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Papers by Jonathan Wiesen

Indian Journal of Critical Care Medicine, 2015

The United States experienced a postpandemic outbreak of H1N1 influenza in 2013-2014. Unlike the ... more The United States experienced a postpandemic outbreak of H1N1 influenza in 2013-2014. Unlike the pandemic in 2009 clinical course and outcomes associated with critical illness in this postpandemic outbreak has been only sparsely described. We conducted a retrospective analysis of all patients admitted to the Medical Intensive Care Unit with H1N1 influenza infection in 2009-2010 (pandemic) and 2013-2014 (postpandemic). Patients admitted in the postpandemic period were older (55 ± 13 vs. 45 ± 12, P = 0.002), and had a higher incidence of underlying pulmonary (17 vs. 7, P = 0.0007) and cardiac (16 vs. 8, P = 0.005) disease. Mechanical ventilation was initiated in most patients in both groups (27 vs. 21, P = 1.00). The PaO2/FiO2 ratio was significantly higher in the pandemic group on days 1 (216 vs. 81, P = 0.0009), 3 (202 ± 99 vs. 100 ± 46, P = 0.002) and 7 (199 ± 103 vs. 113 ± 44, P = 0.019) but by day 14 no difference was seen between the groups. Rescue therapies were used in more patients in the postpandemic period (48% vs. 20%, P = 0.028), including more frequent use of prone ventilation (10 vs. 3, P = 0.015), inhaled vasodilator therapy (11 vs. 4, P = 0.015) and extracorporeal membrane oxygenation (ECMO) (4 vs. 2, P = NS). No significant differences in mortality were seen between the two cohorts. Compared to the 2009-2010 pandemic, the 2013-2014 H1N1 strain affected older patients with more underlying co-morbid cardio-pulmonary diseases. The patients had worse oxygenation indices and rescue modalities such as prone ventilation, inhaled epoprostenol and ECMO, were used more consistently as compared to the 2009 pandemic.

Indian Journal of Critical Care Medicine, 2015

The United States experienced a postpandemic outbreak of H1N1 influenza in 2013-2014. Unlike the ... more The United States experienced a postpandemic outbreak of H1N1 influenza in 2013-2014. Unlike the pandemic in 2009 clinical course and outcomes associated with critical illness in this postpandemic outbreak has been only sparsely described. We conducted a retrospective analysis of all patients admitted to the Medical Intensive Care Unit with H1N1 influenza infection in 2009-2010 (pandemic) and 2013-2014 (postpandemic). Patients admitted in the postpandemic period were older (55 ± 13 vs. 45 ± 12, P = 0.002), and had a higher incidence of underlying pulmonary (17 vs. 7, P = 0.0007) and cardiac (16 vs. 8, P = 0.005) disease. Mechanical ventilation was initiated in most patients in both groups (27 vs. 21, P = 1.00). The PaO2/FiO2 ratio was significantly higher in the pandemic group on days 1 (216 vs. 81, P = 0.0009), 3 (202 ± 99 vs. 100 ± 46, P = 0.002) and 7 (199 ± 103 vs. 113 ± 44, P = 0.019) but by day 14 no difference was seen between the groups. Rescue therapies were used in more patients in the postpandemic period (48% vs. 20%, P = 0.028), including more frequent use of prone ventilation (10 vs. 3, P = 0.015), inhaled vasodilator therapy (11 vs. 4, P = 0.015) and extracorporeal membrane oxygenation (ECMO) (4 vs. 2, P = NS). No significant differences in mortality were seen between the two cohorts. Compared to the 2009-2010 pandemic, the 2013-2014 H1N1 strain affected older patients with more underlying co-morbid cardio-pulmonary diseases. The patients had worse oxygenation indices and rescue modalities such as prone ventilation, inhaled epoprostenol and ECMO, were used more consistently as compared to the 2009 pandemic.

