ARTICLE TITLE: Do patients with suspected heart failure and
preserved left ventricular systolic function suffer from "diastolic
heart failure" or from misdiagnosis? A prospective descriptive study
[see comments]
COMMENTS: Comment in: BMJ 2000 Jul 22; 321(7255):188-9
ARTICLE SOURCE: BMJ (England), Jul 22 2000, 321(7255) p215-8
AUTHOR(S): Caruana L; Petrie MC; Davie AP; McMurray JJ
AUTHOR'S ADDRESS: Department of Cardiology, Western Infirmary,
Glasgow G11 6NT.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: For most patients with a diagnosis of heart failure but
preserved left ventricular systolic function there is an alternative
explanation for their symptoms-for example, obesity, lung disease,
and myocardial ischaemia-and the diagnosis of diastolic heart failure
is rarely needed. These alternative diagnoses should be rigorously
sought and managed accordingly.
MB: A lot of things are diagnosed & treated as cardiac failure
but are not.
ARTICLE TITLE: Rates for obstetric intervention among private and
public patients in Australia: population based descriptive study
[see comments]
COMMENTS: Comment in: BMJ 2000 Jul 15; 321(7254):125-6
ARTICLE SOURCE: BMJ (England), Jul 15 2000, 321(7254) p137-41
AUTHOR(S): Roberts CL; Tracy S; Peat B
AUTHOR'S ADDRESS: NSW Centre for Perinatal Health Services Research,
School of Population Health and Health Services Research, University
of Sydney 2006, Australia. christiner@pub.health.usyd.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: To compare the risk profile of women receiving
public and private obstetric care and to compare the rates of
obstetric intervention among women at low risk in these groups.
DESIGN: Population based descriptive study. SETTING: New South Wales,
Australia. SUBJECTS: All 171,157 women having a live baby during 1996
and 1997. INTERVENTIONS: Epidural, augmentation or induction of
labour, episiotomy, and births by forceps, vacuum, or caesarean
section. MAIN OUTCOME MEASURES: Risk profile of public and private
patients, intervention rates, and the accumulation of interventions
by both patient and hospital classification (public or private).
RESULTS: Overall, the frequency of women classified as low risk was
similar (48%) among those choosing private obstetric care and those
receiving standard care in a public hospital. Among low risk women,
rates of obstetric intervention were highest in private patients in
private hospitals, lowest in public patients, and generally
intermediate for private patients in public hospitals. Among
primiparas at low risk, 34% of private patients in private hospitals
had a forceps or vacuum delivery compared with 17% of public
patients. For multiparas the rates were 8% and 3% respectively.
Private patients were significantly more likely to have interventions
before birth (epidural, induction or augmentation) but this alone did
not account for the increased interventions at birth, particularly
the high rates of instrumental births. CONCLUSIONS: Public patients
have a lower chance of an instrumental delivery. Women should have
equal access to quality maternity services, but information on the
outcomes associated with the various models of care may influence
their choices.
MB: It is fairly obvious what is going on here. Why can't they say
it?
ARTICLE TITLE: Obstetric interventions among private and public
patients. High rates of operative vaginal interventions in private
patients need analysis [editorial; comment]
COMMENTS: Comment on: BMJ 2000 Jul 15; 321(7254):137-41
ARTICLE SOURCE: BMJ (England), Jul 15 2000, 321(7254) p125-6
AUTHOR(S): King JF
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Corticosteroids in head injury. It's time for a
large simple randomised trial. CRASH trial management group.
Corticosteroid randomisation after significant head injury
[editorial]
ARTICLE SOURCE: BMJ (England), Jul 15 2000, 321(7254) p128-9
AUTHOR(S): Yates D; Roberts I
PUBLICATION TYPE: EDITORIAL
MB: They want a trial of 20,000. Even a 2 or 3% improvement would
save a substantial number as there are so many head injuries.
ARTICLE TITLE: Hospital doctors face rising threat of suspension
[news]
ARTICLE SOURCE: BMJ (England), Jul 8 2000, 321(7253) p72
AUTHOR(S): Jones J
PUBLICATION TYPE: NEWS
ARTICLE TITLE: The NHS plan [editorial]
ARTICLE SOURCE: BMJ (England), Aug 5 2000, 321(7257) p315-6
AUTHOR(S): Dixon J; Dewar S
PUBLICATION TYPE: EDITORIAL
MB: They are giving more money but I suppose that is money they have
cut back in the past. The reforms are of course wishful thinking
ARTICLE TITLE: A "common sense revolution" for UK health care? The
conservatives unveil their latest plans [editorial]
ARTICLE SOURCE: BMJ (England), Jul 8 2000, 321(7253) p63-4
AUTHOR(S): Dixon J
PUBLICATION TYPE: EDITORIAL
MB: The suggestions are not very sensible. They are the Opposition's
suggestions.
ARTICLE TITLE: Randomised controlled trial of homoeopathy versus
placebo in perennial allergic rhinitis with overview of four trial
series.
ARTICLE SOURCE: BMJ (England), Aug 19-26 2000, 321(7259) p471-6
AUTHOR(S): Taylor MA; Reilly D; Llewellyn-Jones RH; McSharry C;
Aitchison TC
AUTHOR'S ADDRESS: University Department of Medicine, Glasgow Royal
Infirmary, Glasgow G31 2ER.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
PARTICIPANTS: 51 patients with perennial allergic rhinitis.
Intervention: Random assignment to an oral 30c homoeopathic
preparation of principal inhalant allergen or to placebo. MAIN
OUTCOME MEASURES: Changes from baseline in nasal inspiratory peak
flow and symptom visual analogue scale score over third and fourth
weeks after randomisation. RESULTS: Fifty patients completed the
study. The homoeopathy group had a significant objective improvement
in nasal airflow compared with the placebo group (mean difference
19.8 l/min, 95% confidence interval 10.4 to 29.1, P=0.0001). Both
groups reported improvement in symptoms, with patients taking
homoeopathy reporting more improvement in all but one of the centres,
which had more patients with aggravations. On average no significant
difference between the groups was seen on visual analogue scale
scores. Initial aggravations of rhinitis symptoms were more common
with homoeopathy than placebo (7 (30%) v 2 (7%), P=0.04). Addition of
these results to those of three previous trials (n=253) showed a mean
symptom reduction on visual analogue scores of 28% (10.9 mm) for
homoeopathy compared with 3% (1.1 mm) for placebo (95% confidence
interval 4.2 to 15.4, P=0.0007). CONCLUSION: The objective results
reinforce earlier evidence that homoeopathic dilutions differ from
placebo.
ARTICLE TITLE: Herbal medicines: where is the evidence?
[editorial]
ARTICLE SOURCE: BMJ (England), Aug 12 2000, 321(7258) p395-6
AUTHOR(S): Ernst E
PUBLICATION TYPE: EDITORIAL
ARTICLE TITLE: Effectiveness of interventions to help people stop
smoking: findings from the Cochrane Library [see
comments]
COMMENTS: Comment in: BMJ 2000 Aug 5; 321(7257):311-2
ARTICLE SOURCE: BMJ (England), Aug 5 2000, 321(7257) p355-8
AUTHOR(S): Lancaster T; Stead L; Silagy C; Sowden A
AUTHOR'S ADDRESS: Imperial Cancer Research Fund General Practice
Research Group, Department of Primary Health Care, University of
Oxford, Institute of Health Sciences, Oxford OX3 7LF.
tim.lancaster@dphpc.ox.ac.uk.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (27 references); REVIEW
LITERATURE
ARTICLE TITLE: GMC urged to be more radical [news]
ARTICLE SOURCE: BMJ (England), Sep 23 2000, 321(7263) p725
AUTHOR(S): Beecham L
PUBLICATION TYPE: NEWS
MB: The Governance Subcommittee of the GMC was told it had to
recommend more radical changes to the GMC. What a hopeless
approach.
ARTICLE TITLE: US parents sue psychiatrists for promoting ritalin
[news]
ARTICLE SOURCE: BMJ (England), Sep 23 2000, 321(7263) p723
AUTHOR(S): Charatan F
PUBLICATION TYPE: NEWS
ARTICLE TITLE: Risks of interrupting drug treatment before surgery
[editorial]
ARTICLE SOURCE: BMJ (England), Sep 23 2000, 321(7263) p719-20
AUTHOR(S): Noble DW; Kehlet H
PUBLICATION TYPE: EDITORIAL
MB: What they say is obvious but the whole thing is not very
sensible.
ARTICLE TITLE: Inquiring into inquiries [editorial;
comment]
COMMENTS: Comment on: BMJ 2000 Sep 23; 321(7263):752-6
ARTICLE SOURCE: BMJ (England), Sep 23 2000, 321(7263) p715-6
AUTHOR(S): Smith R
PUBLICATION TYPE: COMMENT; EDITORIAL
MB: About shambolic inquiries that get it all wrong. More
governance.
ARTICLE TITLE: Dutch waiting lists increase despite 36m (sterling
pounds) campaign [news]
ARTICLE SOURCE: BMJ (England), Sep 2 2000, 321(7260) p530
AUTHOR(S): Sheldon T
PUBLICATION TYPE: NEWS
MB: Money did not fix the problem. Surprise. Surprise.
ARTICLE TITLE: Effects of antiarrhythmic medication on implantable
cardioverter-defibrillator function [editorial]
ARTICLE SOURCE: Am J Cardiol (United States), Jun 15 2000, 85(12)
p1481-5
AUTHOR(S): Page RL
PUBLICATION TYPE: EDITORIAL
ARTICLE TITLE: Anatomic landmarks for use when measuring
intracardiac pressure with fluid-filled catheters.
ARTICLE SOURCE: Am J Cardiol (United States), Jul 1 2000, 86(1)
p121-4
AUTHOR(S): Brown LK; Kahl FR; Link KM; Hamilton CA; Goff DC; Little
WC; Hundley WG
AUTHOR'S ADDRESS: Department of Internal Medicine (Section on
Cardiology), Wake Forest University School of Medicine,
Winston-Salem, North Carolina 27157-1045, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
MB: This is a bit confusing. I would hope that they are not trying to
make decisions on the differences that they are making such a meal
of. They think the left atrial pressure is nearer to half the
distance between the front and back of the chest than any particular
distance from either the front or the back of the chest. I have used
that point for a long time.
ARTICLE TITLE: Comparison of intravenous adrenomedullin with
atrial natriuretic peptide in patients with congestive heart
failure.
ARTICLE SOURCE: Am J Cardiol (United States), Jul 1 2000, 86(1)
p94-8
AUTHOR(S): Oya H; Nagaya N; Furuichi S; Nishikimi T; Ueno K;
Nakanishi N; Yamagishi M; Kangawa K; Miyatake K
AUTHOR'S ADDRESS: Department of Internal Medicine, Research
Institute, Osaka, Japan.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ARTICLE TITLE: Management of sexual dysfunction in patients with
cardiovascular disease: recommendations of The Princeton Consensus
Panel [editorial]
ARTICLE SOURCE: Am J Cardiol (United States), Jul 15 2000, 86(2)
p175-81
AUTHOR(S): De Busk R; Drory Y; Goldstein I; Jackson G; Kaul S; Kimmel
SE; Kostis JB; Kloner RA; Lakin M; Meston CM; Mittleman M; Muller JE;
Padma-Nathan H; Rosen RC; Stein RA; Zusman R Finally, patients in the
high-risk category include those with (1) unstable or refractory
angina; (2) uncontrolled hypertension; (3) congestive heart failure
(class III or IV); (4) very recent MI (<2 weeks); (5) high-risk
arrhythmias; (6) obstructive cardiomyopathies; and (7)
moderate-to-severe valvular disease. These patients should be
stabilized by specific treatment for their cardiac condition before
resuming sexual activity or being treated for sexual dysfunction. A
simple algorithm is provided for guiding physicians in the management
of sexual dysfunction in patients with varying degrees of cardiac
risk.
