ARTICLE TITLE: Is laparoscopic donor nephrectomy here to stay?
ARTICLE SOURCE: Am J Surg (United States), May 1999, 177(5)
p368-70
AUTHOR(S): Sasaki T; Finelli F; Barhyte D; Trollinger J; Light J
AUTHOR'S ADDRESS: Transplantation Services, Washington Hospital
Center, DC 20010, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Proper surgical training and patient selection can
result in a safe donor operation that provides kidneys of excellent
quality.
ARTICLE TITLE: Toward evidence-based medical statistics. 1: The P
value fallacy [see comments]
COMMENTS: Comment in: Ann Intern Med 1999 Jun 15; 130(12):1019-21
ARTICLE SOURCE: Ann Intern Med (United States), Jun 15 1999, 130(12)
p995-1004
AUTHOR(S): Goodman SN
AUTHOR'S ADDRESS: Johns Hopkins University School of Medicine,
Baltimore, Maryland, USA. sgoodman@jhu.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: An important problem exists in the interpretation of modern
medical research data: Biological understanding and previous research
play little formal role in the interpretation of quantitative
results. This phenomenon is manifest in the discussion sections of
research articles and ultimately can affect the reliability of
conclusions. The standard statistical approach has created this
situation by promoting the illusion that conclusions can be produced
with certain "error rates," without consideration of information from
outside the experiment. This statistical approach, the key components
of which are P values and hypothesis tests, is widely perceived as a
mathematically coherent approach to inference. There is little
appreciation in the medical community that the methodology is an
amalgam of incompatible elements, whose utility for scientific
inference has been the subject of intense debate among statisticians
for almost 70 years. This article introduces some of the key elements
of that debate and traces the appeal and adverse impact of this
methodology to the P value fallacy, the mistaken idea that a single
number can capture both the long-run outcomes of an experiment and
the evidential meaning of a single result. This argument is made as a
prelude to the suggestion that another measure of evidence should be
used--the Bayes factor, which properly separates issues of long-run
behavior from evidential strength and allows the integration of
background knowledge with statistical findings.
MB. Must read full text.
ARTICLE TITLE: Toward evidence-based medical statistics. 2: The
Bayes factor [see comments]
COMMENTS: Comment in: Ann Intern Med 1999 Jun 15; 130(12):1019-21
ARTICLE SOURCE: Ann Intern Med (United States), Jun 15 1999, 130(12)
p1005-13
AUTHOR(S): Goodman SN
AUTHOR'S ADDRESS: Johns Hopkins University School of Medicine,
Baltimore, Maryland, USA. sgoodman@jhu.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Bayesian inference is usually presented as a method for
determining how scientific belief should be modified by data.
Although Bayesian methodology has been one of the most active areas
of statistical development in the past 20 years, medical researchers
have been reluctant to embrace what they perceive as a subjective
approach to data analysis. It is little understood that Bayesian
methods have a data-based core, which can be used as a calculus of
evidence. This core is the Bayes factor, which in its simplest form
is also called a likelihood ratio. The minimum Bayes factor is
objective and can be used in lieu of the P value as a measure of the
evidential strength. Unlike P values, Bayes factors have a sound
theoretical foundation and an interpretation that allows their use in
both inference and decision making. Bayes factors show that P values
greatly overstate the evidence against the null hypothesis. Most
important, Bayes factors require the addition of background knowledge
to be transformed into inferences--probabilities that a given
conclusion is right or wrong. They make the distinction clear between
experimental evidence and inferential conclusions while providing a
framework in which to combine prior with current evidence.
ARTICLE TITLE: Standing statistics right side up [editorial;
comment]
COMMENTS: Comment on: Ann Intern Med 1999 Jun 15; 130(12):995-1004;
Comment on: Ann Intern Med 1999 Jun 15; 130(12):1005-13
ARTICLE SOURCE: Ann Intern Med (United States), Jun 15 1999, 130(12)
p1019-21
AUTHOR(S): Davidoff F
MAJOR SUBJECT HEADING(S): Statistics [standards]
MINOR SUBJECT HEADING(S): Bayes Theorem; Probability; Sensitivity and
Specificity
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Low-molecular-weight heparins compared with
unfractionated heparin for treatment of acute deep venous thrombosis.
A meta-analysis of randomized, controlled trials.
ARTICLE SOURCE: Ann Intern Med (United States), May 18 1999, 130(10)
p800-9
AUTHOR(S): Gould MK; Dembitzer AD; Doyle RL; Hastie TJ; Garber AM
AUTHOR'S ADDRESS: Pulmonary and Critical Care Medicine Section,
Veterans Affairs Palo Alto Health Care System, California 94304, USA.
gould@stanford.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: Low-molecular-weight heparin treatment reduces mortality
rates after acute deep venous thrombosis. These drugs seem to be as
safe as unfractionated heparin with respect to major bleeding
complications and appear to be as effective in preventing
thromboembolic recurrences.
ARTICLE TITLE: Low-molecular-weight heparins compared with
unfractionated heparin for treatment of acute deep venous thrombosis.
A cost-effectiveness analysis [see comments]
COMMENTS: Comment in: Ann Intern Med 1999 May 18; 130(10):857-8
ARTICLE SOURCE: Ann Intern Med (United States), May 18 1999, 130(10)
p789-99
AUTHOR(S): Gould MK; Dembitzer AD; Sanders GD; Garber AM
AUTHOR'S ADDRESS: Pulmonary and Critical Care Section, Veterans
Affairs Palo Alto Health Care System, California 94304, USA.
gould@stanford.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: Low-molecular-weight heparins are highly cost-effective
for inpatient management of venous thrombosis. This treatment reduces
costs when small numbers of patients are eligible for outpatient
management.
ARTICLE TITLE: Ministernotomy versus median sternotomy for aortic
valve replacement: a prospective, randomized study [see
comments]
COMMENTS: Comment in: Ann Thorac Surg 1999 Jun; 67(6):1545-6
ARTICLE SOURCE: Ann Thorac Surg (United States), Jun 1999, 67(6)
p1583-7; discussion 1587-8
AUTHOR(S): Aris A; Camara ML; Montiel J; Delgado LJ; Galan J; Litvan
H
AUTHOR'S ADDRESS: Department of Cardiac Surgery, Hospital de la Santa
Creu i Sant Pau, Barcelona, Spain. aaris@hsp.santpau.es.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ABSTRACT: BACKGROUND: Minimally invasive aortic valve replacement
reduces surgical trauma and, supposedly, postoperative pain, blood
loss, and length of stay. A prospective, randomized study was
designed to prove these theoretical advantages. METHODS: Forty
patients undergoing isolated, elective aortic valve replacement were
randomized into two equal groups. Patients in group M underwent
aortic valve replacement through a ministernotomy (reversed L or
reversed C). In group S, a median sternotomy was used. The anesthetic
and surgical protocol was identical for both groups. Pain was
evaluated on a daily basis. Pulmonary function tests were performed
preoperatively and before hospital discharge in all patients.
RESULTS: There were two deaths in each group. Cross-clamp time was
longer in group M: 70 +/- 19 minutes versus 51 +/- 13 minutes in
group S (p = 0.005). There were no statistically significant
differences between groups M and S in pump time (95 +/- 20 minutes
versus 83 +/- 19 minutes), extubation time (9.9 hours in both
groups), chest drainage (479 +/- 274 mL/L 24 hours versus 355 +/- 159
mL/24 hours), transfusion requirements (27% in both groups), pain
evaluation (1.34 +/- 1.3 versus 2.15 +/- 1.5), length of stay (6.2
+/- 2.3 days versus 6.3 +/- 2.5 days), and cosmetic appraisal. Forced
vital capacity decreased 26% from preoperative reference values in
group M and 33% in group S (p = not significant). Forced expiratory
volume in 1 second decreased 22% and 35%, respectively (p = not
significant). CONCLUSIONS: This study has failed to prove the
theoretical advantages of minimally invasive aortic valve
replacement. With this technique, cross-clamp time is longer than
with a median sternotomy.
MB. I suppose they will get better and quicker. Endoluminal AAAs
& laparoscopic gall bladders used to take longer than open
ones.
ARTICLE TITLE: Informed advice [editorial;
comment]]
COMMENTS: Comment on: Ann Thorac Surg 1999 Jun; 67(6):1583-7;
discussion 1587-8
ARTICLE SOURCE: Ann Thorac Surg (United States), Jun 1999, 67(6)
p1545-6
AUTHOR(S): Olinger GN
MAJOR SUBJECT HEADING(S): Aortic Valve [surgery]; Cardiac
Surgical Procedures [methods]; Heart Valve Diseases
[surgery]; Surgical Procedures, Minimally Invasive
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. The above editorial refers to the proceeding article. They lost
enthusiasm for the new method during the study
ARTICLE TITLE: Epsilon-aminocaproic acid administration and stroke
following coronary artery bypass graft surgery.