The clinical respiratory journal, Jan 10, 2015

Yellow nail syndrome is a rare disorder involving characteristic nail changes, lymphedema and chr... more Yellow nail syndrome is a rare disorder involving characteristic nail changes, lymphedema and chronic respiratory symptoms. Currently there is no definitive treatment and there have been no prospective randomised controlled trials evaluating the available options. In order to strengthen the literature on this topic, we present the case of a 67-year-old man with YNS and a detailed review of current treatment options. We included 40 articles for the final review according to their relevance with the subject. Data for use of the commonly chosen therapies for YNS remains inconclusive, with small studies and case reports showing mixed results of efficacy. Although the date indicates that it is reasonable to recommend a trial of conservative therapy including vitamin E, antibiotics and compression stockings before pursuing more aggressive or invasive modalities, larger scale studies are required to determine the true efficacy of all treatment options.

Critical Care Medicine

Introduction: Objective measures with precise guidelines are employed to ensure standardized and ... more Introduction: Objective measures with precise guidelines are employed to ensure standardized and reproducible assessments of the mental status of patients in the medical intensive care unit (MICU). We hypothesize that, despite using similar clinical scoring tools, there is still discordance between nurse and physician evaluation of patients' mental status. Methods: An IRB-approved cross sectional trial evaluating the mental and sedation status of all patients in the MICU during the daytime was performed. Using our electronic medical record we recorded the last documented nursing (RN) assessment of each patient's mental and sedation status by the Glascow Coma Scale (GCS), Confusion Assessment Method for the ICU (CAM-ICU), and Richmond Agitation and Sedation Score (RASS). We then assessed the same evaluations by a study physician's (MD). We compared both evaluations. Results: One hundred and twenty seven patients were evaluated who were in the hospital for a mean +/- SD of...

Critical Care Medicine

Introduction: Delirium is common in the medical intensive care unit (MICU). It often interferes w... more Introduction: Delirium is common in the medical intensive care unit (MICU). It often interferes with patient care and extends hospital and ICU length of stay. A multicomponent non-pharmacological intervention on the regular nursing floors (RNF) decreased the incidence of delirium (Inouye et al. NEJM 1999;340(9):669-676). We hypothesize that due to higher acuity and increased level of patient care required, many of the interventions are not utilized in the MICU. Methods: A cross-sectional study, IRB approved, was conducted. We performed mid-day assessments on all patients in the MICU. We adapted the Yale Delirium Prevention Study to define the non-pharmacological delirium prevention strategies as follows: 1) Orientation, a board with team member's names, date and daily activities; 2) Cognitive stimulation, family at bedside or an intellectual activity (e.g. reading, a computer); 3) Sleep -wake cycle, allowing uninterrupted sleep and 4) lights on during the day; 5) Mobility, out o...

German Studies Review, 2015

D103. CASE REPORTS: GENERAL PULMONARY, 2012

Cleveland Clinic Journal of Medicine, 2012

The fractional excretion of urea (FEU) is a useful index for differentiating the main categories ... more The fractional excretion of urea (FEU) is a useful index for differentiating the main categories of causes of acute kidney injury, ie, prerenal causes and intrinsic causes. It may be used in preference to the more widely used fractional excretion of sodium (FENa) in situations in which the validity of the latter is limited, such as in patients taking a diuretic.

