical Ventilation for Pneumocystis сarinii Pneumonia in Patients With the Acquired Immunodeficiency Syndrome: MethodsPneumocystis carinii, alone or in association with other opportunistic pathogens, accounts for 85 percent of the respiratory tract infections in patients with the acquired immunodeficiency syndrome (AIDS). In France, P carinii pneumonia (PCP) occurs in 60 percent of AIDS patients during the course of the disease and is the presenting manifestation in about 35 percent of cases.2 Between 5 and 30 percent of first PCP episodes are fatal.2 Mechanical ventilation (MV) for acute respiratory failure (ARF) during PCP was initially associated with mortality rates close to 100 percent, but survival rates of 50 percent have recently been reported. These contradictory results prompted us to reevaluate the prognosis of PCP requiring MV for ARF and to question the existence of subgroups of patients with different prognosis. my canadian pharmacy online

Patients
In a retrospective study, we analyzed the files of all human immunodeficiency virus (HIV)-infected patients intubated and ventilated for ARF secondary to PCP in 2 ICUs over a 60-month period (January 1, 1987 to January 1, 1992). The admission in ICUs was guided by the presence of ARF, which was defined by clinical signs of respiratory failure and a PaO, value of 50 mm Hg or less on room air. The indications of MV were muscular weakness (appearance of hypercarbia) and/or threatening hypoxemia (tachycardia, hyperventilation, PaO <50 mm Hg) in spite of a strong flow of oxygen administered by facial mask or nasal prong. Patient s initial severity was assessed using the simplified acute physiology score.® Pneumocystis carinii was sought in bronchoalveolar lavage (BAL) fluid and/or open-chest lung biopsy (ОС LB) specimens by staining with Gomori-Grocott and Ciemsa, silver stain and, more recently, with human monoclonal anti-Pneumocystis antibodies. In addition, BAL specimens were studied for the presence of other pathogens by means of Cram staining, direct immunofluorescence for legio-nellae, and culture for Mycobacterium species, viruses, and fungi.
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Rapid Resolution of Hyperkinesis After Exercise: ConclusionQuantitative Two-Dimensional Echocardiography
While there are few data on intraobserver variability in wall thickness measurements, the 8 percent interobserver variability was similar to the 6 to 8 percent reported by others. These previous studies, however, used area-based methods for wall thickness measurements, tracing the endocardial and epicardial borders, and measuring myocardial area at end-dias-tole and end-systole. We used a linear method, since acoustic shadowing from ribs and lung at peak exercise prevented the visualization of the entire endocardial circumference. While an area method may be more robust than a linear method because of spatial averaging, we averaged multiple linear dimensions. Such clinically useful Unear measurements of wall thickness obtained from two-dimensional echocardiograms are similar to those obtained with M-mode echocardiography. canadianfamilypharmacy

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The major finding of this study was that maximal systolic wall thickening occurred within 2 min after exercise, then returned to baseline, corresponding to changes in hemodynamics.
Temporal Variability in Thickening
Exercise two-dimensional echocardiography is used to identify wall motion abnormalities that develop during ischemia in patients with coronary artery disease. When myocardial perfusion is inadequate during the increased oxygen consumption associated with exercise, wall motion is reduced. In contrast, normal myocardium, after exercise, is hyperkinetic, with increased wall thickening, decreased systolic cavity size, and essentially normal diastolic dimensions. However, there are few studies on the time course of normal systolic function after exercise. In an M-mode echocardiographic study of normal subjects, Berberich et al demonstrated a trend toward baseline function by 3 min after exercise; by 4 to 5 minutes, function had returned to baseline. In their study, cavity dimensions, not wall thicknesses, were measured.
In our study, the return of systolic wall thickening to baseline occurred with the return of hemodynamics toward normal. This reflects the influence of circulating catecholamines on both contractility (specifically, wall thickening) and heart rate. Since systolic wall thickening returned to baseline at 2 to 4 min after exercise, our study provides objective data in support of the recommendations of other authors that imaging should be completed within 2 min of peak exercise 13.16.20 jn order to assess maximal wall thickening.
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Rapid Resolution of Hyperkinesis After Exercise: ResultsThere were significant (p<0.0001) changes over the time course of the study for heart rate, systolic BP, and rate pressure product (Table 1). Each postexercise heart rate mean was significantly increased over baseline (p<0.01). There was a significant elevation (p<0.005) of systolic BP until 5 to 7 min postexercise when there was a return to baseline. The pattern of elevation and recovery of the rate pressure product was the same as for systolic BP with a significant elevation (p<0.001) until 5 to 7 minutes postexercise when there was a return to baseline.
Wall thickness change could be measured in six of the eight subjects at 0 to 2 minutes postexercise. In the parasternal long-axis view, wall thickness change could be measured from the basal anterior septum (n = 6) and basal posterior region (n = 5), but not from the mid anterior or mid inferior lateral regions. In the parasternal short-axis view, wall thickness could be measured from the mid-inferior lateral (n = 5), mid-anterior septal (n = 3), mid-inferior (n = 2), and mid-septal (n = 1) regions, but not from the mid-anterior and lateral regions. Wall thickening is reported for the regions with the highest yields for measurement: in the parasternal long-axis view, the basal anterior septal and basal posterior regions, and in the parasternal short-axis views, the mid-anterior septal and midinferior lateral regions. These four regions were included in the analysis of variance model.
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Only the parasternal long- and short-axis views were used for wall thickening measurements; endocardial surfaces were not consistendy visualized from the apical views at peak exercise. End-diastolic and end-systolic frames were digitized from videotape using a frame grabber (Nova Microsonics Color-Vue II) (512 X 240 x 6 bit matrix). End-diastole was defined as the frame just prior to, or during, mitral valve closure. End-systole was defined as the frame prior to mitral valve opening in long-axis views or as the smallest cavity area in short-axis views.® Parasternal long- and short-axis views were divided into four and six regions, respectively (Fig 1). Regional end-diastolic and end-systolic wall thickness was measured by averaging ten lengths evenly distributed within each region, using the leading edge-to-leading edge method.
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