ARTICLE SOURCE: Ann Thorac Surg (United States), May 1999, 67(5)
p1283-7
AUTHOR(S): Bennett-Guerrero E; Spillane WF; White WD; Muhlbaier LH;
Gall SA Jr; Smith PK; Newman MF
AUTHOR'S ADDRESS: Department of Anesthesiology, The Mount Sinai
Medical Center, New York, New York 10029-6574, USA.
elliott_guerrero@smtplink.mssm.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Epsilon-aminocaproic acid is routinely used to
reduce bleeding during cardiac surgery. Anecdotal reports of
thrombotic complications have led to speculation regarding this
drug's safety. We investigated the association between
epsilon-aminocaproic acid administration and postoperative stroke.
METHODS: Six thousand two hundred ninety-eight patients undergoing
isolated coronary artery bypass graft surgery between 1989 and 1995
were studied. Data was obtained from the Duke Cardiovascular Database
as well as from an automated intraoperative anesthesia record keeper.
Patients identified as having postoperative stroke were reviewed and
confirmed by a board certified neurologist blinded to
epsilon-aminocaproic acid administration. RESULTS: Postoperative
stroke occurred in 97 patients (1.5%). Three thousand one hundred
thirty-five (49.8%) patients received epsilon-aminocaproic acid.
Increased age was associated with a higher incidence of postoperative
stroke (p = 0.0001). In contrast, there was no significant difference
(p = 0.7370) in the incidence of stroke between use of
epsilon-aminocaproic acid (1.3%) and nonuse (1.7%). Multivariable
logistic regression found no significant effect of
epsilon-aminocaproic acid use on stroke after accounting for age,
date of surgery, and history of diabetes. CONCLUSIONS: This series
suggests that epsilon-aminocaproic acid administration does not
increase the risk of postoperative stroke.
MB..About half had episilon anino caproic acid apparently on the whim
of the people involved. The stroke incidence was not different. There
is no mention if the blood loss was different although they used
automatic anaesthetic recording.
ARTICLE TITLE: Acute pain control and accelerated postoperative
surgical recovery.
ARTICLE SOURCE: Surg Clin North Am (United States), Apr 1999, 79(2)
p431-43
AUTHOR(S): Kehlet H
AUTHOR'S ADDRESS: Department of Surgical Gastroenterology, Hvidovre
University Hospital, University of Copenhagen, Denmark.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (36 references); REVIEW,
TUTORIAL
ABSTRACT: Postoperative pain relief continues to demand our
awareness, and surgeons should be fully aware of the potential
physiologic benefits of effective dynamic pain relief regimens and
the great potential to improve postoperative outcome if such
analgesia is used for rehabilitation. To achieve advantageous
effects, accelerated multimodal postoperative recovery programs
should be developed as a multidisciplinary effort, with integration
of postoperative pain management into a postoperative rehabilitation
program. This requires revision of traditional care programs, which
should be adjusted according to recent knowledge within surgical
pathophysiology. Such efforts must be expected to lead to improved
quality of care for patients, with less pain and reduced morbidity
leading to cost efficiency.
MB. They obviously did not find evidence for the truth of the last
sentence which expresses a `necessity'.
ARTICLE TITLE: Postoperative pain control in ambulatory
surgery.
ARTICLE SOURCE: Surg Clin North Am (United States), Apr 1999, 79(2)
p401-30
AUTHOR(S): Tong D; Chung F
AUTHOR'S ADDRESS: Department of Anaesthesia, University of Toronto,
Ontario, Canada. doris.tong@utoronto.ca.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (130 references); REVIEW
LITERATURE
ABSTRACT: Optimizing postoperative pain control is the key to further
advancement in the field of ambulatory anesthesia. The current
situation in postoperative pain management indicates room for
improvement, especially in the area of patient education and the
development of individualized discharge analgesic packages.
Multimodal analgesia provides superior analgesia with a lower
side-effect profile. Preoperative administration of analgesia would
decrease the intraoperative analgesic requirement, which may lead to
a smooth and rapid recovery. Finally, new, portable analgesic
delivery systems are under investigation and may prove to be the
method of choice for future postoperative pain, management in
ambulatory anesthesia.
ARTICLE TITLE: Pain management in cardiothoracic practice.
ARTICLE SOURCE: Surg Clin North Am (United States), Apr 1999, 79(2)
p387-400
AUTHOR(S): Kruger M; McRae K
AUTHOR'S ADDRESS: Department of Anaesthesia, Toronto Hospital-Mt.
Sinai Hospital, Ontario, Canada.
ABSTRACT: All analgesia regimens have benefits and side effects, and
personal expertise can greatly influence the efficacy of regional
techniques. A multimodal approach to analgesic management allows
physicians to achieve maximum analgesic efficacy while limiting side
effects. An appropriate analgesic plan takes into account the extent
of pain associated with the type of incision and adjusts this
according to each patient's individual needs. As we enter the new
millennium, thoracic and cardiac surgery is becoming more innovative,
and the life expectancy of people in the first world is constantly
increasing. Older people with less physiologic reserve and more
multisystem dysfunction are undergoing more major surgical
procedures, and adequate pain control in the postoperative period is
becoming increasingly important.
MB. A string of cliches.
ARTICLE TITLE: Management of pain in intensive care settings.
ARTICLE SOURCE: Surg Clin North Am (United States), Apr 1999, 79(2)
p371-86
AUTHOR(S): Stevens DS; Edwards WT
AUTHOR'S ADDRESS: Department of Anesthesiology, University of
Massachusetts Medical Center, Worcester, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (76 references); REVIEW,
TUTORIAL
ABSTRACT: An organized treatment plan for providing analgesia in ICU
settings can make a significant difference in patient comfort and
outcome. Advanced analgesic techniques are available for use at each
level of the "pain pathway." These include agents and methods that
act at the periphery, at the spinal cord level, and through a
systemic approach. Consultation with specialists in pain management
can help achieve optimum therapy for patients in the ICU setting.
MB. Another string of cliches.
ARTICLE TITLE: Local and regional block in postoperative pain
control.
ARTICLE SOURCE: Surg Clin North Am (United States), Apr 1999, 79(2)
p345-70
AUTHOR(S): Peng PW; Chan VW
AUTHOR'S ADDRESS: Department of Anaesthesia, University of Toronto,
Ontario, Canada. ppeng@torhosp.toronto.on.ca.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (181 references); REVIEW
LITERATURE
ABSTRACT: Local and regional block provides an effective means for
the control of postoperative pain. In surgery involving the trunk, it
serves as a useful alternative to epidural analgesia. With the
increasing use of low molecular weight heparin, the use of peripheral
nerve block is increasingly popular for patients undergoing lower
limb surgery.
ARTICLE TITLE: Epidural and spinal agents for postoperative
analgesia.
ARTICLE SOURCE: Surg Clin North Am (United States), Apr 1999, 79(2)
p313-44
AUTHOR(S): Rawal N
AUTHOR'S ADDRESS: Department of Anesthesiology and Intensive Care,
Orebro Medical Center Hospital, Sweden. n.rawal@orebroll.se.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (191 references); REVIEW
LITERATURE
ABSTRACT: The discovery of opioid receptors and the subsequent
development of the technique of epidural and intrathecal opioid
administration are undoubtedly two of the most significant advances
in pain management in recent decades. The use of spinal opioids is
widespread and increasing. The technique is used widely to treat
intraoperative, postoperative, traumatic, obstetric, chronic, and
cancer pain. Newer developments include the increasing use of
combined local anesthetics and opioids or nonopioids and also PCEA,
particularly in the obstetric population. Meta-analysis of controlled
trials has demonstrated improved pulmonary outcome in patients
receiving epidural postoperative analgesia. Although rare,
respiratory depression continues to be a major problem of the
technique. None of the currently available opioids is completely
safe; however, extensive international experience has shown that
patients receiving spinal opioids for postoperative analgesia can be
safely nursed on regular wards, provided that trained personnel and
appropriate guidelines are available. The importance of a good acute
pain service to provide the safe and effective use of spinal opioids
cannot be overemphasized.
MB. They must doubt as they say `undoubtedly'. They persist in using
non-numerical or % descriptions of the pain world.
ARTICLE TITLE: Patient-controlled analgesia.
