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Search Results: 1 - 10 of 59396 matches for " Mohamed Y Rady "
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Bench-to-bedside review: Resuscitation in the emergency department
Mohamed Y Rady
Critical Care , 2004, DOI: 10.1186/cc2986
Abstract: Resuscitation from circulatory and respiratory failure represents the mainstay of emergency and critical care practice. Resuscitation alone will not ensure patient survival unless definitive treatment for the primary cause of the circulatory and/or respiratory failure is delivered in a timely manner. This review highlights some of the recent advances in the practice of resuscitation by emergency medicine physicians in the emergency department (ED). Advances in the resuscitation of cardiopulmonary arrest are not discussed here.Life-threatening illness can be defined as an acute illness for which delay or incorrect treatment will ultimately result in catastrophic morbidity or death. The commonest presentation is cardiovascular instability because the underlying illness has advanced to shock. Several types of shock have been described, based on the type of hemodynamic response (Table 1): cardiogenic, hypovolemic, obstructive, and distributive. Shock is characterized by inadequate tissue perfusion with an imbalance between tissue oxygen delivery and oxygen utilization, and cumulative build up of tissue hypoxia or oxygen debt. Oxygen debt is indicted by extracellular release of anaerobic metabolism products (e.g. lactic acid). Oxygen debt can result from a decrease in oxygen delivery and/or an increase in oxygen consumption, such as in hypovolemic, cardiogenic, or obstructive shock (Table 1). Under such conditions tissue oxygen extraction is increased, with simultaneous decrease in mixed venous oxygen saturation (SvO2).Distributive shock is characterized by impaired tissue oxygen extraction despite adequate or high systemic oxygen delivery (Table 1). Anaerobic metabolites (e.g. lactic acid) are released into the circulation in the face of a normal or elevated SvO2, with a characteristic decrease in systemic oxygen extraction ratio. Other clinical presentations include acute respiratory and/or neurologic decompensation. Emergent interventions are necessary to stabilize vi
Retraction: End-of-life discontinuation of destination therapy with cardiac and ventilatory support medical devices: physician-assisted death or allowing the patient to die?
Mohamed Y Rady, Joseph L Verheijde
BMC Medical Ethics , 2010, DOI: 10.1186/1472-6939-11-20
Abstract: The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6939/11/20/prepub
End-of-life discontinuation of destination therapy with cardiac and ventilatory support medical devices: physician-assisted death or allowing the patient to die?
Mohamed Y Rady, Joseph L Verheijde
BMC Medical Ethics , 2010, DOI: 10.1186/1472-6939-11-15
Abstract: The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6939/11/15/prepub
Organ donation after circulatory death: the forgotten donor?
Mohamed Y Rady, Joseph L Verheijde, Joan McGregor
Critical Care , 2006, DOI: 10.1186/cc5038
Abstract: A mandatory implementation of donation after circulatory death (DCD) from eligible patients facing imminent or cardiac death in hospitals across the USA was introduced at a national conference and is to be effective from January 2007 [1]. The DCD requirement is focused on patients who are neurologically intact or do not fulfill neurologic death criteria before withdrawal of ventilator support [2]. The mandatory requirement will be implemented through the collaboration of the Institute of Medicine, Joint Commission on Accreditation of Healthcare Organizations, Center for Medicare and Medicaid Services, and the Department of Health and Human Services (see the glossary of terms in Table 1) [3,4].The transplantation community has been reorganized into 58 donation service areas (DSAs) to cover the entire country [5]. Each DSA is centered on one organ procurement organization (OPO) that facilitates the recovery and flow of transplantable organs from donor hospital(s) to regional transplant center(s) within a defined geographic location. Each of the DSAs will have to meet a target goal of 75% or higher of cadaveric organ donation rate from its affiliated hospitals.The uniform determination of death relies on irreversible cessation of circulatory or neurologic function. The unitarian determination of death by either neurologic or circulatory criteria rather than fulfilling both criteria simultaneously is accepted as the standard for cadaveric organ procurement [2]. The DCD criteria relies on expert opinion, which permits the procurement process after 5 min of apnea, unresponsiveness, and pulselessness [6].The pivotal assumption that DCD will eliminate the possibility that the procurement process is the direct cause of death has been challenged. Spontaneous return of both circulatory and neurologic function (autoresuscitation or Lazarus phenomenon) has been reported after 10 min of electric asystole [7]. The notion of a specific time interval for determination of irreversibl