ARTICLE TITLE: Sexual Activity and Cardiac Risk: The Princeton
Conference. New Jersey, USA, June 1999.
ARTICLE SOURCE: Am J Cardiol (United States), Jul 20 2000, 86(2A)
p1F-68F
PUBLICATION TYPE: CONGRESSES; OVERALL
ARTICLE TITLE: Interventions in cardiology: what does and does not
work.
ARTICLE SOURCE: Am J Cardiol (United States), Aug 24 2000, 86(4B)
p3H-5H
AUTHOR(S): King SB 3rd
AUTHOR'S ADDRESS: Emory University School of Medicine, Atlanta,
Georgia, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ARTICLE TITLE: Physician leadership is essential to the survival
of teaching hospitals.
ARTICLE SOURCE: Am J Surg (United States), Jun 2000, 179(6)
p462-8
AUTHOR(S): Schwartz RW; Pogge C
AUTHOR'S ADDRESS: Department of Surgery, College of Medicine,
University of Kentucky Chandler Medical Center, Lexington, Kentucky,
USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (31 references); REVIEW,
TUTORIAL
ABSTRACT: BACKGROUND: Academic medical centers (AMCs) face severe
financial constraints because they must now compete directly with
private providers that focus exclusively on cost-effective healthcare
delivery. Educational and research capacities developed at AMCs have
been supported by government and third party payers, but government
support is diminishing. Physicians are ill-equipped to respond to
market pressures. DATA SOURCES: Analyses of cultural change and
restructuring in corporate giants such as Greyhound, IBM and FedEx
are relevant to teaching hospitals. To succeed, organizations must
flatten hierarchy, empower staff, train leaders, and mobilize
intellectual capital. Effective leadership is essential. CONCLUSION:
Physicians must educate themselves on forces impacting the AMC,
understand changes needed in the structure and processes of AMC
governance and acquire competencies for leadership and management if
AMCs are to survive and thrive. Surgeons should acquire competencies
that will enable them to become leaders in the process of AMC
transformation.
ARTICLE TITLE: Correlation between physiological assessment and
outcome after liver transplantation.
ARTICLE SOURCE: Am J Surg (United States), May 2000, 179(5)
p396-9
AUTHOR(S): Chung SW; Kirkpatrick AW; Kim HL; Scudamore CH; Yoshida
EM
AUTHOR'S ADDRESS: Departments of Surgery and Medicine, University of
British Columbia, and the British Columbia Transplant Society,
Vancouver, British Columbia, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Detailed physiological scoring systems are no more
accurate in predicting outcome after liver transplant than current
listing status parameters.
ARTICLE TITLE: Patient satisfaction after carotid endarterectomy
using a selective policy of local anesthesia.
ARTICLE SOURCE: Am J Surg (United States), May 2000, 179(5)
p382-5
AUTHOR(S): Quigley TM; Ryan WR; Morgan S
AUTHOR'S ADDRESS: Section of General, Thoracic, and Vascular Surgery,
Virginia Mason Medical Center, Seattle, Washington 98111, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Patient outcome and perception of pain and recovery were
not statistically significantly different in patients undergoing
carotid endarterectomy using local anesthesia compared with general
anesthesia.
MB: And that from a fanatical regional anaesthesia hospital.
ARTICLE TITLE: Combined thoracic epidural and general anaesthesia
with laryngeal mask airway for laparoscopic cholecystectomy in a
patient with myasthenia gravis [letter]
ARTICLE SOURCE: Anaesthesia (England), Aug 2000, 55(8) p821-2
AUTHOR(S): Georgiou L; Bousoula M; Spetsaki M
PUBLICATION TYPE: LETTER
MB: I suppose you can do anything if you try hard enough.
ARTICLE TITLE: Calcium and the anaesthetist.
ARTICLE SOURCE: Anaesthesia (England), Aug 2000, 55(8) p779-90
AUTHOR(S): Aguilera IM; Vaughan RS
AUTHOR'S ADDRESS: Department of Anaesthesia and Intensive Care,
University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (75 references); REVIEW,
TUTORIAL
ARTICLE TITLE: The effect of intravenous epinephrine on the
bispectral index and sedation.
ARTICLE SOURCE: Anaesthesia (England), Aug 2000, 55(8) p761-3
AUTHOR(S): Andrzejowski J; Sleigh JW; Johnson IA; Sikiotis L
AUTHOR'S ADDRESS: Anaesthetic Department, Waikato Hospital, Hamilton,
New Zealand.
PUBLICATION TYPE: CLINICAL TRIAL; CONTROLLED CLINICAL TRIAL; JOURNAL
ARTICLE
ABSTRACT: Eight patients were given a propofol infusion until they no
longer responded to loud verbal stimuli, a sedation score of two
(modified Observer Assessment of Alertness and Sedation Scale). After
receiving 15 microg of intravenous epinephrine, changes in sedation
score and bispectral index (BIS) were observed. Mean pulse rate
increased from 68 to 96 (SD 10) beat.min-1, mean blood pressure
increased from 107/60 (SD 10/8) mmHg to 140/70 (SD 27/14) mmHg, and
mean BIS level rose from 63 to 76 (p < 0.005). Sedation scores
increased in six of the eight patients. Exogenous catecholamines seem
to have an arousal effect on lightly anaesthetised patients. This
could be due to changes in neurotransmitter levels in the brain, or
due to the effects consequent on increased cardiac output.
MB: It looks as though BIS is developing a life of it own.
ARTICLE TITLE: Cricoid pressure: which hand?
ARTICLE SOURCE: Anaesthesia (England), Jul 2000, 55(7) p648-53
AUTHOR(S): Cook TM; Godfrey I; Rockett M; Vanner RG
AUTHOR'S ADDRESS: Royal United Hospital, Bath, UK.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ABSTRACT: We studied 20 anaesthetic assistants applying simulated
cricoid pressure with the left or right hand in random order.
Simulated cricoid pressure was continued for up to 5 min with one
hand and then, after resting, with the other hand. Applied pressure
was measured at intervals and the subjects were blind to the results.
Nineteen assistants were right-handed and all routinely applied
cricoid pressure with their right hand. Mean (SD) force applied
during simulated 'awake' cricoid pressure was 13.8 (5.7) N with
either left or right hand, and during 'anaesthetised' cricoid
pressure it was initially 25.1 (8.2) N and 24.7 (8.8) N with left or
right hand, respectively. Mean force was maintained above 20 N and
below 30 N throughout the study period with either hand. Force
applied with the left hand was significantly lower than with the
right hand but the difference was clinically insignificant (0.4 N).
Inadequate or excessive force was more frequently associated with use
of the left hand (p < 0.0001). Cricoid pressure was released
before 5 min in three cases, two left-handed and one right-handed.
Our results demonstrate that anaesthetic assistants apply a lower
force than is classically taught and are able to maintain the force
with either hand for a sustained period. Application with the left
hand is justified where clinically indicated but may have a lower
margin for error than when applied with the right hand.
MB: I don't remember any particular force in Newtons being taught.
This is a simulated study pressing on a elastoplast roll. I doubt
that is much better than simulated sex.
ARTICLE TITLE: "The lower the better" in hypercholesterolemia
therapy: a reliable clinical guideline?
ARTICLE SOURCE: Ann Intern Med (United States), Oct 3 2000, 133(7)
p549-54
AUTHOR(S): Jacobson TA
AUTHOR'S ADDRESS: Department of Medicine, Emory University, Atlanta,
Georgia, USA. tjaco02@emory.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (31 references); REVIEW,
TUTORIAL
In light of the current climate involving competing health care
costs, the pursuit of progressively diminishing returns in terms of
reductions in coronary artery disease risk through more aggressive
lowering of LDL cholesterol levels appears to be unwarranted. Until
data are published from ongoing randomized, clinical trials that can
more effectively resolve the clinical utility of aggressive
lipid-lowering strategies to improve coronary event rates, a prudent,
evidence-based strategy seems warranted.
ARTICLE TITLE: Update in gastroenterology.
ARTICLE SOURCE: Ann Intern Med (United States), Oct 3 2000, 133(7)
p542-8
AUTHOR(S): Greenberger NJ; Gillock MR; Kramer D; Kefalides PT
AUTHOR'S ADDRESS: University of Kansas Medical Center, Kansas City,
Kansas, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (13 references); REVIEW
LITERATURE
ARTICLE TITLE: Prediction of perioperative risk: the glass may be
three-quarters full [comment] [editorial]
COMMENTS: Comment on: Ann Intern Med 2000 Sep 5; 133(5):356-9
ARTICLE SOURCE: Ann Intern Med (United States), Sep ?? 2000, 133(5)
p384-6
AUTHOR(S): Bach DS; Eagle KA
PUBLICATION TYPE: COMMENT; EDITORIAL
MB: This is a comment on the next article. I think that they think
that scoring systems are hardly worth the trouble.
ARTICLE TITLE: Prospective evaluation of cardiac risk indices for
patients undergoing noncardiac surgery [see comments]
COMMENTS: Comment in: Ann Intern Med 2000 Sep 5; 133(5):384-6
ARTICLE SOURCE: Ann Intern Med (United States), Sep ?? 2000, 133(5)
p356-9
AUTHOR(S): Gilbert K; Larocque BJ; Patrick LT
AUTHOR'S ADDRESS: University of Western Ontario, London, Canada.
kgilbert@julian.uwo.ca.
RESULTS: Cardiac complications occurred in 6.4% of patients. The area
under the ROC curve was 0.625 (95% CI, 0.575 to 0.676) for the
American Society of Anesthesiologists index, 0.642 (CI, 0.588 to
0.695) for the Goldman index, 0.601 (CI, 0.544 to 0.657) for the
modified Detsky index, and 0.654 (0.601 to 0.708) for the Canadian
Cardiovascular Society index. These values did not significantly
differ. CONCLUSIONS: Existing indices for prediction of cardiac
complications perform better than chance, but no index is
significantly superior. There is room for improvement in our ability
to predict such complications.
ARTICLE TITLE: Hemodynamic effects of carbon dioxide insufflation
during endoscopic vein harvesting.
ARTICLE SOURCE: Ann Thorac Surg (United States), Sep 2000, 70(3)
p1098-9
AUTHOR(S): Vitali RM; Reddy RC; Molinaro PJ; Sabado MF; Jacobowitz
IJ
AUTHOR'S ADDRESS: Maimonides Medical Center and State University of
New York, Downstate Medical Center, Brooklyn 11203-2098, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Carbon dioxide insufflation during endoscopic vein
harvesting leads to no adverse hemodynamic consequences or systemic
CO2 absorption. The technique appears to be safe and well
tolerated.
ARTICLE TITLE: Ventricular thrombosis and systemic embolism in
bodybuilders: etiology and management.
ARTICLE SOURCE: Ann Thorac Surg (United States), Aug 2000, 70(2)
p658-60
AUTHOR(S): McCarthy K; Tang AT; Dalrymple-Hay MJ; Haw MP
AUTHOR'S ADDRESS: Department of Cardiac Surgery, Wessex Cardiac &
Thoracic Unit, Southampton General Hospital, United Kingdom.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Increased thrombogenicity and acute embolism are
well-recognized complications of chronic anabolic steroid abuse. The
following cases highlight such dangers in steroid-enhanced
bodybuilders who developed intracardiac thrombosis that subsequently
embolized. Systemic anticoagulation and surgical thrombectomy
constituted the mainstay treatment. This represents the first report
of such devastating cardiovascular complications after anabolic
steroid abuse and their management.