ARTICLE SOURCE: Surg Clin North Am (United States), Apr 1999, 79(2)
p297-312
AUTHOR(S): Etches RC
AUTHOR'S ADDRESS: Wickham Terrace Anaesthesia, Arnold Janssen Centre,
Brisbane, Queensland, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (24 references); REVIEW,
TUTORIAL
ABSTRACT: In appropriately selected patients, PCA safely provides
analgesia superior to that obtained with traditional IM prn opioid
administration; however, to date, no compelling evidence shows that
PCA is associated with a reduction in morbidity or a more rapid
recovery. PCA is deceptively easy to prescribe; however, to use it
effectively and safely requires experience, frequent patient
assessment, and a skilled and knowledgeable nursing staff.
MB. A bit more realistic.
ARTICLE TITLE: Analgesic agents for the postoperative period.
Nonopioids.
ARTICLE SOURCE: Surg Clin North Am (United States), Apr 1999, 79(2)
p275-95
AUTHOR(S): Power I; Barratt S
AUTHOR'S ADDRESS: Department of Anaesthesia and Pain Management,
University of Sydney, Royal North Shore Hospital, St. Leonards, New
South Wales, Australia. ipower@med.usyd.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (141 references); REVIEW
LITERATURE
ABSTRACT: For many reasons, nonopioid analgesics have proven to be of
immense benefit in postoperative pain relief. Consideration of the
limitations and side effects of opioids confirms the need for
alternative, complementary analgesics. The current understanding of
pain pathophysiology recognizes that many tissue and neuronal factors
and changes are invoked by tissue damage, producing peripheral and
central sensitization, and some of these may be modulated by the use
of NSAIDs, NMDA antagonists, and local anesthetic agents. If
successful preemptive analgesic techniques are developed, they will
likely include the use of NSAIDs and perhaps NMDA antagonists.
Nonopioids are of benefit in multimodal analgesia and allow acute
rehabilitation of surgical patients. Acetaminophen, NSAIDs, alpha
2-antagonists, and NMDA antagonists are in routine use as components
of multimodal analgesia, in combination with opioids or local
anesthetic techniques. Tramadol is interesting because it has
nonopioid and opioid actions that can be attributed to the two
isomers found in the racemic mixture. Spinal neostigmine and the use
of adenosine represent completely different mechanisms of nonopioid
analgesia being investigated. Nonopioids, including lidocaine,
ketamine, the anticonvulsants, and the antidepressants, are necessary
for the treatment of patients with the difficult clinical problem of
neuropathic pain that can present in the postoperative period.
MB. Reflect the enthusiasm of proselytisers.
ARTICLE TITLE: Analgesic agents for the postoperative period.
Opioids.
ARTICLE SOURCE: Surg Clin North Am (United States), Apr 1999, 79(2)
p253-73
AUTHOR(S): Austrup ML; Korean G
AUTHOR'S ADDRESS: Department of Anaesthesia, Toronto Hospital-Mount
Sinai Hospital, Ontario, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (49 references); REVIEW,
TUTORIAL
ABSTRACT: Opioids are the most commonly used medication for patients
with acute pain. Morphine is the prototype with which all other
opioids are compared. Synthetic and semisynthetic derivatives of
morphine have unique properties, allowing for the use of a larger
selection of medication. An understanding of the mechanisms of
action, adverse effects, and routes of administration of the various
potent opioids is important for good postoperative pain
management.
ARTICLE TITLE: Measurement of pain.
ARTICLE SOURCE: Surg Clin North Am (United States), Apr 1999, 79(2)
p231-52
AUTHOR(S): Katz J; Melzack R
AUTHOR'S ADDRESS: Department of Psychology, Toronto Hospital,
Ontario, Canada. j.katz@utoronto.ca.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (111 references); REVIEW
LITERATURE
ABSTRACT: Pain is a personal, subjective experience influenced by
cultural learning, the meaning of the situation, attention, and other
psychologic variables. Approaches to the measurement of pain include
verbal and numeric self-rating scales, behavioral observation scales,
and physiologic responses. The complex nature of the experience of
pain suggests that measurements from these domains may not always
show high concordance. Because pain is subjective, patients'
self-reports provide the most valid measure of the experience. The
VAS (visual analogue score) and the MP (Magill pain questionnaire)
are probably the most frequently used self-rating instruments for the
measurement of pain in clinical and research settings. The MPQ is
designed to assess the multidimensional nature of pain experience and
has been demonstrated to be a reliable, valid, and consistent
measurement tool. A short-form MPQ is available for use in specific
research settings when the time to obtain information from patients
is limited and when more information than simply the intensity of
pain is desired. The DDS was developed using sophisticated
psychophysical techniques and was designed to measure separately the
sensory and unpleasantness dimensions of pain. It has been shown to
be a valid and reliable measurement of pain with ratio-scaling
properties and has recently been used in a clinical setting.
Behavioral approaches to the measurement of pain also provide
valuable data. Further development and refinement of pain measurement
techniques will lead to increasingly accurate tools with greater
predictive powers.
MB. It is impossible to measure mental events by empirical
scales.
ARTICLE TITLE: Acute pain mechanisms.
ARTICLE SOURCE: Surg Clin North Am (United States), Apr 1999, 79(2)
p213-29
AUTHOR(S): Sorkin LS; Wallace MS
AUTHOR'S ADDRESS: School of Medicine, Department of Anesthesiology,
University of California, San Diego, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (103 references); REVIEW
LITERATURE
These linkages reflect the complexity of the encoding mechanisms that
transduce the tissue injury into the behavioral sequela known as
pain. This article also emphasizes that, although considerable
progress has been made in the past decade, the current pace of
research promises greater insights.
MB. We all live in hope.
ARTICLE TITLE: Bedside evaluation of efficient airway
humidification during mechanical ventilation of the critically
ill.
ARTICLE SOURCE: Chest (United States), Jun 1999, 115(6) p1646-52
AUTHOR(S): Ricard JD; Markowicz P; Djedaini K; Mier L; Coste F;
Dreyfuss D
AUTHOR'S ADDRESS: Service de Reanimation Medicale, Hopital Louis
Mourier (Assistance Publique-Hopitaux de Paris), Colombes,
France.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
CONCLUSION: In mechanically ventilated ICU patients, visual
evaluation of the condensation in the flex-tube provides an
estimation of the heating and humidifying efficacy of the heating and
humidifying device used, thus allowing the clinician bedside
monitoring of airway humidification.
MB. Haven't we always done that.
ARTICLE TITLE: Patient satisfaction with conscious sedation for
bronchoscopy.
ARTICLE SOURCE: Chest (United States), May 1999, 115(5) p1437-40
AUTHOR(S): Putinati S; Ballerin L; Corbetta L; Trevisani L; Potena
A
AUTHOR'S ADDRESS: Divisione di Fisiopatologia Respiratoria,
Arcispedale S. Anna, Ferrara, Italy.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ABSTRACT: STUDY OBJECTIVE: Bronchoscopic technique is not
standardized. Controversies exist with regard to premedication with
sedatives before the test. To evaluate safety and efficacy of
conscious sedation, we studied 100 randomized patients undergoing
diagnostic bronchoscopy; patients received premedication with
lidocaine spray and atropine sulfate i.m. (nonsedation group; 50
patients) or lidocaine spray, atropine i.m. and diazepam i.v.
(sedation group; 50 patients). METHODS AND RESULTS: Monitoring during
flexible fiberoptic bronchoscopy included continuous ECG and pulse
oximetry. The procedure could not be completed in six patients. None
received premedication with diazepam; among the patients who ended
the examination, tolerance to the examination (visual analogue scale,
0 to 100; 0 = excellent; 100 = unbearable) was better in the sedation
group. Low anxiety, male sex, but not age were also associated with
improved patient tolerance to the test. Oxygen desaturation occurred
in 17% of patients, and it was not more frequent after diazepam
treatment. CONCLUSIONS: In our study, sedation had a beneficial
effect on patient tolerance and rarely induced significant
alterations in cardiorespiratory monitoring parameters.
ARTICLE TITLE: Risk factors for an outbreak of
multi-drug-resistant Acinetobacter nosocomial pneumonia among
intubated patients [see comments]
COMMENTS: Comment in: Chest 1999 May; 115(5):1226-8
ARTICLE SOURCE: Chest (United States), May 1999, 115(5) p1378-82
AUTHOR(S): Husni RN; Goldstein LS; Arroliga AC; Hall GS; Fatica C;
Stoller JK; Gordon SM
AUTHOR'S ADDRESS: Department of Infectious Diseases, Cleveland Clinic
Foundation, OH 44195, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: INTRODUCTION: Acinetobacter baumanii is a Gram-negative
coccobacillus that is normally a commensal pathogen but can be a
nosocomial pathogen. An epidemiologic study was performed to
investigate an outbreak of A baumanii that occurred in our medical
intensive care unit (MICU) from March to September 1995. CONCLUSION:
The use of ceftazidime was associated with an increased risk of
nosocomial pneumonia with resistant strains of Acinetobacter.
Health-care workers need to improve compliance with hand-washing
recommendations.
