Andrew D Bersten

Flinders University, Tarndarnya, South Australia, Australia

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Publications (107)539.07 Total impact

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    ABSTRACT: Background Chronic heart failure (CHF) following coronary artery ligation and myocardial infarction in the rat leads to a homeostatic reduction in surface tension with associated alveolar type II cell hyperplasia and increased surfactant content, which functionally compensates for pulmonary collagen deposition and increased tissue stiffness. To differentiate the effects on lung remodelling of the sudden rise in pulmonary microvascular pressure (Pmv) with myocardial infarction from its consequent chronic elevation, we examined a hypertensive model of CHF. Methods Cardiopulmonary outcomes due to chronic pulmonary capillary hypertension were assessed at six and 15 weeks following abdominal aortic banding (AAB) in the rat. Results At six weeks post-surgery, despite significantly elevated left ventricular end-diastolic pressure, myocardial hypertrophy and increased left ventricular internal circumference in AAB rats compared with sham operated controls (p≤0.003), lung weights and tissue composition remained unchanged, and lung compliance was normal. At 15 weeks post-surgery increased lung oedema was evident in AAB rats (p = 0.002) without decreased lung compliance or evidence of tissue remodelling. Conclusion Despite chronically elevated Pmv, comparable to that resulting from past myocardial infarction (LVEDP >19 mmHg), there is no evidence of pulmonary remodelling in the AAB model of CHF.
    Heart Lung &amp Circulation 09/2014; · 1.25 Impact Factor
  • Shailesh Bihari, Shivesh Prakash, Andrew D Bersten
    Intensive care medicine. 07/2014;
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    ABSTRACT: Because increased serum osmolarity may be lung protective, we hypothesized that increased mortality associated with increased serum sodium would be ameliorated in critically ill patients with an acute respiratory diagnosis.
    Journal of critical care. 06/2014;
  • Shailesh Bihari, Susan Taylor, Andrew D Bersten
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    ABSTRACT: Inadvertent sodium (Na(+)) flux may occur during renal replacement therapy (RRT) in ICU. The objective of this study was to estimate sodium flux during RRT. Between September 2011 to December 2012 we studied 60 ICU patients receiving extended daily dialysis (EDD, Fresenius 4008S) or continuous renal replacement technique (CRRT, Aquarius 6.01). CRRT was categorized as dialysis with continuous veno-venous haemofiltration (CVVH) or haemodiafiltration (CVVHDF). Sodium balance was calculated as the difference between affluent and effluent fluid sodium concentration corrected for volume. The duration of study was either the duration of a single EDD session or 24 h of CRRT. Both EDD and CRRT contributed to a positive Na(+) flux. Despite similar demographics, CRRT patients had a greater positive sodium flux (p < 0.001). At multivariate analysis, factors [exp(b) (SE), p] which significantly affected sodium flux in each mode of RRT were: (1) EDD (R(2) = 0.42): gradient between RRT Na(+) and serum Na(+) [20.9 (5.8), p < 0.02], and total litres of exchange [1.5 (0.68), p < 0.04]; (2) CVVH (R(2) = 0.77): gradient between RRT Na(+) and serum Na(+) [21.8 (4.7), p < 0.001], dialysis day [-20.9 (9.8), p < 0.05], and total litres of exchange [5.2 (0.96), p < 0.001]; (3) CVVHDF (R(2) = 0.73): gradient between RRT Na(+) and serum Na(+) [23.8 (3.7), p < 0.001], and total fluid removal [-18.5 (3.26), p < 0.001]. RRT may inadvertently contribute to sodium load in critically ill patients and is affected by multiple factors including gradient between RRT Na(+) and serum Na(+).
    Journal of nephrology 02/2014; · 2.02 Impact Factor
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    Russell D Laver, Ubbo F Wiersema, Andrew D Bersten
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    ABSTRACT: Indirect assessment of mean pulmonary arterial pressure (MPAP) may assist management of critically ill patients with pulmonary hypertension and right heart dysfunction. MPAP can be estimated as the sum of echocardiographically derived mean right ventricular to right atrial systolic pressure gradient and right atrial pressure; however, this has not been validated in critically ill patients.
    Critical ultrasound journal 01/2014; 6(1):9.