ARTICLE TITLE: Myasthenia gravis: recommendations for clinical
research standards. Task Force of the Medical Scientific Advisory
Board of the Myasthenia Gravis Foundation of America.
ARTICLE SOURCE: Ann Thorac Surg (United States), Jul 2000, 70(1)
p327-34
AUTHOR(S): Jaretzki A 3rd; Barohn RJ; Ernstoff RM; Kaminski HJ;
Keesey JC; Penn AS; Sanders DB
AUTHOR'S ADDRESS: Department of Surgery, Columbia Presbyterian
Medical Center, New York, New York, USA.
PUBLICATION TYPE: GUIDELINE; JOURNAL ARTICLE; PRACTICE GUIDELINE
ARTICLE TITLE: Association between postoperative hypothermia and
adverse outcome after coronary artery bypass surgery.
ARTICLE SOURCE: Ann Thorac Surg (United States), Jul 2000, 70(1)
p175-81
AUTHOR(S): Insler SR; O'Connor MS; Leventhal MJ; Nelson DR; Starr
NJ
AUTHOR'S ADDRESS: Department of Cardiothoracic Anesthesia, The
Cleveland Clinic Foundation, Ohio 44195, USA. inslers@ccf.org.
MAJOR SUBJECT HEADING(S): Coronary Artery Bypass [adverse
effects]; Hypothermia [complications]
[etiology]
MINOR SUBJECT HEADING(S): Aged; Intensive Care Units; Logistic
Models; Middle Age; Multivariate Analysis; Patient Admission;
Retrospective Studies; Severity of Illness Index; Treatment
Outcome
INDEXING CHECK TAG(S): Female; Human; Male
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: bladder core temperature of less than 36 degrees C, upon
ICU admission, has a significant association with adverse outcome
after CABG with CPB.
ARTICLE TITLE: Ventilator-associated pneumonia.
ARTICLE SOURCE: Arch Intern Med (United States), Jul 10 2000, 160(13)
p1926-36
AUTHOR(S): Morehead RS; Pinto SJ
AUTHOR'S ADDRESS: Division of Pulmonary and Critical Care Medicine,
University of Kentucky School of Medicine, Lexington, KY, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (164 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Risk of hepatitis C transmission from infected
medical staff to patients: model-based calculations for surgical
settings.
ARTICLE SOURCE: Arch Intern Med (United States), Aug 14-28 2000,
160(15) p2313-6
AUTHOR(S): Ross RS; Viazov S; Roggendorf M
AUTHOR'S ADDRESS: Essen University Hospital, National Reference
Centre for Hepatitis C, Essen, Germany. stefan.ross@uni-essen.de.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The calculated risks for HCV transmission from a surgeon
to a susceptible patient during a single invasive procedure are
comparable to the chance of acquiring HCV by receiving a blood
transfusion. These figures could provide a basis for further
discussions on this controversial subject and might also be relevant
for future recommendations on the management of HCV-infected health
care workers.
ARTICLE TITLE: Dying well after discontinuing the life-support
treatment of dialysis.
ARTICLE SOURCE: Arch Intern Med (United States), Sep 11 2000, 160(16)
p2513-8
AUTHOR(S): Cohen LM; Germain MJ; Poppel DM; Woods AL; Pekow PS;
Kjellstrand CM
AUTHOR'S ADDRESS: Department of Psychiatry, Baystate Medical Center,
Springfield, MA 01199, USA. lewis.cohen@bhs.org.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
CONCLUSIONS: Most deaths following withdrawal of dialysis were good
or very good. The influence of site of death and physician attitudes
about decisions to stop life support deserves more research
attention. Quality of dying tools can be used to establish benchmarks
for the provision of terminal care.
ARTICLE TITLE: Reality and meta-analyses.
ARTICLE SOURCE: Chest (United States), Sep 2000, 118(3) p835-6
AUTHOR(S): Machtay M; Kaiser LR; Glatstein E
AUTHOR'S ADDRESS: Department of Radiation Oncology, University of
Pennsylvania Medical Center, Philadelphia, PA 19104, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (8 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Is meta-analysis a metaphysical or a scientific
method?
ARTICLE SOURCE: Chest (United States), Sep 2000, 118(3) p832-4
AUTHOR(S): Arriagada R; Pignon JP
AUTHOR'S ADDRESS: Department of Radiation Oncology, Instituto de
Radiomedicina, Santiago, Chile. gocchi@ctcinternet.cl.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (22 references); REVIEW,
TUTORIAL
MB: This and the one before are about radiotherapy in small cell
carcinoma of the lung, There are very few randomised trials.
ARTICLE TITLE: High-frequency ventilation for acute lung injury
and ARDS.
ARTICLE SOURCE: Chest (United States), Sep 2000, 118(3) p795-807
AUTHOR(S): Krishnan JA; Brower RG
AUTHOR'S ADDRESS: Department of Medicine, Johns Hopkins University,
Baltimore, MD 21287, USA. satish@welch.jhu.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (104 references); REVIEW,
ACADEMIC
ARTICLE TITLE: Evidence for the effectiveness of techniques To
change physician behavior.
ARTICLE SOURCE: Chest (United States), Aug 2000, 118(2 Suppl)
p8S-17S
AUTHOR(S): Smith WR
AUTHOR'S ADDRESS: Division of Quality Health Care, Department of
Internal Medicine, Virginia Commonwealth University, Medical College
of Virginia Campus, Richmond, VA 23298, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: The answer to the question of what works to improve an
individual physician's clinical performance is not simple. Emerging
theory and evidence suggests that applications of behavior-change
methods should not be focused on which tools (don't) always work.
Instead, guideline development and implementation methods should be
theory driven and evidence based (supported by evidence that proves
the theory correct). In particular, the framework of evidence-based
quality assessment offers some insight into past failures and offers
hope for organizing attempts at guideline implementation.
ARTICLE TITLE: Guideline implementation in the department of
defense.
ARTICLE SOURCE: Chest (United States), Aug 2000, 118(2 Suppl)
p65S-69S
AUTHOR(S): Mitchell JP
AUTHOR'S ADDRESS: Travis Air Force Base, CA 94535, USA.
john.mitchell@60mdg.travis.af.mil.
MAJOR SUBJECT HEADING(S): Asthma [therapy]; Guideline
Adherence; Military Medicine; Practice Guidelines
MINOR SUBJECT HEADING(S): Case Management; Quality Assurance, Health
Care; United States
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (12 references); REVIEW,
TUTORIAL
ABSTRACT: To improve the effectiveness of evidence-based clinical
practice guidelines (CPGs), four other components of implementation
are necessary. Together, they impressively optimize the process and
outcomes of health care, and reduce undesirable variation of care.
Aside from CPGs, the four components help make up a successful,
long-term, facility-wide, comprehensive disease-management program.
First, executive clinical and administrative leaders need to create
the expectation and reveal hands-on commitment. Second,
work-simplification tools are needed to accomplish the tasks more
effectively and to encourage a path of least resistance. Third,
useful, accurate metrics are needed to provide feedback for patients
and health-care providers who need the most assistance. These metrics
must be easily obtained, disseminated in near-real time,
patient-specific, anonymous to others, and penalty free. Fourth, and
most important, with nonmonetary compensation, this review addresses
the question, "What's in it for all the passionate people who assist
in the delivery of health care?"
MB: Sounds hopeless.
ARTICLE TITLE: Blood transfusion-always a minimum of two units?
[letter]
ARTICLE SOURCE: Chest (United States), Aug 2000, 118(2) p567-8
AUTHOR(S): Judson JP
PUBLICATION TYPE: LETTER
MB: He is against it. It is fairly obvious. A single unit blood
transfusion was a criterion of frivolous use of blood. I always
thought this was silly.
ARTICLE TITLE: Reduction in tracheal lumen due to endotracheal
intubation and its calculated clinical significance.
ARTICLE SOURCE: Chest (United States), Aug 2000, 118(2) p468-72
AUTHOR(S): Bock KR; Silver P; Rom M; Sagy M
AUTHOR'S ADDRESS: Division of Critical Care Medicine, Schneider
Children's Hospital, Hyde Park, NY 11040, USA.
krbcngb@massmed.org.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The common value of X due to endotracheal intubation is
between 0.5 and 0.6, which in and of itself results in an increase in
R across the intubated trachea up to 32-fold. The calculated increase
in P as a result of this is between 2 and 3 cm H(2)O for adolescents
or young adults. The addition of pressure support of at least 3 cm
H(2)O during spontaneous ventilation via an endotracheal tube, which
is common practice in pediatric critical care, should alleviate any
respiratory distress emanating from the increased R. However, a value
for X < 0.5, which was found in 10% of our patients (2 of 20
patients), results in a much higher calculated increase in the
pressure gradient and, therefore, a higher level of pressure support
is required to overcome this increase.
ARTICLE TITLE: Protocol weaning of mechanical ventilation in
medical and surgical patients by respiratory care practitioners and
nurses: effect on weaning time and incidence of ventilator-associated
pneumonia.
ARTICLE SOURCE: Chest (United States), Aug 2000, 118(2) p459-67
AUTHOR(S): Marelich GP; Murin S; Battistella F; Inciardi J; Vierra T;
Roby M
AUTHOR'S ADDRESS: Division of Pulmonary and Critical Care Medicine,
Department of Internal Medicine, University of California, Sacramento
95823, USA. gregory.p.marelich@kp.org.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
CONCLUSIONS: A ventilator management protocol (VMP) designed for
multidisciplinary use was effective in reducing duration of
mechanical ventilatory support without any adverse effects on patient
outcome. The VMP was also associated with a decrease in incidence of
ventilator-associated pneumonia. in trauma patients. These results,
in conjunction with prior studies, suggest that VMPs are highly
effective means of improving care, even in university ICUs.
ARTICLE TITLE: Sleepiness, fatigue, tiredness, and lack of energy
in obstructive sleep apnea.
ARTICLE SOURCE: Chest (United States), Aug 2000, 118(2) p372-9
AUTHOR(S): Chervin RD
AUTHOR'S ADDRESS: Sleep Disorders Center and Department of Neurology,
University of Michigan, Ann Arbor 48109-0117, USA.
chervin@umich.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Complaints of fatigue, tiredness, or lack of energy may
be as important as that of sleepiness to obstructive sleep apnea
syndrome (OSAS) patients, among whom women appear to have all such
complaints more frequently than men. The diagnosis of OSAS should not
be excluded based only on a person's tendency to emphasize fatigue,
tiredness, or lack of energy more than sleepiness.
ARTICLE TITLE: Unpredictability of deception in compliance with
physician-prescribed bronchodilator inhaler use in a clinical trial
[see comments]
COMMENTS: Comment in: Chest 2000 Aug; 118(2):281-3
ARTICLE SOURCE: Chest (United States), Aug 2000, 118(2) p290-5
AUTHOR(S): Simmons MS; Nides MA; Rand CS; Wise RA; Tashkin DP
AUTHOR'S ADDRESS: UCLA School of Medicine, Los Angeles, CA
90095-1690, USA. msimm@ucla.edu.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY;
RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: Deception among noncompliers occurs frequently in
clinical trials, is often not revealed by the usual methods of
monitoring, and cannot be predicted by data readily available in
clinical trials.
