MB's Articles of Interest - August 2000

ARTICLE TITLE: A rationale for the use of beta-blockers as standard treatment for heart failure.
ARTICLE SOURCE: Am Heart J (United States), Mar 2000, 139(3) p511-21
AUTHOR(S): Metra M; Nodari S; D'Aloia A; Bontempi L; Boldi E; Cas LD
AUTHOR'S ADDRESS: Cattedra di Cardiologia, Universita di Brescia, Brescia, Italy. deicas@master.cci.unibs.it.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (50 references); REVIEW, TUTORIAL
ABSTRACT: BACKGROUND: Cardiac sympathetic activation is one of the major and earlier changes observed in patients with heart failure. Its relation to the severity of the disease and its independent prognostic value show that it may directly contribute to the progression of heart failure. beta-Blockers are the most effective tool to counteract the untoward effects of sympathetic activation on the cardiovascular system. METHODS AND RESULTS: We reviewed the results of the placebo-controlled, double-blind studies about the effects of beta-blockers in patients with heart failure. These studies have involved almost 10,000 patients to date and have consistently shown that the long-term administration of beta-blockers is associated with a highly significant improvement in both left ventricular function and prognosis of the patients with heart failure. The evidence supporting the use of beta-blockers now equals or even surpasses that of angiotensin-converting enzyme inhibitors; therefore beta-blockers should be considered part of standard therapy. Issues that remain unclarified include the mechanisms through which beta-blockers may improve cardiac function and their tolerability and efficacy in specific groups of patients (such as those with asymptomatic left ventricular dysfunction, severe heart failure, the elderly, or those with left ventricular diastolic dysfunction). It is not currently clear whether the pharmacologic differences between individual beta-blockers are clinically relevant. If they are, the potential for even greater benefit with certain agents exists. It is hoped that these issues will be clarified by the results of ongoing multicenter trials.
MB: Cardiology has been turned upsidedown. Good things are now bad and vice-versa.

ARTICLE TITLE: Differences between patients with heart failure treated by cardiologists, internists, family physicians, and other physicians: analysis of a large, statewide database [see comments]
COMMENTS: Comment in: Am Heart J 2000 Mar; 139(3):392-3
ARTICLE SOURCE: Am Heart J (United States), Mar 2000, 139(3) p491-6
AUTHOR(S): Philbin EF; Jenkins PL
AUTHOR'S ADDRESS: Section of Heart Failure & Cardiac Transplantation, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA. ephilbi1@hfhs.org.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Cardiologists' management of HF is not economically disadvantageous. The relations among physician specialty, process of care, resource utilization, and clinical outcomes require further study before rational and evidence-based health care staffing recommendations can be formulated.

ARTICLE TITLE: Cardiology, for what it's worth [editorial; comment]
COMMENTS: Comment on: Am Heart J 2000 Mar; 139(3):491-6
ARTICLE SOURCE: Am Heart J (United States), Mar 2000, 139(3) p392-3
AUTHOR(S): Kandzari DE; Jollis JG
PUBLICATION TYPE: COMMENT; EDITORIAL; HISTORICAL ARTICLE

ARTICLE TITLE: Increase in ST-segment elevation immediately after reperfusion: cause and meaning [editorial; comment]
COMMENTS: Comment on: Am Heart J 2000 Mar; 139(3):430-6
ARTICLE SOURCE: Am Heart J (United States), Mar 2000, 139(3) p390-1
AUTHOR(S): Greenfield JC Jr
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: When not doing tests is the right thing to do [editorial; comment]
COMMENTS: Comment on: Am Heart J 2000 Mar; 139(3):394-8
ARTICLE SOURCE: Am Heart J (United States), Mar 2000, 139(3) p388-9
AUTHOR(S): Gibbons RJ
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Three-dimensional echocardiographic assessment of annular shape changes in the normal and regurgitant mitral valve.
ARTICLE SOURCE: Am Heart J (United States), Mar 2000, 139(3) p378-87
AUTHOR(S): Kaplan SR; Bashein G; Sheehan FH; Legget ME; Munt B; Li XN; Sivarajan M; Bolson EL; Zeppa M; Arch MZ; Martin RW
AUTHOR'S ADDRESS: Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA 98195-6422, USA.
PUBLICATION TYPE: CLINICAL TRIAL; CONTROLLED CLINICAL TRIAL; JOURNAL ARTICLE
CONCLUSIONS: Functional mitral regurgitation (FMR) is associated with annular dilation and reduced cyclic variation in annular shape and area. Normal mitral valve function may depend on normal annular 3D shape and dimensions as well as annular plasticity. These observations may have implications for design and selection of mitral annular prostheses.

ARTICLE TITLE: Prevalence of nonfatal coronary heart disease among American adults.
ARTICLE SOURCE: Am Heart J (United States), Mar 2000, 139(3) p371-7
AUTHOR(S): Ford ES; Giles WH; Croft JB
AUTHOR'S ADDRESS: Division of Nutrition and Physical Activity and the Division of Adult Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA. esf2@cdc.gov.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Although the management of coronary heart disease has improved during the past 2 decades, it remains an important prevalent disease burden among adults.

ARTICLE TITLE: Efficacy and safety of calcium channel blockers in heart failure: focus on recent trials with second-generation dihydropyridines.
ARTICLE SOURCE: Am Heart J (United States), Feb 2000, 139(2 Pt 1) p185-94
AUTHOR(S): de Vries RJ; van Veldhuisen DJ; Dunselman PH
AUTHOR'S ADDRESS: Department of Cardiology/Thoraxcenter, University Hospital Groningen, and the Department of Cardiology, Ignatius Hospita, Breda.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (54 references); REVIEW, TUTORIAL
CONCLUSIONS: In this review we have focused on the efficacy and safety of dihydropyridines in patients with CHF, as reported in recent trials. The data do not support the use of dihydropyridines when primarily given as treatment for CHF. The results, however, suggest that these drugs can be safely given to patients with left ventricular dysfunction or CHF who need additional treatment for angina pectoris or hypertension.

ARTICLE TITLE: Age of transfused blood is an independent risk factor for postinjury multiple organ failure.
ARTICLE SOURCE: Am J Surg (United States), Dec 1999, 178(6) p570-2
AUTHOR(S): Zallen G; Offner PJ; Moore EE; Blackwell J; Ciesla DJ; Gabriel J; Denny C; Silliman CC
AUTHOR'S ADDRESS: Department of Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center, 80204, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: The age of transfused packed red blood cell (PRBC)s transfused in the first 6 hours is an independent risk factor for postinjury multiple organ failure (MOF). This suggests that current blood bank processing and storage technique should be reexamined. Moreover, fresh blood may be more appropriate for the initial resuscitation of trauma patients requiring transfusion.

ARTICLE TITLE: Autologous blood transfusion does not reduce postoperative infection rates in elective surgery.
ARTICLE SOURCE: Am J Surg (United States), Dec 1999, 178(6) p549-55
AUTHOR(S): Sauaia A; Alexander W; Moore EE; Stevens BR; Rosen H; Dunn TR
AUTHOR'S ADDRESS: Colorado Foundation for Medical Care, Aurora 80014, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: The influence of blood transfusions in the risk of postoperative infection remains controversial. We examined the association between blood transfusions with postoperative infection in elective surgery. METHODS: The medical records of 991 Medicare patients aged > or =65 years submitted to hysterectomy and hip and knee replacement were reviewed. Logistic regression analysis was used to control for age, comorbidity, year, and type of procedure. RESULTS: Overall, 451 (46%) patients required transfusions. AB was given to 324 (72%), HB to 94 (21%); 33 (7%) patients received both. Forty-two patients (4%) developed postoperative infections. The infection rate was not different among patients receiving HB (7%), AB (5%), AB+HB (0), and nontransfused patients (4%); P = 0.18). After adjustment for confounders, HB and AB remained not associated with infections. CONCLUSION: In elective surgery with small volume transfusion, neither autologous (AB) nor homologous (HB) transfusions were associated with an increased risk of postoperative infections.