Innate regulatory networks within organs maintain tissue homeostasis and facilitate rapid respons... more Innate regulatory networks within organs maintain tissue homeostasis and facilitate rapid responses to damage. We identified a novel pathway regulating vessel stability in tissues that involves matrix metalloproteinase 14 (MMP14) and transforming growth factor beta 1 (TGFb 1 ). Whereas plasma proteins rapidly extravasate out of vasculature in wild-type mice following acute damage, short-term treatment of mice in vivo with a broadspectrum metalloproteinase inhibitor, neutralizing antibodies to TGFb 1 , or an activin-like kinase 5 (ALK5) inhibitor significantly enhanced vessel leakage. By contrast, in a mouse model of age-related dermal fibrosis, where MMP14 activity and TGFb bioavailability are chronically elevated, or in mice that ectopically express TGFb in the epidermis, cutaneous vessels are resistant to acute leakage. Characteristic responses to tissue damage are reinstated if the fibrotic mice are pretreated with metalloproteinase inhibitors or TGFb signaling antagonists. Neoplastic tissues, however, are in a constant state of tissue damage and exhibit altered hemodynamics owing to hyperleaky angiogenic vasculature. In two distinct transgenic mouse tumor models, inhibition of ALK5 further enhanced vascular leakage into the interstitium and facilitated increased delivery of high molecular weight compounds into premalignant tissue and tumors. Taken together, these data define a central pathway involving MMP14 and TGFb that mediates vessel stability and vascular response to tissue injury. Antagonists of this pathway could be therapeutically exploited to improve the delivery of therapeutics or molecular contrast agents into tissues where chronic damage or neoplastic disease limits their efficient delivery.

Annals of Intensive Care, 2012

Background: Critical illness due to 2009 H1N1 influenza has been characterized by respiratory com... more Background: Critical illness due to 2009 H1N1 influenza has been characterized by respiratory complications, including acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), and associated with high mortality. We studied the severity, outcomes, and hospital charges of patients with ALI/ARDS secondary to pandemic influenza A infection compared with ALI and ARDS from other etiologies. Methods: A retrospective review was conducted that included patients admitted to the Cleveland Clinic MICU with ALI/ARDS and confirmed influenza A infection, and all patients admitted with ALI/ARDS from any other etiology from September 2009 to March 2010. An itemized list of individual hospital charges was obtained for each patient from the hospital billing office and organized by billing code into a database. Continuous data that were normally distributed are presented as the mean ± SD and were analyzed by the Student's t test. The chi-square and Fisher exact tests were used to evaluate differences in proportions between patient subgroups. Data that were not normally distributed were compared with the Wilcoxon rank-sum test.

C49. INTENSIVE CARE UNIT MANAGEMENT AND OUTCOME, 2011

Infectious Diseases in Clinical Practice, 2014

ABSTRACT Klebsiella pneumoniae is a Gram-negative bacillus with a strong presence in the health c... more ABSTRACT Klebsiella pneumoniae is a Gram-negative bacillus with a strong presence in the health care setting. Carbapenem-resistant strains of K pneumoniae (KPC) have recently become an increasing cause of nosocomial morbidity and mortality. In an era that has witnessed the production of bacteria highly resistant to conventional antibiotics, atypical sites of infection are often caused by multidrug-resistant pathogens, further complicating treatment of infectious diseases.Klebsiella pneumoniae is rarely a cause of endocarditis; however, in patients with KPC bacteremia, physicians should be aware of the possibility of KPC endocarditis. The presence of KPC endocarditis should prompt surgical evaluation in addition to targeted antibiotic therapy. This is, to our knowledge, the first reported case of prosthetic valve KPC endocarditis.

When the Federal Republic of Germany was founded in 1949, few would have predicted the remarkable... more When the Federal Republic of Germany was founded in 1949, few would have predicted the remarkable success of its democratic order. A nation with the shallowest of roots in democratic traditions grew to be one of the world's most stable democracies. But how democratic is Germany's post- war republic? One way of assessing its achievement is to explore how the country has dealt with social and political challenges, how it has debated fundamental questions and sought to resolve crises. The lecturers in this series will offer their interpretations by considering central issues, events, and long term trends that accompanied the development of German democracy.