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    ABSTRACT: Inadvertent sodium administration in excess of recommended daily requirements has been reported during routine care of critically ill patients. Aim: To determine the amount and sources of sodium administered in Australian and New Zealand intensive care units. Prospective, observational, single-day, point prevalence survey conducted in 46 Australian and New Zealand ICUs on 21 September 2011. All patients present in ICU at 10 am and not receiving an oral diet on the study day were evaluated. Demographic data, ICU admission diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE) II score and sources of sodium administration over the study day were recorded. 356 patients (64% male) were enrolled. Mean (SD) age and weight were 58.5 years (18.0 years) and 81.6 kg (24.0 kg), respectively. Mean ICU admission APACHE II score was 20 (SD, 8). Overall median (interquartile range [IQR]) sodium administration was 224.5 mmol (IQR, 144.9-367.6 mmol), or 2.8 mmol/kg (IQR, 1.6-4.7 mmol/kg). Among patients who were on Day 2-10 of their ICU admission on the study day, sodium sources and amounts administered were: i) maintenance or replacement intravenous (IV) infusions, 69.3mmol; 30.9% of all sodium sources; ii) IV fluid boluses, 36.5 mmol; 16.3%; iii) IV drug boluses, 27.6 mmol; 12.3%; iv) enteral nutrition, 26.5 mmol; 11.8%; v) IV drug infusions, 19.3 mmol; 8.6%; vi) IV flushes, 16.6mmol; 7.4%; vii) blood products, 13.5 mmol; 6%; viii) IV antimicrobials, 11.2mmol; 5%; and ix) parenteral nutrition, 4.3 mmol; 1.9%. Factors associated with sodium administration were site (P = 0.04), age (P < 0.001), administered fluid (P = 0.03) and day of ICU stay (P = 0.01) (multiple linear regression). This point prevalence study suggests that sodium administration in excess of recommended daily requirements may be common in Australia and New Zealand ICUs. The main sodium source was IV maintenance fluids, followed by fluid boluses and drug boluses.
    Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine 12/2013; 15(4):294-300. · 1.51 Impact Factor
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    ABSTRACT: Without robust clinical evidence to guide titration of vasopressors in septic shock, it is unclear how dosing of these potent medications occurs. We sought to measure the proportion of vasopressor prescriptions for septic shock that were missing explicit targets and to describe the targets that we identified.
    CMAJ open. 10/2013; 1(4):E127-33.
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    Canadian respiratory journal: journal of the Canadian Thoracic Society 09/2013; · 1.29 Impact Factor
  • Claire E Baldwin, Andrew D Bersten
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    ABSTRACT: Skeletal muscle wasting and weakness is common in intensive care unit (ICU) patients with sepsis, although less is known about deficits in diaphragm and limb muscles when mechanical ventilation is also required. To concurrently investigate relative differences in both thickness and strength of respiratory and peripheral muscles during routine care. Prospective cross-sectional study of sixteen alert patients with sepsis and sixteen healthy controls. Assessment of: diaphragm, upper-arm, forearm and thigh muscle thicknesses with ultrasound; respiratory muscle strength with maximal inspiratory pressure; isometric hand grip, elbow flexion and knee extension forces with portable dynamometry. To describe relative changes, data were also normalised to fat free body mass (FFM) measured by bioelectrical impedance spectroscopy. Patients (nine males, seven females, aged 62(17) years) were assessed after 16(11-29) days of ICU admission. Patients' diaphragm thickness did not differ from healthy controls (p=0.44), even for a given FFM (p=0.16). When normalised to FFM, only the difference in patients' mid-thigh muscle size significantly deviated from controls (p≤0.001). Within the patient sample, all peripheral muscle groups were thinner, as compared to the diaphragm (p≤0.01). Patients were significantly weaker than healthy controls in all muscle groups (p≤0.001), including for a given FFM (p≤0.001). Within the critically ill, limb weakness was greater than already significant respiratory muscle weakness (p≤0.02). Volitional strength tests were applied such that successive measurements from earlier in the course of illness could not be reliably obtained. When measured at the bedside, survivors of sepsis and a period of mechanical ventilation may experience respiratory muscle weakness without remarkable diaphragm wasting. Furthermore, deficits in peripheral muscle strength and size may exceed those in the diaphragm.