ARTICLE TITLE: Fatal postoperative pulmonary edema: pathogenesis
and literature review [see comments]
COMMENTS: Comment in: Chest 1999 May; 115(5):1224-6
ARTICLE SOURCE: Chest (United States), May 1999, 115(5) p1371-7
AUTHOR(S): Arieff AI
AUTHOR'S ADDRESS: Department of Medicine, University of California
School of Medicine, San Francisco, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (45 references); REVIEW,
TUTORIAL
ABSTRACT: STUDY OBJECTIVES: Pulmonary edema is a known postoperative
complication, but the clinical manifestations and danger levels for
fluid administration are not known. We studied (1) 13 postoperative
patients (11 adult, 2 pediatric) who developed fatal pulmonary edema,
and (2) one contemporaneous year of inpatient operations at two
university teaching hospitals to determine the clinical
manifestations, causes, epidemiology, and guidelines for fluid
administration. DESIGN: Retrospective analysis of 13 patients with
fatal postoperative pulmonary edema and one contemporaneous year of
major inpatient surgery. PATIENTS AND METHODS: Thirteen patients had
net fluid retention of at least 67 mL/kg in the initial 24
postoperative hours and developed pulmonary edema. Ten were generally
healthy while three had serious associated medical conditions.
MEASUREMENTS AND RESULTS: There was no measurement, laboratory value,
or clinical finding predictive of impending pulmonary edema. The most
common clinical manifestation following the onset of pulmonary edema
was cardiorespiratory arrest (n = 8). Patients had metabolic acidosis
(pH = 7.15 +/- .33), hypoxia (PO2 = 45 +/- 18 mm Hg), and normal
electrolytes. The diagnosis of pulmonary edema was established by
chest radiograph and confirmed by autopsy and pulmonary artery
pressure (21 +/- 4 mm Hg). The mean net fluid retention was 7.0 +/-
4.5 L (90 +/- 36 mL/kg/d) and exceeded 67 mL/kg/d in all patients.
Autopsy revealed pulmonary edema with no other cause of death. Among
8,195 major operations, 7.6% developed pulmonary edema with a
mortality of 11.9%. Extrapolation to the 8.2 million annual major
surgeries in the United States yields a projection of 8,000 to 74,000
deaths. CONCLUSIONS: Pulmonary edema can occur within the initial 36
postoperative hours when net fluid retention exceeds 67 mL/kg/d.
There are no known predictive warning signs and cardiorespiratory
arrest is the most frequent clinical presentation. The monitoring
systems currently in use neither detect nor predict impending
pulmonary edema, and as yet, there are no known panic values for
excessive fluid administration or retention.
ARTICLE TITLE: Perioperative fluid therapy and postoperative
pulmonary edema: cause-effect relationship? [editorial;
comment]
COMMENTS: Comment on: Chest 1999 May; 115(5):1371-7
ARTICLE SOURCE: Chest (United States), May 1999, 115(5) p1224-6
AUTHOR(S): Kirby RR
MAJOR SUBJECT HEADING(S): Fluid Therapy [adverse effects];
Postoperative Care; Postoperative Complications [etiology];
Pulmonary Edema [etiology]
MINOR SUBJECT HEADING(S): Acute Disease; Adult; Causality; Child
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. This editorial doubts the reality of the preceding article. Kirby
cannot imagine that these pulmonary oedemas could not have been
noticed before cardiac arrest.
ARTICLE TITLE: Assessing and modifying the risk of postoperative
pulmonary complications.
ARTICLE SOURCE: Chest (United States), May 1999, 115(5 Suppl)
p77S-81S
AUTHOR(S): Doyle RL
AUTHOR'S ADDRESS: Division of Pulmonary and Critical Care Medicine,
Stanford University Medical Center, CA 94305-5236, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (43 references); REVIEW,
TUTORIAL
ABSTRACT: Preoperative pulmonary evaluation and preparation involve
first identifying patients at risk for complications and then
attempting to modify that risk. For most patients without underlying
lung disease, a thorough history and physical examination and
preoperative instruction in the use of incentive spirometry is
sufficient. In patients with known or suspected lung disease,
preoperative pulmonary function tests, while unproven as prognostic
tools, may reduce risk by aiding in medical management, and in the
case of the lung resection candidate, by helping determine very
directly his or her viability for the procedure.
ARTICLE TITLE: Preoperative assessment of pulmonary risk.
ARTICLE SOURCE: Chest (United States), May 1999, 115(5 Suppl)
p58S-63S
AUTHOR(S): Ferguson MK
AUTHOR'S ADDRESS: Department of Surgery, the University of Chicago,
IL, USA. mferguso@surgery.bsd.uchicago.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (59 references); REVIEW,
TUTORIAL
CONCLUSIONS: Pulmonary complications are an important form of
postoperative morbidity after major cardiothoracic and abdominal
operations. The appropriate preoperative assessment of the risk of
such complications is well defined for lung resection and
esophagectomy operations, but it requires refinement for general
surgical and cardiovascular operations.
ARTICLE TITLE: Preoperative cardiac risk assessment.
ARTICLE SOURCE: Chest (United States), May 1999, 115(5 Suppl)
p51S-57S
AUTHOR(S): Hollenberg SM
AUTHOR'S ADDRESS: Section of Cardiology, Rush-Presbyterian-St. Luke's
Medical Center, Chicago, IL 60612, USA. shollenb@rpslmc.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (27 references); REVIEW,
TUTORIAL
ABSTRACT: Preoperative cardiac evaluation is aimed at evaluating the
patient's current medical status, making recommendations concerning
the risk of cardiac problems in the perioperative period, and
providing a clinical risk profile that the patient, primary
physician, consultants, anesthesiologist, and surgeon can use in
making treatment decisions. Patients can be stratified on clinical
grounds into low-, medium-, and high-risk categories. Use of these
categories, along with consideration of the type and urgency of
noncardiac surgery, allows for a reasonable approach to preoperative
testing. In general, indications for cardiac testing and treatment
are similar to the nonoperative setting, but their choice and timing
is dependent on factors specific to the patient, the type of surgery,
and the clinical situation. Use of invasive and noninvasive testing
should be limited to situations in which the results of the tests
will clearly affect patient management. Further research is necessary
to define the most appropriate role of such testing, both in terms of
efficacy and of cost-effectiveness. Cardiac intervention is rarely
necessary to lower the risk of surgery, but noncardiac surgery often
represents the first opportunity for a patient to receive an
appropriate assessment of short- and long-term cardiac risk, and this
should be taken into consideration in planning perioperative
evaluation.
MB. Should have said `evaluation & optimisation' instead of
`risk' in the last sentance.
ARTICLE TITLE: Who goes to the ICU postoperatively?
ARTICLE SOURCE: Chest (United States), May 1999, 115(5 Suppl)
p125S-129S
AUTHOR(S): Sirio CA; Martich GD
AUTHOR'S ADDRESS: Department of Anesthesiology and Critical Care
Medicine, University of Pittsburgh School of Medicine, PA 15213, USA.
sirio@smtp.anes.upmc.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (29 references); REVIEW,
TUTORIAL
CONCLUSIONS: Despite the paucity of controlled data, rapid recovery,
extubation, and discharge from the ICU following cardiac surgery is
an approach to care that is growing in acceptance. The goals include
reduction in the utilization of resources and costs associated with
cardiac surgery and maintenance of quality of care and patient
satisfaction. Assessment of outcomes requires a program to monitor
outcomes. Success does not appear to be linked to preoperative risk
for most patients but does relate directly to the anesthetic
management delivered in the operating room. Few adverse consequences
from this approach have been reported. Experience to date suggests
that programs designed to truncate ICU admission following cardiac
surgery can be implemented with the cooperation between the health
delivery team including surgeon, anesthesiologist, intensivist where
available, nursing, respiratory care, and patient and family. These
programs can serve as useful models for reassessing the utilization
and role of the ICU in the postoperative treatment of routine
surgical patients.
MB. Routine ICU availability was a relief when all cardiac surgery
was for severe physiologicial defects which were usually made acutely
worse by surgery. It is not surprising that some cardiac surgery can
be treated like not non-major surgery in non-cardiac patients. There
is now a craze to apply such fast tracking fashions to patients
having major surgery with major cardiac &/or respiratory
problems. This is sometimes done by replacing ICU by analgesic
methods which have not been shown to alter surgical outcome.
There is then wondering why a late prolonged ICU stay or death
occurs.
ARTICLE TITLE: Perioperative blood transfusions: indications and
options.