ARTICLE TITLE: Surgical progress and understanding in the treatment of the melanoma epidemic.
ARTICLE SOURCE: Am J Surg (United States), Dec 1999, 178(6) p443-8
AUTHOR(S): Polk HC Jr
AUTHOR'S ADDRESS: Department of Surgery, University of Louisville School of Medicine, Kentucky 40292, USA.
PUBLICATION TYPE: LECTURES

ARTICLE TITLE: Heat loss during induction of anaesthesia for elective aortic surgery.
ARTICLE SOURCE: Anaesthesia (England), Jan 2000, 55(1) p79-82
AUTHOR(S): Stoneham M; Howell S; Neill F
AUTHOR'S ADDRESS: Nuffield Department of Anasthetics, Oxford Radcliffe NHS Hospital, Oxford, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: We have studied core temperature changes occurring during induction of general anaesthesia and surgery in 18 patients undergoing elective aortic aneurysm repair. In the operating theatre, all patients were warmed with a forced-air warmer and a warming mattress, and received warmed (37 degrees C) intravenous fluids. Despite this, mean (SD) [range] core temperatures in the anaesthetic room decreased by 1.5 (0.3)[1.1-2.2] degrees C, while intravascular lines, epidural and urinary catheters were inserted before the introduction of warming methods in theatre. In one-third of patients, the core temperature was still below 36 degrees C at the end of surgery. The overall temperature decrease correlated significantly with the duration of time between induction of general anaesthesia and surgical incision (R2 = 0.6912), when the patients were not being warmed. Hypothermia may thus be prevented by minimising the period that the patient is anaesthetised without being warmed. Vascular lines, urinary and epidural catheters should be inserted before the induction of general anaesthesia or, alternatively, warming methods should be introduced in the anaesthetic room.
MB: A few blankets before getting to theatre would help. Warming matresses are quite dangerous in Abdominal Aortic Aneurysms.

ARTICLE TITLE: Anaesthesia for organ donation in the brainstem dead--why bother? [editorial]
ARTICLE SOURCE: Anaesthesia (England), Feb 2000, 55(2) p105-6
AUTHOR(S): Young PJ; Matta BF
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Training in obstetric general anaesthesia: a vanishing art?
ARTICLE SOURCE: Anaesthesia (England), Feb 2000, 55(2) p179-83
AUTHOR(S): Johnson RV; Lyons GR; Wilson RC; Robinson AP
AUTHOR'S ADDRESS: Department of Anaesthesia, Royal Halifax Infirmary, Free School Lane, Halifax HX1 2YP, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: General anaesthesia in obstetric practice has largely been replaced by the use of regional techniques. We have studied this phenomenon and the subsequent impact on training in this technique both retrospectively and with a prospective audit. There has been a decline in the use of general anaesthesia for Caesarean section such that trainee anaesthetists are getting less practical exposure to this important procedure. Audit revealed a deficit with consultant involvement in training and heightened awareness has resulted in improved supervision. Possible implications for future consultant working practices are discussed.
MB: They think that you will have to have a consultant for a caesarian under GA.

ARTICLE TITLE: Stress in trainee anaesthetists [editorial]
ARTICLE SOURCE: Anaesthesia (England), Mar 2000, 55(3) p203-5
AUTHOR(S): Greenwell SK
PUBLICATION TYPE: EDITORIAL
MB. Hopeless. They propose no sensible explanation of the apparent/supposed increase in stress both in and out of the anaesthetic world.

ARTICLE TITLE: A new practical classification of laryngeal view.
ARTICLE SOURCE: Anaesthesia (England), Mar 2000, 55(3) p274-9
AUTHOR(S): Cook TM
AUTHOR'S ADDRESS: Royal United Hospital, Combe Park, Bath BA1 3NG, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: A new practical classification of laryngeal view at laryngoscopy is presented and evaluated. The best laryngeal view obtained with or without anterior laryngeal pressure is recorded. The laryngeal view is easy (E) when the laryngeal inlet is visible. The view is restricted (R) when the posterior glottic structures (posterior commissure or arytenoids) are visible or the epiglottis is visible and can be lifted; this includes some grade 2 and some grade 3 views as classified by Cormack and Lehane. A difficult (D) view is present when the epiglottis cannot be lifted or when no laryngeal structures are visible. Five hundred patients were studied. Laryngoscopy, with the patient anaesthetised and paralysed, was performed with a Macintosh laryngoscope. If the vocal cords were not visible, a gum elastic bougie was used to aid intubation. Other aids were used only if this did not allow intubation. Each laryngeal view was graded according to the new classification and that of Cormack and Lehane. Intubation was timed and the equipment needed to facilitate intubation was recorded. The new classification stratified increasing difficulty with intubation (time for intubation longer and increasingly complex methods needed) better than the Cormack and Lehane classification. The new classification is as sensitive and more specific than the Cormack and Lehane classification in predicting difficult intubation. It is also more sensitive and more specific in predicting easy intubation.

ARTICLE TITLE: Towards a pain-free venepuncture.
ARTICLE SOURCE: Anaesthesia (England), Mar 2000, 55(3) p260-2
AUTHOR(S): Ong EL; Lim NL; Koay CK
AUTHOR'S ADDRESS: Changi General Hospital, Department of Anaesthesia and Surgical Intensive Care, 2 Simei Street 3, Singapore 529889.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: A randomised, prospective trial was conducted to assess the efficacy of various means of alleviating the pain of subcutaneous lidocaine infiltration. One hundred and twenty-two patients were randomly allocated to different groups to receive buffered lidocaine 1%, warmed lidocaine 1% or infiltration by the counter-irritation technique. A visual analogue pain score was recorded at different stages of cannulation and results showed that pain scores were significantly lower in the group receiving buffered lidocaine 1% (p < 0.02) and in the counter-irritation group (p < 0.05). Thus buffering lidocaine 1% and administration of lidocaine 1% by the counter-irritation technique is effective in relieving the pain of lidocaine infiltration.
MB. How the local is injected is crucial---a fine needle and a little bleb to start with.

ARTICLE TITLE: Evaluation of a needle-free injection system for local anaesthesia prior to venous cannulation.
ARTICLE SOURCE: Anaesthesia (England), Mar 2000, 55(3) p247-50
AUTHOR(S): Cooper JA; Bromley LM; Baranowski AP; Barker SG
AUTHOR'S ADDRESS: Royal Free and University College Medical School, Room 103, 1st Floor Crosspiece, Middlesex Hospital, Mortimer Street, London W1N 8AA, UK.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
We conclude that the device certainly delivers a less painful subcutaneous injection than a 25 G needle, but perhaps provides less effective skin anaesthesia for venous cannulation at sites where the subcutaneous space is small; its use might be better suited to areas where the subcutaneous space is deeper.

ARTICLE TITLE: An assessment of the thermal safety of microwave warming of crystalloid fluids.
ARTICLE SOURCE: Anaesthesia (England), Mar 2000, 55(3) p251-4
AUTHOR(S): Lindhoff GA; MacGPalmer JH
AUTHOR'S ADDRESS: Department of Anaesthesia, Dumfries and Galloway Royal Infirmary, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: We performed an in vitro study to determine the thermal safety of a domestic microwave to warm intravenous crystalloid solutions. Five-hundred-millilitre bags of crystalloid, randomly allocated to groups which differed in power setting, timer setting and whether or not agitation was performed after warming, were heated in a microwave oven to a calculated temperature of 39 degrees C. Timer accuracy was checked by stopwatch. Bag temperature was measured using an infrared tympanic temperature probe and fluid temperature was measured with an in-line thermocouple. Mean times measured by stopwatch were higher than set. No in-line temperatures reached 40 degrees C. Wider overall ranges and a higher mean were found with the tympanic probe compared with in-line temperature measurement. There were significant differences between the in-line temperatures of shaken and unshaken bags at each power setting, but not when groups were added together. There was no change in colour or odour of bags or fluid. One bag developed a pinhole leak when the packaging was removed.
MB. The practice is banned in our institution after an accident with the method.