    Physical Therapy 09/2013; · 2.78 Impact Factor
  • Shailesh Bihari, Claire E Baldwin, Andrew D Bersten
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    ABSTRACT: Distribution of total body water (TBW) depends on local and systemic factors including osmolality, relative sodium content and permeability. Although positive fluid balance has been associated with increased morbidity and mortality in critically ill patients, the mechanisms and relative roles of sodium balance and water distribution are uncertain. To track changes in sodium and fluid balance, respiratory function and body composition in patients who required mechanical ventilation for ≥48 hours. Prospective observational study, set in a tertiary intensive care unit, of 10 patients (seven men) with a mean age of 60 years (standard deviation [SD],12 years) and mean admission Acute Physiology and Chronic Health Evaluation (APACHE) III score of 71 (SD, 26). Sodium and fluid balances were estimated daily for up to 5 days, following institution of mechanical ventilation on Day 0. Serum sodium level, oxygenation (PaO2/FIO2), body weight, intracellular and extracellular fluid (ECF) distribution (bioelectrical impedance spectroscopy), and blinded chest x-ray oedema scores were performed daily. After 5 days of mechanical ventilation, the cumulative fluid balance was - 954 mL (SD, 3181 mL) and estimated cumulative sodium balance was 253 mmol (SD, 346 mmol). Serum sodium had increased from 140mmol/L (SD, 4mmol/L) to 147 mmol/L (SD, 5mmol/L). Cumulative sodium balance was weakly correlated with worsening chest x-ray score (r = 0.35, P = 0.004), a reduction in PaO2/ FIO2 ratio (r = - 0.52, P = 0.001) and 24-hour urinary sodium (r = - 0.24, P = 0.02). Between Days 1 and 5, body weight decreased (- 2.7 kg; SD, 1.4 kg) and TBW decreased (- 3.4 L; SD, 1.3 L), despite a rise in ECF distribution (1.4% of TBW; SD, 1.9% of TBW). Fluid balance may not reflect sodium balance in critically ill patients. As sodium balance correlates with respiratory dysfunction and increased extracellular volume, further studies examining sodium balance and morbidity seem warranted.
    Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine 06/2013; 15(2):89-96. · 1.51 Impact Factor
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    ABSTRACT: ABSTRACT BACKGROUND: In a recent multicenter randomized trial comparing unfractionated heparin (UFH) with low-molecular-weight heparin (dalteparin) for thromboprophylaxis in 3746 critically-ill patients, 17 (0.5%) patients developed heparin-induced thrombocytopenia (HIT) based on serotonin-release assay-positive (SRA+) status. A trend to lower frequency of HIT with dalteparin vs UFH was observed in the intention-to-treat analysis (5 vs 12 patients; P=0.14), which was statistically significant (3 vs 12 patients; P=0.046) in a prespecified per-protocol analysis which excluded patients with deep-vein thrombosis (DVT) at study entry. We sought to characterize HIT outcomes and to determine how dalteparin thromboprophylaxis might reduce HIT frequency in ICU patients. METHODS: In 17 patients with HIT, we analyzed platelet counts and thrombotic events in relation to study drug and other open-label heparin, to determine whether study drug plausibly explained seroconversion to SRA+ status and/or breakthrough of thrombocytopenia/thrombosis. We also compared antibody frequencies (dalteparin vs UFH) in 409 patients serologically investigated for HIT. RESULTS: HIT-associated thrombosis occurred in 10/17 (58.8%) patients (8:1:1 venous:arterial:both). Dalteparin was associated with fewer study drug-attributable HIT-related events (P=0.020), including less seroconversion (P=0.058) and less breakthrough of thrombocytopenia/thrombosis (P=0.032). Anti-PF4/heparin IgG antibodies by ELISA were less frequent among patients receiving dalteparin vs UFH (13.5% vs 27.3%; P<0.001). One patient with HIT-associated DVT died post-UFH bolus, whereas platelet counts recovered in two others with HIT-associated VTE despite continuation of therapeutic-dose UFH. CONCLUSIONS: The lower risk of HIT in ICU patients receiving dalteparin appears related to both decreased antibody formation and decreased clinical breakthrough of HIT among patients forming antibodies.
