MB's Articles of interest - July '99

ARTICLE TITLE: Prolonged endotracheal intubation in infants and children. 1965 [classical article]
ARTICLE SOURCE: Br J Anaesth (England), Sep 1998, 81(3) p474-81; discussion 473
Original article.BJA (Eng) Aug, 1965, 37(8) p566-73
AUTHOR(S): Allen TH; Steven IM
PUBLICATION TYPE: BIOGRAPHY; CLASSICAL ARTICLE; HISTORICAL ARTICLE; JOURNAL ARTICLE
NAMED SUBJECT(S): Allen TH; Steven IM
MB. This is indeed a classical article. As I was changed when it came out I must be a classic too.
The discussion on p 473 is all about this article changed paediatric `ICU' from crash tracheostomies to intubation. That is true but its bigger effect was in allowing in adults more than 2 days of intubation without a mandatory tracheostomy.
I immediately started using prolonged intubation
(KAFER, E.R. AND BOOKALLIL, M.J. GROSS PULMONARY ARTERIO-VENOUS SHUNTS IN ACUTE RESPIRATORY FAILURE REQUIRING THE PROLONGED ADMINISTRATION OF OXYGEN. MED.J.AUST., 1,572, 1972) This article describes my first 19 day intubation patient.
The following 2 from last months list indicate that although the myth that tracheostomy should occur after a given time of intubation should have died after 1965 it is still alive.

ARTICLE TITLE: The timing of tracheotomy: a systematic review [see comments]
ARTICLE SOURCE: Chest (United States), Aug 1998, 114(2) p605-9
AUTHOR(S): Maziak DE; Meade MO; Todd TR
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: There is insufficient evidence to support that the timing of tracheotomy alters the duration of mechanical ventilation or extent of airway injury in critically ill patients.
MB. I have always thought that since 1965.

ARTICLE TITLE: Timing tracheotomy: calendar watching or individualization of care? [editorial; comment]
ARTICLE SOURCE: Chest (United States), Aug 1998, 114(2) p361-3
AUTHOR(S): Heffner JE
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Granisetron-droperidol combination for the prevention of postoperative nausea and vomiting in female patients undergoing breast surgery.
ARTICLE SOURCE: Br J Anaesth (England), Sep 1998, 81(3) p387-9
AUTHOR(S): Fujii Y; Toyooka H; Tanaka H
AUTHOR'S ADDRESS: Department of Anaesthesiology, University of Tsukuba, Ibaraki, Japan.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We conclude that the granisetron-droperidol combination was more effective than each antiemetic alone in the prevention of PONV in female patients undergoing breast surgery.

ARTICLE TITLE: High-dose ondansetron regimen vs droperidol for morphine patient-controlled analgesia.
ARTICLE SOURCE: Br J Anaesth (England), Sep 1998, 81(3) p384-6
AUTHOR(S): Dresner M; Dean S; Lumb A; Bellamy M
AUTHOR'S ADDRESS: Department of Anaesthetics, St James's University Hospital, Leeds.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: The only significant difference between the groups was increased morphine consumption in the ondansetron group up until 12 h after operation (P < 0.05), but by 24 h this difference was not significant. The ondansetron regimen was more expensive (at local prices) by a factor of 27, and our results suggested no clinical advantage over droperidol.

ARTICLE TITLE: A qualitative systematic review of incisional local anaesthesia for postoperative pain relief after abdominal operations.
ARTICLE SOURCE: Br J Anaesth (England), Sep 1998, 81(3) p377-83
AUTHOR(S): Moiniche S; Mikkelsen S; Wetterslev J; Dahl JB
AUTHOR'S ADDRESS: Department of Anaesthesiology, Hvidovre University Hospital, Copenhagen, Denmark.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
ABSTRACT: In a qualitative systematic review, we have evaluated randomized controlled trials (RCT) of incisional local anaesthesia compared with placebo or no treatment in the control of postoperative pain after open abdominal operations. Twenty-six studies with data from 1211 patients were considered appropriate for analysis. Five RCT considered inguinal herniotomy, four hysterectomy, eight cholecystectomy and nine studies a variety of surgical procedures. Outcome measures were pain scores, supplementary analgesics and time to first analgesic request. Efficacy was estimated by significant difference (P < 0.05), as reported in the original investigation. All studies of herniotomy showed a 2-7-h duration of clinically relevant improved pain relief. Results of hysterectomy studies were inconclusive, with two being negative. Five of the cholecystectomy studies showed significant differences but questionable clinical importance and validity in three. In various other procedures results were inconsistent and in some of minor clinical importance. Except for herniotomy, there was a lack of evidence for effect of incisional local anaesthesia on postoperative pain and further standardized studies are needed before recommendations can be made.

ARTICLE TITLE: Ketorolac, diclofenac and ketoprofen are equally efficacious for pain relief after total hip replacement surgery.
ARTICLE SOURCE: Br J Anaesth (England), Sep 1998, 81(3) p369-72
AUTHOR(S): Kostamovaara PA; Hendolin H; Kokki H; Nuutinen LS
AUTHOR'S ADDRESS: Department of Anaesthesiology, Oulu University Hospital, Finland.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We have compared the efficacy of ketorolac 30 mg i.v. followed by infusion at a rate of 90 mg/15.5 h, with that of diclofenac 75 mg followed by infusion of 75 mg/15.5 h or ketoprofen 100 mg followed by infusion of 100 mg/15.5 h, on postoperative pain in 85 patients after hip replacement surgery under spinal anaesthesia in a prospective, double-blind, randomized study. Supplementary analgesia was administered during the 16-h postoperative period with bolus doses of fentanyl delivered by a patient-controlled analgesia system. Mean total consumption of PCA-administered fentanyl was 890 (SD 400) micrograms in the ketorolac group, 920 (550) micrograms in the diclofenac group and 850 (350) micrograms in the ketoprofen group (ns). Median VAS (Visual analogue score) scores were low over the entire study in each group and there was no significant difference between groups. No serious adverse events were recorded.
MB The article could just as well have had `inefficacious' instead of `efficacious'.

ARTICLE TITLE: Patient-maintained remifentanil target-controlled infusion for the transition to early postoperative analgesia.
ARTICLE SOURCE: Br J Anaesth (England), Sep 1998, 81(3) p365-8
AUTHOR(S): Schraag S; Kenny GN; Mohl U; Georgieff M
AUTHOR'S ADDRESS: Department of Anaesthesiology, University of Ulm, Germany.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: We studied 30 male patients in the early postoperative period to assess the efficacy, safety and feasibility of a patient-demand, target-controlled infusion (TCI) of remifentanil. All patients received the same TCI-based propofol-remifentanil anaesthetic for elective orthopaedic surgery. At the end of surgery, infusion of remifentanil was reduced progressively until patients were breathing spontaneously. After extubation and transfer to the post-anaesthesia care unit, patients were given control of a hand-set and were able to increase the target remifentanil blood concentration by increments of 0.2 ng ml-1. If there were no demands, the TCI controller automatically reduced the target concentration. Pain scores, sedation level, ventilatory frequency, oxygen saturation and nausea were assessed. Mean time to onset of satisfactory analgesia (VAS < or = 3, out of 10) was 18.9 (95% confidence interval (Cl) 15.8-21.9) min at a mean target remifentanil concentration of 2.02 (Cl 1.87-2.16) ng ml-1. There were no episodes of hypoxaemia and the lowest ventilatory frequency was 9 bpm. Nausea occurred in 26.6% of patients and 10% vomited. The majority of patients were only slightly sedated. These results imply an effective tool without respiratory side effects in the early postoperative period after anaesthesia using remifentanil as the analgesic component.

ARTICLE TITLE: An open, randomized comparison of alfentanil, remifentanil and alfentanil followed by remifentanil in anaesthesia for craniotomy.
ARTICLE SOURCE: Br J Anaesth (England), Sep 1998, 81(3) p361-4
AUTHOR(S): Sneyd JR; Whaley A; Dimpel HL; Andrews CJ
AUTHOR'S ADDRESS: Plymouth Postgraduate Medical School.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We studied 52 adults undergoing elective craniotomy, allocated randomly to one of three opioid treatments: alfentanil 50 micrograms kg-1 followed by 0.833 microgram kg-1 min-1 until dural closure (group Alf.); alfentanil 50 micrograms kg-1 followed by 0.833 microgram kg-1 min-1 for 2 h, then remifentanil 0.25 microgram kg-1 min-1 (group Alf.-Remi.); or remifentanil 1 microgram kg-1 followed by 0.5 microgram kg-1 min-1 reducing to 0.25 microgram kg-1 min-1 after craniotomy (group Remi.). Anaesthesia was maintained with infusion of propofol and 66% nitrous oxide in oxygen. Infusions of propofol and remifentanil were stopped at head bandaging. Group Remi. had the least intraoperative haemodynamic responses and group Alf. the most (P < 0.05). Times to tracheal extubation and obey commands were similar in all groups. In all patients in group Alf.-Remi. and group Remi., the trachea was extubated 27 min from the end of anaesthesia; three patients in group Alf. were slower to recover. Use of analgesia in the recovery room and time to transfer to the neurosurgical unit were similar in the three groups.