ARTICLE TITLE: Reality-based medicine [editorial;
comment]
COMMENTS: Comment on: Chest 2000 Aug; 118(2):290-5
ARTICLE SOURCE: Chest (United States), Aug 2000, 118(2) p281-3
AUTHOR(S): Chapman KR
PUBLICATION TYPE: COMMENT; EDITORIAL
MB: Often failed therapy is due to non-compliance.
ARTICLE TITLE: Empiric antibiotic use and resistant microbes. A
"catch-22" for the 21st century [editorial; comment]
COMMENTS: Comment on: Chest 2000 Jul; 118(1):146-55
ARTICLE SOURCE: Chest (United States), Jul 2000, 118(1) p9-11
AUTHOR(S): Manthous CA; Amoateng-Adjepong Y
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Role of respiratory function in exercise limitation
in chronic heart failure [see comments]
COMMENTS: Comment in: Chest 2000 Jul; 118(1):5-7
ARTICLE SOURCE: Chest (United States), Jul 2000, 118(1) p53-60
AUTHOR(S): Chauhan A; Sridhar G; Clemens R; Krishnan B; Marciniuk DD;
Gallagher CG
AUTHOR'S ADDRESS: Division of Respiratory Medicine, Department of
Medicine, University of Saskatchewan, Saskatoon, Dublin, Ireland.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
CONCLUSION: Because patients with chronic heart failure had
significant ventilatory reserve at the end of exercise and were able
to further increase their maximal minute ventilation, we conclude
that respiratory function does not contribute to limitation of
exercise in patients with chronic heart failure.
ARTICLE TITLE: Exertional dyspnea in congestive heart failure.
Living longer and doing more? [editorial; comment]
COMMENTS: Comment on: Chest 2000 Jul; 118(1):53-60
ARTICLE SOURCE: Chest (United States), Jul 2000, 118(1) p5-7
AUTHOR(S): Sue DY
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Update in pulmonary disease.
ARTICLE SOURCE: Ann Intern Med (United States), Sep ?? 2000, 133(5)
p360-6
AUTHOR(S): Anzueto A; Angel L
AUTHOR'S ADDRESS: University of Texas Health Science Center at San
Antonio and South Texas Veterans Affairs Health Care System, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (13 references); REVIEW
LITERATURE :
ARTICLE TITLE: Efficacy of postoperative blood salvage following
total hip arthroplasty in patients with and without deposited
autologous units.
ARTICLE SOURCE: J Bone Joint Surg Am (United States), Jul 2000,
82-A(7) p951-4
AUTHOR(S): Grosvenor D; Goyal V; Goodman S
AUTHOR'S ADDRESS: Division of Orthopaedic Surgery, Stanford
University Medical Center, California 94305, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Despite a limited sample size, the study results showed
that postoperative blood salvage significantly reduced the risk of
allogeneic transfusion among patients managed with total hip
replacement, whether or not they had deposited autologous blood (p
< 0.0001). With control for donated units, age, gender,
preoperative hematocrit, intraoperative blood loss, and cementless
technique, patients who were treated without postoperative blood
salvage were approximately ten times more likely to require
allogeneic transfusion than were patients who had a drain.
ARTICLE TITLE: Ketamine sedation for the reduction of children's
fractures in the emergency department [see comments]
COMMENTS: Comment in: J Bone Joint Surg Am 2000 Jul; 82-A(7):911
ARTICLE SOURCE: J Bone Joint Surg Am (United States), Jul 2000,
82-A(7) p912-8
AUTHOR(S): McCarty EC; Mencio GA; Walker LA; Green NE
AUTHOR'S ADDRESS: Vanderbilt University Sports Medicine Center,
Nashville, Tennessee 37212, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Ketamine reliably, safely, and quickly provided adequate
sedation to effectively facilitate the reduction of children's
fractures in the emergency department at our institution. Ketamine
should only be used in an environment such as the emergency
department, where proper one-on-one monitoring is used and
board-certified physicians skilled in airway management are directly
involved in the care of the patient.
MB: It sounds like anaesthesia to me. This involves 114 patients.
This is not enough to expect one anaesthetic death which is in the
one in tens of thousands.
ARTICLE TITLE: The use of ketamine sedation [editorial;
comment]
COMMENTS: Comment on: J Bone Joint Surg Am 2000 Jul;
82-A(7):912-8
ARTICLE SOURCE: J Bone Joint Surg Am (United States), Jul 2000,
82-A(7) p911
AUTHOR(S): Heckman JD
PUBLICATION TYPE: COMMENT; EDITORIAL.
MB: The editorial author does not realise that this is anaesthesia.
He does realise that the people involved---emergency docs---have to
be able to look after the airway.
ARTICLE TITLE: Poor prediction of blood transfusion requirements
in adult liver transplantations from preoperative variables.
ARTICLE SOURCE: J Clin Anesth (United States), Jun 2000, 12(4)
p319-23
AUTHOR(S): Findlay JY; Rettke SR
AUTHOR'S ADDRESS: Department of Anesthesiology, Mayo Clinic and
Foundation, Rochester, MN 55902, USA. findlay.james@mayo.edu.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
PATIENTS: 583 sequential adult patients undergoing orthotopic liver
transplantation. CONCLUSION: Preoperative variables are poor
predictors of intraoperative transfusion requirements even when
significant associations exist, identifying a small proportion of the
variability observed. A predictive approach based on this method
would be too inaccurate to be of clinical use. The majority of the
variability in transfusion requirements during liver transplantation
most likely results from intraoperative and donor organ factors.
ARTICLE TITLE: Maintaining sevoflurane anesthesia during low-flow
anesthesia using a single vaporizer setting change after overpressure
induction.
ARTICLE SOURCE: J Clin Anesth (United States), Jun 2000, 12(4)
p303-7
AUTHOR(S): Hendrickx JF; Vandeput DM; De Geyndt AM; De Ridder KP;
Haenen JS; Deloof T; De Wolf AM
AUTHOR'S ADDRESS: Departments of Anesthesiology, Onze Lieve
Vrouwziekenhuis, Aalst, Belgium.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
CONCLUSIONS: After high-flow overpressure induction with sevoflurane,
a single change in vaporizer setting (to 1.9%) and fresh gas flow (to
1 L. min(-1)) suffices for the the end-expired sevoflurane
concentration (Et(sevo) to approach the predicted Et(sevo) (1.3%)
within 10-15 min; thereafter the Et(sevo) remains nearly constant. As
expected, the predicted Et(sevo) is attained slightly faster when the
vaporizer is temporarily turned off. Clinically applying previously
derived pharmacokinetic parameters simplifies low-flow sevoflurane
anesthesia after overpressure induction.
ARTICLE TITLE: Patients' perception of sound levels in the
surgical suite.
ARTICLE SOURCE: J Clin Anesth (United States), Jun 2000, 12(4)
p298-302
AUTHOR(S): Liu EH; Tan S
AUTHOR'S ADDRESS: Department of Anesthesia, National University
Hospital, Singapore, Japan.
MAJOR SUBJECT HEADING(S): Anesthesia; Auditory Perception; Noise,
Occupational; Operating Rooms
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: STUDY OBJECTIVES: To measure sound levels that our patients
are exposed to in the surgical suite and their perception of these
sound levels. DESIGN: Sound levels experienced by 100 patients
undergoing general anesthesia for elective surgery during three
phases: induction and maintenance of anesthesia in the operating room
(OR), and recovery from anesthesia in the recovery room, were
measured using a Type 4436 Noise Dose Meter. The equivalent
continuous sound levels (Leq), maximum sound levels (Lmax), and the
sources of sounds were noted. Patients were interviewed 24 hours
after anesthesia about their perception of the sound levels they had
experienced in the OR and recovery rooms. MEASUREMENTS AND MAIN
RESULTS: The Leq during the induction, maintenance, and recovery
phases were 70.3 +/- 16.8 dB(A), 66.2 +/- 4.1 dB(A) and 71.8 +/- 6.1
dB(A), respectively. These sound levels are much higher than
international recommendations for hospital acute care areas and
exceed the thresholds to produce noise-induced cardiovascular and
endocrine effects. Sound levels were significantly higher during the
induction and recovery phases compared to the maintenance phase.
Thirty-two patients found the induction phase noisy and 33 patients
found the recovery phase noisy. The sound levels distressed 16
patients and 52 patients would have preferred a quieter environment.
There was no difference in the sound levels experienced by those who
expressed dissatisfaction with the sound levels and those who did
not. Much of the noise, particularly staff conversations, unnecessary
alarms, and preparation of equipment, could have been prevented by
simple measures. CONCLUSION: Noise prevention in the OR and recovery
room needs more attention and should be a routine part of patient
care.
ARTICLE TITLE: The use of propofol for its antiemetic effect: a
survey of clinical practice in the United States [see
comments]
COMMENTS: Comment in: J Clin Anesth 2000 Jun; 12(4):263-9
ARTICLE SOURCE: J Clin Anesth (United States), Jun 2000, 12(4)
p265-9
AUTHOR(S): Soppitt AJ; Glass PS; Howell S; Weatherwax K; Gan TJ
AUTHOR'S ADDRESS: Dept. of Anesthesiology, Duke University Medical
Center, Durham, NC 27710, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Many anesthesiologists used propofol for its antiemetic
effect. There is strong evidence for its antiemetic efficacy after
anesthesia maintained by a propofol infusion and also for its use in
the postanesthesia care unit (PACU). However, there is little
evidence to support its use purely at induction of anesthesia or as
part of a "sandwich" technique in an attempt to reduce postoperative
nausea and vomiting. This is especially true in cases lasting longer
than a few minutes.
ARTICLE TITLE: Myths in anesthesiology [editorial;
comment]
COMMENTS: Comment on: J Clin Anesth 2000 Jun; 12(4):265-9
ARTICLE SOURCE: J Clin Anesth (United States), Jun 2000, 12(4)
p263-4
AUTHOR(S): Bosek V
MAJOR SUBJECT HEADING(S): Anesthesiology
MINOR SUBJECT HEADING(S): Anesthetics, Intravenous
[administration & dosage] [pharmacology];
Antiemetics [pharmacology]; Propofol [administration
& dosage] [pharmacology]
PUBLICATION TYPE: COMMENT; EDITORIAL
MB: There are plenty of other myths in anaesthesia.
ARTICLE TITLE: Repeated hypotensive episodes due to hepatic
outflow obstruction during liver transplantation in adult
patients.
ARTICLE SOURCE: J Clin Anesth (United States), May 2000, 12(3)
p231-3
AUTHOR(S): Jawan B; Cheung HK; Chen CC; Chen YS; Chiang YC; Wang CC;
Cheng YF; Huang TL; Eng HL; Goto S; Pan TL; De Villa V; Liu PP; Wang
SH; Lin CL; Lee JH
AUTHOR'S ADDRESS: Department of Anesthesiology and Liver
Transplantation Program, Chang Gung Memorial Hospital, Kaohsiung
Medical Center, Kaohsiung, Taiwan. jawanb@hotmail.com.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: We report two cases of unusual repeated hypotension,
decreased cardiac output, decreased mixed venous oxygen saturation,
decreased central venous pressure, pulmonary artery pressure, and
pulmonary wedge pressure after the completion of all vascular
anastamoses of liver transplantation. These unstable hemodynamics
appear to reflect a clinically relevant picture of hypovolemia.
However, the real cause was partial hepatic outflow obstruction. The
obstruction was suspected because hypotension was alleviated by
elevating the full-sized liver graft ventrally and to the left.