ARTICLE TITLE: Pathogenesis, natural history, treatment, and prevention of hepatitis C.
ARTICLE SOURCE: Ann Intern Med (United States), Feb 15 2000, 132(4) p296-305
AUTHOR(S): Liang TJ; Rehermann B; Seeff LB; Hoofnagle JH
AUTHOR'S ADDRESS: Liver Diseases Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892-1800, USA.
PUBLICATION TYPE: CONSENSUS DEVELOPMENT CONFERENCE; CONSENSUS DEVELOPMENT CONFERENCE, NIH; JOURNAL ARTICLE; REVIEW (77 references)
ABSTRACT: Approximately 4 million persons in the United States and probably more than 100 million persons worldwide are infected with hepatitis C virus. The virus has the unique ability to cause persistent infection in susceptible hosts after parenteral or percutaneous transmission, and its underlying mechanisms are not well understood. The immunologic correlates of protection and viral clearance and the pathogenesis of liver injury are yet to be defined, but recent studies suggest the importance of cell-mediated immune responses. Although 70% to 80% of infected persons become chronic carriers, most have relatively mild disease with slow progression. However, chronic and progressive hepatitis C carries significant morbidity and mortality and is a major cause of cirrhosis, end-stage liver disease, and liver cancer. Development of an effective hepatitis C virus vaccine is not imminent, but recent advances in technology and basic knowledge of molecular virology and immunology have engendered novel approaches to the fundamental problems encountered in vaccine development. Current therapy for hepatitis C, although effective in some patients, is problematic and still evolving. Advances in modern biology and immunology promise new therapies for this important disease.

ARTICLE TITLE: Eugenic sterilization and a qualified Nazi analogy: the United States and Germany, 1930-1945.
ARTICLE SOURCE: Ann Intern Med (United States), Feb 15 2000, 132(4) p312-9
AUTHOR(S): Sofair AN; Kaldjian LC
AUTHOR'S ADDRESS: Yale University, New Haven, Connecticut, USA.
PUBLICATION TYPE: HISTORICAL ARTICLE; JOURNAL ARTICLE
ABSTRACT: In the United States and Germany before World War II, physicians participated in state-authorized eugenic sterilization programs in an attempt to prevent persons deemed to possess undesirable heritable characteristics from propagating. A comparison of U.S. and German histories reveals similarities that argue against easy dismissal of a Nazi analogy. On the basis of a review of editorials in New England Journal of Medicine and Journal of the American Medical Association from 1930 to 1945 it is difficult to accept the suggestion that the alliance between the medical profession and the eugenics movement in the United States was short-lived. Comparison of the histories of the eugenic sterilization campaigns in the United States and Nazi Germany reveals important similarities of motivation, intent, and strategy and differences that explain why support for eugenic sterilization in the United States gradually weakened. The eugenics movement in Germany was influenced by economic crisis, radical nationalism, Hitler's totalitarianism, and the medical profession's willing participation and attraction to Nazism for financial and ideological reasons. In the United States, a combination of public unease, Roman Catholic opposition, federal democracy, judicial review, and critical scrutiny by the medical profession reversed the momentum of the eugenics movement and led to the conclusion that eugenic sterilization should be voluntary.

ARTICLE TITLE: Antiretroviral therapy: time to think strategically [editorial; comment]
COMMENTS: Comment on: Ann Intern Med 2000 Feb 15; 132(4):306-11
ARTICLE SOURCE: Ann Intern Med (United States), Feb 15 2000, 132(4) p320-2
AUTHOR(S): Cohen OJ
PUBLICATION TYPE: COMMENT; EDITORIAL )

ARTICLE TITLE: Prevention of intravascular catheter-related infections.
ARTICLE SOURCE: Ann Intern Med (United States), Mar 7 2000, 132(5) p391-402
AUTHOR(S): Mermel LA
AUTHOR'S ADDRESS: Division of Infectious Diseases, Rhode Island Hospital and Brown University School of Medicine, Providence 02903, USA. lmermel@lifespan.org.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: Simple interventions can reduce the risk for serious catheter-related infection. Adequately powered randomized trials are needed.

ARTICLE TITLE: Nasogastric tubes permit reflux and aspiration: is there any evidence? [letter]
ARTICLE SOURCE: Ann Intern Med (United States), Apr 4 2000, 132(7) p594-5
AUTHOR(S): Castell DO
PUBLICATION TYPE: LETTER
MB. They quote their own study Am J Gastroenterology 1995: 90:1804-7. They suggest that a tube increases competence of lower oesophageal sphincter.

ARTICLE TITLE: Hyponatremia, cerebral edema, and noncardiogenic pulmonary edema in marathon runners.
ARTICLE SOURCE: Ann Intern Med (United States), May 2 2000, 132(9) p711-4
AUTHOR(S): Ayus JC; Varon J; Arieff AI
AUTHOR'S ADDRESS: Baylor College of Medicine, Houston, Texas 77024, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: In healthy marathon runners, noncardiogenic pulmonary edema can be associated with hyponatremic encephalopathy. The condition may be fatal if undiagnosed and can be successfully treated with hypertonic NaCl.
MB. This is difficult to interpret because although they have not specified otherwise it appears that they probably ingested hypotonic fluid.

ARTICLE TITLE: Error in medicine: what have we learned?
ARTICLE SOURCE: Ann Intern Med (United States), May 2 2000, 132(9) p763-7
AUTHOR(S): Bates DW; Gawande AA
AUTHOR'S ADDRESS: Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA 02115, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
MB. Gives anaesthesia a plug.

ARTICLE TITLE: New treatments for multiple sclerosis.
ARTICLE SOURCE: Aust N Z J Med (Australia), Dec 1999, 29(6) p801-10
AUTHOR(S): Kilpatrick TJ; Soilu-Hanninen M
AUTHOR'S ADDRESS: Development and Neurobiology Group, The Walter and Eliza Hall Institute of Medical Research, Parkville, Vic.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (38 references); REVIEW, TUTORIAL

ARTICLE TITLE: Clinical practice guidelines: who reads them? who needs them? [editorial; comment]
COMMENTS: Comment on: Aust N Z J Med 1999 Oct; 29(5):678-83
ARTICLE SOURCE: Aust N Z J Med (Australia), Oct 1999, 29(5) p655-7
AUTHOR(S): Thompson PL
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Survival and functional outcome after prolonged intensive care unit stay.
ARTICLE SOURCE: Ann Surg (United States), Feb 2000, 231(2) p262-8
AUTHOR(S): Lipsett PA; Swoboda SM; Dickerson J; Ylitalo M; Gordon T; Breslow M; Campbell K; Dorman T; Pronovost P; Rosenfeld B
AUTHOR'S ADDRESS: Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: An acute surgical illness that results in a prolonged SICU stay has a substantial in-hospital death rate and is costly, but the functional outcome from both a physical and physiologic standpoint is compatible with a good quality of life.

