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Search Results: 1 - 10 of 300345 matches for " Lewis J. Kaplan "
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To dose or not to dose: that is the (starch) question ...
Lewis J Kaplan
Critical Care , 2010, DOI: 10.1186/cc8973
Abstract: Hydroxyethyl starch (HES) has been vilified, praised, or largely ignored as a resuscitation fluid depending on the setting within which the HES is administered. The most recent HES focus has been on renal injury when HES is administered to patients with severe sepsis or septic shock. Boussekey and colleagues have provided us with a single-center, 2-year view of how HES use in the intensive care unit relates to renal function [1]. Several elements of this study merit discussion.First, Boussekey and colleagues' study is similar to another that provided a snapshot view of fluid resuscitation in a host of European intensive care units [2]. Most notably, HES use was not associated with renal injury even when administered to patients with sepsis. This finding reflects a relatively low dose of HES, consistent with that used in the current study - quite different from the doses used in studies decrying the use of HES [3-5].Like the study of Sakr and colleagues [2], HES was only one component of a multimodal approach to fluid management. This critical element underscores the observation that HES does not provide significant free water. Resuscitation with only HES (as predominantly occurs in HES trials) will therefore establish a hyperoncotic state and predictably lead to acute kidney injury (AKI) or acute renal failure (ARF) [6].Third, the authors are to be congratulated on applying an objective and evidence-based approach to categorizing renally relevant events - the RIFLE criteria [7]. Most trials evaluating renal dysfunction are binary, in that ARF is present or absent; AKI is often not addressed. Moreover, the definitions used in non-RIFLE trials are often based on a percentage change in creatinine (100%), a creatinine threshold (>2.0 mg%), and the need for dialysis regardless of modality without specifying the triggering criteria. Worse still, the HES and diluents used are vastly different between trials.Boussekey and colleagues used a modern low molecular weight and de
Clinical review: Acid–base abnormalities in the intensive care unit – part II
Lewis J Kaplan, Spiros Frangos
Critical Care , 2004, DOI: 10.1186/cc2912
Abstract: Deranged acid–base physiology drives admission to a critical care arena for vast numbers of patients. Management of diverse disorders ranging from diabetic ketoacidosis to hypoperfusion with lactic acidosis from hemorrhagic or septic shock shares a variety of common therapies for disordered acid–base balance. It is encumbent upon the intensivist to decode the deranged physiology and to categorize the disorder in a meaningful fashion to direct effective repair strategies [1].Besides the traditional classification of respiratory versus metabolic, acidosis versus alkalosis, and gap versus nongap (normal gap), the intensivist benefits from classifying acid–base disorders into three discrete groups: iatrogenically induced (i.e. hyperchloremic metabolic acidosis), a fixed feature of a pre-existing disease process (i.e. chronic renal failure, hyperlactatemia), or a labile feature of an evolving disease process (i.e. lactic acidosis from hemorrhage, shock of any cause). The therapy for, and the outcome from, each of these three categories may be distinctly different. A review of the genesis of acid–base abnormalities is appropriate but will be limited to metabolic derangements, as respiratory acid–base abnormalities are usually reparable with adjustments in sedative or ventilator prescription.Traditional paradigms of acid–base abnormalities hinge on generation of protons from the liberation of metabolic acids such as lactate or carbonic acid from increased CO2. Most traditional views rely on the Henderson–Hasselbach equation to determine the pH and proton concentration. Other attempts at classification rely upon nomograms with imprecise 'grey zones' to account for the imprecision in the Henderson–Hasselbach equation solutions. The key fault with these determinations is reliance upon bicarbonate as a determinant of the pH. In 1983, Peter Stewart clarified the physical chemistry principles that describe the independent determinants of proton concentration and pH, allowing the