ARTICLE SOURCE: Chest (United States), May 1999, 115(5 Suppl)
p113S-121S
AUTHOR(S): McFarland JG
AUTHOR'S ADDRESS: Blood Center of Southeastern Wisconsin, Milwaukee
53201-2178, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (59 references); REVIEW,
TUTORIAL
ABSTRACT: A reevaluation of the indications for and alternatives to
transfusion of allogeneic blood was precipitated by
transfusion-induced HIV. The transfusion trigger has shifted from an
optimal hemoglobin level and hematocrit (10/30) to that level of
hemoglobin necessary to meet the patient's tissue oxygen demands.
This critical level can best be determined by physiologic
measurements. A number of autologous blood options can reduce the
patient's allogeneic blood needs. Pharmacologic measures to increase
hemoglobin levels (erythropoietin) and to decrease blood loss at
surgery are discussed as are the potential contributions of blood
substitutes to transfusion support of the surgical patient.
MB. Why was this not precipitated by non A ie B & C after B was
recognised and before C could not be identified. Hep B & C are
much worse than HIV.
ARTICLE TITLE: Intraoperative fluid management--what and how
much?
ARTICLE SOURCE: Chest (United States), May 1999, 115(5 Suppl)
p106S-112S
AUTHOR(S): Rosenthal MH
AUTHOR'S ADDRESS: Department of Anesthesia, Stanford University
School of Medicine, CA 94305, USA. mhr@leland.stanford.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (32 references); REVIEW,
TUTORIAL
ABSTRACT: An approach to intraoperative fluid management based on a
monitored physiologic application of the Starling principles of
cardiac function is recommended to individualize therapy to optimize
hemodynamic function and tissue perfusion. The complexity of
intraoperative fluid administration, beginning with preoperative
cardiovascular function followed by innumerable intraoperative
considerations, including anesthetic pharmacology, positive pressure
ventilation, operative site, and surgical technique may lead to
serious intraoperative and postoperative complications. Emphasis must
be given to intraoperative fluid shifts resulting in hidden fluid
loss and intravascular hypovolemia that must be replaced.
Explanations for this fluid redistribution have included tissue
trauma, endotoxemia, and proinflammatory cytokines with resultant
increased capillary permeability.
MB. It's not really that complex.
ARTICLE TITLE: What intraoperative monitoring makes sense?
ARTICLE SOURCE: Chest (United States), May 1999, 115(5 Suppl)
p101S-105S
AUTHOR(S): Brodsky JB
AUTHOR'S ADDRESS: Department of Anesthesiology, Stanford University
School of Medicine, CA, USA. Jbrodsky@leland.stanford.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (20 references); REVIEW,
TUTORIAL
ABSTRACT: The routine practice of monitoring oxygenation,
ventilation, circulation, and temperature during surgery is now the
standard of care. However, with the possible exception of pulse
oximetry and capnography, extensive physiologic monitoring has not
been shown to reduce the incidence of adverse anesthetic-related
events. Monitors are useful adjuncts, but they alone cannot replace
careful observation by a vigilant anesthesiologist.
MB. Being vigilant and observant does not help if you don't know what
to do or not do.
ARTICLE TITLE: Bronchodilator therapy in status asthmaticus
[editorial; comment]
COMMENTS: Comment on: Chest 1999 Apr; 115(4):937-44
ARTICLE SOURCE: Chest (United States), Apr 1999, 115(4) p911-2
AUTHOR(S): Teeter JG
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Emergency department care of the asthma patient:
predicting "bounce-back" patients [editorial; comment]
COMMENTS: Comment on: Chest 1999 Apr; 115(4):919-27
ARTICLE SOURCE: Chest (United States), Apr 1999, 115(4) p909-11
AUTHOR(S): Varon J; Fromm RE Jr
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Accuracy of an infrared tympanic thermometer.
ARTICLE SOURCE: Chest (United States), Apr 1999, 115(4) p1002-5
AUTHOR(S): Amoateng-Adjepong Y; Del Mundo J; Manthous CA
AUTHOR'S ADDRESS: Bridgeport Hospital, Department of Pulmonary and
Critical Care, Yale University School of Medicine, New Haven, CT,
USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: The use of infrared thermometry to measure
temperatures in hospitalized patients is increasing. Although
infrared thermometers have been proven to be accurate when they are
used by well-trained personnel, no previous studies have examined
their accuracy during routine hospital use. OBJECTIVE: To determine
the accuracy and observer variability of temperatures measured with
an infrared tympanic thermometer (TT). DESIGN: Prospective,
observational study. SETTING: ICUs of a 300-bed teaching community
hospital. PATIENTS: Fifty-one critically ill patients. MEASUREMENTS:
The mean of three tympanic temperatures measured with the infrared TT
(tempTTs) was compared to temperatures simultaneously measured with
the thermistor of right heart catheters and rectal mercury
thermometers for the following three groups of observers who had been
certified in the use of the infrared TT: a single critical care nurse
(CCN)/educator (Ed); CCNs, and floor nurses (FNs)/clinical care
practitioners (CCPs). RESULTS: Two rounds of measurements were given
to 51 patients by 153 observers. Temperatures of the pulmonary artery
(PA) measured with the thermistor of right heart catheters (tempPAs)
ranged from 96.5 to 102.6 degrees F, with a mean (-/+ SD) of
99.3+/-1.1 degrees F. The intraobserver variabilities (correlation
coefficients) of the tempTTs ranged from 0.90 for those measured by
FNs/CCPs, to 0.92 for those measured by CCNs, to 0.98 for those
measured by the CCN/Ed. Accuracy, arbitrarily defined as within a
deviation of -/+0.5 degrees F of the tempPA, was 100% for the rectal
mercury thermometer and 98.0% for the infrared TT when used by the
CCN/Ed. The accuracy of the infrared TT was 80% when measured by CCNs
and 61% when measured by FNs/CCPs. Differences between tempPAs and
tempTTs measured by the CCN/Ed ranged from 0 to 0.7 degrees F, with a
mean of 0.2 degrees F. Similarly, differences between tempPAs and
tempTTs measured by CCNs ranged from 0 to 2.4 degrees F, with a mean
difference of 0.3 degrees F. However, differences between tempPAs and
tempTTs measured by FNs/CCPs ranged from 0 to 3.0 degrees F, with a
mean of 0.6 degrees F (greater differences than those obtained by the
CCNs; p < 0.01). The accuracy of rectal mercury thermometry was
100%. If a temperature > or = 101.0 degrees F had been considered
as the threshold at which a fever is present, and if the mean of
three measurements had been used to designate temperature, workups
that were either inappropriately performed or omitted would have
resulted from 2% of tempTTs measured by the CCN/Ed, 1% of those
measured by CCNs, and 4% of those measured by FNs/CCPs. CONCLUSION:
When used properly, both tympanic and rectal thermometry are very
accurate. However, the infrared TT produced measurements that were
both less accurate and less reproducible when used by nurses who
routinely used it in clinical practice.
ARTICLE TITLE: Heart-rate turbulence after ventricular premature
beats as a predictor of mortality after acute myocardial infarction
[see comments]
COMMENTS: Comment in: Lancet 1999 Apr 24; 353(9162):1377-9
ARTICLE SOURCE: Lancet (England), Apr 24 1999, 353(9162) p1390-6
AUTHOR(S): Schmidt G; Malik M; Barthel P; Schneider R; Ulm K;
Rolnitzky L; Camm AJ; Bigger JT Jr; Schomig AUTHOR'S ADDRESS: Erste
Medizinische Klinik, Technischen Universitat Munchen, Germany.
gschmidt@med1.med.tu-menchen.de. t
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Identification of high-risk patients after
acute myocardial infarction is essential for successful prophylactic
therapy. The predictive accuracy of currently used risk predictors is
modest even when several factors are combined. Thus, establishment of
a new powerful method for risk prediction independent of the
available stratifiers is of considerable practical value. METHODS:
The study investigated fluctuations of sinus-rhythm cycle length
after a single ventricular premature beat recorded in Holter
electrocardiograms, and characterised the fluctuations (termed
heart-rate turbulence) by two numerical parameters, termed turbulence
onset and slope. INTERPRETATION: The absence of the heart rate
turbulence after ventricular premature beats is a very potent
postinfarction risk stratifier that is independent of other known
risk factors and which is stronger than other presently available
risk predictors.
ARTICLE TITLE: Renaissance in electrocardiography [see
comments]
COMMENTS: Comment in: Lancet 1999 Apr 24; 353(9162):1390-6
ARTICLE SOURCE: Lancet (England), Apr 24 1999, 353(9162) p1377-9
AUTHOR(S): Macfarlane PW
AUTHOR'S ADDRESS: University Department of Medical Cardiology, Royal
Infirmary, Glasgow, UK]
PUBLICATION TYPE: JOURNAL ARTICLE
MB. Comment on the preceding article. They are about a derived
ECG.
ARTICLE TITLE: Reflections on randomised controlled trials in
surgery.