Doppler ultrasound examination confirmed that the flow velocity of
the hepatic vein outflow was insufficient when the liver fell to its
resting position in the right hepatic fossa. An additional
side-to-side cavo-caval anastomosis resolved the problem in one
patient, whereas the other required not only the additional
anastomosis, but also application of a tissue expander filled with
770 mL normal saline beneath the liver to eliminate the obstruction.
We emphasize that obstruction of the hepatic outflow causes only
temporal hypovolemia because of a decrease of venous return and that
treatment of this complication should be surgical intervention to
relieve the obstruction. Blind resuscitation with fluids will not
solve the problem and, in fact, may result in fluid overload with
subsequent complications.
MB: I think we worked this out 30 y ago in the pig lab. It is a
surgical problem. They used to think that you had to have the liver
transplant patients lie flat for a few days to stop the liver
flopping about on its vessels.
ARTICLE TITLE: Determinants of core temperature at the time of
admission to intensive care following cardiac surgery.
ARTICLE SOURCE: J Clin Anesth (United States), May 2000, 12(3)
p177-83
AUTHOR(S): El-Rahmany HK; Frank SM; Vannier CA; Schneider G; Okasha
AS; Bulcao CF
AUTHOR'S ADDRESS: Department of Anesthesiology and Critical Care
Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD
21287, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
.CONCLUSIONS: To reduce the incidence of hypothermia after cardiac
surgery, the most important variable is rewarming endpoint achieved
before separation from bypass. A warm ambient temperature (>21
degrees C) may be beneficial if the duration of time in the OR after
bypass is prolonged (>90 min).
MB: You would think they would have worked this out by now.
ARTICLE TITLE: Mind-body dualism and the biopsychosocial model of
pain: what did Descartes really say? [see comments]
COMMENTS: Comment in: J Med Philos 2000 Aug; 25(4):367-77
ARTICLE SOURCE: J Med Philos (Netherlands), Aug 2000, 25(4)
p485-513
AUTHOR(S): Duncan G
AUTHOR'S ADDRESS: Massey University, Auckland, New Zealand.
L.G.Duncan@massey.ac.nz.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (30 references); REVIEW,
TUTORIAL
ABSTRACT: In the last two decades there have been many critics of
western biomedicine's poor integration of social and psychological
factors in questions of human health. Such critiques frequently begin
with a rejection of Descartes' mind-body dualism, viewing this as the
decisive philosophical moment, radically separating the two realms in
both theory and practice. It is argued here, however, that many such
readings of Descartes have been selective and misleading. Contrary to
the assumptions of many recent authors, Descartes' dualism does
attempt to explain the union of psyche and soma - with more depth
than is often appreciated. Pain plays a key role in Cartesian as well
as contemporary thinking about the problem of dualism. Theories of
the psychological origins of pain symptoms persisted throughout the
history of modern medicine and were not necessarily discouraged by
Cartesian mental philosophy. Moreover, the recently developed
biopsychosocial model of pain may have more in common with Cartesian
dualism than it purports to have. This article presents a rereading
of Descartes' mental philosophy and his views on pain. The intention
is not to defend his theories, but to re-evaluate them and to ask in
what respect contemporary theories represent any significant advance
in philosophical terms.
MB: The whole article is quite difficult to read. I subscribe so I
have a hard copy if any one wants to see it. When I read Deacartes
first in about 1975 I could not find his supposed dualism. I thought
he thought that biological organisms were one. The author who has of
course gone into it much more thoroughly than I did seems to think
that poor Descartes has been misrepresented and blamed for everything
that the philosophers call dualism which for reasons I have never
been able to figure they cannot abide.
ARTICLE TITLE: Good enough for the Third world [see
comments]
COMMENTS: Comment in: J Med Philos 2000 Aug; 25(4):367-77
ARTICLE SOURCE: J Med Philos (Netherlands), Aug 2000, 25(4)
p427-50
AUTHOR(S): Cooley D
AUTHOR'S ADDRESS: East Carolina University, Greenville, North
Carolina 27858-4353, USA. CooleyD@mail.ecu.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (45 references); REVIEW,
TUTORIAL
ABSTRACT: Over the past two years, much has been made by some
governments and the media about the possible callous and racist
distribution of Quinacrine by two Americans to sterilize women in the
Third World. The main criticism of the practice is that though
Quinacrine is unapproved by the developed world's health regulatory
agencies for this particular use in the developed world due to
inadequate testing for long-term side effects, it is used on
defenseless women in the developing world.I argue that the
distribution of unapproved medical and other products is morally
permissible if it satisfies two conditions: agent-centered
utilitarianism and Kant's Categorical Imperative. Roughly, I contend
that if the situation will probably improve and no one is treated as
a mere means, then it is ethical either to give or to sell the
products to those who choose to have them, regardless of where in the
world they live.
ARTICLE TITLE: The ambiguity and the exigency: clarifying
'standard of care' arguments in international research [see
comments]
COMMENTS: Comment in: J Med Philos 2000 Aug; 25(4):367-77
ARTICLE SOURCE: J Med Philos (Netherlands), Aug 2000, 25(4)
p379-97
AUTHOR(S): London AJ
AUTHOR'S ADDRESS: Carnegie Mellon University, Pittsburgh,
Pennsylvania 15213-3890, USA. ajl8h@alumni.virginia.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (20 references); REVIEW,
TUTORIAL
ABSTRACT: This paper examines the concept of a 'standard of care' as
it has been used in recent arguments over the ethics of international
human-subjects research. It argues that this concept is ambiguous
along two different axes, with the result that there are at least
four possible standard of care arguments that have not always been
clearly distinguished. As a result, it has been difficult to assess
the implications of opposing standard of care arguments, to recognize
important differences in their supporting rationales, and even to
locate the crux of the disagreement in some instances. The goal of
the present discussion, therefore, is to disambiguate the concept of
a 'standard of care' and to highlight the areas of genuine
disagreement among different standards. In the end it is argued that
one standard of care argument in particular is more complex than
either its proponents or its critics may have recognized and that
understanding this possibility opens up a potentially promising
avenue of inquiry that remains to be carefully explored.
MB: 'Standard of care' as an absolute does not seem to have any real
basis. It is often medicolegally driven. That is things are claimed
to be standard of practice for fear of litigation, which of course is
illegal. They are being done for the benefit of the doctor.
ARTICLE TITLE: Primary endoleakage in endovascular treatment of
the thoracic aorta: importance of intraoperative transesophageal
echocardiography.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Sep 2000,
120(3) p490-5
AUTHOR(S): Fattori R; Caldarera I; Rapezzi C; Rocchi G; Napoli G;
Parlapiano M; Favali M; Pierangeli A; Gavelli G
AUTHOR'S ADDRESS: Departments of Radiology, Cardiovascular Surgery,
and Cardiology, University of Bologna, Bologna, Italy.
ross@med.unibo.it.
INDEXING CHECK TAG(S): Female; Human; Male
PUBLICATION TYPE: JOURNAL ARTICLE
RESULTS: Information from transesophageal echocardiography was
relevant in the selection of the landing zone in 62% of cases. In 8
patients, transesophageal echocardiography with color Doppler
sonography showed a perigraft leak, 6 of which were not visible on
angiography, suggesting the need for further balloon expansion or
graft extension. Postoperative computed tomographic scanning in the
25 patients showed 1 endoleak, which sealed spontaneously. At 3
months, computed tomographic examination confirmed the absence of
perigraft leakage in all patients. CONCLUSIONS: During implantation
of a stent-graft in the descending thoracic aorta, transesophageal
echocardiography provides information in addition to that provided by
angiography, improving immediate and late procedural results.
ARTICLE TITLE: At last--a national plan for the National Health
Service? [news]
ARTICLE SOURCE: Lancet (England), Jul 29 2000, 356(9227) p407
AUTHOR(S): Dean M
PUBLICATION TYPE: NEWS
ARTICLE TITLE: Morbidity and mortality in patients randomised to
double-blind treatment with a long-acting calcium-channel blocker or
diuretic in the International Nifedipine GITS study: Intervention as
a Goal in Hypertension Treatment (INSIGHT) [see comments]
COMMENTS: Comment in: Lancet 2000 Jul 29; 356(9227):352-3
ARTICLE SOURCE: Lancet (England), Jul 29 2000, 356(9227) p366-72
AUTHOR(S): Brown MJ; Palmer CR; Castaigne A; de Leeuw PW; Mancia G;
Rosenthal T; Ruilope LM
AUTHOR'S ADDRESS: Clinical Pharmacology Unit, University of
Cambridge, UK. morris.brown@cai.cam.ac.uk.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY;
RANDOMIZED CONTROLLED TRIAL
INTERPRETATION: Nifedipine once daily and co-amilozide were equally
effective in preventing overall cardiovascular or cerebrovascular
complications. The choice of drug can be decided by tolerability and
blood-pressure response rather than long-term safety or efficacy.
ARTICLE TITLE: Randomised trial of effects of calcium antagonists
compared with diuretics and beta-blockers on cardiovascular morbidity
and mortality in hypertension: the Nordic Diltiazem (NORDIL) study
[see comments]
COMMENTS: Comment in: Lancet 2000 Jul 29; 356(9227):352-3
ARTICLE SOURCE: Lancet (England), Jul 29 2000, 356(9227) p359-65
AUTHOR(S): Hansson L; Hedner T; Lund-Johansen P; Kjeldsen SE;
Lindholm LH; Syvertsen JO; Lanke J; de Faire U; Dahlof B; Karlberg
BE
AUTHOR'S ADDRESS: Department of Public Health and Social Sciences,
University of Uppsala, Sweden.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
INTERPRETATION: Diltiazem was as effective as treatment based on
diuretics, beta-blockers, or both in preventing the combined primary
endpoint of all stroke, myocardial infarction, and other
cardiovascular death.
ARTICLE TITLE: Differences between blood-pressure-lowering drugs
[comment]
COMMENTS: Comment on: Lancet 2000 Jul 29; 356(9227):359-65; Comment
on: Lancet 2000 Jul 29; 356(9227):366-72
ARTICLE SOURCE: Lancet (England), Jul 29 2000, 356(9227) p352-3
AUTHOR(S): MacMahon S; Neal B
AUTHOR'S ADDRESS: Institute for International Health, University of
Sydney, NSW, Australia.
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE
ARTICLE TITLE: Can anaesthetic management influence surgical-wound
healing?
ARTICLE SOURCE: Lancet (England), Jul 29 2000, 356(9227) p355-7
AUTHOR(S): Buggy D
AUTHOR'S ADDRESS: Department of Anaesthesia, Leicester University and
University Hospitals of Leicester NHS Trust, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
MB: I am still sceptical.
ARTICLE TITLE: Rate of heart failure and 1-year survival for older
people receiving low-dose beta-blocker therapy after myocardial
infarction.
ARTICLE SOURCE: Lancet (England), Aug 19 2000, 356(9230) p639-44
AUTHOR(S): Rochon PA; Tu JV; Anderson GM; Gurwitz JH; Clark JP; Lau
P; Szalai JP; Sykora K; Naylor CD
AUTHOR'S ADDRESS: Kunin-Lunenfeld Applied Research Unit, Baycrest
Centre for Geriatric Care, University of Toronto, Ontario,
Canada.
PUBLICATION TYPE: JOURNAL ARTICLE
INTERPRETATION: Compared with high-dose beta-blocker therapy,
low-dose treatment is associated with a lower rate of hospital
admission for heart failure and has a similar 1-year survival
benefit. Our findings support the need for a randomised controlled
trial comparing doses of beta-blocker therapy in elderly
patients.