ARTICLE TITLE: Does speed of intrathecal injection affect the distribution of 0.5% hyperbaric bupivacaine?
ARTICLE SOURCE: Br J Anaesth (England), Sep 1998, 81(3) p355-7
AUTHOR(S): Casati A; Fanelli G; Cappelleri G; Leoni A; Berti M; Aldegheri G; Torri G
AUTHOR'S ADDRESS: University of Milan, Department of Anaesthesiology, IRCCS H San Raffaele, Italy.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We have evaluated the influence of speed of intrathecal injection on lateral distribution of 0.5% hyperbaric bupivacaine. We studied 60 patients undergoing lower limb surgery who were placed in the lateral position with the operative side in the dependent position. After dural puncture (25-gauge Whitacre spinal needle), the needle aperture was turned towards the dependent side and 0.5% hyperbaric bupivacaine 8 mg was injected randomly at a rate of 0.02 ml s-1 (group slow, n = 30) or 0.25 ml s-1 (group fast, n = 30). Lateral position was maintained for 15 min while a blinded observer recorded loss of pinprick sensation and degree of motor block on both surgical and non-surgical sides. There were no differences between the groups. Forty-five minutes after patients were turned to the supine position, spinal anaesthesia was unilateral in 17 patients in group slow (56%) and in 13 patients in group fast (43%). We conclude that using extremely low speeds for intrathecal injection were not clinically advantageous in obtaining unilateral spinal anaesthesia.

ARTICLE TITLE: Effect of graft reperfusion on haemodynamics and gas exchange during liver transplantation.
ARTICLE SOURCE: Br J Anaesth (England), Sep 1998, 81(3) p311-6
AUTHOR(S): Walsh TS; Hopton P; Garden OJ; Lee A
AUTHOR'S ADDRESS: Department of Anaesthetics, Royal Infirmary of Edinburgh.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: We have documented the changes in gas exchange, haemodynamic state and associated physiological variables which occurred after graft reperfusion in 20 patients undergoing uncomplicated orthotopic liver transplantation. Gas exchange was measured during constant ventilation using a metabolic monitor. After reperfusion, there were increases in VO2 (mean increase 57 (SD 25) ml min-1) (P < 0.001), VCO2 (mean increase 38 (17) ml min-1) (P < 0.001) and PaCO2 (mean increase 0.88 (0.56) kPa) (P < 0.001). [MB. ie about 7mm Hg which we have seen too.] These were associated with increases in cardiac output (1.2 (1.0) litre min-1 m-2) (P < 0.001) and mean pulmonary artery pressure (9 (6) mm Hg) (P < 0.001). There was a decrease in standard bicarbonate concentration (0.96 (1.6) mmol litre-1) (P < 0.02) and increase in hydrogen ion concentration (8.15 (5.9) mmol litre-1) (P < 0.001) consistent with the release of an acid load from the graft and previously ischaemic tissues. The increases in PaCO2 and hydrogen ion concentration were significantly larger in patients in whom venovenous bypass was used during the anhepatic period compared with the "piggyback" surgical technique. We found correlations between the changes in PaCO2 and VCO2 (r2 = 0.25, P < 0.02), cardiac output and VCO2 (r2 = 0.34, P < 0.01), and cardiac output and VO2 (r2 = 0.34, P < 0.01). We conclude that major alterations in gas exchange occur after reperfusion which result from alterations in metabolic rate and haemodynamic changes. These may be clinically relevant, particularly in patients at risk of cerebral oedema.

ARTICLE TITLE: Adrenocortical function in critical illness [editorial; comment]
COMMENTS: Comment on: Br J Anaesth 1998 Sep; 81(3):468-70
ARTICLE SOURCE: Br J Anaesth (England), Sep 1998, 81(3) p308-10
AUTHOR(S): Masterson GR; Mostafa SM
PUBLICATION TYPE: COMMENT; EDITORIAL
MB> They think we need MORE double blind trials. L

ARTICLE TITLE: Education and training in airway management [editorial]
ARTICLE SOURCE: Br J Anaesth (England), Sep 1998, 81(3) p305-7
AUTHOR(S): Mason RA
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Effects of lightwand (Trachlight) compared with direct laryngoscopy on circulatory responses to tracheal intubation.
ARTICLE SOURCE: Br J Anaesth (England), Aug 1998, 81(2) p253-5
AUTHOR(S): Hirabayashi Y; Hiruta M; Kawakami T; Inoue S; Fukuda H; Saitoh K; Shimizu R
AUTHOR'S ADDRESS: Department of Anaesthesiology, Jichi Medical School, Tochigi, Japan.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We conclude that the effects of the lightwand technique on circulatory responses to tracheal intubation were similar to those of direct-vision laryngoscopy.

ARTICLE TITLE: Meta-analysis of the efficacy of extradural clonidine to relieve postoperative pain: an impossible task.
ARTICLE SOURCE: Br J Anaesth (England), Aug 1998, 81(2) p126-34
AUTHOR(S): Armand S; Langlade A; Boutros A; Lobjoit K; Monrigal C; Ramboatiana R; Rauss A; Bonnet F
AUTHOR'S ADDRESS: Service d'Anesthesie-Reanimation, Hopital Cochin, Paris, France.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
ABSTRACT: One hundred and fifty-nine articles were retrieved of which 38 dealt with extradural clonidine and postoperative pain. All but 16 studies suffered from serious design flaws, such as lack of controls and/or randomization, or inadequate statistical analysis. The data from these studies were difficult to interpret because of the tremendous variation in variables, especially dose of clonidine, level of extradural injection, time of administration, type of anaesthesia, type of surgery, and reference and rescue drugs. The simultaneous extradural use of local anaesthetics and opioids further hindered data interpretation, and precluded any meta-analysis. Proposals for a standard study design are made to help comparison between studies involving extradural clonidine and postoperative pain.
MB. How hopeless can we get

ARTICLE TITLE: Mathematical coupling in medical research: lessons from studies of oxygen kinetics [editorial]
ARTICLE SOURCE: Br J Anaesth (England), Aug 1998, 81(2) p118-20
AUTHOR(S): Walsh TS; Lee A
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Dynamic hyperinflation--the anaesthetist applying a tourniquet to the right heart [editorial]
ARTICLE SOURCE: Br J Anaesth (England), Aug 1998, 81(2) p116-7
AUTHOR(S): Conacher ID
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: "Old ideas, new applications" [editorial]
ARTICLE SOURCE: Br J Anaesth (England), Aug 1998, 81(2) p113-5
AUTHOR(S): Leach A
PUBLICATION TYPE: EDITORIAL; HISTORICAL ARTICLE

ARTICLE TITLE: The nonspecific inflammatory response to injury.
ARTICLE SOURCE: Can J Anaesth (Canada), Sep 1998, 45(9) p871-9
AUTHOR(S): Mayers I; Johnson D
AUTHOR'S ADDRESS: Department of Medicine, University of Alberta, Edmonton. irvin.mayers@ualberta.ca.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (94 references); REVIEW, TUTORIAL
ABSTRACT: PURPOSE: The role of the nonspecific inflammatory response in causing injury related to surgery has become better understood over the last decade. There are complex interactions between neutrophils, cytokines and nitric oxide metabolites that may cause organ injury following surgery. The purpose of this review is to summarize some of the processes causing injury through these nonspecific pathways. METHODS: A review of the medical and anaesthetic literature related to inflammation, neutrophils and pro-inflammatory cytokines were performed using Medline. Bibliographies of relevant articles were searched and additional articles were then selected and reviewed. RESULTS: Pro-inflammatory cytokines, such as tumour necrosis factor, are released in response to a variety of noxious stimuli (e.g. burns, sepsis, or CABG surgery). These cytokines cause activation of neutrophils with increased upregulation of adhesion complexes on neutrophils and vascular endothelium. Nitric oxide synthase activity is also increased with a resultant increased production of nitric oxide. The increased nitric oxide concentration in the presence of superoxide free radicals secreted by activated neutrophils forms peroxynitrite, a more reactive and toxic molecule. Once this process is initiated, diffuse organ injury can result. Although some information related to specific anaesthetics is available, firm recommendations related to clinical practice cannot be made. CONCLUSIONS: There is a complex interplay of inflammatory mediators that can cause injury. Although specific clinical applications for manipulating these pathways are not yet generally available, this area holds promise to develop new techniques to improve outcomes following surgery.
MB. Seems about as useless as the stress response to trauma or surgery.