The Journal of Urology, 2007

The incidence of kidney stones in adults has increased in the last 30 years. This retrospective, ... more The incidence of kidney stones in adults has increased in the last 30 years. This retrospective, single site review was done to test the hypotheses that the incidence of urolithiasis in pediatric patients increased from 1994 to 2005, and that metabolic abnormalities were more common in patients with renal stones in the final 3 years of the study period. Charts from 2 time periods were reviewed, 1994 to 1996 (period 1) and 2003 to 2005 (period 2). Clinical and laboratory data, including demographics, presenting complaints, laboratory assessment, treatment and outcome, were tabulated in patients with confirmed urolithiasis. The number of patients with urolithiasis increased from 7 in period 1 to 61 in period 2. When expressed as cases per 100 new patients the incidence increased 4.6 times (p = 0.014). Focusing on period 2, 28% of patients were younger than 10 years. While blood tests were generally normal, 76% of patients had at least 1 abnormality in the 24-hour urine collection. Hypocitraturia, which was the most common metabolic abnormality, was noted in 52% of patients. The small number of patients in period 1 precluded determination as to whether metabolic abnormalities were more common in period 2. Surgery and/or lithotripsy was required in 12 children. Stone disease recurred in 39% of the patients. The incidence of urolithiasis in the pediatric population increased nearly 5-fold at our institution during the last decade. We recommend that the primary diagnostic test be a 24-hour urine collection. The most common metabolic abnormality was hypocitraturia, followed by hypercalciuria. Recurrence of stones is common (approximately 40% rate) and followup is advised.

Heart, 2013

The need to provide invasive mechanical ventilatory support to patients with myocardial infarctio... more The need to provide invasive mechanical ventilatory support to patients with myocardial infarction and acute left heart failure is common. Despite the large number of patients requiring mechanical ventilation in this setting, there are remarkably few data addressing the ideal mode of respiratory support in such patients. Although there is near universal acceptance regarding the use of non-invasive positive pressure ventilation in patients with acute pulmonary oedema, there is more concern with invasive positive pressure ventilation owing to its more significant haemodynamic impact. Positive end-expiratory pressure (PEEP) is almost universally applied in mechanically ventilated patients due to benefits in gas exchange, recruitment of alveolar units, counterbalance of hydrostatic forces leading to pulmonary oedema and maintenance of airway patency. The limited available clinical data suggest that a moderate level of PEEP is safe to use in severe left ventricular (LV) dysfunction and cardiogenic shock, and may provide haemodynamic benefits as well in LV failure which exhibits afterload-sensitive physiology.

Indian Journal of Critical Care Medicine, 2015

The United States experienced a postpandemic outbreak of H1N1 influenza in 2013-2014. Unlike the ... more The United States experienced a postpandemic outbreak of H1N1 influenza in 2013-2014. Unlike the pandemic in 2009 clinical course and outcomes associated with critical illness in this postpandemic outbreak has been only sparsely described. We conducted a retrospective analysis of all patients admitted to the Medical Intensive Care Unit with H1N1 influenza infection in 2009-2010 (pandemic) and 2013-2014 (postpandemic). Patients admitted in the postpandemic period were older (55 ± 13 vs. 45 ± 12, P = 0.002), and had a higher incidence of underlying pulmonary (17 vs. 7, P = 0.0007) and cardiac (16 vs. 8, P = 0.005) disease. Mechanical ventilation was initiated in most patients in both groups (27 vs. 21, P = 1.00). The PaO2/FiO2 ratio was significantly higher in the pandemic group on days 1 (216 vs. 81, P = 0.0009), 3 (202 ± 99 vs. 100 ± 46, P = 0.002) and 7 (199 ± 103 vs. 113 ± 44, P = 0.019) but by day 14 no difference was seen between the groups. Rescue therapies were used in more patients in the postpandemic period (48% vs. 20%, P = 0.028), including more frequent use of prone ventilation (10 vs. 3, P = 0.015), inhaled vasodilator therapy (11 vs. 4, P = 0.015) and extracorporeal membrane oxygenation (ECMO) (4 vs. 2, P = NS). No significant differences in mortality were seen between the two cohorts. Compared to the 2009-2010 pandemic, the 2013-2014 H1N1 strain affected older patients with more underlying co-morbid cardio-pulmonary diseases. The patients had worse oxygenation indices and rescue modalities such as prone ventilation, inhaled epoprostenol and ECMO, were used more consistently as compared to the 2009 pandemic.