    Chest 05/2013; · 7.13 Impact Factor
  • Shailesh Bihari, Shivesh Prakash, Andrew D Bersten
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    ABSTRACT: INTRODUCTION: Administration of fluid boluses(FB) beyond initial resuscitation in patients with severe sepsis are common, and may contribute to positive fluid balance. Little is known regarding the efficacy and risk profile of this strategy. OBJECTIVE: To estimate the prevalence and efficacy of FB post initial resuscitation in septic patients. METHODS: In a prospective study, patients with severe sepsis/septic shock were recruited post initial resuscitation and followed for 3 days. Number, types and volumes of FB, resuscitation goals and their perceived success rates were recorded. Data are presented as median (IQR). RESULTS: Over a 1 year period, 50 patients were recruited, 47(94%) of them received FB, with a total of 184 FB [3(2-5) per patient] administered over the 72 hours. On day 1, 2(1-3) FB, totalling 750(500-1720)ml were administered which comprised 52.4%(22.1-124.2) of the fluid balance. Low blood pressure (MAP)(76.0%) and increased vasopressor requirement(60.3%) were the two most common indications for FB. Low filling pressure(70.9%) and clinical signs(79.4%) were perceived as the most successful indications. One hour after these FB, there was a small increase in MAP(p<0.01) and central venous pressure(p<0.01), however, there was also concomitant increase in noradrenaline administered. There was a significant decrease in PaO2/FiO2 ratio, haemoglobin and temperature, while urine output remained unchanged. Factors[Exp(b)(SE)p-value](R=0.296) which affected the increase in MAP were baseline MAP[-0.49(.057)p<0.001] and amount of these FB[-0.05(.01)p=0.001]. Cumulative fluid balance had a weak correlation with delta SOFA score(r=0.32,p=0.001) and lung injury score(r=0.13,p=0.02) and negative correlation with PaO2/FiO2 ratio(r=-0.28,p=0.001). CONCLUSION: Post-resuscitation FB are common in septic patients, meet limited success and may be harmful.
    Shock (Augusta, Ga.) 04/2013; · 2.87 Impact Factor
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    Dani-Louise Dixon, Andrew D Bersten
    Critical care medicine 01/2013; 41(1):354-5. · 6.37 Impact Factor
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    ABSTRACT: AIMS: Chronic heart failure leads to pulmonary vascular remodelling and thickening of the alveolar-capillary barrier. We examined whether this protective effect may slow resolution of pulmonary oedema consistent with decreased bi-directional fluid flux. METHODS AND RESULTS: Seven weeks following left coronary artery ligation, we measured both fluid flux during an acute rise in left atrial pressure (n = 29) and intrinsic alveolar fluid clearance (n = 45) in the isolated rat lung. Chronic elevation of pulmonary microvascular pressure prevented pulmonary oedema and decreased lung compliance when left atrial pressure was raised to 20 cmH(2)O, and was associated with reduced expression of endothelial aquaporin 1 (P = 0.03). However, no other changes were found in mediators of fluid flux or cellular fluid channels. In isolated rat lungs, chronic LV dysfunction (LV end-diastolic pressure and infarct circumference) was also inversely related to alveolar fluid clearance (P ≤ 0.001). The rate of pulmonary oedema reabsorption was estimated by plasma volume expansion in eight patients with a previous clinical history of chronic heart failure and eight without, who presented with acute pulmonary oedema. Plasma volume expansion was reduced at 24 h in those with chronic heart failure (P = 0.03). CONCLUSIONS: Chronic elevation of pulmonary microvascular pressure in CHF leads to decreased intrinsic bi-directional fluid flux at the alveolar-capillary barrier. This adaptive response defends against alveolar flooding, but may delay resolution of alveolar oedema.
    European Journal of Heart Failure 12/2012; · 5.25 Impact Factor
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    ABSTRACT: BACKGROUND: The synthetic tripeptide feG is a novel pharmacological agent that decreases neutrophil recruitment, infiltration, and activation in various animal models of inflammatory disease. In human and rat cell culture models, feG requires pre-stimulation in order to decrease in vitro neutrophil chemotaxis. We aimed to investigate the effect of feG on neutrophil chemotaxis in a lipopolysaccharide-induced acute lung injury model without pre-stimulation. METHODS: The efficacy of feG as both a preventative treatment, when administered before lung injury (prophylactic), or as a therapeutic treatment, administered following lung injury (therapeutic), was investigated. RESULTS: Prophylactic or therapeutic feG administration significantly reduced leukocyte infiltration, ameliorated the severity of inflammatory damage, and restored lung function. feG was demonstrated to significantly decrease bronchoalveolar lavage cell infiltration, lung myeloperoxidase activity, lung oedema, histological tissue injury scores, and improve arterial blood oxygenation and respiratory mechanics. CONCLUSIONS: feG reduced leukocyte infiltration, ameliorated the severity of inflammatory damage, and restored lung function when administered prophylactically or therapeutically in a rodent model of lipopolysaccharide-induced acute lung injury, without the need for pre-stimulation, suggesting a direct rather than indirect mechanism of action in the lung.