Organ procurement organizations Internet enrollment for organ donation: Abandoning informed consent
Sandra Woien, Mohamed Y Rady, Joseph L Verheijde, Joan McGregor
BMC Medical Ethics , 2006, DOI: 10.1186/1472-6939-7-14
Abstract: An analysis of OPO Web sites available to the public for enrollment and consent for organ donation. The Web sites and consent forms were examined for the minimal information recommended by the United States Department of Health and Human Services for informed consent. Content scores were calculated as percentages of data elements in four information categories: donor knowledge, donor consent reinforcement, donation promotion, and informed consent.There were 60 Web sites for organ donation enrollment serving the 52 states. The median percent (10 percentile-90 percentile) content scores of the Web sites for donor knowledge, donor consent reinforcement, and donation promotion were 33% (20–47), 79% (57–86), and 75% (50–100), respectively. The informed consent score was 0% (0–33). The content scores for donor knowledge and informed consent were significantly lower than donor consent reinforcement and donation promotion for all Web sites (P < .05). The content scores for the four categories were similar among the 11 regions of the United Network for Organ Sharing.The Web sites and consent forms for public enrollment in organ donation do not fulfill the necessary requirements for informed consent. The Web sites predominantly provide positive reinforcement and promotional information rather than the transparent disclosure of organ donation process. Independent regulatory oversight is essential to ensure that Internet enrollment for organ donation complies with legal and ethical standards for informed consent.Recent advances in transplantation have expanded the criteria of age and end organ diseases for organ recipients thus exponentially increasing the waiting list for new organs[1,2]. The expanded pool of recipients has increased the demand for the donation and use of deceased organs [3]. The Health Resources and Services Administration (HRSA) of the United States Department of Health and Human Services (DHHS) has introduced the Organ Donation Breakthrough Collaborative to
Presumed consent for organ preservation in uncontrolled donation after cardiac death in the United States: a public policy with serious consequences
Joseph L Verheijde, Mohamed Y Rady, Joan McGregor
Philosophy, Ethics, and Humanities in Medicine , 2009, DOI: 10.1186/1747-5341-4-15
Abstract: Since the first kidney transplant in 1954, transplantation has been an area of medicine of utmost complexity and has often been a polarizing one as well [1]. Nevertheless, as of April 17, 2009, the United Network for Organ Sharing and Organ Procurement and Transplantation Network reported that 101,761 persons are waiting for organ transplantation, and this number continues to grow [2]. To increase the number of organs available for transplantation, major initiatives have been implemented, and new strategies are being developed. Before 1968, organs were procured exclusively from donors with cardiorespiratory failure, ie, non-heart-beating organ donation. The Harvard Ad Hoc Committee subsequently defined irreversible coma as "brain death," equating "brain death" with human death and, in so doing, opened the way to procure organs from heart-beating donors [3]. Because of the increasing number of patients in need of organs for transplantation and the subsequent growing disparity between supply and demand for transplantable organs [4], the US Department of Health and Human Services asked the Institute of Medicine (IOM) to form a committee with the charge to conduct a review of proposals and efforts to increase organ donation. This request was made in response to the legislative requirements laid down in the Organ Donation and Recovery Improvement Act of 2004. The 2006 IOM Committee was charged with the development of strategies to improve organ-donation rates, taking into consideration ethical implications, possible impact on public perceptions, cost-effectiveness, feasibility, and practicality of implementing such proposals [5]. The Committee proposed to expand the pool of potential donors, postulating that out of the roughly 335,000 annual deaths by cardiac arrest, at least 22,000 individuals would meet the criteria for uncontrolled donation after cardiac death (uDCD). In controlled DCD, circulatory arrest follows consented removal of mechanical ventilation and hemodyn