ARTICLE SOURCE: Lancet (England), Apr 1999, 353 Suppl 1 pSI6-8
AUTHOR(S): Baum M
AUTHOR'S ADDRESS: Department of Surgery, University College Hospital,
London, UK.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (19 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Prediction of benefit from carotid endarterectomy
in individual patients: a risk-modelling study. European Carotid
Surgery Trialists' Collaborative Group.
ARTICLE SOURCE: Lancet (England), Jun 19 1999, 353(9170) p2105-10
AUTHOR(S): Rothwell PM; Warlow CP
AUTHOR'S ADDRESS: Department of Clinical Neurology, Radcliffe
Infirmary, Oxford, UK. peter.rothwell@clneuro.ox.ac.uk.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY;
RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: Carotid endarterectomy lowers the risk of
carotid territory ipsilateral ischaemic stroke, and is the treatment
of choice, in patients with recently symptomatic 70-99% carotid
stenosis. However, the 3-year risk of stroke on medical treatment
alone is only about 20%. We investigated whether the efficacy of
endarterectomy would be improved if patients with a high risk of
stroke on medical treatment and a low risk of operative stroke or
death could be identified.. INTERPRETATION: Many patients with
recently symptomatic 70-99% carotid stenosis may not benefit from
carotid endarterectomy. Validation of the predictive score is needed
on external datasets, but risk-factor modelling could be useful to
identify those patients in whom endarterectomy will
ARTICLE TITLE: Comparison of therapeutic and subtherapeutic nasal
continuous positive airway pressure for obstructive sleep apnoea: a
randomised prospective parallel trial [see comments]
COMMENTS: Comment in: Lancet 1999 Jun 19; 353(9170):2086-7
ARTICLE SOURCE: Lancet (England), Jun 19 1999, 353(9170) p2100-5
AUTHOR(S): Jenkinson C; Davies RJ; Mullins R; Stradling JR
AUTHOR'S ADDRESS: Division of Public Health and Primary Health Care,
University of Oxford Institute of Health Sciences, UK.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
INTERPRETATION: Therapeutic NCPAP reduces excessive daytime
sleepiness and improves self-reported health status compared with a
subtherapeutic control. Compared with controls, the effects of
therapeutic NCPAP are large and confirm previous uncontrolled
clinical observations and the results of controlled trials that used
an oral placebo.
ARTICLE TITLE: 16-year mortality from breast cancer in the UK
Trial of Early Detection of Breast Cancer [see comments]
COMMENTS: Comment in: Lancet 1999 Jun 5; 353(9168):1896-7
ARTICLE SOURCE: Lancet (England), Jun 5 1999, 353(9168) p1909-14
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER
STUDY
INTERPRETATION: The results from the UK Trial of Early Detection of
Breast Cancer (TEDBC) support those from randomised trials in
Edinburgh and elsewhere, and show that a reduction in breast-cancer
mortality resulting from screening can be achieved in the UK. There
was no evidence of less benefit in women aged 45-46 years at the
start of screening; the effect of screening in this age-group begins
to emerge after 3-4 years.
ARTICLE TITLE: 14 years of follow-up from the Edinburgh randomised
trial of breast-cancer screening [see comments]
COMMENTS: Comment in: Lancet 1999 Jun 5; 353(9168):1896-7
ARTICLE SOURCE: Lancet (England), Jun 5 1999, 353(9168) p1903-8
AUTHOR(S): Alexander FE; Anderson TJ; Brown HK; Forrest AP; Hepburn
W; Kirkpatrick AE; Muir BB; Prescott RJ; Smith A
AUTHOR'S ADDRESS: Department of Community Health Sciences, University
of Edinburgh, UK. freda.alexander@ed.ac.uk.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY;
RANDOMIZED CONTROLLED TRIAL
INTERPRETATION: Our findings confirm results from randomised trials
in Sweden and the USA that screening for breast cancer lowers
breast-cancer mortality. Similar results are reported by the UK
geographical comparison, UK Trial of Early Detection of Breast
Cancer. The results for younger women suggest benefit from
introduction of screening before 50 years of age.
ARTICLE TITLE: Breast screening in women aged 40-49 years: what
next? [comment]
COMMENTS: Comment on: Lancet 1999 Jun 5; 353(9168):1903-8; Comment
on: Lancet 1999 Jun 5; 353(9168):1909-14
ARTICLE SOURCE: Lancet (England), Jun 5 1999, 353(9168) p1896-7
AUTHOR(S): Dickersin K
AUTHOR'S ADDRESS: Department of Community Health, Brown University,
Providence, RI 02912, USA.
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE
ARTICLE TITLE: If I had an acute coronary syndrome...
ARTICLE SOURCE: Lancet (England), Jun 1999, 353 Suppl 2 pSII24-6
AUTHOR(S): Delehanty JM; Ling FS; Berk BC
AUTHOR'S ADDRESS: Cardiology Unit, University of Rochester Medical
Center, NY 14642, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ARTICLE TITLE: "Doctor, is wine good for my heart?"
ARTICLE SOURCE: Lancet (England), May 29 1999, 353(9167) p1815-6
AUTHOR(S): Bradley KA; Merrill JO
AUTHOR'S ADDRESS: Health Services Research and Development and
Primary and Specialty Medical Care Service, VA Puget Sound Health
Care System, Seattle, WA 98108, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
MB.No real evidence of benefit. There is a review in last month's
stuff from a wine area in France which says the same thing.
ARTICLE TITLE: Neurosurgeons wake up to awake-brain surgery
[news]
ARTICLE SOURCE: Lancet (England), May 22 1999, 353(9166) p1772
AUTHOR(S): Larkin M
PUBLICATION TYPE: NEWS
MB. The wheel turns. They were doing this when I was young for the
same reasons.
ARTICLE TITLE: Development of a nurse-led sedation service for
paediatric magnetic resonance imaging.
ARTICLE SOURCE: Lancet (England), May 15 1999, 353(9165) p1667-71
AUTHOR(S): Sury MR; Hatch DJ; Deeley T; Dicks-Mireaux C; Chong WK
AUTHOR'S ADDRESS: Department of Anaesthesia, Great Ormond Street
Hospital for Children NHS Trust, London, UK.
mike.sury@gosh-tr.nthames.nhs.uk.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Children generally lie still enough for
magnetic resonance imaging (MRI) only if they are asleep, either
under sedation, which is deeper than conscious sedation, or under
anaesthesia. Anaesthesia resources, however, are limited, and
non-anaesthetists must use sedation frequently. FINDINGS: During the
30 month study, there were 1155 sedations. 61 (5%) were unsuccessful,
and there were no adverse events relating to the airway or breathing.
After scanning had finished all children, in response to gently
pinching the nose, could open their mouths to maintain their airway.
INTERPRETATION: This study suggests that it is possible to have a
nurse-led sedation service for MRI of children that is both
successful and safe.
ARTICLE TITLE: Pain: an overview.
ARTICLE SOURCE: Lancet (England), May 8 1999, 353(9164) p1607-9
AUTHOR(S): Loeser JD; Melzack R
AUTHOR'S ADDRESS: Department of Neurological Surgery, University of
Washington, Seattle 98195, USA. jdloeser@u.washington.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (13 references); REVIEW,
TUTORIAL
ABSTRACT: Until the 1960s, pain was considered an inevitable sensory
response to tissue damage. There was little room for the affective
dimension of this ubiquitous experience, and none whatsoever for the
effects of genetic differences, past experience, anxiety, or
expectation. In recent years, great advances have been made in our
understanding of the mechanisms that underlie pain and in the
treatment of people who complain of pain. The roles of factors
outside the patient's body have also been clarified. Pain is probably
the most common symptomatic reason to seek medical consultation. All
of us have headaches, burns, cuts, and other pains at some time
during childhood and adult life. Individuals who undergo surgery are
almost certain to have postoperative pain. Ageing is also associated
with an increased likelihood of chronic pain. Health-care
expenditures for chronic pain are enormous, rivalled only by the
costs of wage replacement and welfare programmes for those who do not
work because of pain. Despite improved knowledge of underlying
mechanisms and better treatments, many people who have chronic pain
receive inadequate care.
MB. I think there was morphine before 1960.
ARTICLE TITLE: What is "hypertension"?
ARTICLE SOURCE: Lancet (England), May 8 1999, 353(9164) p1541-3
AUTHOR(S): O'Brien E; Staessen JA
AUTHOR'S ADDRESS: Blood Pressure Unit, Beaumont Hospital, Dublin,
Ireland.