ARTICLE TITLE: Normalised intrinsic mortality risk in liver
transplantation: European Liver Transplant Registry study.
ARTICLE SOURCE: Lancet (England), Aug 19 2000, 356(9230) p621-7
AUTHOR(S): Adam R; Cailliez V; Majno P; Karam V; McMaster P; Caine
RY; O'Grady J; Pichlmayr R; Neuhaus P; Otte JB; Hoeckerstedt K;
Bismuth H
AUTHOR'S ADDRESS: ELTR Coordinating Centre, Paul Brousse Hospital,
Villejuif, France. rene.adam@pbr.ap-hop-paris.fr.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
ABSTRACT: BACKGROUND: No model exists for liver transplantation to
estimate the mortality risk in a given patient, and no standard by
which to assess performance in different centres. We investigated the
intrinsic mortality risk in the absence of known mortality risk
factors. METHODS: We identified mortality risk factors and risk
ratios quantified in data from the European Liver Transplant Registry
(22,089 patients at 102 centres in 18 countries) registered from 1988
to 1997. To develop a model of the intrinsic risk and the risk ratios
for specific factors, univariate and multivariate analyses were done
separately for the overall population, for adults, and for children
younger than 15 years, and the number of deaths were estimated. We
validated the model by comparing mortality in patients without risk
factors with the model-adjusted mortality in patients with risk
factors. FINDINGS: Overall 5-year and 8-year actuarial survival was
66% (95% CI 65-66) and 61% (60-62). 65% of deaths occurred within 6
months. Retransplantation, transplantation for cancer, acute liver
failure, fewer than 20 split-liver grafts per year, and a centre
workload of fewer than 25 transplants per year were the main risk
factors of 12 identified factors. 1-year and 5-year death rates among
adults with no risk factors were similar to model estimates (15
[13-16] vs 14% [13-15], and 22 (20-24) vs 23%
[21-24]). Corresponding data for paediatric transplants were
9% (7-12) compared with 11% (9-12) and 13% (10-17) compared with 14%
(11-16). The reduction of mortality risk in high-volume centres was
even greater in patients without risk factors (48 vs 23%,
p<0.001). INTERPRETATION: The normalised intrinsic mortality risk
can be combined with the relative risk ratios of known risk factors
to better estimate the mortality risk of a given procedure in a given
patient. Centres can assess performance by removing potential bias of
donor and recipient selection.
MB: I doubt it. They can't find a sensible figure for the normal
mortality of coronary artery grafting. You have to assume that the
normal mortality of all operations is zero.
ARTICLE TITLE: Heart-bypass pioneer's death puts Argentine health
care in spotlight [news]
ARTICLE SOURCE: Lancet (England), Aug 5 2000, 356(9228) p492
AUTHOR(S): Iglesias-Rogers G
PUBLICATION TYPE: BIOGRAPHY; HISTORICAL ARTICLE; NEWS
MB: He did the first CABGs in the US in 1967 but returned to
Argentina. He shot himself because of financial difficulties with his
work.
ARTICLE TITLE: The NHS plan: promises that fail the most
vulnerable [editorial]
ARTICLE SOURCE: Lancet (England), Aug 5 2000, 356(9228) p441
PUBLICATION TYPE: EDITORIAL
MB: Obviously the new proposals for the British NHS are not looking
at the real things. Typically they are about spending money of some
particular aspects.
ARTICLE TITLE: Endovascular stenting of abdominal aortic aneurysm
in patients unfit for elective open surgery. Eurostar group. EUROpean
collaborators registry on Stent-graft Techniques for abdominal aortic
Aneurysm Repair [letter]
ARTICLE SOURCE: Lancet (England), Sep 2 2000, 356(9232) p832
AUTHOR(S): Laheij RJ; van Marrewijk CJ
PUBLICATION TYPE: LETTER
ABSTRACT: Endovascular aneurysm repair is useful for patients who are
judged unfit for surgery. We investigated the outcome of endovascular
repair of abdominal aortic aneurysm in patients fit and unfit for
surgery. The 1-year cumulative survival for patients unfit for
surgery and patients unfit for general anaesthesia was 20% and 23%,
respectively. The overall health status of patients was an important
predictor of survival after endovascular repair. The risks of
endovascular aneurysm repair might, therefore, exceed that of
non-operative management. Caution should be used when advising these
patients about endovascular repair.
ARTICLE TITLE: Drug-company influence on medical education in USA
[editorial]
ARTICLE SOURCE: Lancet (England), Sep 2 2000, 356(9232) p781
PUBLICATION TYPE: EDITORIAL
MB: Corruption, Corruption, Corruption. They conclude they we should
have to pay a greater fraction of the cost of CMEs ourselves. Ha Ha
Ha.
ARTICLE TITLE: Accuracy of the pelvic examination in detecting
adnexal masses.
ARTICLE SOURCE: Obstet Gynecol (United States), Oct 2000, 96(4)
p593-8
AUTHOR(S): Padilla LA; Radosevich DM; Milad MP
AUTHOR'S ADDRESS: Division of Gynecologic Oncology, Department of
Obstetrics and Gynecology, University of Minnesota, Minneapolis,
Minnesota 55455, USA. padi0013@tc.umn.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Bimanual pelvic examination has marked limitations for
evaluating adnexa, even with ideal circumstances. Experience during
postgraduate training in gynecology did not seem to improve
examination accuracy. Patient characteristics such as obesity,
uterine size, and abdominal scars limit the accurate palpation of the
adnexa.
MB: Well I thought so. I could never feel anything.
When I was a student they decided to have gynaecology seminars. The
resident got fed up with having to put up with the prolonged
discussions of the incompatibility of the clinical findings, the
operative findings and the pathological findings. He decided to find
out the pathology first and then invented clinical findings &
operative findings.
ARTICLE TITLE: International Guidelines for Neonatal
Resuscitation: An excerpt from the Guidelines 2000 for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care:
International Consensus on Science. Contributors and Reviewers for
the Neonatal Resuscitation Guidelines.
ARTICLE SOURCE: Pediatrics (United States), Sep 2000, 106(3) pE29
AUTHOR(S): Niermeye S; Kattwinkel J; Van Reempts P; Nadkarni V;
Phillips B; Zideman D; Azzopardi D; Berg R; Boyle D; Boyle R;
Burchfield D; Carlo W; Chameides L; Denson S; Fallat M; Gerardi M;
Gunn A; Hazinski MF; Keenan W; Knaebel S; Milner A; Perlman J;
Saugstad OD; Schleien C; Solimano A; Speer M; Toce S; Wiswell T;
Zaritsky A
PUBLICATION TYPE: GUIDELINE; JOURNAL ARTICLE; PRACTICE GUIDELINE
ABSTRACT: The International Guidelines 2000 Conference on
Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC)
formulated new evidenced-based recommendations for neonatal
resuscitation. These guidelines comprehensively update the last
recommendations, published in 1992 after the Fifth National
Conference on CPR and ECC. As a result of the evidence evaluation
process, significant changes occurred in the recommended management
routines for: * Meconium-stained amniotic fluid: If the newly born
infant has absent or depressed respirations, heart rate <100 beats
per minute (bpm), or poor muscle tone, direct tracheal suctioning
should be performed to remove meconium from the airway. * Preventing
heat loss: Hyperthermia should be avoided. * Oxygenation and
ventilation: 100% oxygen is recommended for assisted ventilation;
however, if supplemental oxygen is unavailable, positive-pressure
ventilation should be initiated with room air. The laryngeal mask
airway may serve as an effective alternative for establishing an
airway if bag-mask ventilation is ineffective or attempts at
intubation have failed. Exhaled CO(2) detection can be useful in the
secondary confirmation of endotracheal intubation. * Chest
compressions: Compressions should be administered if the heart rate
is absent or remains <60 bpm despite adequate assisted ventilation
for 30 seconds. The 2-thumb, encircling-hands method of chest
compression is preferred, with a depth of compression one third the
anterior-posterior diameter of the chest and sufficient to generate a
palpable pulse. * Medications, volume expansion, and vascular access:
Epinephrine in a dose of 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000
solution) should be administered if the heart rate remains <60 bpm
after a minimum of 30 seconds of adequate ventilation and chest
compressions. Emergency volume expansion may be accomplished with an
isotonic crystalloid solution or O-negative red blood cells;
albumin-containing solutions are no longer the fluid of choice for
initial volume expansion. Intraosseous access can serve as an
alternative route for medications/volume expansion if umbilical or
other direct venous access is not readily available. * Noninitiation
and discontinuation of resuscitation: There are circumstances
(relating to gestational age, birth weight, known underlying
condition, lack of response to interventions) in which noninitiation
or discontinuation of resuscitation in the delivery room may be
appropriate.
ARTICLE TITLE: Best articles relevant to pediatric allergy and
immunology. Selected by members of the section on allergy and
immunology of the American Academy of Pediatrics from articles
appearing in the medical literature between December 1, 1998 and
November 30, 1999.
ARTICLE SOURCE: Pediatrics (United States), Aug 2000, 106(2 Pt 3)
p429-76
PUBLICATION TYPE: OVERALL
ARTICLE TITLE: Does the participation of a surgical trainee
adversely impact patient outcomes? A study of major pancreatic
resections in California.
ARTICLE SOURCE: Surgery (United States), Aug 2000, 128(2) p286-92
AUTHOR(S): Hutter MM; Glasgow RE; Mulvihill SJ
AUTHOR'S ADDRESS: Department of Surgery at the University of
California, San Francisco, 94143-0788, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
CONCLUSIONS: The presence of surgical trainees does not have an
adverse impact on the quality of care for One complex procedure,
pancreatectomy, and is associated with superior operative mortality
rate in university teaching hospitals.
MB: I would hope so.
ARTICLE TITLE: Aggressive warming reduces blood loss during hip
arthroplasty.
ARTICLE SOURCE: Anesth Analg (United States), Oct 2000, 91(4)
p978-84
AUTHOR(S): Winkler M; Akca O; Birkenberg B; Hetz H; Scheck T; Arkilic
CF; Kabon B; Marker E; Grubl A; Czepan R; Greher M; Goll V;
Gottsauner-Wolf F; Kurz A; Sessler DI
AUTHOR'S ADDRESS: Department of Anesthesia, General Intensive Care
and Orthopedics, University of Vienna, Vienna, Austria.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ABSTRACT: We evaluated the effects of aggressive warming and
maintenance of normothermia on surgical blood loss and allogeneic
transfusion requirement. We randomly assigned 150 patients undergoing
total hip arthroplasty with spinal anesthesia to aggressive warming
(to maintain a tympanic membrane temperature of 36.5 degrees C) or
conventional warming (36 degrees C). Autologous and allogeneic blood
were given to maintain a priori designated hematocrits. Blood loss
was determined by a blinded investigator based on sponge weight and
scavenged cells; postoperative loss was determined from drain output.
Results were analyzed on an intention-to-treat basis. Average
intraoperative core temperatures were warmer in the patients assigned
to aggressive warming (36.5 degrees +/- 0.3 degrees vs 36.1 degrees
+/- 0.3 degrees C, P< 0.001). Mean arterial pressure was similar
in each group preoperatively, but was greater intraoperatively in the
conventionally warmed patients: 86+/-12 vs 80+/-9 mm Hg, P<0.001.