ARTICLE TITLE: Negative pressure pulmonary oedema induced by direct suctioning of endotracheal tube adapter.
ARTICLE SOURCE: Can J Anaesth (Canada), Aug 1998, 45(8) p785-8
AUTHOR(S): Pang WW; Chang DP; Lin CH; Huang MH
AUTHOR'S ADDRESS: Department of Anesthesia and Surgery, Show-Chwan Memorial Hospital, Changhua, Taiwan, R.O.C.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: PURPOSE: Negative pressure pulmonary oedema (NPPE) is a well-recognized but rare complication secondary to upper airway obstruction such as laryngeal spasm during emergence from general anaesthesia. Cauterization of the second and third thoracic sympathetic ganglia is a treatment for hyperhidrosis of the hands. We report a case of NPPE induced by direct suctioning of the endotracheal tube adapter during thoracic sympathetic ganglionectomy without recognized upper airway obstruction. CLINICAL FEATURES: A 19-yr-old otherwise healthy, non-smoking man was scheduled for elective bilateral chest endoscopic ablation of the second and third thoracic sympathetic ganglion for hyperhidrosis of the hands under general anaesthesia. To view and cauterize the ganglion with the endoscope, the surgeon requested cessation of positive pressure ventilation. As the surgeon could not satisfactorily visualize the target ganglia, he requested brief application of wall suction via the ETT tube adapter. A pressure of -100 mmHg was generated which lasted for three to four seconds. The goal was to reduce further the lung volume by increasing the pneumothorax produced by the endoscope. The patient developed negative pressure pulmonary oedema without upper airway obstruction. CONCLUSION: This case demonstrated that intrathoracic negative pressure generated by direct ETT adapter suctioning may produce pulmonary oedema similar to that induced by laryngeal spasm during the emergence of general anaesthesia.
MB. Don't suck on the lung. Don't blow on the lung.

ARTICLE TITLE: The difficult airway--a Canadian perspective [editorial]
ARTICLE SOURCE: Can J Anaesth (Canada), Aug 1998, 45(8) p713-8
AUTHOR(S): Finucane B
PUBLICATION TYPE: EDITORIAL
MB. There was nothing Canadian about it.

ARTICLE TITLE: Influence of arrhythmias on accuracy of non-invasive blood pressure monitors.
ARTICLE SOURCE: Can J Anaesth (Canada), Jul 1998, 45(7) p699-705
AUTHOR(S): Cleland MJ; Pham B; Miller DR
AUTHOR'S ADDRESS: Department of Biomedical Engineering, Ottawa General Hospital, Ontario, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: PURPOSE: To compare the accuracy of non-invasive blood pressure (NIBP) monitors in response to common cardiac arrhythmias. METHODS: Simulated signals of normal sinus rhythm (NSR), premature ventricular contractions (PVCs), atrial fibrillation (AF) and missed beats (MB) were generated from a Cufflink (Dynatech Nevada) NIBP simulator. Using these signals, the Critikon 1846SX (C1846), Critikon 845xt (C845). Critikon Vital Signs (CVIT), and Hewlett Packard M1008a (HP1008) were studied at a standard dynamic blood pressure of 120/90/80 mmHg, in order to compare monitor accuracy and signal response times. RESULTS: The C845 monitors most closely estimated a simulated SBP of 120 mmHg, although SBP was greater during PVCs and AF than NSR (P < 0.05). The Critikon 1846, Critikon Vital Signs, and Hewlett Packard systematically underestimated SBP during these arrhythmias, but variability was modest, as reflected by small coefficients of variation (< 2% for SBP) with all monitor types. In general, MAP and DBP were less sensitive to the effects of these arrhythmias. Finally, missed beats prolonged signal response times with all four monitor types (P < 0.05), whereas PVCs and AF did not alter this parameter. CONCLUSIONS: This study demonstrates the extent to which the accuracy of NIBP monitors is altered by common cardiac arrhythmias. Differences in the electromechanical characteristics of these devices may help to explain the observed similarities and discrepancies.

ARTICLE TITLE: Walking epidural analgesia in labour [editorial; comment]
COMMENTS: Comment on: Can J Anaesth 1998 Jul; 45(7):620-5
ARTICLE SOURCE: Can J Anaesth (Canada), Jul 1998, 45(7) p607-11
AUTHOR(S): Douglas MJ
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Current surgical practice in screening for colorectal cancer based on family history criteria.
ARTICLE SOURCE: Br J Surg (England), Nov 1998, 85(11) p1543-6
AUTHOR(S): Scholefield JH; Johnson AG; Shorthouse AJ
AUTHOR'S ADDRESS: Department of Surgery, University Hospital, Nottingham, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: As awareness about colorectal cancer increases there has been a steady rise in the number of referrals of relatives of patients with colorectal cancer to colorectal surgeons for screening investigations based on family history criteria. Surgeons are generally not trained in either risk assessment of inherited colorectal cancer or genetic counselling. As this is a relatively new area of service, there is likely to be variation in the management of these individuals. METHODS: This study investigated the family history criteria used and the colonic screening practices employed by a group of consultant colorectal surgeons by means of a postal questionnaire distributed and collected through their specialist association. RESULTS: The results show not only wide variation in the practice of colorectal screening based on family history criteria, but also a considerable waste of resources in the provision of illogical and inappropriate investigations. CONCLUSION: Given the lack of evidence on which to base this clinical practice and the current financial difficulties in the health service, the authors question whether it is appropriate for surgeons to continue to provide such a service.
MB. They may well question the practice. Obviously the authors don't have family histories. I do.

ARTICLE TITLE: Preoperative duplex imaging is required before all operations for primary varicose veins.
ARTICLE SOURCE: Br J Surg (England), Nov 1998, 85(11) p1495-7
AUTHOR(S): Mercer KG; Scott DJ; Berridge DC
AUTHOR'S ADDRESS: Department of Vascular, St James's and Seacroft University Hospital NHS Trust, Leeds, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Examination with HHD ultrasonography is not sufficiently accurate to plan varicose vein surgery. Duplex imaging is recommended before all operations for primary varicose veins.

ARTICLE TITLE: Outcome in patients with a large abdominal aortic aneurysm considered unfit for surgery.
ARTICLE SOURCE: Br J Surg (England), Oct 1998, 85(10) p1382-4
AUTHOR(S): Jones A; Cahill D; Gardham R
AUTHOR'S ADDRESS: Chase Farm Hospitals NHS Trust, The Ridgeway, Enfield, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: The risk of rupture of large abdominal aortic aneurysms (AAAs) remains uncertain. This study aimed to provide data to help decide whether or not to operate on high-risk patients. METHODS: Clinicians were asked to refer all patients with an AAA, even if unfit or elderly. One hundred and ninety-two patients with an intact AAA of 5 cm or greater in diameter were seen in 9 years; 59 had no elective operation and follow-up data were available for 57 at a minimum of 2 years. Initial AAA diameters were 5.0-5-9 cm (n=25) and 6.0 cm or more (n=32). Survival curves were constructed for both groups. RESULTS: At the end of the study 50 of 57 patients had died. Median survival was 18 (range 1-90) months. Twenty (35 per cent) suffered rupture at a median interval of 18 (range 1-38) months. The risk of rupture within 3 years was 28 (95 per cent confidence interval 12-49) per cent for 5.0-5.9-cm AAAs and 41 (24-59) per cent for AAAs of 6 cm or greater. In 133 elective AAA operations in fit patients the 30-day mortality rate was 3 per cent. CONCLUSION: The risk of rupture within 3 years of diagnosis of an AAA of 5 cm or greater exceeds the expected operative mortality rate for fit patients. However, the majority of patients unfit for surgery died from other causes, and only a few would have benefited from aneurysm repair.
MB. There must be no one unsuitable now with endoluminals.