Airway pressure release ventilation increases cardiac performance in patients with acute lung injury/adult respiratory distress syndrome
Lewis J Kaplan, Heatherlee Bailey, Vincent Formosa
Critical Care , 2001, DOI: 10.1186/cc1027
Abstract: Patients with severe acute lung injury or ARDS who were managed with inverse-ratio pressure control ventilation, neuromuscular blockade and a pulmonary artery catheter were switched to APRV. Hemodynamic performance, as well as pressor and sedative needs, was assessed after discontinuing neuromuscular blockadeMean age was 58 ± 9 years (n = 12) and mean Lung Injury Score was 7.6 ± 2.1. Temperature and arterial oxygen tension/fractional inspired oxygen (FiO2) were similar among the patients. Peak airway pressures fell from 38 ± 3 for PCV to 25 ± 3 cmH2O for APRV, and mean pressures fell from 18 ± 3 for PCV to 12 ± 2 cmH2O for APRV. Paralytic use and sedative use were significantly lower with APRV than with PCV. Pressor use decreased substantially with ARPV. Lactate levels remained normal, but decreased on APRV. Cardiac index rose from 3.2 ± 0.4 for PCV to 4.6 ± 0.3 l/min per m2 body surface area (BSA) for APRV, whereas oxygen delivery increased from 997 ± 108 for PCV to 1409 ± 146 ml/min for APRV, and central venous pressure declined from 18 ± 4 for PCV to 12 ± 4 cmH2O for APRV. Urine output increased from 0.83 ± 0.1 for PCV to 0.96 ± 0.12 ml/kg per hour for APRV.APRV may be used safely in patients with ALI/ARDS, and decreases the need for paralysis and sedation as compared with PCV-inverse ratio ventilation (IRV). APRV increases cardiac performance, with decreased pressor use and decreased airway pressure, in patients with ALI/ARDS.The optimal method of ventilating and oxygenating patients with ALI or ARDS remains a hotly debated topic. Recent advances in lung injury research have refocused clinical attention on reduced tidal volumes and limited peak airway pressures in order to diminish the impact of gas delivery to lungs with abnormal compliance, volume, and regional time constants [1]. Despite such focus, the benefits of a pressure-limited or volume-limited strategy for ALI remain controversial [2]. From the midst of multiple competing methods, the open lung model
Abdominal Compartment Syndrome: Risk Factors, Diagnosis, and Current Therapy
Gina M. Luckianow,Matthew Ellis,Deborah Governale,Lewis J. Kaplan
Critical Care Research and Practice , 2012, DOI: 10.1155/2012/908169
Abstract: Abdominal compartment syndrome’s manifestations are difficult to definitively detect on physical examination alone. Therefore, objective criteria have been articulated that aid the bedside clinician in detecting intra-abdominal hypertension as well as the abdominal compartment syndrome to initiate prompt and potentially life-saving intervention. At-risk patient populations should be routinely monitored and tiered interventions should be undertaken as a team approach to management. 1. Introduction The concepts of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are pervasive, but the objective criteria by which to diagnose each of these entities are often misunderstood [1]. IAH and ACS occur in both medical and surgical Intensive Care Units (ICU), the general ward, and may even occur the Emergency Department. Successful outcomes rely on early and accurate diagnosis combined with timely therapy [2–4]. Herein we describe these conditions, identify the at-risk patient populations, review diagnostic techniques as well as tiered medical management strategies, acute surgical therapy and long-term interventions to improve patient safety, optimize survival, and decrease morbidity. 