ARTICLE TITLE: Redefining the role of surgery for perforated duodenal ulcer in the Helicobacter pylori era [editorial; comment]
COMMENTS: Comment on: Ann Surg 2000 Feb; 231(2):153-8
ARTICLE SOURCE: Ann Surg (United States), Feb 2000, 231(2) p159-60
AUTHOR(S): Stabile BE
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Postoperative pain management and recovery after remifentanil-based anaesthesia with isoflurane or propofol for major abdominal surgery. Remifentanil Study Group.
ARTICLE SOURCE: Br J Anaesth (England), Feb 2000, 84(2) p169-73
AUTHOR(S): Kochs E; Cote D; Deruyck L; Rauhala V; Puig M; Polati E; Verbist J; Upadhyaya B; Haigh C
AUTHOR'S ADDRESS: Technische Universitat Munchen, Germany.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We have assessed if recovery times after morphine or fentanyl, given before terminating remifentanil anaesthesia with isoflurane or propofol, are compromised. We studied patients undergoing elective, major abdominal surgery, allocated randomly to receive remifentanil and isoflurane (n = 277) or remifentanil and propofol (n = 274) anaesthesia. Twenty-five minutes before the end of surgery, patients received fentanyl 0.15 mg or morphine 15 mg in a randomized, double-blind manner followed by a second dose (fentanyl 0.05 mg, morphine 7 mg) for moderate or severe pain in recovery. Recovery was rapid and at an Aldrete score > or = 9 (median 12-15 min), 42-51% of patients reported none or mild pain. However, 26-35% of patients reported severe pain and > 90% required a second dose of opioid within 21-27 min after anaesthesia.
MB. I wonder if patient recalls this early pain a day later.

ARTICLE TITLE: Fractured femur in the elderly: intensive perioperative care is warranted [editorial; comment]
COMMENTS: Comment on: Br J Anaesth 2000 Feb; 84(2):260-2
ARTICLE SOURCE: Br J Anaesth (England), Feb 2000, 84(2) p139-40
AUTHOR(S): Sharrock NE
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Aprotinin and renal function in patients undergoing cardiac surgery [editorial; comment]
COMMENTS: Comment on: Br J Anaesth 2000 Jan; 84(1):16-22
ARTICLE SOURCE: Br J Anaesth (England), Jan 2000, 84(1) p3-5
AUTHOR(S): Horl WH
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Aprotinin does not impair renal haemodynamics and function after cardiac surgery [see comments]
COMMENTS: Comment in: Br J Anaesth 2000 Jan; 84(1):3-5
ARTICLE SOURCE: Br J Anaesth (England), Jan 2000, 84(1) p16-22
AUTHOR(S): Schweizer A; Hohn L; Morel DR; Kalangos A; Licker M
AUTHOR'S ADDRESS: Division of Anaesthesiology, Hopital Cantonal Universitaire, Geneve, Switzerland.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
Aprotinin had no apparent adverse effect on renal function and it did not alter mechanisms involving prostanoids and atrial natriuretic peptide during cardiac surgery.

ARTICLE TITLE: Fatal paradoxical air embolism during liver transplantation.
ARTICLE SOURCE: Br J Anaesth (England), Jan 2000, 84(1) p112-4
AUTHOR(S): Olmedilla L; Garutti I; Perez-Pena J; Sanz J; Teigell E; Avellanal M
AUTHOR'S ADDRESS: Department of Anaesthesiology, Hospital General Universitario Gregorio Maranon, Madrid, Spain.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: We describe a case of fatal paradoxical coronary air embolism during liver transplantation. The literature on the diagnosis and prophylaxis of paradoxical air embolism during liver transplantation is reviewed and discussed.
MB. We had one who never regained consciousness. We now use no nitrous, apply PEEP & keep the venous pressure about 15 mmHg when PEEP is off.

ARTICLE TITLE: Validity and reliability of a postoperative quality of recovery score: the QoR-40 [see comments]
COMMENTS: Comment in: Br J Anaesth 2000 Jan; 84(1):1-2
ARTICLE SOURCE: Br J Anaesth (England), Jan 2000, 84(1) p11-5
AUTHOR(S): Myles PS; Weitkamp B; Jones K; Melick J; Hensen S
AUTHOR'S ADDRESS: Department of Anaesthesia and Pain Management, Alfred Hospital, Prahran, Victoria, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Quality of recovery after anaesthesia is an important measure of the early postoperative health status of patients. We attempted to develop a valid, reliable and responsive measure of quality of recovery after anaesthesia and surgery. We studied 160 patients and asked them to rate postoperative recovery using three methods: a 100-mm visual analogue scale (VAS), a nine-item questionnaire and a 50-item questionnaire; the questionnaires were repeated later on the same day. From these results, we developed a 40-item questionnaire as a measure of quality of recovery (QoR-40; maximum score 200). We found good convergent validity between QoR-40 and VAS (r = 0.68, P < 0.001). Construct validity was supported by a negative correlation with duration of hospital stay (rho = -0.24, P < 0.001) and a lower mean QoR-40 score in women (162 (SD 26)) compared with men (173 (17)) (P = 0.002). There was also good test-retest reliability (intra-class ri = 0.92, P < 0.001), internal consistency (Cronbach's alpha = 0.93, P < 0.001) and split-half coefficient (alpha = 0.83, P < 0.001). The standardized response mean, a measure of responsiveness, was 0.65. The QoR-40 was completed in less than 6.3 (4.9) min. We believe that the QoR-40 is a good objective measure of quality of recovery after anaesthesia and surgery. It would be a useful end-point in perioperative clinical studies.

ARTICLE TITLE: Percussion--a new way to diagnose a pneumothorax.
ARTICLE SOURCE: Br J Anaesth (England), Dec 1999, 83(6) p960-1
AUTHOR(S): Winter R; Smethurst D
AUTHOR'S ADDRESS: Adult Intensive Care Unit, Queen's Medical Centre, University Hospital, Nottingham, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: We describe a new clinical sign in a case series of three patients who developed pneumothoraces during mechanical ventilation in the intensive care unit. All three patients were in the supine position. Two patients had x-rays that were inconclusive before insertion of chest drains and the third had a pneumothorax diagnosed on clinical findings alone. On each occasion we were able to diagnose pneumothorax using sternal percussion and simultaneous auscultation. The method relies on percussion of the sternum while simultaneously ausculating the anterior (superior) chest on the side of the suspected pneumothorax. The stethoscope is then placed on the other side of the chest. The percussion sound on the affected side has an exaggerated, resonant and booming quality. The percussion note is exaggerated partly because a stethoscope is used and partly because, in the supine patient, air localizes upwards to the anterior thorax.

ARTICLE TITLE: Why we need large randomized studies in anaesthesia [editorial]
ARTICLE SOURCE: Br J Anaesth (England), Dec 1999, 83(6) p833-4
AUTHOR(S): Myles PS
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Effect of omitting regular ACE inhibitor medication before cardiac surgery on haemodynamic variables and vasoactive drug requirements.
ARTICLE SOURCE: Br J Anaesth (England), Nov 1999, 83(5) p715-20
AUTHOR(S): Pigott DW; Nagle C; Allman K; Westaby S; Evans RD
AUTHOR'S ADDRESS: Nuffield Department of Anaesthetics, John Radcliffe Hospital, Headington, Oxford, UK.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: Adverse events during coronary artery bypass graft (CABG) surgery have been described in patients receiving angiotensin converting enzyme (ACE) inhibitors, including hypotension on induction of anaesthesia and an increase in vasoconstrictor requirements after cardiopulmonary bypass (CPB). Omitting regular ACE inhibitor medication before surgery may improve cardiovascular stability during anaesthesia. We evaluated prospectively the effect of omitting regular ACE inhibitor medication before CABG surgery on haemodynamic variables and use of vasoactive drugs. We studied 40 patients with good left ventricular function, allocated randomly to omit or continue ACE inhibitor medication before surgery. Arterial pressure, cardiac output, systemic vascular resistance and use of vasoactive drugs were recorded during anaesthesia and in the early postoperative period. Patients who omitted their ACE inhibitors had greater mean arterial pressure during the study and required less vasopressors during CPB. However, these patients required more vasodilators to control hypertension after CPB and in the early postoperative period. There was no difference in hypotension on induction of anaesthesia or in the use of vasoconstrictors after CPB. We conclude that omitting ACE inhibitors before surgery did not have sufficient advantage to be recommended routinely.