Indian Journal of Critical Care Medicine, 2015

The United States experienced a postpandemic outbreak of H1N1 influenza in 2013-2014. Unlike the ... more The United States experienced a postpandemic outbreak of H1N1 influenza in 2013-2014. Unlike the pandemic in 2009 clinical course and outcomes associated with critical illness in this postpandemic outbreak has been only sparsely described. We conducted a retrospective analysis of all patients admitted to the Medical Intensive Care Unit with H1N1 influenza infection in 2009-2010 (pandemic) and 2013-2014 (postpandemic). Patients admitted in the postpandemic period were older (55 ± 13 vs. 45 ± 12, P = 0.002), and had a higher incidence of underlying pulmonary (17 vs. 7, P = 0.0007) and cardiac (16 vs. 8, P = 0.005) disease. Mechanical ventilation was initiated in most patients in both groups (27 vs. 21, P = 1.00). The PaO2/FiO2 ratio was significantly higher in the pandemic group on days 1 (216 vs. 81, P = 0.0009), 3 (202 ± 99 vs. 100 ± 46, P = 0.002) and 7 (199 ± 103 vs. 113 ± 44, P = 0.019) but by day 14 no difference was seen between the groups. Rescue therapies were used in more patients in the postpandemic period (48% vs. 20%, P = 0.028), including more frequent use of prone ventilation (10 vs. 3, P = 0.015), inhaled vasodilator therapy (11 vs. 4, P = 0.015) and extracorporeal membrane oxygenation (ECMO) (4 vs. 2, P = NS). No significant differences in mortality were seen between the two cohorts. Compared to the 2009-2010 pandemic, the 2013-2014 H1N1 strain affected older patients with more underlying co-morbid cardio-pulmonary diseases. The patients had worse oxygenation indices and rescue modalities such as prone ventilation, inhaled epoprostenol and ECMO, were used more consistently as compared to the 2009 pandemic.

The clinical respiratory journal, Jan 10, 2015

Yellow nail syndrome is a rare disorder involving characteristic nail changes, lymphedema and chr... more Yellow nail syndrome is a rare disorder involving characteristic nail changes, lymphedema and chronic respiratory symptoms. Currently there is no definitive treatment and there have been no prospective randomised controlled trials evaluating the available options. In order to strengthen the literature on this topic, we present the case of a 67-year-old man with YNS and a detailed review of current treatment options. We included 40 articles for the final review according to their relevance with the subject. Data for use of the commonly chosen therapies for YNS remains inconclusive, with small studies and case reports showing mixed results of efficacy. Although the date indicates that it is reasonable to recommend a trial of conservative therapy including vitamin E, antibiotics and compression stockings before pursuing more aggressive or invasive modalities, larger scale studies are required to determine the true efficacy of all treatment options.

Critical Care Medicine

Introduction: Objective measures with precise guidelines are employed to ensure standardized and ... more Introduction: Objective measures with precise guidelines are employed to ensure standardized and reproducible assessments of the mental status of patients in the medical intensive care unit (MICU). We hypothesize that, despite using similar clinical scoring tools, there is still discordance between nurse and physician evaluation of patients' mental status. Methods: An IRB-approved cross sectional trial evaluating the mental and sedation status of all patients in the MICU during the daytime was performed. Using our electronic medical record we recorded the last documented nursing (RN) assessment of each patient's mental and sedation status by the Glascow Coma Scale (GCS), Confusion Assessment Method for the ICU (CAM-ICU), and Richmond Agitation and Sedation Score (RASS). We then assessed the same evaluations by a study physician's (MD). We compared both evaluations. Results: One hundred and twenty seven patients were evaluated who were in the hospital for a mean +/- SD of...