2. Epidemiology Changes in fluid resuscitation paradigms, such as Early Goal Directed Therapy (EGDT) in the medical realm, and “damage control resuscitation” in the trauma realm, have increased patient survival [5, 6]. As a result of vigorous fluid resuscitation, however, each has also been associated with an unanticipated and undesired consequence—intra-abdominal hypertension and abdominal compartment syndrome (ACS). Given the detrimental effects of ACS (organ failure and death), heightened awareness surrounding the recognition of IAH and its progression to ACS, as well as the reporting of ACS, is paramount for optimal patient care. IAH is estimated to occur in 32.1% of ICU patients, and ACS has been reported in up to 4.2% of patients requiring critical care [7]. In order to identify each of these, one must be familiar with their definitions. 3. Definitions According to the World Society of the Abdominal Compartment Syndrome (WSACS), ACS may be defined as sustained intra-abdominal pressure (IAP) of >20?mm?Hg with the presence of an attributable organ failure [8]. While the WSACS has defined the parameters of ACS, it is important to delineate ACS from its predecessor, intra-abdominal hypertension. Absent from any disease processes, the average intra-abdominal pressure ranges from 5 to 7?mm?Hg with a normal upper limit of 12?mm?Hg [8]. Thus, a sustained IAP
Type I Interferons Are Associated with Subclinical Markers of Cardiovascular Disease in a Cohort of Systemic Lupus Erythematosus Patients
Emily C. Somers, Wenpu Zhao, Emily E. Lewis, Lu Wang, Jeffrey J. Wing, Baskaran Sundaram, Ella A. Kazerooni, W. Joseph McCune, Mariana J. Kaplan
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0037000
Abstract: Background Systemic lupus erythematosus (SLE) patients have a striking increase in cardiovascular (CV) comorbidity not fully explained by the Framingham risk score. Recent evidence from in vitro studies suggests that type I interferons (IFN) could promote premature CV disease (CVD) in SLE. We assessed the association of type I IFN signatures with functional and anatomical evidence of vascular damage, and with biomarkers of CV risk in a cohort of lupus patients without overt CVD. Methodology/Principal Findings Serum type I IFN activity (induction of five IFN-inducible genes; IFIGs) from 95 SLE patient and 38 controls was quantified by real-time PCR. Flow mediated dilatation (FMD) of the brachial artery and carotid intima media thickness (CIMT) were quantified by ultrasound, and coronary calcification by computed tomography. Serum vascular biomarkers were measured by ELISA. We evaluated the effect of type I IFNs on FMD, CIMT and coronary calcification by first applying principal components analysis to combine data from five IFIGs into summary components that could be simultaneously modeled. Three components were derived explaining 97.1% of the total IFIG variation. Multivariable linear regression was utilized to investigate the association between the three components and other covariates, with the outcomes of FMD and CIMT; zero-inflated Poisson regression was used for modeling of coronary calcification. After controlling for traditional CV risk factors, enhanced serum IFN activity was significantly associated with decreased endothelial function in SLE patients and controls (p<0.05 for component 3), increased CIMT among SLE patients (p<0.01 for components 1 and 2), and severity of coronary calcification among SLE patients (p<0.001 for component 3). Conclusions Type I IFNs are independently associated with atherosclerosis development in lupus patients without history of overt CVD and after controlling for Framingham risk factors. This study further supports the hypothesis that type I IFNs promote premature vascular damage in SLE.
Measuring CMB polarisation with the Planck HFI
J. Delabrouille,J. Kaplan
Physics , 2001, DOI: 10.1063/1.1471836
Abstract: We describe the Planck HFI design and expected performances for measuring CMB polarisation.