Intraoperative blood loss was significantly greater in the
conventional warming (618 mL; interquartile range, 480-864 mL) than
the aggressive warming group (488 mL; interquartile range, 368-721
mL; P: = 0.002), whereas postoperative blood loss did not differ in
the two groups. Total blood loss during surgery and over the first
two postoperative days was also significantly greater in the
conventional warming group (1678 mL; interquartile range, 1366-1965
mL) than in the aggressively warmed group (1,531 mL; interquartile
range, 1055-1746 mL, P = 0.031). A total of 40 conventionally warmed
patients required 86 units of allogeneic red blood cells, whereas 29
aggressively warmed patients required 62 units (P = 0.051 and 0.061,
respectively). We conclude that aggressive intraoperative warming
reduces blood loss during hip arthroplasty. Implications: Aggressive
warming better maintained core temperature (36.5 degrees vs 36.1
degrees C) and slightly decreased intraoperative blood pressure.
Aggressive warming also decreased blood loss by approximately 200 mL.
Aggressive warming may thus, be beneficial in patients undergoing hip
arthroplasty.
MB: The differences in temperature, blood loss and blood replacement
are trivial.
ARTICLE TITLE: A magnetic resonance imaging study of modifications
to the infraclavicular brachial plexus block [see
comments]
COMMENTS: Comment in: Anesth Analg 2000 Oct; 91(4):771-2
ARTICLE SOURCE: Anesth Analg (United States), Oct 2000, 91(4)
p929-33
AUTHOR(S): Klaastad O; Lilleas FG; Rotnes JS; Breivik H; Fosse E
AUTHOR'S ADDRESS: Department of Anesthesiology, The National Hospital
Orthopedic Centre, Oslo, Norway.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: A previously described infraclavicular brachial plexus
block may be modified by using a more lateral needle insertion point,
while the patient abducts the arm 45 degrees or 90 degrees. In
performing the modified block on patients abducting 45 degrees, we
often had problems finding the cords of the brachial plexus.
Therefore, we designed an anatomic study to describe the ability of
the recommended needle direction to consistently reach the cords.
Additionally, we assessed the risk of penetrating the pleura by the
needle. Magnetic resonance images were obtained in 10 volunteers.
From these images, a virtual reality model of each volunteer was
created, allowing precise positioning of a simulated needle according
to the modified block, without exposing the volunteers to actual
needle placement. In both arm positions, the recommended needle angle
of 45 degrees to the skin was too shallow to reach a defined target
on the cords. Comparing the two arm positions, target precision and
risk of contacting the pleura were more favorable with the greater
arm abduction. We conclude that when the arm is abducted to 90
degrees, a 65 degrees -needle angle to the skin appears optimal for
contacting the cords, still with a minimal risk of penetrating the
pleura. However, this needs to be confirmed by a clinical study.
ARTICLE TITLE: Don't try this at home! [comment]
[editorial]
COMMENTS: Comment on: Anesth Analg 2000 Oct; 91(4):929-33
ARTICLE SOURCE: Anesth Analg (United States), Oct 2000, 91(4)
p771-2
AUTHOR(S): Wedel DJ
AUTHOR'S ADDRESS: Department of Anesthesiology, Mayo Clinic,
Rochester, Minnesota, USA.
MAJOR SUBJECT HEADING(S): Brachial Plexus; Magnetic Resonance
Imaging; Nerve Block [methods]; Radiology, Interventional
MINOR SUBJECT HEADING(S): Anesthesiology [education];
Anesthetics, Local [administration & dosage]; Clavicle;
Education, Medical, Continuing; Human; Needles; Reproducibility of
Results
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Multiple-injection axillary brachial plexus block:
A comparison of two methods of nerve localization-nerve stimulation
versus paresthesia.
ARTICLE SOURCE: Anesth Analg (United States), Sep 2000, 91(3)
p647-51
AUTHOR(S): Sia S; Bartoli M; Lepri A; Marchini O; Ponsecchi P
AUTHOR'S ADDRESS: Department of Anesthesiology, Centro Traumatologico
Ortopedico, Firenze, Italy.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL IMPLICATIONS: Two methods of nerve localization were
compared when performing an axillary brachial plexus block by the
multiple-injection technique. Nerve stimulation provided a faster
onset and a greater incidence of complete block, related to a better
success rate for anesthetizing the radial and the musculocutaneous
nerves, than paresthesia elicitation.
ARTICLE TITLE: The good, the bad, and the ugly: should we
completely banish human albumin from our intensive care units?
ARTICLE SOURCE: Anesth Analg (United States), Oct 2000, 91(4)
p887-95, table of contents
AUTHOR(S): Boldt J
AUTHOR'S ADDRESS: Department of Anesthesiology and Intensive Care
Medicine, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany.
BoldtJ@gmx.net.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
ABSTRACT: Implications: Human albumin is still widely used in
critically ill patients for volume replacement therapy or for
correcting hypoproteinemia. Most meta-analyses on the value of
albumin administration are over 15 yr old and raise more questions
than they answer. With the help of a MEDLINE analysis, we examined
more recent studies in humans using albumin. Most of these studies
have recommended a very cautious use of albumin in critically ill
patients.
ARTICLE TITLE: The lack of benefit of tracheal extubation in the
operating room after coronary artery bypass surgery.
ARTICLE SOURCE: Anesth Analg (United States), Oct 2000, 91(4)
p776-80
AUTHOR(S): Montes FR; Sanchez SI; Giraldo JC; Rincon JD; Rincon IE;
Vanegas MV; Charris H
AUTHOR'S ADDRESS: Department of Anesthesia, Fundacion Cardio
Infantil-Instituto de Cardiologia, Santafe de Bogota, Colombia, South
America. cfmont@col1.telecom.com.co.
PUBLICATION TYPE: CLINICAL TRIAL; CONTROLLED CLINICAL TRIAL; JOURNAL
ARTICLE
ABSTRACT: Although early tracheal extubation in cardiac anesthesia is
safe and cost beneficial, questions still remain regarding how early
after cardiac surgery patients should be tracheally extubated (TE).
Our objective was to determine the effects on resource use if
patients scheduled for coronary artery bypass grafting have TE in the
operating room (OR). We studied 100 consecutive patients undergoing
elective coronary artery bypass grafting, requiring extracorporeal
circulation, and those eligible for a fast-track pathway. At the end
of the procedure, the patients were evaluated for TE in the OR if
they were hemodynamically stable, were without significant bleeding,
and fulfilled clinical and blood gas analysis variables. Patients who
did not meet the requirements had TE in the intensive care unit
(ICU). Fifty patients had TE in the OR and 50 patients in the ICU.
Time in the OR after skin closure, ICU length of stay, and
postoperative length of stay were similar between the groups. Four
patients (8%) in the OR group were tracheally reintubated secondary
to respiratory depression (P = 0.11). Three patients (6%) in the OR
group had postoperative myocardial infarction, and one postoperative
myocardial infarction (2%) occurred in the ICU group (P = 0.61). All
four patients recovered satisfactorily. The incidences of other
complications were similar between groups.
MB: You would hardly expect it to benefit anyone but the
administrators.
ARTICLE TITLE: Vasopressin improves survival after cardiac arrest
in hypovolemic shock.
ARTICLE SOURCE: Anesth Analg (United States), Sep 2000, 91(3)
p627-34
AUTHOR(S): Voelckel WG; Lurie KG; Lindner KH; Zielinski T; McKnite S;
Krismer AC; Wenzel V
AUTHOR'S ADDRESS: Cardiac Arrhythmia Center, Cardiovascular Division,
Department of Medicine at the University of Minnesota, Minneapolis
55455, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Survival after hypovolemic shock and cardiac arrest is
dismal with current therapies IMPLICATIONS: The chances of surviving
cardiac arrest in hemorrhagic shock are considered dismal without
adequate fluid replacement. However, treatment of hypovolemic cardiac
arrest with vasopressin, but not with large-dose epinephrine or
saline placebo, resulted in sustained vital organ perfusion and
prolonged survival in an animal model of suspended infusion
therapy.
ARTICLE TITLE: Enterprise-wide patient scheduling information
systems to coordinate surgical clinic and operating room scheduling
can impair operating room efficiency.
ARTICLE SOURCE: Anesth Analg (United States), Sep 2000, 91(3)
p617-26
AUTHOR(S): Dexter F; Macario A; Traub RD
AUTHOR'S ADDRESS: Departments of Anesthesia, University of Iowa, Iowa
City 52242, USA. franklin-dexter@uiowa.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (14 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Analgesia and anesthesia: etymology and literary
history of related Greek words.
ARTICLE SOURCE: Anesth Analg (United States), Aug 2000, 91(2)
p486-91
AUTHOR(S): Askitopoulou H; Ramoutsaki IA; Konsolaki E
AUTHOR'S ADDRESS: Department of Anaesthesiology, Medical School,
University of Crete. University Hospital of Heraklion, Greece.
askitop@her.forthnet.gr.
PUBLICATION TYPE: HISTORICAL ARTICLE; JOURNAL ARTICLE
ARTICLE TITLE: Inhaled anesthetics have hyperalgesic effects at
0.1 minimum alveolar anesthetic concentration.
ARTICLE SOURCE: Anesth Analg (United States), Aug 2000, 91(2)
p462-6
AUTHOR(S): Zhang Y; Eger EI 2nd; Dutton RC; Sonner JM
AUTHOR'S ADDRESS: Department of Anesthesia and Perioperative Care,
University of California, San Francisco 94143-0464, USA.
INDEXING CHECK TAG(S): Animal; Male; Support, U.S. Gov't, P.H.S.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: We investigated the hyperalgesic (antianalgesic) effect of
the inhaled anesthetics isoflurane, halothane, nitrous oxide, and
diethyl ether, or the nonimmobilizer 1,
2-dichlorohexafluorocyclobutane at subanesthetic partial pressures
(or, for the nonimmobilizer, subanesthetic partial pressures
predicted from lipid solubility) in rats. Hyperalgesia was assessed
as a decrease in the time to withdrawal of a rat hind paw exposed to
heat. All four anesthetics, including nitrous oxide and diethyl
ether, produced hyperalgesia at low partial pressures, with a maximal
effect at 0.1 minimum alveolar anesthetic concentration (MAC)
required to prevent response to movement in 50% of animals, and
analgesia (an increased time to withdrawal of the hind paw) at 0. 4
to 0.8 MAC. The nonimmobilizer had neither analgesic nor hyperalgesia
effects. We propose that inhaled anesthetics with a higher MAC-Awake
(the MAC-fraction that suppresses appropriate responsiveness to
command), such as nitrous oxide and diethyl ether, can be used as
analgesics because patients are conscious at higher anesthetic
partial pressures, including those which have analgesic effects,
whereas anesthetics with a lower MAC-Awake do not produce analgesic
effects at concentrations that permit consciousness. Implications:
The inhaled anesthetics isoflurane, halothane, nitrous oxide, and
diethyl ether produce antianalgesia at subanesthetic concentrations,
with a maximal effect at approximately one-tenth the concentration
required for anesthesia. This effect may enhance perception of pain
when such small concentrations are reached during recovery from
anesthesia.
ARTICLE TITLE: A randomized, double-blinded comparison of
ondansetron, droperidol, and placebo for prevention of postoperative
nausea and vomiting after supratentorial craniotomy.
ARTICLE SOURCE: Anesth Analg (United States), Aug 2000, 91(2)
p358-61
AUTHOR(S): Fabling JM; Gan TJ; El-Moalem HE; Warner DS; Borel CO
AUTHOR'S ADDRESS: Department of Anesthesiology, Duke University
Medical Center, Durham, NC 27710, USA.
Implications: Nausea and vomiting after brain surgery are
particularly troubling, because effective treatment may cause
sedation, making postoperative neurological assessment difficult. Our
study shows that both ondansetron and droperidol are effective in
reducing nausea, and that droperidol is particularly effective in
reducing vomiting. Neither drug caused more sedation than
placebo.