    Pulmonary Pharmacology &amp Therapeutics 10/2012; · 2.54 Impact Factor
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    ABSTRACT: ABSTRACT BACKGROUND: The synthetic tripeptide feG is a novel pharmacological agent that decreases neutrophil recruitment, infiltration, and activation in various animal models of inflammatory disease. We aimed to investigate the effect of feG as both a preventative treatment when administered before acute lung injury (prophylactic), or as a therapeutic treatment administered following initiation of acute lung injury (therapeutic). METHODS: Lung injury was assessed following prophylactic or therapeutic intratracheal feG administration in a 'two-hit' rodent model of acute pancreatitis plus intratracheal lipopolysaccharide. RESULTS: Following both prophylactic and therapeutic feG administration there were significant improvements in arterial blood oxygenation and respiratory mechanics, and decreased lung edema, bronchoalveolar lavage protein concentration, histological tissue injury scores, bronchoalveolar lavage cell infiltration and lung myeloperoxidase activity. Most indices of lung damage were reduced to baseline control values. CONCLUSIONS: feG reduced leukocyte infiltration, ameliorated the severity of inflammatory damage, and restored lung function when administered both prophylactically or therapeutically in a 'two-hit' rat model of acute pancreatitis plus intratracheal lipopolysaccharide.
    Chest 07/2012; · 7.13 Impact Factor
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    Alpesh R Patel, Susan Taylor, Andrew D Bersten
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    ABSTRACT: To compare respiratory mechanics estimated by the (pulse) technique in spontaneously breathing patients during proportional assist ventilation (PAV) with load-adjustable gain factor (PAV+) mode with those measured using the flow-interruption technique during controlled ventilation. Observational study of 21 haemodynamically stable post-cardiac surgery patients with routine weaning from mechanical ventilation (Puritan-Bennett 840 ventilator) in the intensive care unit of a tertiary hospital. Bland-Altman and linear correlation of respiratory system compliance and inspiratory resistance estimated during PAV+ (C(pulse) and R(pulse)) with that measured during controlled mechanical ventilation (C(int) and Rint). C(pulse) overestimated C(int) (67.4 [SD, 27.7] v 51.6 [SD, 9.7] mL/cmH(2)O; P = 0.02), although the correlation between C(int) and C(pulse) was strong. Using the Bland-Altman method, the bias and limits of agreement were outside a clinically useful range. R(pulse) underestimated Rint (9.3 [SD, 3.0] v 11.5 [SD, 3.0] cmH(2)O/L/s; P = 0.02), with a weak positive correlation. Although the bias calculated by the Bland-Altman method was small, the limits of agreement were too large to be clinically useful. Based on these data, respiratory mechanics estimated from the (pulse) technique are too inaccurate to be clinically useful.
    Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine 06/2012; 14(2):130-4. · 1.51 Impact Factor
  • Shailesh Bihari, Andrew D Bersten
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    ABSTRACT: INTRODUCTION: Potentially beneficial effects of positive end-expiratory pressure (PEEP) in patients with chronic obstructive pulmonary disease (COPD) must be balanced against further overinflation and increased alveolar dead space. Concurrent chronic heart failure (CHF) is common and can lead to changes in lung that can reduce the detrimental effects of PEEP. OBJECTIVE: The aim of this study was to compare the effect of PEEP on volumetric capnography, blood gases, pulmonary mechanics, and vital signs in subjects with either COPD (n = 13) or COPD + CHF (n = 7) during pressure support ventilation. METHODS: Positive end-expiratory pressure was administered at 0, 5, 10, 15, and 0 cm H(2)O for 15 minutes with pressure support maintained at 10 cm H(2)O. Data are expressed as mean ± SD, and the effect of PEEP and differences between COPD alone and COPD + CHF were tested with repeated-measures analysis of variance. RESULTS: Subjects were elderly (72.5 ± 13.3 years) with severe COPD (force expired volume in 1 second, 1.3 ± 0.6L; force expired volume in 1 second/force vital capacity, 40% ± 15%). With increasing PEEP in COPD subjects, dead space ratio increased (P < .001), minute alveolar ventilation decreased (P = .001), and Paco(2) increased (P = .013), with no change in COPD + CHF subjects. Subjects with COPD + CHF had improvement in Pao(2) and lower mean arterial pressure, whereas both were unchanged in subjects with COPD alone. CONCLUSION: In subjects with severe COPD alone, caution must be used when administering PEEP 10 cm H(2)O or greater. Subjects with COPD + CHF may benefit from higher levels of PEEP.