ARTICLE TITLE: Cost effectiveness of general anaesthesia: inhalation vs i.v. [editorial; comment]
COMMENTS: Comment on: Br J Anaesth 1999 Oct; 83(4):564-70
ARTICLE SOURCE: Br J Anaesth (England), Oct 1999, 83(4) p547-9
AUTHOR(S): Crozier TA; Kettler D
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Cisatracurium neuromuscular block at the adductor pollicis and the laryngeal adductor muscles in humans.
ARTICLE SOURCE: Br J Anaesth (England), Sep 1999, 83(3) p483-4
AUTHOR(S): Kim KS; Chung CW; Shin WJ
AUTHOR'S ADDRESS: Department of Anaesthesiology, Hanyang University Hospital, Songdong-Ku, Seoul.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
We found that the laryngeal adductors were more resistant to the action of cisatracurium than the adductor pollicis muscle, but onset and recovery were faster at the larynx.

ARTICLE TITLE: Magnesium: physiology and pharmacology [see comments]
COMMENTS: Comment in: Br J Anaesth 1999 Aug; 83(2):202-3
ARTICLE SOURCE: Br J Anaesth (England), Aug 1999, 83(2) p302-20
AUTHOR(S): Fawcett WJ; Haxby EJ; Male DA
AUTHOR'S ADDRESS: Department of Anaesthesia, Royal Surrey County Hospital, Guildford, Surrey, UK.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (201 references); REVIEW, ACADEMIC
ABSTRACT: Magnesium has an established role in obstetrics and an evolving role in other clinical areas, in particular cardiology. Many of the effects involving magnesium are still a matter of controversy. Over the next decade, it is likely that improvements in the measurement of magnesium, a clearer understanding of the mechanisms of its actions and further results of clinical studies will help to elucidate its role, both in terms of treating deficiency and as a pharmacological agent.

ARTICLE TITLE: Aspirin.
ARTICLE SOURCE: Circulation (United States), Mar 14 2000, 101(10) p1206-18
AUTHOR(S): Awtry EH; Loscalzo J
AUTHOR'S ADDRESS: Cardiology Section, Evans Department of Medicine, Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA 02118, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (166 references); REVIEW, ACADEMIC

ARTICLE TITLE: President proposes steps to prevent medical mistakes [news]
ARTICLE SOURCE: Circulation (United States), Mar 7 2000, 101(9) pE9015
AUTHOR(S): So Relle R
INDEXING CHECK TAG(S): Human
ARTICLE TITLE: Reducing the rate of medical errors in the United States [news]
ARTICLE SOURCE: Circulation (United States), Jan 25 2000, 101(3) pE39-40
AUTHOR(S): So Relle R
PUBLICATION TYPE: NEWS

ARTICLE TITLE: Reducing the rate of medical errors in the United States [news]
ARTICLE SOURCE: Circulation (United States), Jan 25 2000, 101(3) pE39-40
AUTHOR(S): So Relle R
PUBLICATION TYPE: NEWS

ARTICLE TITLE: Randomized trial comparing intravenous nitroglycerin and heparin for treatment of unstable angina secondary to restenosis after coronary artery angioplasty.
ARTICLE SOURCE: Circulation (United States), Mar 7 2000, 101(9) p955-61
AUTHOR(S): Doucet S; Malekianpour M; Theroux P; Bilodeau L; Cote G; de Guise P; Dupuis J; Joyal M; Gosselin G; Tanguay JF; Juneau M; Harel F; Nattel S; Tardif JC; Lesperance J
AUTHOR'S ADDRESS: Cardiac Catheterization Laboratory and Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: The treatment of unstable angina targets the specific pathophysiological CONCLUSIONS: Intravenous nitroglycerin is highly effective in preventing adverse ischemic events (recurrent or refractory angina) in patients with unstable angina secondary to restenosis, whereas heparin has no effect.

ARTICLE TITLE: beta-adrenergic receptor blockade in chronic heart failure.
ARTICLE SOURCE: Circulation (United States), Feb 8 2000, 101(5) p558-69
AUTHOR(S): Bristow MR
AUTHOR'S ADDRESS: Division of Cardiology, University of Colorado Health Sciences Center, Denver, CO 80262, USA. Michael.Bristow@UCHSC.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (117 references); REVIEW, ACADEMIC

ARTICLE TITLE: Chaos theory, heart rate variability, and arrhythmic mortality [editorial; comment]
COMMENTS: Comment on: Circulation 2000 Jan 4-11; 101(1):47-53
ARTICLE SOURCE: Circulation (United States), Jan 4-11 2000, 101(1) p8-10
AUTHOR(S): Lombardi F
PUBLICATION TYPE: COMMENT; EDITORIAL; REVIEW (20 references); REVIEW, TUTORIAL

ARTICLE TITLE: The cardiomyopathies: an overview.
ARTICLE SOURCE: Heart (England), Apr 2000, 83(4) p469-74
AUTHOR(S): Davies MJ
AUTHOR'S ADDRESS: St George's Hospital Medical School, Histopathology Department, London, UK.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (11 references); REVIEW, TUTORIAL

ARTICLE TITLE: Alcohol intake and mortality in middle aged men with diagnosed coronary heart disease.
ARTICLE SOURCE: Heart (England), Apr 2000, 83(4) p394-9
AUTHOR(S): Shaper AG; Wannamethee SG
AUTHOR'S ADDRESS: Department of Primary Care and Population Sciences, Royal Free and University College Medical Schools, Rowland Hill Street, London NW3 2PF, UK. agshaper@wentworth.u-net.com.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Compared to occasional drinking, regular light alcohol consumption (1-14 units per week) in men with established coronary heart disease is not associated with any significant benefit or deleterious effect for CHD, cardiovascular disease or all cause mortality. Higher levels of intake (>/= 3 drinks per day) are associated with increased mortality in men with previous myocardial infarction. In contrast, smoking cessation in men with established CHD substantially reduces the risk of mortality.
MB. Well there you go.

ARTICLE TITLE: Postinfarction left ventricular remodelling: where are the theories and trials leading us?
ARTICLE SOURCE: Heart (England), Jan 2000, 83(1) p76-80
AUTHOR(S): Yousef ZR; Redwood SR; Marber MS
AUTHOR'S ADDRESS: Department of Cardiology, The Rayne Institute, St Thomas' Hospital, King's College London, London SE1 7EH, UK.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (40 references); REVIEW, TUTORIAL

ARTICLE TITLE: Acute myocardial infarction: thrombolysis.
ARTICLE SOURCE: Heart (England), Jan 2000, 83(1) p122-6
AUTHOR(S): Topol EJ
AUTHOR'S ADDRESS: Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA. topole@ccf.org.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (12 references); REVIEW, TUTORIAL