ARTICLE TITLE: Should patients have access to their medical records?
ARTICLE SOURCE: Med J Aust (Australia), Dec 7-21 1998, 169(11-12) p596-7
AUTHOR(S): Carter M
AUTHOR'S ADDRESS: Health Issues Centre, Melbourne, VIC. hicjmc@vicnet.net.au.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Patient, client or customer?
ARTICLE SOURCE: Med J Aust (Australia), Dec 7-21 1998, 169(11-12) p593
AUTHOR(S): Nair BR
AUTHOR'S ADDRESS: Department of Geriatric Medicine, John Hunter Hospital, Newcastle, NSW. mdbn@cc.newcastle.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Buteyko breathing techniques in asthma: a blinded randomised controlled trial [see comments]
COMMENTS: Comment in: Med J Aust 1998 Dec 7-21; 169(11-12):573-4
ARTICLE SOURCE: Med J Aust (Australia), Dec 7-21 1998, 169(11-12) p575-8
AUTHOR(S): Bowler SD; Green A; Mitchell CA
AUTHOR'S ADDRESS: Mater Adult Hospital, South Brisbane, QLD. sbowler@mater.org.au.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSION: Those practising BBT reduced hyperventilation and their use of beta 2-agonists. A trend toward reduced inhaled steroid use and better quality of life was observed in these patients without objective changes in measures of airway calibre.

ARTICLE TITLE: Promoting evidence-based alternative medicine [comment]
COMMENTS: Comment on: Med J Aust 1998 Dec 7-21; 169(11-12):575-8; Comment on: Med J Aust 1998 Dec 7-21; 169(11-12):579-82
ARTICLE SOURCE: Med J Aust (Australia), Dec 7-21 1998, 169(11-12) p573-4
AUTHOR(S): Hensley MJ; Gibson PG
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE

ARTICLE TITLE: Cardiovascular ageing and heart failure.
ARTICLE SOURCE: Med J Aust (Australia), Nov 2 1998, 169(9) p480-4
AUTHOR(S): Macdonald PS; O'Rourke MF
AUTHOR'S ADDRESS: Department of Cardiology, St Vincent's Hospital, Sydney, NSW. pmacdonald@stvincents.com.au.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (56 references); REVIEW, TUTORIAL
ABSTRACT: Increase in arterial stiffness with age causes elevation of systolic blood pressure, which is the most common antecedent of heart failure in older people. Heart failure results from systolic and diastolic dysfunction; in either case, reducing mechanical load is the basis for preventing and treating heart failure.

ARTICLE TITLE: Transferred patients--more complex and more costly?
ARTICLE SOURCE: Med J Aust (Australia), Oct 19 1998, 169 Suppl pS42-3
AUTHOR(S): Butt WW; Shann FA
AUTHOR'S ADDRESS: Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC. buttw@cryptic.rch.unimelb.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: AN-DRGs have some splits which take illness severity and complexity into account. Age is also often used as a proxy for severity of illness. The need to transfer a patient may be a marker of illness severity or complexity and therefore resource utilisation. This is supported by studies of patients transferred to intensive care units. Data on the costs and outcomes of all transferred patients should be collected; depending on the results, refinements of DRGs may be indicated.

ARTICLE TITLE: Doctors detected self-administering opioids in New South Wales, 1985-1994: characteristics and outcomes [see comments]
COMMENTS: Comment in: Med J Aust 1998 Oct 19; 169(8):404-5
ARTICLE SOURCE: Med J Aust (Australia), Oct 19 1998, 169(8) p419-21
AUTHOR(S): Cadman M; Bell J
AUTHOR'S ADDRESS: Pharmaceutical Services Branch, NSW Health, Gladesville, NSW. mcadm@doh.health.nsw.gov.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: To describe the characteristics and outcomes of doctors whose drug authorities were withdrawn as a result of self-administering opioids for non-medical purposes. DESIGN: Retrospective review of New South Wales Health Department information relating to all doctors whose authorities to possess, supply, prescribe or administer drugs of addiction had been withdrawn in the period 1985 to 1994 as a result of confirmed self-administration of opioids. OUTCOME MEASURES: Age, sex, geographical location and practice category at the time of intervention; drugs used; period of opioid use before authority withdrawal; means of detection; and registration status as at August 1995. RESULTS: From 1985 to 1994, 79 doctors had their drug authorities withdrawn (0.4% of the NSW medical profession in 1994). The groups significantly over-represented were general practitioners and those aged 30-39 years. Pethidine was the main drug used (66 doctors; 84%). Drug use for more than two years before detection was reported by 34 (43%) doctors. Community pharmacists were the source of reports leading to detection of 28 (35%) doctors. As at August 1995, 27 (34%) of the study group were not practising; 10 (13%) had died. CONCLUSION: Outcomes for these doctors were poor. There was substantial attrition from practice and a high mortality rate.

ARTICLE TITLE: Doctors who self-administer drugs of dependence [editorial; comment]
COMMENTS: Comment on: Med J Aust 1998 Oct 19; 169(8):419-21
ARTICLE SOURCE: Med J Aust (Australia), Oct 19 1998, 169(8) p404-5
AUTHOR(S): Breen KJ; Court JM
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: The short life and rapid death of a novel antihypertensive and antianginal agent [editorial]
ARTICLE SOURCE: Med J Aust (Australia), Oct 19 1998, 169(8) p408-9
AUTHOR(S): Krum H; McNeil JJ
MAJOR SUBJECT HEADING(S): Adrenergic beta-Antagonists [administration & dosage]; Antihypertensive Agents [adverse effects]; Benzimidazoles [adverse effects]; Bradycardia [chemically induced]; Calcium Channel Blockers [adverse effects]; Tachycardia [chemically induced]; Tetrahydronaphthalenes [adverse effects]
MINOR SUBJECT HEADING(S): Adrenergic beta-Antagonists [adverse effects]; Antihypertensive Agents [administration & dosage]; Benzimidazoles [administration & dosage]; Calcium Channel Blockers [administration & dosage]; Conflict of Interest; Drug Interactions; Drug Therapy, Combination; Tetrahydronaphthalenes [administration & dosage]
PUBLICATION TYPE: EDITORIAL
MB. Mibefradil lasted one month on PBS before world wide withdrawl.

ARTICLE TITLE: Should we be screening blood donors for hepatitis G virus? The case against screening.
ARTICLE SOURCE: Med J Aust (Australia), Oct 5 1998, 169(7) p375-7
AUTHOR(S): Wong PY; Coghlan PJ; Angus PW
AUTHOR'S ADDRESS: Australian Red Cross Blood Service-Victoria, South Melbourne. pwong@rcbbv.org.au.
PUBLICATION TYPE: JOURNAL ARTICLE
MB. They suggest that the virus is not pathogenic.

ARTICLE TITLE: Surgery and the randomised controlled trial: past, present and future [see comments]
COMMENTS: Comment in: Med J Aust 1998 Oct 5; 169(7):348-9
ARTICLE SOURCE: Med J Aust (Australia), Oct 5 1998, 169(7) p380-3
AUTHOR(S): Solomon MJ; McLeod RS
AUTHOR'S ADDRESS: Department of Surgery, University of Sydney, NSW.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (49 references); REVIEW, TUTORIAL
ABSTRACT: Randomised controlled trials (RCTs), with their prospective definition of methods and outcome measures, double-blind assessment of outcomes and unbiased selection of subjects and controls, provide the best possible evidence for deciding the value of a medical or surgical intervention. Few surgical studies are designed as RCTs, and those that are should be of a higher quality. The lack of good surgical RCTs may be a result of surgeons lacking the necessary training, expertise and desire to perform RCTs, inadequate funding from granting agencies, difficulties in securing patient consent or a lack of sufficient patient numbers. If an RCT is not feasible for a particular study, then alternative research designs, such as prospective matched-pair trials, may need to be better developed and used. If RCTs can be performed, other strategies to increase the number and quality of RCTs may be needed: Education of surgeons in clinical research methods Improved funding of surgical RCTs Compulsory evaluation of new techniques and technology before their general adoption is permitted.

ARTICLE TITLE: Clinical trials in general surgical journals: are methods better reported?
ARTICLE SOURCE: Surgery (United States), Jan 1999, 125(1) p41-5
AUTHOR(S): Schumm LP; Fisher JS; Thisted RA; Olak J
AUTHOR'S ADDRESS: University of Chicago Hospitals, Ill., USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Reports of clinical trials often lack adequate descriptions of their design and analysis. Thus readers cannot properly assess the strength of the findings and are limited in their ability to draw their own conclusions. A review of 6 surgical journals in 1984 revealed that the frequency of reporting 11 basic elements of design and analysis in clinical trials was only 59%. This study attempted to identify areas that still need improvement. METHODS: Eligible studies published from July 1995 through June 1996 included all reports of comparative clinical trials on human subjects that were prospective and had at least 2 treatment arms. A total of 68 articles published in 6 general surgery journals were reviewed. The frequency that the previously identified 11 basic elements of design and analysis were reported was determined. RESULTS: Seventy-four percent of all items were reported accurately (a 15% increase from the previous study), 4% were reported ambiguously, and 23% were not reported; improvement was seen in every journal. The reporting of eligibility criteria and statistical power improved the most. For 3 items, reporting was still not adequate; 32% of reports provided information about statistical power, 40% about the method of randomization, and 49% about whether the person assessing outcomes was blind to the treatment assignment. CONCLUSIONS: Improvements have been made in reporting surgical clinical trials, but in general methodologic questions poorly answered in the 1980s continue to be answered poorly in the 1990s. Editors of surgical journals are urged to provide authors with guidelines on how to report clinical trial design and analysis.