Critical Care Medicine

Introduction: Delirium is common in the medical intensive care unit (MICU). It often interferes w... more Introduction: Delirium is common in the medical intensive care unit (MICU). It often interferes with patient care and extends hospital and ICU length of stay. A multicomponent non-pharmacological intervention on the regular nursing floors (RNF) decreased the incidence of delirium (Inouye et al. NEJM 1999;340(9):669-676). We hypothesize that due to higher acuity and increased level of patient care required, many of the interventions are not utilized in the MICU. Methods: A cross-sectional study, IRB approved, was conducted. We performed mid-day assessments on all patients in the MICU. We adapted the Yale Delirium Prevention Study to define the non-pharmacological delirium prevention strategies as follows: 1) Orientation, a board with team member's names, date and daily activities; 2) Cognitive stimulation, family at bedside or an intellectual activity (e.g. reading, a computer); 3) Sleep -wake cycle, allowing uninterrupted sleep and 4) lights on during the day; 5) Mobility, out o...

German Studies Review, 2015

D103. CASE REPORTS: GENERAL PULMONARY, 2012

Cleveland Clinic Journal of Medicine, 2012

The fractional excretion of urea (FEU) is a useful index for differentiating the main categories ... more The fractional excretion of urea (FEU) is a useful index for differentiating the main categories of causes of acute kidney injury, ie, prerenal causes and intrinsic causes. It may be used in preference to the more widely used fractional excretion of sodium (FENa) in situations in which the validity of the latter is limited, such as in patients taking a diuretic.

Innate regulatory networks within organs maintain tissue homeostasis and facilitate rapid respons... more Innate regulatory networks within organs maintain tissue homeostasis and facilitate rapid responses to damage. We identified a novel pathway regulating vessel stability in tissues that involves matrix metalloproteinase 14 (MMP14) and transforming growth factor beta 1 (TGFb 1 ). Whereas plasma proteins rapidly extravasate out of vasculature in wild-type mice following acute damage, short-term treatment of mice in vivo with a broadspectrum metalloproteinase inhibitor, neutralizing antibodies to TGFb 1 , or an activin-like kinase 5 (ALK5) inhibitor significantly enhanced vessel leakage. By contrast, in a mouse model of age-related dermal fibrosis, where MMP14 activity and TGFb bioavailability are chronically elevated, or in mice that ectopically express TGFb in the epidermis, cutaneous vessels are resistant to acute leakage. Characteristic responses to tissue damage are reinstated if the fibrotic mice are pretreated with metalloproteinase inhibitors or TGFb signaling antagonists. Neoplastic tissues, however, are in a constant state of tissue damage and exhibit altered hemodynamics owing to hyperleaky angiogenic vasculature. In two distinct transgenic mouse tumor models, inhibition of ALK5 further enhanced vascular leakage into the interstitium and facilitated increased delivery of high molecular weight compounds into premalignant tissue and tumors. Taken together, these data define a central pathway involving MMP14 and TGFb that mediates vessel stability and vascular response to tissue injury. Antagonists of this pathway could be therapeutically exploited to improve the delivery of therapeutics or molecular contrast agents into tissues where chronic damage or neoplastic disease limits their efficient delivery.

Annals of Intensive Care, 2012

Background: Critical illness due to 2009 H1N1 influenza has been characterized by respiratory com... more Background: Critical illness due to 2009 H1N1 influenza has been characterized by respiratory complications, including acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), and associated with high mortality. We studied the severity, outcomes, and hospital charges of patients with ALI/ARDS secondary to pandemic influenza A infection compared with ALI and ARDS from other etiologies. Methods: A retrospective review was conducted that included patients admitted to the Cleveland Clinic MICU with ALI/ARDS and confirmed influenza A infection, and all patients admitted with ALI/ARDS from any other etiology from September 2009 to March 2010. An itemized list of individual hospital charges was obtained for each patient from the hospital billing office and organized by billing code into a database. Continuous data that were normally distributed are presented as the mean ± SD and were analyzed by the Student's t test. The chi-square and Fisher exact tests were used to evaluate differences in proportions between patient subgroups. Data that were not normally distributed were compared with the Wilcoxon rank-sum test.