The United States Revised Uniform Anatomical Gift Act (2006): New challenges to balancing patient rights and physician responsibilities
Joseph L Verheijde, Mohamed Y Rady, Joan L McGregor
Philosophy, Ethics, and Humanities in Medicine , 2007, DOI: 10.1186/1747-5341-2-19
Abstract: The Revised UAGA (2006) poses challenges to the Patient Self Determination Act (PSDA) embodied in advance health care directives and individual expression about the use of life support systems at the end-of-life. The challenges are predicated on the UAGA revising the default choice to presumption of donation intent and the use of life support systems to ensure medical suitability of organs for transplantation. The default choice trumps the expressed intent in an individual's advance health care directive to withhold and/or withdraw life support systems at the end-of-life. The Revised UAGA (2006) overrides advance directives on utilitarian grounds, which is a serious ethical challenge to society. The subtle progression of the Revised UAGA (2006) towards the presumption about how to dispose of one's organs at death can pave the way for an affirmative "duty to donate". There are at least two steps required to resolve these challenges. First, physicians and hospitals must fulfill their responsibilities to educate patients on the new legislations and document their preferences about the use of life support systems for organ donation at the end-of-life. Second, a broad based societal discussion must be initiated to decide if the Revised UAGA (2006) infringes on the PSDA and the individual's right of autonomy. The discussion should also address other ethical concerns raised by the Revised UAGA (2006), including the moral stance on 1) the interpretation of the refusal of life support systems as not applicable to organ donation and 2) the disregarding of the diversity of cultural beliefs about end-of-life in a pluralistic society.In 1990, the U.S. Congress passed the Patient Self-Determination Act (PSDA) reinforcing individuals' rights to determine their final health care. The PSDA became effective in 1991 so that patients can make decisions about their medical care and specify whether they want to accept or refuse specific medical care [1]. Patients' wishes can be clearly d
Recovery of transplantable organs after cardiac or circulatory death: Transforming the paradigm for the ethics of organ donation
Joseph L Verheijde, Mohamed Y Rady, Joan McGregor
Philosophy, Ethics, and Humanities in Medicine , 2007, DOI: 10.1186/1747-5341-2-8
Abstract: Medical and pharmacologic advancements have made it possible to transplant organs successfully and thereby to save the lives of many persons who otherwise would die from irreversible end-stage organ disease. The greatly enhanced technical ability to transplant organs has also led to an ever-increasing need for transplantable organs [1]. The explosive growth in the demand for and the marginal increase in the supply of transplantable organs have together been characterized as an 'evolving national health care crisis' [2]. In fact, organ donation rates nationally have changed little in the past 15 years [3], whereas the need for donated organs has grown 5 times faster than the number of available cadaveric organs [4]. It is therefore no surprise that the transplantation community and society as a whole now consider balancing the demand for and the supply of transplantable organs as one of their biggest challenges.The continually increasing need for organs led to the reintroduction of the principle of donation after cardiac or circulatory death (DCD) in the early 1990s with the Pittsburgh protocol to complement already available organ procurement from brain-dead persons [5,6]. A new federal mandate requires hospitals as of January 2007 to design policies and procedures for organ procurement in DCD to increase the rate of organ donation and recovery from decedents to 75% or greater [7-9].However, DCD is controversial because of medical, ethical, and legal uncertainties about the premise that donors are indeed dead before their organs are procured [10-13]. In this article, we contend that the recovery of viable organs useful for transplantation in DCD is not compatible with the dead donor rule and we explain the ethical and legal ramifications of DCD. We also examine the current process of consent for organ donation and whether it includes the necessary elements for voluntary informed consent (i.e., the full disclosure of information relevant to decision making and respec