ARTICLE TITLE: Respiratory jugular venodilation: a new landmark for right internal jugular vein puncture in ventilated patients.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Feb 2000, 14(1) p40-4
AUTHOR(S): Hayashi H; Ootaki C; Tsuzuku M; Amano M
AUTHOR'S ADDRESS: Department of Anesthesia, Labor and Welfare Organization, Kansai Rosai Hospital, Hyogo, Japan.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: To report a new technique for right internal jugular vein puncture using respiratory jugular venodilation as a landmark for vein location. DESIGN: Prospective observational study. SETTING: Single community hospital. PARTICIPANTS: Two hundred patients undergoing right internal jugular vein cannulation under general anesthesia. INTERVENTIONS: Catheter placement was attempted using respiratory jugular venodilation as the primary landmark. When it was not applicable, an alternative technique using the carotid pulse as a landmark was used. MEASUREMENTS AND MAIN RESULTS: Visibility of the venodilation, the number of needle passes, the success rate, and the incidence of arterial puncture were analyzed. Respiratory jugular venodilation was observed in 158 patients (79%). In this group of patients, the jugular vein was cannulated at the first attempt in 83.5% of patients, and arterial puncture occurred in one patient (0.6%). In the remaining 42 patients (21%) lacking the visible venodilation, catheter placement was accomplished at the first attempt in 42.9% of patients (p<0.01 v. the venodilation-visible group), and 4 patients (9.5%) suffered arterial puncture (p<0.01). The overall incidence of arterial puncture was 2.5%. The success rate of cannulation (within four needle passes and no arterial puncture) was 98.1% in the venodilation-visible patients and 73.8% in the others (p<0.01), with the overall success rate of 93%. CONCLUSIONS: Respiratory jugular venodilation can be identified in a large proportion of ventilated patients. This experience suggests that respiratory jugular venodilation could be favorably used as the primary landmark for right internal jugular vein puncture in anesthetized patients.

ARTICLE TITLE: Volume therapy in cardiac surgery: does the kind of fluid matter?
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Dec 1999, 13(6) p752-63
AUTHOR(S): Boldt J
AUTHOR'S ADDRESS: Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Germany.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (107 references); REVIEW LITERATURE

ARTICLE TITLE: The anterior spinal artery: the main arterial supply of the human spinal cord--a preliminary anatomic study.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Feb 2000, 119(2) p376-9
AUTHOR(S): Biglioli P; Spirito R; Roberto M; Grillo F; Cannata A; Parolari A; Maggioni M; Coggi G
AUTHOR'S ADDRESS: Department of Cardiovascular Surgery, Centro Cardiologico "I Monzino" Foundation IRCCS, Milan, Italy.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Changes in whole blood lactate levels during cardiopulmonary bypass for surgery for congenital cardiac disease: an early indicator of morbidity and mortality.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Jan 2000, 119(1) p155-62
AUTHOR(S): Munoz R; Laussen PC; Palacio G; Zienko L; Piercey G; Wessel DL
AUTHOR'S ADDRESS: Department of Cardiology, Children's Hospital, Boston, Massachusetts, USA. munoz_r@a1.tch.harvard.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Hyperlactatemia occurs during cardiopulmonary bypass in patients undergoing operations for congenital cardiac disease and may be an early indicator for postoperative morbidity and mortality.

ARTICLE TITLE: Ethics of intensive neonatal care [editorial]
ARTICLE SOURCE: Lancet (England), Jan 8 2000, 355(9198) p79
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial [see comments]
COMMENTS: Comment in: Lancet 2000 Jan 8; 355(9198):83-4
ARTICLE SOURCE: Lancet (England), Jan 8 2000, 355(9198) p93-7
AUTHOR(S): Carman WF; Elder AG; Wallace LA; McAulay K; Walker A; Murray GD; Stott DJ
AUTHOR'S ADDRESS: Institute of Virology, University of Glasgow, UK.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
INTERPRETATION: Vaccination of health-care workers was associated with a substantial decrease in mortality among patients. However, virological surveillance showed no associated decrease in non-fatal influenza infection in patients.

ARTICLE TITLE: Systolic blood pressure and mortality [see comments]
COMMENTS: Comment in: Lancet 2000 Jan 15; 355(9199):159
ARTICLE SOURCE: Lancet (England), Jan 15 2000, 355(9199) p175-80
AUTHOR(S): Port S; Demer L; Jennrich R; Walter D; Garfinkel A
AUTHOR'S ADDRESS: Department of Mathematics, University of California, Los Angeles 90025, USA. sport@ucla.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
INTERPRETATION: The Framingham data contradict the concept that lower pressures imply lower risk and the idea that 140 mm Hg is a useful cut-off value for hypertension for all adults. There is an age-dependent and sex-dependent threshold for hypertension. A substantial proportion of the population who would currently be thought to be at increased risk are, therefore, at no increased risk.

ARTICLE TITLE: Measures and meaning of blood pressure [comment]
COMMENTS: Comment on: Lancet 2000 Jan 15; 355(9199):175-80
ARTICLE SOURCE: Lancet (England), Jan 15 2000, 355(9199) p159
AUTHOR(S): Alderman MH
AUTHOR'S ADDRESS: Albert Einstein College of Medicine, Department of Epidemiology and Social Medicine, Bronx, New York 10461, USA.
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE

ARTICLE TITLE: Should men still go bald gracefully?
ARTICLE SOURCE: Lancet (England), Jan 15 2000, 355(9199) p161-2
AUTHOR(S): Barth JH
AUTHOR'S ADDRESS: Department of Clinical Biochemistry and Immunology, General Infirmary at Leeds, UK.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: When doctors become agents of the state [editorial]
ARTICLE SOURCE: Lancet (England), Jan 22 2000, 355(9200) p245
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: HOPE and extension of the indications for ACE inhibitors? Heart Outcomes Prevention Evaluation [see comments]
COMMENTS: Comment in: Lancet 2000 Jan 22; 355(9200):246-7
ARTICLE SOURCE: Lancet (England), Jan 22 2000, 355(9200) p246-7
AUTHOR(S): Chaturvedi N
AUTHOR'S ADDRESS: Department of Medicine, University College London, UK.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Efficacy of oral anticoagulants compared with aspirin after infrainguinal bypass surgery (The Dutch Bypass Oral Anticoagulants or Aspirin Study): a randomised trial [see comments]
COMMENTS: Comment in: Lancet 2000 Jan 29; 355(9201):334
ARTICLE SOURCE: Lancet (England), Jan 29 2000, 355(9201) p346-51
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: Oral anticoagulants and aspirin are antithrombotic drugs that are commonly used in patients with vascular disease. We investigated whether either of these treatments prevented more effectively than the other bypass complications after infrainguinal bypass surgery. METHODS: We did a multicentre, randomised, open trial. 2690 patients who had undergone infrainguinal grafting were randomly assigned oral anticoagulants (target international normalised ratio 3.0-4.5, n=1339) or aspirin (80 mg daily, n=1351). We followed up patients for a mean of 21 months. The primary outcome was graft occlusion. FINDINGS: 308 graft occlusions occurred in the oral-anticoagulants group compared with 322 in the aspirin group (hazard ratio 0.95 [95% CI 0.82-1.11]), which suggested no overall advantage for either treatment. Oral anticoagulants were beneficial in patients with vein grafts (0.69 [0.54-0.88]), whereas aspirin had better results for nonvenous grafts (1.26 [1.03-1.55]). The composite outcome of vascular death, myocardial infarction, stroke, or amputation occurred 248 times in the oral-anticoagulants group and 275 times in the aspirin group (0.89 [0.75-1.06]). Patients treated with oral anticoagulants had more major bleeding episodes than those treated with aspirin (108 vs 56; 1.96 [1.42-2.71]). INTERPRETATION: Oral anticoagulation was better for the prevention of infrainguinal-vein-graft occlusion and for lowering the rate of ischaemic events. Aspirin was better for the prevention of non-venous graft occlusion, and was associated with fewer bleeding episodes.