C49. INTENSIVE CARE UNIT MANAGEMENT AND OUTCOME, 2011

Infectious Diseases in Clinical Practice, 2014

ABSTRACT Klebsiella pneumoniae is a Gram-negative bacillus with a strong presence in the health c... more ABSTRACT Klebsiella pneumoniae is a Gram-negative bacillus with a strong presence in the health care setting. Carbapenem-resistant strains of K pneumoniae (KPC) have recently become an increasing cause of nosocomial morbidity and mortality. In an era that has witnessed the production of bacteria highly resistant to conventional antibiotics, atypical sites of infection are often caused by multidrug-resistant pathogens, further complicating treatment of infectious diseases.Klebsiella pneumoniae is rarely a cause of endocarditis; however, in patients with KPC bacteremia, physicians should be aware of the possibility of KPC endocarditis. The presence of KPC endocarditis should prompt surgical evaluation in addition to targeted antibiotic therapy. This is, to our knowledge, the first reported case of prosthetic valve KPC endocarditis.

When the Federal Republic of Germany was founded in 1949, few would have predicted the remarkable... more When the Federal Republic of Germany was founded in 1949, few would have predicted the remarkable success of its democratic order. A nation with the shallowest of roots in democratic traditions grew to be one of the world's most stable democracies. But how democratic is Germany's post- war republic? One way of assessing its achievement is to explore how the country has dealt with social and political challenges, how it has debated fundamental questions and sought to resolve crises. The lecturers in this series will offer their interpretations by considering central issues, events, and long term trends that accompanied the development of German democracy.

The Journal of Urology, 2007

The incidence of kidney stones in adults has increased in the last 30 years. This retrospective, ... more The incidence of kidney stones in adults has increased in the last 30 years. This retrospective, single site review was done to test the hypotheses that the incidence of urolithiasis in pediatric patients increased from 1994 to 2005, and that metabolic abnormalities were more common in patients with renal stones in the final 3 years of the study period. Charts from 2 time periods were reviewed, 1994 to 1996 (period 1) and 2003 to 2005 (period 2). Clinical and laboratory data, including demographics, presenting complaints, laboratory assessment, treatment and outcome, were tabulated in patients with confirmed urolithiasis. The number of patients with urolithiasis increased from 7 in period 1 to 61 in period 2. When expressed as cases per 100 new patients the incidence increased 4.6 times (p = 0.014). Focusing on period 2, 28% of patients were younger than 10 years. While blood tests were generally normal, 76% of patients had at least 1 abnormality in the 24-hour urine collection. Hypocitraturia, which was the most common metabolic abnormality, was noted in 52% of patients. The small number of patients in period 1 precluded determination as to whether metabolic abnormalities were more common in period 2. Surgery and/or lithotripsy was required in 12 children. Stone disease recurred in 39% of the patients. The incidence of urolithiasis in the pediatric population increased nearly 5-fold at our institution during the last decade. We recommend that the primary diagnostic test be a 24-hour urine collection. The most common metabolic abnormality was hypocitraturia, followed by hypercalciuria. Recurrence of stones is common (approximately 40% rate) and followup is advised.

Heart, 2013

The need to provide invasive mechanical ventilatory support to patients with myocardial infarctio... more The need to provide invasive mechanical ventilatory support to patients with myocardial infarction and acute left heart failure is common. Despite the large number of patients requiring mechanical ventilation in this setting, there are remarkably few data addressing the ideal mode of respiratory support in such patients. Although there is near universal acceptance regarding the use of non-invasive positive pressure ventilation in patients with acute pulmonary oedema, there is more concern with invasive positive pressure ventilation owing to its more significant haemodynamic impact. Positive end-expiratory pressure (PEEP) is almost universally applied in mechanically ventilated patients due to benefits in gas exchange, recruitment of alveolar units, counterbalance of hydrostatic forces leading to pulmonary oedema and maintenance of airway patency. The limited available clinical data suggest that a moderate level of PEEP is safe to use in severe left ventricular (LV) dysfunction and cardiogenic shock, and may provide haemodynamic benefits as well in LV failure which exhibits afterload-sensitive physiology.