ARTICLE TITLE: Apneic oxygenation associated with patient-controlled analgesia.
ARTICLE SOURCE: J Clin Anesth (United States), Sep 1998, 10(6) p499-501
AUTHOR(S): Smyth E; Egan TD
AUTHOR'S ADDRESS: Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City 84132, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: We report a case in which morphine in combination with intravenous diazepam delivered via patient-controlled analgesia resulted in complete apnea and carbon dioxide narcosis in a patient admitted for cervical traction. A patent airway and high flow oxygen face mask maintained oxygenation despite complete apnea, thus rendering the pulse oximeter useless in detecting the respiratory depression. The case illustrates the limitations of pulse oximetry in detecting opioid induced respiratory depression when the conditions necessary for apneic oxygenation are present.

ARTICLE TITLE: Teeth and trauma: res ipsa loquitur in a case of intubation.
ARTICLE SOURCE: J Clin Anesth (United States), Aug 1998, 10(5) p432-4
AUTHOR(S): Liang BA
AUTHOR'S ADDRESS: Pepperdine University School of Law, Malibu, CA 90263, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Preventing hypothermia: convective and intravenous fluid warming versus convective warming alone.
ARTICLE SOURCE: J Clin Anesth (United States), Aug 1998, 10(5) p380-5
AUTHOR(S): Smith CE; Desai R; Glorioso V; Cooper A; Pinchak AC; Hagen KF
AUTHOR'S ADDRESS: Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH 44109, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: STUDY OBJECTIVE: To test the hypothesis that warming intravenous (i.v.) fluids in conjunction with convective warming results in less intraoperative hypothermia (core temperature < 36.0 degrees C) than that seen with convective warming alone. DESIGN: Prospective, randomized study. SETTING: University affiliated tertiary care teaching hospital. PATIENTS: 61 ASA physical status, I, II, and III adults undergoing major surgery and general anesthesia with isoflurane. INTERVENTIONS: All patients received convective warming. Group 1 patients received warmed fluids (setpoint 42 degrees C). Group 2 patients received room temperature fluids (approximately 21 degrees C). MEASUREMENTS AND MAIN RESULTS: Lowest and final intraoperative distal esophageal temperatures were higher (p < 0.05) in Group 1 (mean +/- SEM: 35.8 +/- 0.1 degrees C and 36.6 +/- 0.1 degrees C) versus Group 2 (35.4 +/- 0.1 degrees C and 36.1 +/- 0.1 degrees C, respectively). Compared with Group 1, more Group 2 patients were hypothermic at the end of anesthesia (10 of 26 patients, or 38.5% vs. 4 of 30 patients, or 13%; p < 0.05). After 30 minutes in the recovery room, there were no differences in temperature between groups (36.7 +/- 0.1 degrees C and 36.5 +/- 0.1 degrees C in Groups 1 and 2, respectively). Intraoperative cessation of convective warming because of core temperature greater than 37 degrees C was required in 33% of Group 1 patients (vs. 11.5% in Group 2; p = 0.052). CONCLUSIONS: The combination of convective and fluid warming was associated with a decreased likelihood of patients leaving the operating room hypothermic. However, average final temperatures were greater than 36 degrees C in both groups, and intergroup differences were small. Care must be taken to avoid overheating the patient when both warming modalities are employed together.
MB. Fairly obvious. There are also several other factors which would minimise hypothermia.

ARTICLE TITLE: Transurethral resection syndrome: effect of the introduction into clinical practice of a new method for monitoring fluid absorption [see comments]
COMMENTS: Comment in: J Clin Anesth 1998 Aug; 10(5):357-9
ARTICLE SOURCE: J Clin Anesth (United States), Aug 1998, 10(5) p360-5
AUTHOR(S): Konrad C; Gerber HR; Schuepfer G; Schmucki O
AUTHOR'S ADDRESS: Department of Anesthesiology, Kantonsspital, Lucerne, Switzerland.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: STUDY OBJECTIVE: To determine the effects of introduction of a new monitoring system for fluid absorption during transurethral resection of the prostate (TURP) using an irrigating solution containing 0.5% alcohol. STUDY DESIGN: Prospective clinical investigation, with implementation of statistical process control. SETTING: Inpatients for TURP at a major non-university teaching hospital. PATIENTS: 312 male ASA physical status I, II, III, and IV patients scheduled for TURP. INTERVENTIONS: Intraoperative breath alcohol levels were measured for detection of fluid absorption. MEASUREMENTS AND MAIN RESULTS: Calculation of the amount of fluid absorbed using measured breath alcohol values. Process variability (i.e., numbers of patients with significant fluid absorption) was defined by statistical process control tools. No trend change of prevalence of fluid absorption was noted until 150 procedures had been completed. Reduction of prevalence of significant fluid absorption was noted and no patients were treated postoperatively in the intensive care unit. No relevant side effects were seen in patients with significant fluid absorption. No mortality and no severe clinical morbidity was seen after the introduction of the new monitoring. CONCLUSION: Using an irrigating fluid marked with 0.5% ethanol resulted in a decreased prevalence of fluid absorption over time.

ARTICLE TITLE: Ethanol monitoring of fluid absorption in anesthesiology practice [editorial; comment]
COMMENTS: Comment on: J Clin Anesth 1998 Aug; 10(5):360-5
ARTICLE SOURCE: J Clin Anesth (United States), Aug 1998, 10(5) p357-9
AUTHOR(S): Hahn RG
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Memories of chronic pain and perceptions of relief.
ARTICLE SOURCE: Pain (Netherlands), Aug 1998, 77(2) p137-41
AUTHOR(S): Feine JS; Lavigne GJ; Dao TT; Morin C; Lund JP
AUTHOR'S ADDRESS: McGill University Faculty of Dentistry, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. feine@medcor.mcgill.ca.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Clinicians and researchers often ask patients to remember their past pain. They also use patient's reports of relief from pain as evidence of treatment efficacy, assuming that relief represents the difference between pretreatment pain and present pain. We have estimated the accuracy of remembering pain and described the relationship between remembered pain, changes in pain levels and reports of relief during treatment. During a 10-week randomized controlled clinical trial on the effectiveness of oral appliances for the management of chronic myalgia of the jaw muscles, subjects recalled their pretreatment pain and rated their present pain and perceived relief. Multiple regression analysis and repeated measures analyses of variance (ANOVA) were used for data analysis. Memory of the pretreatment pain was inaccurate and the errors in recall got significantly worse with the passage of time (P < 0.001). Accuracy of recall for pretreatment pain depended on the level of pain before treatment (P < 0.001): subjects with low pretreatment pain exaggerated its intensity afterwards, while it was underestimated by those with the highest pretreatment pain. Memory of pretreatment pain was also dependent on the level of pain at the moment of recall (P < 0.001). Ratings of relief increased over time (P < 0.001), and were dependent on both present and remembered pain (Ps < 0.001). However, true changes in pain were not significantly related to relief scores (P = 0.41). Finally, almost all patients reported relief, even those whose pain had increased. These results suggest that reports of perceived relief do not necessarily reflect true changes in pain.
MB. As pain memory varies this is another reason not to try to invent units for pain measurement

ARTICLE TITLE: Is placebo analgesia mediated by endogenous opioids? A systematic review.
ARTICLE SOURCE: Pain (Netherlands), Jun 1998, 76(3) p273-5
AUTHOR(S): ter Riet G; de Craen AJ; de Boer A; Kessels AG
AUTHOR'S ADDRESS: Department of Epidemiology, Maastricht University, The Netherlands. g.terriet@epid.unimaas.nl.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (12 references); REVIEW, TUTORIAL
ABSTRACT: This systematic review assesses six experimental studies into the mechanism of placebo analgesia in human subjects suffering from clinical pain or experimentally induced ischaemic arm pain. Due to their sophisticated designs, these studies probably provide the best evidence that placebo analgesia exists. They also indicate that placebo analgesia is mediated by endogenous opiates. However, there seems to be room for additional studies.