ARTICLE TITLE: Awareness during anaesthesia: a prospective case study [see comments]
COMMENTS: Comment in: Lancet 2000 Feb 26; 355(9205):672-4
ARTICLE SOURCE: Lancet (England), Feb 26 2000, 355(9205) p707-11
AUTHOR(S): Sandin RH; Enlund G; Samuelsson P; Lennmarken C
AUTHOR'S ADDRESS: Department of Anaesthesia and Intensive Care, Lanssjukhuset, Kalmar, Sweden. rolfs@ltkalmar.se.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Patients who are given general anaesthesia are not guaranteed to remain unconscious during surgery. Knowledge about the effectiveness of current protective measures is scarce, as is our understanding of patients' responses to this complication. We did a prospective case study to assess conscious awareness during anaesthesia. METHODS: 11785 patients who had undergone general anaesthesia were interviewed for awareness on three occasions: before they left the post-anaesthesia care unit, and 1-3 days and 7-14 days after the operation. FINDINGS: We identified 18 cases of awareness and one case of inadvertent muscle blockade that had occurred before unconsciousness. Incidence of awareness was 0.18% in cases in which neuromuscular blocking drugs were used, and 0.10% in the absence of such drugs. 17 cases of awareness were identified at the final interview, but no more than 11 would have been detected if an interview had been done only when the patients left the post-anaesthesia care unit. Four non-paralysed patients recalled intraoperative events, but none had anxiety during wakefulness or had delayed neurotic symptoms. This finding contrasts with anaesthesia with muscle relaxants, during which 11 of 14 patients had pain, anxiety, or delayed neurotic symptoms. After repeated discussion and information, the delayed neurotic symptoms resolved within 3 weeks in all patients. Analysis of individual cases suggests that a reduced incidence of recall of intraoperative events would not be achieved by monitoring of end-tidal anaesthetic gas concentration or by more frequent use of benzodiazepines. INTERPRETATION: The inability to prevent awareness by conventional measures may advocate monitoring of cerebral activity by neurophysiological techniques. However, the sensitivity of such techniques is not known, and in the light of our findings, at least 861 patients would need to be monitored to avoid one patient from suffering due to awareness during relaxant anaesthesia.
MB. 4 cases they say had awareness without NMBs. They all had LMAs and the stories are not very convincing ie they did not recall anything that could not have been invented. None were distressed. A lot of those with NMBs are obviously technical errors. Other are not convincing.

ARTICLE TITLE: Awareness of awareness during general anaesthesia [comment]
COMMENTS: Comment on: Lancet 2000 Feb 26; 355(9205):707-11
ARTICLE SOURCE: Lancet (England), Feb 26 2000, 355(9205) p672-4
AUTHOR(S): Simini B
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE
MB. Not very useful

ARTICLE TITLE: UK government starts to lose patience with General Medical Council [news]
ARTICLE SOURCE: Lancet (England), Feb 19 2000, 355(9204) p636
AUTHOR(S): Ashraf H
PUBLICATION TYPE: NEWS

ARTICLE TITLE: Are booster immunisations needed for lifelong hepatitis B immunity? European Consensus Group on Hepatitis B Immunity.
ARTICLE SOURCE: Lancet (England), Feb 12 2000, 355(9203) p561-5
PUBLICATION TYPE: CONSENSUS DEVELOPMENT CONFERENCE; JOURNAL ARTICLE; REVIEW (38 references)
ABSTRACT: Long-term protection against clinically significant breakthrough hepatitis B (HB) virus infection and chronic carriage depends on immunological memory, which allows a protective anamnestic antibody response to antigen challenge. Memory seems to last for at least 15 years in immunocompetent individuals. To date there are no data to support the need for booster doses of HB vaccine in immunocompetent individuals who have responded to a primary course. All adequately vaccinated individuals have shown evidence of immunity in the form of persisting anti-HBs and/or in vitro B-cell stimulation or an anamnestic response to a vaccine challenge. Nonetheless several countries and individuals currently have a policy of administering booster doses to certain risk groups. Boosters may be used to provide reassurance of protective immunity against benign breakthrough infection. For immunocompromised patients, regular testing for anti-HBs, and a booster injection when the titre falls below 10 mIU/mL, is advised. Long-term monitoring should continue, to confirm the absence of clinically significant breakthrough episodes of hepatitis B and to find out if a carrier state develops after 15 years. Also, non-responders to a primary course should continue to be studied.

ARTICLE TITLE: New Zealand's pharmaceutical reference-pricing strategy may backfire [news]
ARTICLE SOURCE: Lancet (England), Feb 12 2000, 355(9203) p558
AUTHOR(S): Menkes D
PUBLICATION TYPE: NEWS
MB. Drug companies are leaving NZ.

ARTICLE TITLE: Double gloving--electrical resistance and surgeons' resistance.
ARTICLE SOURCE: Lancet (England), Feb 12 2000, 355(9203) p514-5
AUTHOR(S): Jensen SL
AUTHOR'S ADDRESS: Orthopaedic Research Laboratory, University Hospital of Aarhus, Denmark.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Epidemic and pandemic 'flu [editorial]
ARTICLE SOURCE: Lancet (England), Feb 12 2000, 355(9203) p509
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre randomised double-blind study. EMSALT Study Group [see comments]
COMMENTS: Comment in: Lancet 2000 Apr 15; 355(9212):1289-90
ARTICLE SOURCE: Lancet (England), Apr 15 2000, 355(9212) p1303-9
AUTHOR(S): Porte RJ; Molenaar IQ; Begliomini B; Groenland TH; Januszkiewicz A; Lindgren L; Palareti G; Hermans J; Terpstra OT
AUTHOR'S ADDRESS: Department of Surgery, Leiden University Medical Centre, The Netherlands. r.j.porte@chir.azg.nl.
INDEXING CHECK TAG(S): Comparative Study; Female; Human; Male
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: Intraoperative hyperfibrinolysis contributes to bleeding during adult orthotopic liver transplantation. We aimed to find out whether aprotinin, a potent antifibrinolytic agent, reduces blood loss and transfusion requirements. METHODS: We did a randomised, double-blind, placebo-controlled trial in which six liver-transplant centres participated. Patients undergoing primary liver transplantation were randomly assigned intraoperative high-dose aprotinin, regular-dose aprotinin, or placebo. Primary endpoints were intraoperative blood loss and transfusion requirements. Secondary endpoints were perioperative fluid requirements, postoperative blood transfusions, complications, and mortality. FINDINGS: 137 patients received high-dose aprotinin (n=46), regular-dose aprotinin (n=43), or placebo (n=48). Intraoperative blood loss was significantly lower in the aprotinin-treated patients, with a reduction of 60% in the high-dose group and 44% in the regular-dose group, compared with the placebo group (p=0.03). Total amount of red blood cell (homologous and autologous) transfusion requirements was 37% lower in the high-dose group and 20% lower in the regular-dose group, than in the placebo group (p=0.02). Thromboembolic events occurred in two patients in the high-dose group, none in the regular-dose group, and in two patients in the placebo group (p=0.39). Mortality at 30 days did not differ between the three groups (6.5%, 4.7%, and 8.3%; p=0.79). INTERPRETATION: Intraoperative use of aprotinin in adult patients undergoing orthotopic liver transplantation significantly reduces blood-transfusion requirements and should be routinely used in patients without contraindications.