Cardiometabolic risk in psoriasis: differential effects of biologic agents
Mariana J Kaplan
Vascular Health and Risk Management , 2008,
Abstract: Mariana J KaplanDepartment of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USAAbstract: Psoriasis is associated to an increased risk of cardiovascular (CV) complications. Overall, the pathogenic mechanisms involved in premature CV complications in psoriasis appear to be complex and multifactorial, with traditional and nontraditional risk factors possibly contributing to the increased risk. Based on what is known about the pathogenesis of psoriasis and extrapolating the current knowledge on CV complications in other inflammatory diseases, studies are needed to investigate if appropriate control of the inflammatory, immunologic and metabolic disturbances present in psoriasis can prevent the development of this potentially lethal complication. It is clear that there is a great need for heightened awareness of the increased risk for vascular damage in patients with psoriasis. It is also crucial to closely monitor patients with psoriasis for CV risk factors including obesity, hypertension, diabetes, and hyperlipidemia. Whether treatment regimens that effectively manage systemic inflammation will lead to prevention of CV complications in psoriasis needs to be investigated. Clearly, studies should focus on establishing the exact mechanisms that determine CV risk in psoriasis so that appropriate preventive strategies and treatment guidelines can be established.Keywords: psoriasis, atherosclerosis, inflammation, vascular
Gamma ray lines from TeV dark matter
L. Bergstrom,J. Kaplan
Physics , 1994, DOI: 10.1016/0927-6505(94)90005-1
Abstract: We calculate, using unitarity, a lower bound on the branching ratio $\chi\chi\to \gamma\gamma$ and $\chi\chi\to \gamma Z$, where $\chi$ is any halo dark matter particle that has $W^+W^-$ as one of the major annihilation modes. Examples of such particles are supersymmetric particles with a dominant Higgsino component, or heavy triplet neutrinos. A substantial branching ratio is found for the $\gamma\gamma$ and $\gamma Z$ modes. We estimate the strength of the monoenergetic $\gamma$ ray lines that result from such annihilations in the Galactic or LMC halos. (Latex file; 2 compressed uuencoded postscript figures available by anonymous ftp from vanosf.physto.se in file pub/figures/lines.uu)
On the saturation of non-axisymmetric instabilites of magnetized spherical Couette flow
E. J. Kaplan
Physics , 2014, DOI: 10.1103/PhysRevE.89.063016
Abstract: We numerically investigate the saturation of the hydromagnetic instabilities of a magnetized spherical Couette flow. Previous simulations [Hollerbach, 2009] demonstrated region where the axisymmetric flow, calculated from a 2-D simulation, was linearly unstable to nonaxisymmetric perturbations. Full, nonlinear, 3d simulations [Hollerbach 2009, Travnikov 2011] showed that the saturated state would consist only of harmonics of one azimuthal wave number, though there were bifurcations and transitions as nondimensional parameters (Re, Ha) were varied. Here, the energy transfer between different aziumthal modes is formulated as a network. This demonstrates a mechanism or the saturation of one mode and for the suppression of other unstable modes. A given mode grows by extracting energy from the axisymmetric flow, and then saturates as the energy transfer to its second harmonic equals this inflow. At the same time, this mode suppresses other unstable modes by facilitating an energy transfer to linearly stable modes.
Traumatic Brain Injury and Cerebral Vascular Accident: Application of Rasch Analysis to Examine Differences in Disability and Outcome in Post-Hospital Rehabilitation  [PDF]
Frank D. Lewis, Gordon J. Horn
Open Journal of Statistics (OJS) , 2018, DOI: 10.4236/ojs.2018.84044
Abstract: The purpose of this study was to demonstrate an application of Rasch analysis to identify differences in disability profiles resulting from traumatic brain injury (TBI) and cerebral vascular accident (CVA) and to examine outcome differences between the two groups following post-hospital residential rehabilitation. Participant data were collected from 32 facilities in 16 states. From 2990 neurologically impaired individuals with consecutive admissions from 2011 through 2017, 874 met inclusion criteria: TBI (n = 687) or CVA (n = 187), 18 years or older, minimum length of stay of one month, and maximum chronicity of 1 year. Participants were evaluated at admission and discharge on the Mayo Portland Adaptability Inventory-Version 4 (MPAI-4). Rasch analysis was performed to establish item reliability, construct validity and item difficulty. A Repeated Measures Multivariate Analysis of Covariance (RM MANCOVA) determined group differences and improvement from admission and discharge. Rasch Analysis demonstrated satisfactory construct validity and internal consistency (Person reliability > 0.90, Item reliability > 0.98 for admission and discharge MPAI-4s). Both groups showed significant improvement on the MPAI-4 (p < 0.0005). The TBI group was more impaired on the adjustment scale at both admission and discharge (p < 0.001). Rasch analysis identified two distinct impairment patterns. CVA participants exhibited deficits characteristic of focal impairment while the TBI group presented with deficits reflective of diffuse impairment. Rehabilitation was shown to be beneficial in reducing disability following neurologic injury in both groups. Importantly,
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