ARTICLE TITLE: Economic analysis of linking operating room
scheduling and hospital material management information systems for
just-in-time inventory control.
ARTICLE SOURCE: Anesth Analg (United States), Aug 2000, 91(2)
p337-43
AUTHOR(S): Epstein RH; Dexter F
AUTHOR'S ADDRESS: Department of Anesthesiology, Jefferson Medical
College, Philadelphia, PA, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Operating room (OR) scheduling information systems can
decrease perioperative labor costs. Material management information
systems can decrease perioperative inventory costs. We used computer
simulation to investigate whether using the OR schedule to trigger
purchasing of perioperative supplies is likely to further decrease
perioperative inventory costs, as compared with using sophisticated,
stand-alone material management inventory control. Although we
designed the simulations to favor financially linking the information
systems, we found that this strategy would be expected to decrease
inventory costs substantively only for items of high price ($1000
each) and volume (>1000 used each year). Because expensive items
typically have different models and sizes, each of which is used by a
hospital less often than this, for almost all items there will be no
benefit to making daily adjustments to the order volume based on
booked cases. We conclude that, in a hospital with a sophisticated
material management information system, OR managers will probably
achieve greater cost reductions from focusing on negotiating less
expensive purchase prices for items than on trying to link the OR
information system with the hospital's material management
information system to achieve just-in-time inventory control.
Implications: In a hospital with a sophisticated material management
information system, operating room managers will probably achieve
greater cost reductions from focusing on negotiating less expensive
purchase prices for items than on trying to link the operating room
information system with the hospital's material management
information system to achieve just-in-time inventory control.
ARTICLE TITLE: Pulmonary thromboembolism during liver
transplantation: possible association with antifibrinolytic drugs and
novel treatment options.
ARTICLE SOURCE: Anesth Analg (United States), Aug 2000, 91(2)
p296-9
AUTHOR(S): O'Connor CJ; Roozeboom D; Brown R; Tuman KJ
AUTHOR'S ADDRESS: Department of Anesthesiology, School of Nursing,
Rush Medical College, Rush-Presbyterian-St. Lukes Medical Center,
Chicago, IL 60612, USA. oconnor@rpslmc.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: The authors describe two cases of massive intraoperative
pulmonary thromboembolism resulting in cardiovascular collapse during
liver transplantation. The potential role of antifibrinolytic drugs
is discussed, along with the use of treatment modalities not
previously applied in this setting.
ARTICLE TITLE: Clinical governance and the NHS reforms.
ARTICLE SOURCE: Ann R Coll Surg Engl (England), Jun 2000, 82(6 Suppl)
p194-6
AUTHOR(S): Revell M
PUBLICATION TYPE: JOURNAL ARTICLE
ARTICLE TITLE: What do trainees think about advanced trauma life
support (ATLS)?
ARTICLE SOURCE: Ann R Coll Surg Engl (England), Jul 2000, 82(4)
p263-7
AUTHOR(S): Campbell B; Heal J; Evans S; Marriott S
AUTHOR'S ADDRESS: Department of Surgery, Royal Devon and Exeter
Hospital, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Advanced trauma life support (ATLS) has become a desirable
or even essential part of training for many surgeons and
anaesthetists, but aspects of the ATLS course have attracted
criticism. In the absence of published data on the views of trainees,
this study sought their opinions in a structured questionnaire, which
was completed by trainees in accident and emergency (A & E) (26),
anaesthetic (82), general surgical (26), orthopaedic (42) and other
(5) posts in different hospitals (response rate 66%). Of the
trainees, 78% had done an ATLS course and, of these, 83% considered
ATLS a 'major advantage' or 'essential' for practising their proposed
specialty--100% for A & E, 94% for orthopaedics, 92% for general
surgery, and 75% for anaesthetics. ATLS was considered a major
curriculum vitae (CV) advantage by 94%, 85%, 50%, and 45%,
respectively. Over 90% had positive attitudes towards ATLS, and 74%
selected 'genuine improvement of management of trauma patients' as
the most important reason for doing the course: 93% thought ATLS
saved lives. Of the respondents, 83% thought that all existing
consultants dealing with trauma patients should have done the course,
and 41% thought it offered major advantages to doctors not involved
in trauma. Funding problems for ATLS courses had been experienced by
14% trainees. This survey has shown that most trainees view ATLS
positively. They believe that it provides genuine practical benefit
for patients, and very few regard ATLS primarily as a career
advantage or mandate.
MB: It would be better to find out if they were better at
resuscitation.
ARTICLE TITLE: Patient outcome alone does not justify the
centralisation of vascular services.
ARTICLE SOURCE: Ann R Coll Surg Engl (England), Jul 2000, 82(4)
p268-71
AUTHOR(S): Cook SJ; Rocker MD; Jarvis MR; Whiteley MS
AUTHOR'S ADDRESS: Department of Vascular Surgery, Royal Surrey County
Hospital, Guildford, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: The Provision of Vascular Services document
from the Vascular Surgical Society of Great Britain and Ireland
argues for the centralisation of vascular services into units served
by a minimum of four vascular consultants. The rationale for this is
the presumed advantages of improved patient care, better utilisation
of resources and a more comprehensive arrangement of consultant
vascular cover. Since April 1998, the Royal Surrey County Hospital
(RSCH) has had a single-handed vascular consultant with out-of-hours
cross-district consultant vascular cover. OBJECTIVES: To use P-POSSUM
analysis to determine patient outcome from the RSCH vascular unit,
and to compare these with previously published P-POSSUM analysis from
a major vascular unit in Leeds. PATIENTS AND METHODS: All patients
undergoing major vascular surgery or amputation between April and
November 1998 were analysed. RESULTS: 86 patients underwent 102
surgical procedures in 92 separate admissions. Data retrieval was
100%. Predicted (E) mortality 16 cases; observed (O) mortality 13
cases; O:E ratio 0.80. Predicted morbidity 26 cases; observed
morbidity 19; O:E ratio 0.73. O:E ratio for mortality from Leeds =
0.83. CONCLUSIONS: Patient outcome in a single-handed vascular unit,
with cross-district consultant cover, is equivalent to that found in
a major vascular unit. Centralisation of vascular services cannot be
justified on the basis of differences in patient outcome.
MB: This is a case of special pleading for a small place not far form
London with one not full timevascular surgeon who get good results.
It is not indicated how selected the cases are. Isolated units are
not a good idea. I have not seen the official document mentioned but
it sounds sensible.
ARTICLE TITLE: Anaesthetic simulators: training for the broader
health-care profession.
ARTICLE SOURCE: Aust N Z J Surg (Australia), Oct 2000, 70(10)
p735-7
AUTHOR(S): Watterson L; Flanagan B; Donovan B; Robinson B
AUTHOR'S ADDRESS: Sydney Medical Simulation Centre, Royal North Shore
Hospital, New South Wales, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: The use of high-fidelity patient simulators for
training health-care professionals has increased rapidly in recent
years. Approximately 150 simulation training centres operate
internationally. Australasia has acquired four centres since 1997. A
large component of simulator-based training is experiential. METHODS:
Participants manage clinical scenarios on lifelike
computer-controlled mannikins within realistic clinical environments.
Afterwards they actively reflect upon the experience, an exercise
that is facilitated by observation of a video replay of the event.
RESULTS: This approach to training promotes a consideration of
broader issues which can influence clinical practice and patient
outcomes. This has particular relevance to emergencies. Here, events
that are by nature infrequent and unscheduled can be addressed in a
controlled fashion, in an environment that is supportive and
separated from actual patients. CONCLUSIONS: A broad range of skills
can be addressed with this resource. Of key importance are
situational management and team effectiveness skills. Deficiencies
with respect to these 'non-clinical' skills are being increasingly
identified for their contribution to preventable adverse events
within the health-care environment. Multidisciplinary operation-room
team training has the potential to address these issues as they
relate to the perioperative environment.
ARTICLE TITLE: Cost of endovascular versus open surgical repair of
abdominal aortic aneurysms.
ARTICLE SOURCE: Aust N Z J Surg (Australia), Sep 2000, 70(9)
p660-6
AUTHOR(S): Birch SE; Stary DR; Scott AR
AUTHOR'S ADDRESS: Department of Surgery, Launceston General Hospital,
Tasmania, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Endovascular repair of abdominal aortic
aneurysms (AAA) is a new minimally invasive method of aneurysm
exclusion that has been adopted with increasing enthusiasm, and with
acceptable clinical results. It is important, however, to assess new
health-care technologies in terms of their economic as well as their
clinical impact. The aim of the present study was to compare the
total treatment costs for endovascular (EVR) and open surgical repair
(OSR) for AAA. METHODS: A retrospective review of patient hospital
and outpatient records for 62 patients undergoing either EVR (n = 31)
or OSR (n = 31) was carried out between June 1996 and October 1999.
Resource utilization was determined by a combination of patient
clinical and financial accounting data. Costs were determined for
preoperative assessment, inpatient hospital stay, cost of
readmissions and follow up, and predicted lifetime follow-up costs.
RESULTS: The two groups were well matched, with no significant
difference with respect to age, gender, maximum aneurysm diameter or
comorbid factors. Endovascular treatment resulted in a shorter
intensive care unit (ICU) and hospital stay (mean: 0.07 vs 2.9 days,
P < 0.001; mean: 6.0 vs 13.4 days, P < 0.001; respectively) and
fewer postoperative complications (P = 0.003). The cost of
hospitalization was less for EVR ($7614 vs $15092, P < 0.001), but
this was offset by the more costly vascular prosthesis ($10284 vs
$686). Costs were higher for the EVR group for preoperative
assessment ($2328 vs $1540, P < 0.001) and follow up ($1284 vs
$70, P < 0.001). Lifelong follow up could be expected to cost an
additional $4120 per patient after EVR. Total lifetime treatment
costs including costs associated with readmission for
procedure-related complications were higher for EVR ($26909 vs
$17650). CONCLUSION: Treatment costs for endovascular repair are
higher than conventional surgical repair due to the cost of the
vascular prosthesis and the greater requirement for radiological
imaging studies.
MB: 10 a year is probably not enough of to make the operations
economic.
ARTICLE TITLE: Corpus cavernosum as an alternative means of
intravenous access in the emergency setting.
ARTICLE SOURCE: Aust N Z J Surg (Australia), Jul 2000, 70(7)
p511-4
AUTHOR(S): Nicol D; Watt A; Wood G; Wall D; Miller B
AUTHOR'S ADDRESS: Department of Surgery, University of Queensland,
Princess Alexandra Hospital, Brisbane, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The corpus cavernosum is a practical alternative means
of intravenous access in the emergency setting in the dog model.
MB: You would have to be desperate.
ARTICLE TITLE: Liver transplantation in patients with transjugular
intrahepatic portosystemic shunts.
ARTICLE SOURCE: Aust N Z J Surg (Australia), Jul 2000, 70(7)
p493-5
AUTHOR(S): Chui AK; Rao AR; Waugh RC; Mayr M; Verran DJ; Koorey D;
McCaughan GW; Ong J; Sheil AG
AUTHOR'S ADDRESS: Australian National Liver Transplant Unit, Royal
Prince Alfred Hospital, Sydney, New South Wales.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Transjugular intrahepatic portosystemic shunts offer a
bridge to OLTx by providing effective control of variceal
haemorrhage. In the present series TIPSS did not increase surgical
morbidity or mortality, but emphasis is placed upon the need for
optimal TIPSS placement within the liver to facilitate subsequent
OLTx.