Mild induced hypothermia after out-of-hospital cardiac arrest: persisting doubts about patient safety
Bhavesh M Patel, Alyssa B Chapital, Mohamed Y Rady, Joel S Larson
Critical Care , 2007, DOI: 10.1186/cc6084
Abstract: First, the sixfold increase of the nosocomial bloodstream infection rate (13% versus control 2%) is most probably related to insertion of endovascular catheters for MIH [1]. Bloodstream infection in patients with endovascular catheters can become a significant cause of preventable morbidity and mortality [2].Second, it is unclear why hypokalemia (75% of MIH cases) was dismissed as a factor for the incidence of cardiac dysrhythmia [1]. Temperature changes induce electrolyte shifts and thus influence the depolarization and repolarization times and the conduction velocity of action potentials within the myocardium, promoting aberrant conduction pathways. Electrolyte abnormalities associated with MIH can influence electrophysiological parameters of the myocardium, triggering dysrhythmia [3].Third, it can be argued that MIH may have contributed to refractory cardiogenic shock and early death. MIH blunts the myocardial response to inotropic medications and increases the requirement for vasopressors to maintain hemodynamic stability [4]. The survival benefit for out-of-hospital cardiac arrest from an early intervention for coronary reperfusion and restoration of optimal cardiac performance substantially exceeds the survival benefit from MIH [5].Fourth, MIH can prolong and augment the activation of inflammatory cytokines [6]; manifesting with rebound hyperthermia upon re-warming (74% of MIH cases) [1]. The cytokine response to MIH can diminish the favorable neuro-protective effect, and can perhaps exacerbate acute organ injury.Fifth, the concurrent use of muscle relaxants in MIH may conceal clinical signs of epileptic activity after cardiopulmonary resuscitation and hypoxic insult to the brain. Continuous monitoring of the electroencephalogram is necessary to detect and treat provoked epileptic activity, otherwise secondary neuronal injury can progress during MIH [7]. Immediate neurophysiologic studies after cardiopulmonary resuscitation suggest that MIH has a limited thera
Corticosteroids influence the mortality and morbidity of acute critical illness
Mohamed Y Rady, Daniel J Johnson, Bhavesh Patel, Joel Larson, Richard Helmers
Critical Care , 2006, DOI: 10.1186/cc4971
Abstract: This case–control retrospective study was performed in a single multidisciplinary intensive care unit at a tertiary care institution and consisted of 10,285 critically ill patients admitted between 1 January 1999 and 31 December 2004. Demographics, comorbidities, acute illness characteristics including severity measured by Sequential Organ Failure Assessment, concurrent medications, therapeutic interventions and incidence of infections were obtained from electronic medical records, were examined with multiple regression analysis and were adjusted for propensity of corticosteroid exposure. The primary outcome was hospital death, and the secondary outcome was transfer to a care facility at hospital discharge.Corticosteroid exposure in 2,632 (26%) patients was characterized by younger age, more females, higher Charlson comorbidity and maximal daily Sequential Organ Failure Assessment scores compared with control patients. Corticosteroids potentiated metabolic and neuromuscular sequels of critical illness with increased requirements for diuretics, insulin, protracted weaning from mechanical ventilation, need for tracheostomy and discharge to a care facility. Early exposure to corticosteroids predisposed to recurrent and late onset of polymicrobial and fungal hospital-acquired infections. Corticosteroids increased the risk for death or disability after adjustments for comorbidities and acute illness characteristics.Corticosteroids increased the risk for death or disability in critical illness. Hospital-acquired infections and metabolic and neuromuscular sequels of critical illness were exacerbated by corticosteroids. Careful appraisal of the indications for use of corticosteroids is necessary to balance the benefits and risks from exposure in acute critical illness.Administration of corticosteroids in a variety of settings in acute critical illness has become widespread. Corticosteroids are used therapeutically for relative adrenal insufficiency as well as for the attenu
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