ARTICLE TITLE: Liver resection using total vascular exclusion.
ARTICLE SOURCE: Surgery (United States), Oct 1998, 124(4) p807-13; discussion 814-5
AUTHOR(S): Evans PM; Vogt DP; Mayes JT 3rd; Henderson JM; Walsh RM
AUTHOR'S ADDRESS: Department of General Surgery, Cleveland Clinic Foundation, Ohio 44195, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Total vascular exclusion (TVE) is hemodynamically safe, even in patients older than 70 years. Blood loss during parenchymal transection is minimal; mortality and morbidity are low. The optimal clamp time is less than 45 minutes. Liver dysfunction is associated with clamp times exceeding 1 hour, particularly if the remaining parenchyma is abnormal or small.
MB. It is not as simple as that. It is wise to measure IVC and SVC pressures. If the aorta might be clamped femoral artery pressure might be useful.

ARTICLE TITLE: Effect of hypertonic saline solution and dextran on ventricular blood flow and heart-lung interaction after hemorrhagic shock.
ARTICLE SOURCE: Surgery (United States), Oct 1998, 124(4) p642-9; discussion 649-50
AUTHOR(S): Diebel LN; Tyburski JG; Dulchavsky SA
AUTHOR'S ADDRESS: Department of Surgery, Wayne State University, Detroit, Mich., USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Hypertonic saline solutions may have beneficial hemodynamic effects in the resuscitation of hemorrhagic shock. The effects on cardiac function and potential interaction with lung function are controversial and served as the basis for this study. METHODS: Domestic swine were resuscitated from hemorrhagic shock with equivalent sodium loads of lactated Ringer's solution (LR) or 7.5% NaCl plus 10% dextran (HSD). Hemodynamic data were obtained at baseline, shock, and after resuscitation. Right ventricular ejection fraction and left ventricular change in pressure with respect to time (dP/dt) were used to index contractility. Regional myocardial blood flow was determined with microspheres. Lung water was determined gravimetrically. RESULTS: There were no differences in the ability to restore hemodynamic parameters with equivalent sodium loads of LR and HSD resuscitation. Right ventricular ejection fraction and left ventricular change in pressure with respect to time were only transiently affected by shock and resuscitation. Regional myocardial blood flow was increased above baseline values after HSD. The total resuscitation volumes were 1958 +/- 750 mL and 140 +/- 31 mL with LR and HSD, respectively. CONCLUSIONS: Although LR and HSD were equally effective in the early resuscitation of hemorrhagic shock, this occurred at the expense of significantly greater volume requirements for resuscitation with LR. This may contribute to cardiac dysfunction in this setting. Enhanced regional myocardial blood flow after HSD resuscitation may be beneficial against ongoing myocardial stress.

ARTICLE TITLE: Living unrelated renal donation: the University of Wisconsin experience.
ARTICLE SOURCE: Surgery (United States), Oct 1998, 124(4) p604-10; discussion 610-1
AUTHOR(S): D'Alessandro AM; Pirsch JD; Knechtle SJ; Odorico JS; Van der Werf WJ; Collins BH; Becker YT; Kalayoglu M; Armbrust MJ; Sollinger HW
AUTHOR'S ADDRESS: Department of Surgery, University of Wisconsin Medical School, Madison, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Long-term Living unrelated renal donation (LURD) allograft survival rates are lower than those for HLA-identical but equivalent to those of haploidentical and better than those of cadaveric kidney transplantations. Spousal and nonspousal LURDs should be actively encouraged to help alleviate the current donor kidney shortage.

ARTICLE TITLE: The prevalence of clinically significant sleep apnoea syndrome in The Netherlands.
ARTICLE SOURCE: Thorax (England), Aug 1998, 53(8) p638-42
AUTHOR(S): Neven AK; Middelkoop HA; Kemp B; Kamphuisen HA; Springer MP
AUTHOR'S ADDRESS: Department of General Practice, Leiden University Medical Centre, The Netherlands.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Our findings suggest that the prevalence of clinically significant sleep apnoea syndrome in men aged 35 and over is at least 0.45%. Extrapolation to the population of the Netherlands suggests that at least 16,000 men suffer from sleep apnoea syndrome that should be relieved by medical care. A large proportion of these subjects remains to be diagnosed.

ARTICLE TITLE: Increased mortality among sleepy snorers: a prospective population based study [see comments]
COMMENTS: Comment in: Thorax 1998 Aug; 53(8):627-8
ARTICLE SOURCE: Thorax (England), Aug 1998, 53(8) p631-7
AUTHOR(S): Lindberg E; Janson C; Svardsudd K; Gislason T; Hetta J; Boman G
AUTHOR'S ADDRESS: Department of Lung Medicine, Uppsala University, Akademiska sjukhuset, Sweden.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Snoring without excessive daytime sleepiness (EDS) does not appear to carry an increased risk of mortality. The combination of snoring and EDS appears to be associated with an increased mortality rate, but the effects seems to be age dependent. The increased mortality is partly explained by an association between "snoring and EDS" and cardiovascular disease.

ARTICLE TITLE: Is sleep disordered breathing associated with increased mortality? [editorial; comment]
COMMENTS: Comment on: Thorax 1998 Aug; 53(8):631-7
ARTICLE SOURCE: Thorax (England), Aug 1998, 53(8) p627-8
AUTHOR(S): Fleetham JA
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Low molecular weight heparins in acute ischaemic syndromes.
ARTICLE SOURCE: Aust N Z J Med (Australia), Aug 1998, 28(4) p555-7
AUTHOR(S): White HD; Ellis CJ; French JK
AUTHOR'S ADDRESS: Cardiology Department, Green Lane Hospital, Auckland, New Zealand.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Thrombus formation and ongoing generation play a major role in the pathogenesis of unstable angina and myocardial infarction (MI). Unfractionated heparin is widely used as an adjunctive therapy in the management of acute ischaemic syndromes, but it has a number of limitations including inter-patient variability, need for monitoring, and the fact that its use may be associated with thrombocytopenia. Low molecular weight heparins have pharmacological and pharmacokinetic properties that may result in better clinical outcomes and safety. They are easy to administer and do not require monitoring. Low molecular weight heparins have been shown to reduce mortality and the incidence of MI and recurrent ischaemia compared with placebo in patients with unstable angina and non-Q-wave MI, and have a more predictable anticoagulant effect than standard unfractionated heparin. They also can be used long term in the outpatient setting, in the form of self-administered subcutaneous injections. The clinical relevance of these new developments is still being defined in ongoing clinical trials and cost-effectiveness analyses.

ARTICLE TITLE: Continuous and intermittent infusion of coagulation factor concentrates in patients undergoing surgery: a single centre Australian experience.
ARTICLE SOURCE: Aust N Z J Med (Australia), Aug 1998, 28(4) p440-5
AUTHOR(S): Campbell PJ; Rickard KA
AUTHOR'S ADDRESS: Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Haemophilia patients require large doses of coagulation factor concentrates to optimise haemostasis at the time of surgery. The superior pharmacokinetic profile of continuous infusion over intermittent bolus administration may be more advantageous. AIMS: We report our experience using coagulation factor concentrates delivered by continuous infusion in patients undergoing surgery. METHODS: A retrospective case notes review of all patients treated by continuous infusion at Royal Prince Alfred Hospital (RPAH) over a two year period and a comparison of two cohorts of patients undergoing orthopaedic surgery using either continuous infusion or bolus factor VIII (FVIII) replacement therapy. Patients received a pre-operative bolus of factor concentrate (AHF, Immunine or Recombinate) followed by a continuous infusion calculated according to weight, clearance and target plasma concentration. RESULTS: Twenty-one (19 M, two F) with haemophilia or von Willebrand's disease underwent 26 surgical procedures between July 1995 and July 1997. The mean total consumption of concentrate per patient was 36,676 units (range 6750-82,000) infused over a mean period of 7.6 days (range one-16). One patient experienced minor surgical bleeding on treatment and one patient developed severe bleeding into the replaced joint off infusion requiring additional boluses of treatment. In a separate analysis, ten of these patients who underwent major orthopaedic surgery were compared to a historic cohort (n = 8) of patients who received bolus injections for similar types of operations. CONCLUSIONS: Coagulation factor concentrates delivered by continuous infusion have major clinical and economic advantages in the surgical management of patients with haemophilia.
MB. Us.