PUBLICATION TYPE: JOURNAL ARTICLE
ARTICLE TITLE: Coronary heart disease: where have we been and
where are we going? [comment]
COMMENTS: Comment on: Lancet 1999 May 8; 353(9164):1547-57
ARTICLE SOURCE: Lancet (England), May 8 1999, 353(9164) p1540-1
AUTHOR(S): Alpert JS
AUTHOR'S ADDRESS: Department of Medicine, University of Arizona,
Tucson 85724, USA.
PUBLICATION TYPE: COMMENT; HISTORICAL ARTICLE; JOURNAL ARTICLE
ARTICLE TITLE: Making and covering of surgical footprints
[comment]
COMMENTS: Comment on: Lancet 1999 May 1; 353(9163):1476-80
ARTICLE SOURCE: Lancet (England), May 1 1999, 353(9163) p1456-7
AUTHOR(S): Holmdahl L
AUTHOR'S ADDRESS: Department of Surgery, Sahlgrenska University
Hospital/Ostra, Sweden.
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE
MB. About post surgical adhesions
ARTICLE TITLE: Pulmonary and critical care medicine: a peculiarly
American hybrid? [editorial]
ARTICLE SOURCE: Thorax (England), Apr 1999, 54(4) p286-7
AUTHOR(S): Tobin MJ; Hines E Jr
AUTHOR'S ADDRESS: Division of Pulmonary & Critical Care, Medicine
Loyola University of Chicago Stritch School of Medicine, Maywood,
Illinois 60153, USA.
PUBLICATION TYPE: EDITORIAL
ARTICLE TITLE: Sex differences and sleep apnoea [editorial;
comment]
COMMENTS: Comment on: Thorax 1999 Apr; 54(4):323-8
ARTICLE SOURCE: Thorax (England), Apr 1999, 54(4) p284-5
AUTHOR(S): Schwab J
AUTHOR'S ADDRESS: Center for Sleep and Respiratory Neurobiology
University of Pennsylvania Medical Center Philadelphia, Pennsylvania
19104-4283 USA.
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Percutaneous cervical cordotomy for the control of
pain in patients with pleural mesothelioma.
ARTICLE SOURCE: Thorax (England), Mar 1999, 54(3) p238-41
AUTHOR(S): Jackson MB; Pounder D; Price C; Matthews AW; Neville E
AUTHOR'S ADDRESS: Department of Respiratory Medicine, Portsmouth
Hospitals NHS Trust, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Percutaneous cervical cordotomy is successful in
treating pain from mesothelioma. There was a low complication rate in
this series. Referral to a unit experienced in cordotomy is
recommended as soon as pain from chest wall invasion is
suspected.
ARTICLE TITLE: Treatment of adult respiratory distress syndrome:
plea for rescue therapy of the alveolar epithelium.
ARTICLE SOURCE: Thorax (England), Feb 1999, 54(2) p150-60
AUTHOR(S): Berthiaume Y; Lesur O; Dagenais A
AUTHOR'S ADDRESS: Centre de Recherche, Centre Hospitalier de
l'Universite de Montreal, Quebec, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (154 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Long term effects of inhaled corticosteroids in
chronic obstructive pulmonary disease: a meta-analysis [see
comments]
COMMENTS: Comment in: Thorax 1999 Jan; 54(1):3-4
ARTICLE SOURCE: Thorax (England), Jan 1999, 54(1) p7-14
AUTHOR(S): van Grunsven PM; van Schayck CP; Derenne JP; Kerstjens HA;
Renkema TE; Postma DS; Similowski T; Akkermans RP; Pasker-de Jong PC;
Dekhuijzen PN; van Herwaarden CL; van Weel C
AUTHOR'S ADDRESS: Department of General Practice and Social Medicine,
University of Nijmegen, The Netherlands.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: This meta-analysis in patients with clearly defined
moderately severe chronic obstructive pulmonary disease (COPD) showed
a beneficial course of FEV1 during two years of treatment with
relatively high daily dosages of inhaled corticosteroids.
ARTICLE TITLE: Re-assessing the evidence about inhaled
corticosteroids in chronic obstructive pulmonary disease
[editorial; comment]
COMMENTS: Comment on: Thorax 1999 Jan; 54(1):7-14
ARTICLE SOURCE: Thorax (England), Jan 1999, 54(1) p3-4
AUTHOR(S): Calverley PM
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Teaching medical students about tobacco [see
comments]
COMMENTS: Comment in: Thorax 1999 Jan; 54(1):2
ARTICLE SOURCE: Thorax (England), Jan 1999, 54(1) p70-8
AUTHOR(S): Richmond R
AUTHOR'S ADDRESS: School of Community Medicine, University of New
South Wales, Sydney, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (110 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Medical students' knowledge of smoking
[editorial; comment]
COMMENTS: Comment on: Thorax 1999 Jan; 54(1):70-8
ARTICLE SOURCE: Thorax (England), Jan 1999, 54(1) p2
AUTHOR(S): Allen MB
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Helping people to stop smoking: the new smoking
cessation guidelines [editorial]
ARTICLE SOURCE: Thorax (England), Jan 1999, 54(1) p1-2
AUTHOR(S): Britton J; Knox A
PUBLICATION TYPE: EDITORIAL
ARTICLE TITLE: Outcome following acute myocardial infarction: are
differences among physician specialties the result of quality of care
or case mix?
ARTICLE SOURCE: Arch Intern Med (United States), Jul 12 1999, 159(13)
p1429-36
AUTHOR(S): Frances CD; Go AS; Dauterman KW; Deosaransingh K; Jung DL;
Gettner S; Newman JM; Massie BM; Browner WS
AUTHOR'S ADDRESS: Department of Medicine, University of California,
Veterans Affairs Medical Center, San Francisco 94121, USA.
cdfrances@email.msn.com.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
CONCLUSIONS: Differences in the use of recommended therapies by
physician specialty are generally small and do not explain
differences in patient outcome. In comparison, differences among
patients treated by physicians of various specialties (case mix) have
a large impact on patient outcome and may account for the residual
survival advantage of patients treated by cardiologists. With the
exception of the in-hospital use of aspirin, recommended MI therapies
are markedly underused, regardless of the specialty of the
physician.
MB. Surely the cardiologists would have a larger number of patients
and thus would be expected to get it right more often.
ARTICLE TITLE: National recommendations for the pharmacological
treatment of hypertension: should they be revised?
ARTICLE SOURCE: Arch Intern Med (United States), Jul 12 1999, 159(13)
p1403-6
AUTHOR(S): Moser M
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (23 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Treatment and prevention of sudden cardiac death:
effect of recent clinical trials.
ARTICLE SOURCE: Arch Intern Med (United States), Jun 28 1999, 159(12)
p1281-7
AUTHOR(S): Goldberger JJ
AUTHOR'S ADDRESS: Department of Medicine, Northwestern University
Medical School, and Northwestern Memorial Hospital, Chicago, ILL
60611, USA. j-goldberger@nwu.edu.
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (41 references); REVIEW,
TUTORIAL
ABSTRACT: Tremendous strides have been made in recent years in the
treatment and prevention of sudden cardiac death. Large scale trials
have now established several interventions that may improve survival
in patients susceptible to sudden cardiac death. In patients who have
had a sustained ventricular tachyarrhythmia, the current therapy of
choice is an implantable cardioverter defibrillator. For prophylaxis
of sudden cardiac death in patients without a previous event, several
approaches should be considered. Beta-Adrenergic blocking agents are
an effective pharmacologic therapy in patients following myocardial
infarction, and their efficacy has also most recently been
demonstrated in patients with congestive heart failure. There is no
Vaughan Williams class I or III antiarrhythmic drug that has
demonstrated efficacy as a prophylactic agent to reduce mortality in
these populations, with the possible exception of amiodarone. The
best therapeutic approach for prophylactic therapy to prevent sudden
cardiac death appears to be the implantable cardioverter
defibrillator; however, its use can be justified only in patients at
high risk for developing sudden cardiac death. Further work is needed
to identify the high risk populations in which this therapy is
warranted.
ARTICLE TITLE: Economic analysis of low-dose heparin vs the
low-molecular-weight heparin enoxaparin for prevention of venous
thromboembolism after colorectal surgery.
ARTICLE SOURCE: Arch Intern Med (United States), Jun 14 1999, 159(11)
p1221-8
AUTHOR(S): Etchells E; McLeod RS; Geerts W; Barton P; Detsky AS
AUTHOR'S ADDRESS: Department of Medicine, Toronto Hospital, Ontario,
Canada. eetchells@torhosp.toronto.on.ca.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Although heparin and enoxaparin are equally effective,
low-dose heparin is a more economically attractive choice for
thromboembolism prophylaxis after colorectal surgery.
ARTICLE TITLE: Diagnosing pneumonia by physical examination:
relevant or relic?