    Journal of critical care 05/2012; · 2.13 Impact Factor
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    ABSTRACT: Acute lung injury (ALI) is a common complication of acute pancreatitis (AP) and contributes to the majority of AP-associated deaths, particularly in the setting of secondary infection. This 'two-hit' model mimics clinical cases where the presentation of AP is associated with mild lung injury that, following a secondary direct lung infection, can result in respiratory dysfunction and death. We therefore aimed to characterize lung injury in a clinically-relevant 'two-hit' rat model of caerulein-induced AP combined with intratracheal endotoxin. Rats received 7 hourly intraperitoneal injections of caerulein (50 μg/kg). Twenty four hours following the first caerulein injection, rats were anaesthetised and LPS (15 mg/kg) was instilled intratracheally. Following LPS instillation, rats were ventilated for a total of 2 h. In the present study, AP results in mild pulmonary injury indicated by increased lung myeloperoxidase (MPO) activity and edema, but with no alteration of respiratory function, while intratracheal instillation of LPS results in more substantial pulmonary injury. The induction of AP challenged with secondary intratracheal LPS results in an exacerbation of lung damage indicated by further increased lung edema, plasma and bronchoalveolar (BAL) CINC-1 concentration, lung damage histology score, and lung tissue resistance and elastance, compared with LPS alone. In conclusion, the addition of instilled LPS acted as a "second-hit" and exacerbated caerulein-induced AP, compared with the induction of AP alone or the instillation of LPS alone. Given its clinical relevance, this model could prove useful for examination of therapeutic interventions for ALI following secondary infection.
    Pancreatology 05/2012; 12(3):240-7. · 2.04 Impact Factor
  • Claire E Baldwin, Jennifer D Paratz, Andrew D Bersten
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    ABSTRACT: PURPOSE: Dynamometry is an objective tool for volitional strength evaluation that may overcome the limited sensitivity of the Medical Research Council scale for manual muscle tests, particularly at grades 4 and 5. The primary aims of this study were to investigate the reliability, minimal detectable change, and time to peak muscle force, measured with portable dynamometry, in critically ill patients. MATERIALS AND METHODS: Isometric hand grip, elbow flexion, and knee extension were measured with portable dynamometry. RESULTS: Interrater consistency (intraclass correlation coefficient [95% confidence interval]) (0.782 [0.321-0.930] to 0.946 [0.840-0.982]) and test-retest agreement (0.819 [0.390-0.943] to 0.918 [0.779-0.970]) were acceptable for all dynamometry forces, with the exception of left elbow flexion. Despite generally good reliability, a mean change (upper 95% confidence interval) of 2.8 (7.8) kg, 1.9 (5.2) kg, and 2.6(7.1) kg may be required from a patient's baseline force measurement of right grip, elbow flexion, and knee extension to reflect real force changes. There was also a delay in the time for critically ill patients to generate peak muscle forces, compared with healthy controls (P ≤ .001). CONCLUSIONS: Dynamometry can provide reliable measurements in alert critically ill patients, but moderate changes in strength may be required to overcome measurement error, during the acute recovery period. Deficits in force timing may reflect impaired neuromuscular control.
    Journal of critical care 04/2012; · 2.13 Impact Factor

Publication Stats

2k Citations
539.07 Total Impact Points


  • 1995–2014
    • Flinders University
      • • Flinders Medical Centre
      • • School of Medicine
      • • Department of Critical Care Medicine
      Tarndarnya, South Australia, Australia
  • 2013
    • University of South Australia 
      • School of Health Sciences
      Adelaide, South Australia, Australia
  • 1990–2013
    • Flinders Medical Centre
      Tarndarnya, South Australia, Australia
  • 2012
    • University of Adelaide
      • Research Centre for Reproductive Health
      Adelaide, South Australia, Australia
  • 2011
    • Lyell McEwin Hospital
      • Intensive Care Unit
      Adelaide, South Australia, Australia
  • 2002–2010
    • The Queen Elizabeth Hospital
      Tarndarnya, South Australia, Australia
  • 2008
    • Christian Medical College Vellore
      • Department of Intensive care medicine
      Vellore, State of Tamil Nadu, India
  • 2002–2008
    • Catholic University of Louvain
      • • School of Medicine
      • • Department of Industrial Toxicology and Occupational Medecine
      Louvain-la-Neuve, WAL, Belgium
  • 1999
    • Northern Inyo Hospital
      Bishop, California, United States
    • Austin Health
      Melbourne, Victoria, Australia