ARTICLE TITLE: Aprotinin: pharmacological reduction of perioperative bleeding [comment]
COMMENTS: Comment on: Lancet 2000 Apr 15; 355(9212):1303-9
ARTICLE SOURCE: Lancet (England), Apr 15 2000, 355(9212) p1289-90
AUTHOR(S): Segal H; Hunt BJ
AUTHOR'S ADDRESS: Oxford Haemophilia Centre, Churchill Hospital, Headington, UK.
PUBLICATION TYPE: CLINICAL TRIAL; COMMENT; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL

ARTICLE TITLE: Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial [see comments]
COMMENTS: Comment in: Lancet 2000 Apr 15; 355(9212):1288-9
ARTICLE SOURCE: Lancet (England), Apr 15 2000, 355(9212) p1295-302
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
INTERPRETATION: These results, along with those of the previous meta-analysis, show that aspirin reduces the risk of pulmonary embolism and deep-vein thrombosis by at least a third throughout a period of increased risk. Hence, there is now good evidence for considering aspirin routinely in a wide range of surgical and medical groups at high risk of venous thromboembolism.

ARTICLE TITLE: Place of aspirin in prophylaxis of venous thromboembolism [comment]
COMMENTS: Comment on: Lancet 2000 Apr 15; 355(9212):1295-302
ARTICLE SOURCE: Lancet (England), Apr 15 2000, 355(9212) p1288-9
AUTHOR(S): Sors H; Meyer G
AUTHOR'S ADDRESS: Department of Lung Diseases, Paris V University, Laennec Hospital, France.
PUBLICATION TYPE: CLINICAL TRIAL; COMMENT; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL

ARTICLE TITLE: Patients' perceptions of pain with spinal, intramuscular, and venous injections [letter]
ARTICLE SOURCE: Lancet (England), Mar 25 2000, 355(9209) p1076
AUTHOR(S): Simini B
PUBLICATION TYPE: LETTER
ABSTRACT: Most of 46 patients believed that spinal injection would be more painful than intramuscular or intravenous injections. The reverse proved true: spinal injections were perceived to be less painful than the other two procedures. Intramuscular injections should be avoided. Local anaesthesia should be given for lumbar punctures and intravenous cannulation.

ARTICLE TITLE: Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: randomised controlled trial [see comments]
COMMENTS: Comment in: Lancet 2000 Mar 4; 355(9206):768-9
ARTICLE SOURCE: Lancet (England), Mar 4 2000, 355(9206) p779-81
AUTHOR(S): Rowsell M; Bello M; Hemingway DM
AUTHOR'S ADDRESS: Department of Gastrointestinal and General Surgery, Leicester Royal Infirmary, UK.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
INTERPRETATION: Stapled haemorrhoidectomy is an effective treatment for third degree haemorrhoids with significant advantages for patients compared with conventional haemorrhoidectomy.

ARTICLE TITLE: Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial [see comments]
COMMENTS: Comment in: Lancet 2000 Mar 4; 355(9206):768-9
ARTICLE SOURCE: Lancet (England), Mar 4 2000, 355(9206) p782-5
AUTHOR(S): Mehigan BJ; Monson JR; Hartley JE
AUTHOR'S ADDRESS: Academic Surgical Unit, University of Hull, Castle Hill Hospital, Cottingham, UK.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
INTERPRETATION: The circular stapled technique offers a significantly less painful alternative to Milligan-Morgan haemorrhoidectomy and is associated with an earlier return to normal activity. Early symptom control and functional outcome appear similar. However, long-term symptomatic and functional outcome need further study.

ARTICLE TITLE: Early promise of stapling technique for haemorrhoidectomy [comment]
COMMENTS: Comment on: Lancet 2000 Mar 4; 355(9206):779-81; Comment on: Lancet 2000 Mar 4; 355(9206):782-5; Comment on: Lancet 2000 Mar 4; 355(9206):810
ARTICLE SOURCE: Lancet (England), Mar 4 2000, 355(9206) p768-9
AUTHOR(S): Fazio VW
AUTHOR'S ADDRESS: Department of Colorectal Surgery, Cleveland Clinic Foundation, OH 44195, USA.
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE

ARTICLE TITLE: The role of new anesthetic agents.
ARTICLE SOURCE: Pharmacol Ther (England), Dec 1999, 84(3) p233-48
AUTHOR(S): O'Keeffe NJ; Healy TE
AUTHOR'S ADDRESS: Department of Anesthesia, Manchester Royal Infirmary, Manchester, UK. Niall.okeeffe@man.ac.uk.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (65 references); REVIEW, TUTORIAL
ABSTRACT: The three anesthetic drugs introduced most recently to the market are sevoflurane, desflurane, and ropivacaine. Sevoflurane and desflurane are both inhalational anesthetic agents and ropivacaine is a local anesthetic agent. Sevoflurane provides a rapid onset and offset of action; it is well tolerated with little airway irritation. It is hemodynamically stable, with low potential for toxicity. Concerns about its interaction with soda lime during low-flow anesthesia with the production of Compound A have not proved to be a clinical problem. While desflurane also provides rapid onset and recovery from anesthesia, it is not as hemodynamically stable as sevoflurane, and also causes airway irritation. Ropivacaine is a unique local anesthetic in that it is supplied as the pure S-enantiomer. It is at least as effective as bupivacaine, with lower toxicity and less motor block for the same degree of sensory block.
MB. Hardly new for us.

ARTICLE TITLE: Prevention of multiple organ failure.
ARTICLE SOURCE: Surg Clin North Am (United States), Dec 1999, 79(6) p1471-88
AUTHOR(S): Deitch EA; Goodman ER
AUTHOR'S ADDRESS: Department of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, USA. edeitch@umdnj.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (66 references); REVIEW, TUTORIAL
ABSTRACT: Physicians are still largely ignorant of the underlying biology of SIRS (Systemic Inflamatory Rersponse Syndrome) and multiple organ failure. Nonetheless, strategies to prevent multiple organ failure are possible. These include aggressive resuscitation of hemodynamically unstable patients, careful assessment to avoid missing clinically significant injuries, early operative treatment of all possible injuries with debridement of all nonviable tissue, early nutritional support, and the early diagnosis and prompt treatment of infectious complications. Treatment of patients with established multiple organ failure is still largely supportive and has made little impact on the patient mortality rate over the past 20 years. Future treatment strategies must focus on multimodality combination therapy aimed at specifically suppressing excessive activation of the inflammatory response while preserving immune competence and normal antimicrobial defenses. Only then are physicians likely to begin to see a reduction in the mortality rate of patients with this complex and challenging condition.
MB. I think the reason physicians are ignorant is because it is a useless concept.

ARTICLE TITLE: New concepts in the management of patients with penetrating abdominal wounds.
ARTICLE SOURCE: Surg Clin North Am (United States), Dec 1999, 79(6) p1331-56
AUTHOR(S): Ferrada R; Birolini D
AUTHOR'S ADDRESS: Department of Surgery, University of Valle, Cali, Colombia. rferrada@telesat.com.co. INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (169 references); REVIEW, TUTORIAL

ARTICLE TITLE: Therapeutic hypothermia in traumatology.
ARTICLE SOURCE: Surg Clin North Am (United States), Dec 1999, 79(6) p1269-89
AUTHOR(S): Tisherman SA; Rodriguez A; Safar P
AUTHOR'S ADDRESS: Safar Center for Resuscitation Research, University of Pittsburgh, Pennsylvania, USA. tishermansa@msx.upmc.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (185 references); REVIEW, TUTORIAL

ARTICLE TITLE: Resuscitation in the new millennium.
ARTICLE SOURCE: Surg Clin North Am (United States), Dec 1999, 79(6) p1259-67, viii
AUTHOR(S): Henry S; Scalea TM
AUTHOR'S ADDRESS: R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, Baltimore, USA.
PUBLICATION TYPE: HISTORICAL ARTICLE; JOURNAL ARTICLE
ABSTRACT: This article discusses resuscitation from a historical perspective; physiology; the optimal timing and volume for and fluids and endpoints of resuscitation; and the role of resuscitation in the future. Whether different types of victims of trauma should be resuscitated using different endpoints also is discussed.