ARTICLE SOURCE: Arch Intern Med (United States), May 24 1999, 159(10)
p1082-7
AUTHOR(S): Wipf JE; Lipsky BA; Hirschmann JV; Boyko EJ; Takasugi J;
Peugeot RL; Davis CL
AUTHOR'S ADDRESS: Veterans Affairs Puget Sound Health Care System,
Department of Medicine, University of Washington, Seattle 98108, USA.
jwipf@washington.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The degree of interobserver agreement was highly
variable for different physical examination findings. The most
valuable examination maneuvers in detecting pneumonia were unilateral
rales and rales in the lateral decubitus position. The traditional
chest physical examination is not sufficiently accurate on its own to
confirm or exclude the diagnosis of pneumonia.
MB. I stopped carrying a stethoscope years ago. I lost mine. : -(
ARTICLE TITLE: Systemic adverse effects of inhaled corticosteroid
therapy: A systematic review and meta-analysis.
ARTICLE SOURCE: Arch Intern Med (United States), May 10 1999, 159(9)
p941-55
AUTHOR(S): Lipworth BJ
AUTHOR'S ADDRESS: Department of Clinical Pharmacology and
Therapeutics and Respiratory Medicine, Ninewells Hospital and Medical
School, University of Dundee, Scotland.
b.j.lipworth@dundee.ac.uk.
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: All inhaled corticosteroids exhibit dose-related
systemic adverse effects, although these are less than with a
comparable dose of oral corticosteroids. Metaanalysis shows that
fluticasone propionate exhibits greater dose-related systemic
bioactivity compared with other available inhaled corticosteroids,
particularly at doses above 0.8 mg/d. The long-term systemic burden
will be minimized by always trying to achieve the lowest possible
maintenance dose that is associated with optimal asthmatic control
and quality of life.
ARTICLE TITLE: In-hospital cardiopulmonary resuscitation:
prearrest morbidity and outcome.
ARTICLE SOURCE: Arch Intern Med (United States), Apr 26 1999, 159(8)
p845-50
AUTHOR(S): de Vos R; Koster RW; De Haan RJ; Oosting H; van der Wouw
PA; Lampe-Schoenmaeckers AJ
AUTHOR'S ADDRESS: Resuscitation Committee, Academic Medical Center,
University of Amsterdam, The Netherlands. r.vos@amc.uva.nl.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Time of prearrest morbidity has a prognostic value for
survival after CPR. Patients at risk for poor survival can be
identified on or during hospital admission, but the reliability and
validity of the model needs further research. Although decisions will
not be made by the model, its information can be useful for
physicians in discussions about patient prognoses and to make
decisions about CPR with more confidence.
ARTICLE TITLE: Preventing catheter-related bacteriuria: should we?
Can we? How?
ARTICLE SOURCE: Arch Intern Med (United States), Apr 26 1999, 159(8)
p800-8
AUTHOR(S): Saint S; Lipsky BA
AUTHOR'S ADDRESS: Department of Internal Medicine, University of
Michigan Health System, Ann Arbor, USA. saint@umich.edu.
MAJOR SUBJECT HEADING(S): Anti-Infective Agents, Urinary
[therapeutic use]; Bacteriuria [etiology]
[prevention & control]; Urinary Catheterization
[adverse effects]
MINOR SUBJECT HEADING(S): Bacteriuria [epidemiology];
Catheters, Indwelling [adverse effects]; Hippurates
[therapeutic use]; Methenamine [analogs &
derivatives] [therapeutic use]; Risk Factors; Urinary
Catheterization [statistics & numerical data]
INDEXING CHECK TAG(S): Human; Support, Non-U.S. Gov't
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (103 references); REVIEW,
TUTORIAL
Systemic antimicrobial drug therapy seems to prevent urinary tract
infections (UTIs), but primarily for patients catheterized for 3 to
14 days. Antibiotic drug prophylaxis is especially valuable in
patients undergoing transurethral resection of the prostate or renal
transplantation. Using these methods, urinary catheter-associated UTI
can often be prevented for weeks, but not longer terms.
ARTICLE TITLE: Physician estimates of perioperative cardiac risk
in patients undergoing noncardiac surgery.
ARTICLE SOURCE: Arch Intern Med (United States), Apr 12 1999, 159(7)
p713-7
AUTHOR(S): Devereaux PJ; Ghali WA; Gibson NE; Skjodt NM; Ford DC;
Quan H; Guyatt GH
AUTHOR'S ADDRESS: Department of Medicine, University of Calgary,
Alberta, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
ABSTRACT: BACKGROUND: We know little about how physicians assess
perioperative cardiac risk in patients undergoing noncardiac surgery.
OBJECTIVES: To evaluate preoperative medical consultations and
determine the extent to which consultants used validated cardiac risk
indices and specialized noninvasive cardiac tests, and to assess
agreement between physician ratings of cardiac risk (low, moderate,
or high) and risk estimates derived using validated cardiac risk
indices or, in the case of vascular surgery, a risk index. METHODS:
This observational study was conducted at 5 Canadian teaching
hospitals affiliated with 2 universities. We retrospectively
evaluated 308 preoperative consultations performed in 297 patients
and examined the frequency with which consultants recorded the use of
validated cardiac risk indices. We used K statistics to quantify the
extent to which physician ratings of cardiac risk agreed with risk
estimates derived using validated cardiac risk indices. RESULTS:
Physicians recorded use of a risk index in 31% of the consultations,
but the index used was almost always the suboptimal classification of
the American Society of Anesthesiologists. The agreement between
physician estimates of cardiac risk and the validated cardiac risk
indices was only fair, with a weighted K of 0.38 (95% confidence
interval, 0.28-0.49). Overestimation and underestimation of cardiac
risk occurred in 16% and 13% of the consultations, respectively.
Consultants did not order dipyridamole thallium imaging or dobutamine
stress echocardiography for any moderate-risk patients undergoing
vascular surgery. CONCLUSIONS: Physicians underuse validated cardiac
risk indices, and the agreement between the cardiac risk estimates
and risk as determined by validated cardiac indices is suboptimal.
Physicians are also underusing dipyridamole thallium imaging and
dobutamine stress echocardiography for moderate-risk patients
undergoing vascular surgery.
MB. I am not sure that this makes sense.
ARTICLE TITLE: Oesophagogastrectomy in the elderly high risk
patients: role of effective regional analgesia and early
mobilisation.
ARTICLE SOURCE: J Cardiovasc Surg (Torino) (Italy), Feb 1999, 40(1)
p153-6
AUTHOR(S): Sabanathan S; Shah R; Tsiamis A; Richardson J
AUTHOR'S ADDRESS: Department of Thoracic Surgery, Bradford Royal
Infirmary, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Oesophagogastrectomy is the best available
treatment for patients with carcinoma of the oesophagus or cardia.
However, surgical resection may lead to increased mortality,
morbidity and longer hospital stays in elderly (aged over 70 years)
high risk patients. METHODS: To assess the impact of balanced
pre-emptive and postoperative analgesia combined with early
mobilisation in elderly patients undergoing oesophagogastrectomy we
consecutively studied 52 patients (30 male, 22 female) of 75+/-4.2
years of age (mean+/-SD). Pre-emptive analgesia was by pre-incisional
percutaneous paravertebral block combined with an opiate and a
nonsteroidal anti-inflammatory drug (NSAID) premedication.
Postoperative maintenance analgesia was by NSAID and continuous
extrapleural intercostal nerve block. Following surgery all but three
patients were returned to the ward. RESULTS: The hospital mortality
rate was 7.6%. Morbidity caused by cardiovascular (27%), respiratory
(23%) and cerebrovascular (19%) complications occurred in 19
patients, with two patients requiring ventilatory support. The mean
hospital stay for the survivors was 10 days (range 8 to 30 days). All
the survivors had their swallowing restored to normal and returned to
their accustomed environment. CONCLUSIONS: These data suggests that
surgical treatment can be achieved in the elderly high risk patients
with acceptable mortality and morbidity. This is achieved by early
mobilisation enabled by balanced pre-emptive and postoperative
analgesia.
MB. You can do anything if you try hard enough. It is not a
controlled trial. I could not get the original article. I thus could
not find out if they ventilated them postoperatively.
ARTICLE TITLE: Is 30 minutes the golden period to perform
emergency room thoracotomy (ERT) in penetrating chest injuries?
ARTICLE SOURCE: J Cardiovasc Surg (Torino) (Italy), Feb 1999, 40(1)
p147-51
AUTHOR(S): Frezza EE; Mezghebe H
AUTHOR'S ADDRESS: Howard University Hospital, Department of Surgery,
Washington, DC, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The only role of Emergency room thoracotomy (ERT), in
our opinion is in patients who arrive within 30 minutes of pre
hospital time, with a witnessed vital signed in the field. Multiple
wounds, low SBP and higher caliber bullet injuries are also negative
prognostic factors.