ARTICLE TITLE: Physiological predictors of death in exsanguinating trauma patients undergoing conventional trauma surgery.
ARTICLE SOURCE: Aust N Z J Surg (Australia), Dec 1998, 68(12) p826-9
AUTHOR(S): Krishna G; Sleigh JW; Rahman H
AUTHOR'S ADDRESS: Department of Surgery and Intensive Care, Waikato Hospital, Hamilton, New Zealand. 100254.1066@compuserve.com.
MAJOR SUBJECT HEADING(S): Hemorrhage [surgery]; Multiple Trauma [surgery]
MINOR SUBJECT HEADING(S): Acid-Base Imbalance [etiology]; Acidosis [etiology]; Adolescence; Adult; Aged, 80 and over; Aged; Body Temperature; Cause of Death; Decision Making; Forecasting; Hemorrhage [etiology]; Hypothermia [etiology]; Injury Severity Score; Intensive Care; Logistic Models; Middle Age; Multiple Trauma [complications]; Predictive Value of Tests; Retrospective Studies; Sensitivity and Specificity; Survival Rate; Treatment Outcome
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Severe truncal multi trauma patients often develop coagulopathy, acidosis and hypothermia that makes major reparative trauma surgery dangerous. It was aimed to try to develop physiological indicators that would predict a poor outcome when conventional reparative surgery was applied. These indicators may help in the decision to switch from conventional reparative surgery to surgery limited to the control of major haemorrhage or organ disruption: so-called 'damage-control' surgery. METHOD: A retrospective review was conducted of 40 patients with severe multivisceral trauma (Injury Severity Score (ISS) > 35) who were admitted to the intensive care unit at Waikato Hospital and who underwent conventional reparative surgery. RESULTS: Survival was strongly associated with base deficit (BD), core temperature and ISS. Using multiple logistic regression on these indices, outcome could be predicted with 92.5% accuracy (sensitivity = 93%, specificity = 92%, positive predictive value for death = 96%). Either severe hypothermia (< 33 degrees C) or severe acidosis (BD > 12 mEq/L), or a combination of moderate core temperature < 35.5 degrees C, and a BD of > 5 mEq/L were strong predictors of death if conventional reparative surgery was practised. CONCLUSIONS: At the above mentioned levels of physiological compromise, patient survival after conventional trauma surgery can be predicted to be very unlikely. Damage-control measures would be worth attempting.

ARTICLE TITLE: Preventable trauma deaths in Singapore [see comments]
COMMENTS: Comment in: Aust N Z J Surg 1998 Dec; 68(12):819
ARTICLE SOURCE: Aust N Z J Surg (Australia), Dec 1998, 68(12) p820-5
AUTHOR(S): Iau PT; Ong CL; Chan ST
AUTHOR'S ADDRESS: Department of Surgery, National University Hospital, Singapore. surgen7@nus.edu.sg.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: This study was undertaken to determine the incidence of preventable trauma death at a non-designated trauma centre in Singapore. METHODS: A retrospective audit was carried out on all trauma deaths that occurred between January 1993 and December 1994 at the National University Hospital, Singapore. Of the 138 deaths, 38.4% (53/138) of patients were dead on arrival and were omitted from the study. Data from the remaining 85 deaths were summarized and presented before a multidisciplinary review board and injuries were scored according to the Abbreviated Injury Scale (AIS). RESULTS: Except for one patient, all deaths had an AIS score of 16 or greater. Sixty-one per cent (52/85) of deaths were the result of severe head injuries, and the rest had severe injuries in more than one body region. Following the guidelines of the Trauma Research and Education Foundation of San Diego, the incidence of 'not preventable', 'potentially preventable' and 'frankly preventable' deaths were 77.6, 15.3 and 7.1%, respectively. The most common errors in management were caused by delays in inter-departmental transfer (25.9%) and missed initial diagnosis (16.5%). After assessment by the Coroner's Office, autopsies were carried out in 60% of the cases and yielded information that altered the assessment of preventable deaths, particularly in the group with multiple injuries. CONCLUSIONS: The present study concludes that the preventable death rates in the National University Hospital are comparable to those in non-trauma designated centres elsewhere. There can only be a decrease in the preventable death rate if an improved system of pre-hospital trauma care, improved interdisciplinary communication, closer supervision of the initial attending physicians and stricter protocols on clinical monitoring are established.
MB. I would think that preventable death would be lowered by cutting pre-hospital `care' to a minimum

ARTICLE TITLE: Quality trauma care: the future? [editorial; comment]
COMMENTS: Comment on: Aust N Z J Surg 1998 Dec; 68(12):820-5
ARTICLE SOURCE: Aust N Z J Surg (Australia), Dec 1998, 68(12) p819
AUTHOR(S): Sugrue M
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. Pretty wishy-washy

ARTICLE TITLE: Inguinal hernia repair: a comparison between local and general anaesthesia.
ARTICLE SOURCE: Aust N Z J Surg (Australia), Nov 1998, 68(11) p799-800
AUTHOR(S): Subramaniam P; Leslie J; Gourlay C; Clezy JK
AUTHOR'S ADDRESS: Burnie Division, North-West Regional Hospital, Tasmania, Australia. subramaniam@c031.aone.net.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: A comparative analysis of outcomes of inguinal hernia repair performed under local (LA) and general anaesthesia (GA) by a single surgeon using a standardized technique of anterior transversalis repair was performed. Ninety-three cases were examined, 56 of which were cases of LA hernia repair. METHODS: A retrospective analysis of the patient hospital record was performed with particular attention to intra-operative and post-operative analgesia requirements. RESULTS: An overall series complication rate of 6.5% (6/93) is reported. Only one of 56 LA patients (2%) required more than 24 h of narcotic analgesic injections compared to 11% (4/37) in the GA group (P < 0.05). The mean total postoperative parenteral narcotic requirement in the LA group was 86+/-14 mg of pethidine as compared to the GA group who had a mean total requirement of 121+/-17 mg of pethidine (P > 0.08). CONCLUSIONS: The LA infiltration technique is an effective method for inguinal hernia repair. This series demonstrates benefits in terms of length of hospital stay and a lower incidence of postoperative parenteral narcotic analgesic requirement although when post-operative parenteral narcotics were required by the LA group of patients, the difference in mean total pethidine requirement was not statistically significant.
MB. Conclusion is crotradictory

ARTICLE TITLE: Surgeon, don't heal thyself: a study of the health of Australasian urologists.
ARTICLE SOURCE: Aust N Z J Surg (Australia), Nov 1998, 68(11) p778-81
AUTHOR(S): Wines AP; Khadra MH; Wines RD
AUTHOR'S ADDRESS: Medical Benevolent Association of New South Wales, Royal Prince Alfred Hospital, Sydney, Australia. apwines@bigpond.com.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Modern surgical practice is stressful and anxiety-producing. We investigated urologists health and their attitude to their own health care. METHODS: Two hundred and seventy-five Australasian urologists were surveyed to ascertain their attitudes to their physical and psychological health; 205 responses were received. RESULTS: Ten per cent reported serious physical illnesses. Fewer than half had their own general practitioner (GP), and fewer than one-third had seen a doctor in the previous 12 months. A majority had, at some time, prescribed themselves medication, including antibiotics, narcotic and non-narcotic analgesia and benzodiazepams. Nearly all reported that aspects of their urological practice caused them anxiety. More felt that this anxiety was the result of pressures experienced outside the operating theatre than problems directly related to performing surgery. A small number of psychological problems were reported, and fewer than 10 per cent had ever a visited a psychiatrist. It was evident that most Australasian urologists were unwilling to discuss any psychological problems that they may have. Even when a specific problem had been identified, few sought the appropriate care. CONCLUSIONS: It would be advantageous for Australasian urologists and doctors in general to see their GP more regularly, and be more willing to discuss any psychological difficulties that they may experience.
MB> I know these people. I used to think they were sensible.

ARTICLE TITLE: Dobutamine-induced ST-segment elevation in patients without myocardial infarction.
ARTICLE SOURCE: Am J Cardiol (United States), Dec 15 1998, 82(12) p1528-30, A7
AUTHOR(S): Previtali M; Fetiveau R; Lanzarini L; Cavalotti C
AUTHOR'S ADDRESS: Department of Cardiology, IRCCS Policlinico San Matteo, University of Pavia, Italy. previt@tin.it.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: During dobutamine stress echocardiography, ST-segment elevation developed in 20 of 372 patients (5%) without previous myocardial infarction and was associated with a transient severe asynergy of the myocardial region corresponding to the site of ST elevation. In 17 of 19 patients, ST-segment elevation was associated with a critical stenosis of the ischemia-related coronary artery, whereas in 2 of 19 patients with no critical lesions of the ischemia-related artery, coronary vasospasm was the most likely mechanism of myocardial ischemia.

ARTICLE TITLE: Two- to three-year follow-up of patients with single-vessel coronary artery disease randomized to percutaneous transluminal coronary angioplasty (PTCA) or medical therapy (results of a VA cooperative study). Veterans Affairs Cooperative Studies Program ACME Investigators. Angioplasty Compared to Medicine.
ARTICLE SOURCE: Am J Cardiol (United States), Dec 15 1998, 82(12) p1445-50
AUTHOR(S): Hartigan PM; Giacomini JC; Folland ED; Parisi AF
AUTHOR'S ADDRESS: Cooperative Studies Coordinating Center, Veterans Affairs Connecticut Health Care Systems, West Haven 06516, USA. pamh@connix.com.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: Despite increasing use of percutaneous transluminal coronary angioplasty (PTCA) to treat stenotic coronary artery disease, there are relatively few prospective studies evaluating its long-term effectiveness. We prospectively randomized 212 stable patients with provocable myocardial ischemia and single-vessel subocclusive coronary disease to receive primary therapy with either PTCA or medical therapy. This report presents the clinical follow-up of these patients at a mean, after randomization, of 2.4 years for interview and 3.0 years for exercise testing. Of the 212 patients originally randomized, 175 received an extended follow-up interview, and 132 underwent exercise testing; 62% of patients in the PTCA group were angina free compared with 47% of patients in the medical group (p <0.05). Furthermore, exercise duration as measured by treadmill testing was prolonged by 1.33 minutes over baseline in the PTCA group, whereas it decreased by 0.28 minutes in the medical group (p <0.04). Although the angina-free time on the treadmill was not different (p=0.50), fewer patients in the medical group developed angina on the treadmill at 3 years than those in the PTCA group (p=0.04). By 36 months, excluding the initial randomized PTCA, use of PTCA and use of coronary artery bypass surgery were not different in the 2 treatment groups. These data indicate that some of the early benefits derived from PTCA in patients with single-vessel coronary artery disease are sustained, making it an attractive therapeutic option for these patients.

ARTICLE TITLE: Myocardial infarction, ventricular remodeling, and angiotensin-converting enzyme inhibition: where we stand today [editorial]
ARTICLE SOURCE: Am Heart J (United States), Dec 1998, 136(6) p931-3
AUTHOR(S): Solomon SD; Pfeffer MA
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Why cholesterol as a central theme in coronary artery disease?
ARTICLE SOURCE: Am J Cardiol (United States), Nov 26 1998, 82(10B) p14T-17T
AUTHOR(S): Sacks FM
AUTHOR'S ADDRESS: Harvard School of Public Health, Boston, Massachusetts 02115, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (41 references); REVIEW, TUTORIAL
ABSTRACT: Evidence from epidemiologic studies and clinical trials have conclusively demonstrated a direct association between coronary artery disease and levels of total and low-density lipoprotein (LDL) cholesterol. Data from a number of studies suggest that even "average" or "normal" cholesterol levels are too high with respect to coronary artery disease risk. Low levels of high-density lipoprotein (HDL) cholesterol have also emerged as a coronary artery disease risk. A recent meta-analysis has eliminated much of the controversy surrounding triglyceride's contribution to coronary artery disease risk, establishing triglyceride levels as an independent risk factor. Lowering lipid levels by any means-including pharmacologic, surgical, and dietary/lifestyle changes--decreases coronary artery disease risk.

ARTICLE TITLE: Need for a paradigm shift: the importance of risk factor reduction therapy in treating patients with cardiovascular disease.
ARTICLE SOURCE: Am J Cardiol (United States), Nov 26 1998, 82(10B) p10T-13T
AUTHOR(S): Smith SC Jr
AUTHOR'S ADDRESS: Division of Cardiology and the Academic Center for Cardiovascular Disease, University of North Carolina, Chapel Hill 27599-7075, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (30 references); REVIEW, TUTORIAL
ABSTRACT: Cardiovascular disease remains the number one killer in the United States, despite advances made in diagnosis and therapy. A major shift to expand treatment beyond symptomatic obstructions and infarctions toward comprehensive therapies aimed at treatment of the underlying disease process could decrease the death rate and cost of cardiovascular disease enormously. In the past 5 years, major trials have clearly demonstrated that aggressive intervention with lipid-lowering therapy can dramatically alter the course of disease. Aspirin, smoking cessation, exercise, diet, and other medical and lifestyle interventions can also decrease risk. Successful therapies are not being implemented, however. Making prevention the primary approach to treatment will require increased resource allocation, use of health provider teams, integration of healthcare delivery systems, and expanded emphasis on educating patients about prevention.

ARTICLE TITLE: Acute effects of nicotine content in cigarettes on coronary flow velocity and coronary flow reserve in men.
ARTICLE SOURCE: Am J Cardiol (United States), Nov 15 1998, 82(10) p1275-8, A9
AUTHOR(S): Tanaka T; Oka Y; Tawara I; Sada T; Kira Y
AUTHOR'S ADDRESS: Department of Cardiology, Showa General Hospital, Kodaira-City, Tokyo, Japan.
PUBLICATION TYPE: CLINICAL TRIAL; CONTROLLED CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: We investigated the acute effects of smoking on coronary flow reserve in terms of the nicotine content of cigarettes in 21 smokers. Coronary flow velocity was measured with a Doppler flow wire. Subjects smoked cigarettes containing >1 mg nicotine (n = 8, group 1) or <1 mg (n = 6, group 2). Subjects in the control group mimicked smoking without a cigarette (n = 7). Coronary flow reserve decreased after smoking in group 1, but not in group 2 or the control group. This reduction may have mediated nicotine or some other unknown substances influenced by smoking.
MB. How could one `mimick' smoking without a cigarette.

ARTICLE TITLE: The calcium antagonist controversy: a posthumous commentary.
ARTICLE SOURCE: Am J Cardiol (United States), Nov 12 1998, 82(9B) p35R-39R
AUTHOR(S): Messerli FH; Grossman E
AUTHOR'S ADDRESS: Department of Internal Medicine, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, Louisiana 70121, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (33 references); REVIEW, TUTORIAL
ABSTRACT: In 1995, some retrospective reports showed that certain patients treated with short-acting calcium antagonists were at increased risk for myocardial infarction and had a higher mortality rate compared with patients treated with other cardiovascular drugs. Subsequent reports attempted to establish a connection between calcium antagonists and disorders as diverse as malignancy, Parkinsonism, cognitive dysfunction, and suicide. However, other retrospective studies and, more compelling, several prospective studies have reported that calcium antagonists exert a beneficial effect on morbidity and mortality in a variety of cardiovascular disorders such as hypertension, ischemic heart disease after myocardial infarction, and congestive heart failure due to dilated cardiomyopathy. Calcium antagonists are a heterogeneous drug class, and distinct differences have been documented between short- and long-acting, as well as between dihydropyridine and nondihydropyridine, agents. Sympathetic activation, which is a risk factor for coronary events, occurs with short-acting agents only and is absent with long-acting calcium antagonists. Recent data make it extremely unlikely that calcium antagonists increase the risk of malignancy by affecting apoptosis or immunosuppression or both. Long-acting calcium antagonists have distinct benefits in patients with hypertension and diabetes and may be more beneficial than other drugs in patients with diabetes and left ventricular hypertrophy.

ARTICLE TITLE: Evolving indications for permanent cardiac pacing: an appraisal of the 1998 American College of Cardiology/American Heart Association Guidelines [editorial]
ARTICLE SOURCE: Am J Cardiol (United States), Nov 1 1998, 82(9) p1082-6, A6
AUTHOR(S): Hayes DL; Barold SS; Camm AJ; Goldschlager NF
PUBLICATION TYPE: EDITORIAL
ABSTRACT: Concise and complete guidelines of indications for permanent pacemakers are critical for the clinician involved in permanent pacing. A critical appraisal of the American College of Cardiology/American Heart Association 1998 guidelines on indications for permanent pacing clarifies inconsistencies and expands on information within the current guidelines.

ARTICLE TITLE: Acute hemodynamic changes during carotid artery stenting.
ARTICLE SOURCE: Am J Cardiol (United States), Nov 1 1998, 82(9) p1077-81
AUTHOR(S): Mendelsohn FO; Weissman NJ; Lederman RJ; Crowley JJ; Gray JL; Phillips HR; Alberts MJ; McCann RL; Smith TP; Stack RS
AUTHOR'S ADDRESS: Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: To determine the clinical significance of acute hemodynamic disturbances during stenting in the carotid sinus region, we assessed the relation between intraprocedural changes in heart rate (HR) and blood pressure (BP) and adverse neurologic and cardiac outcomes. Eighteen patients underwent carotid stenting with the Wallstent (Schneider Inc). Suitable candidates had at least 60% diameter stenosis of the carotid artery by angiography. Initial and nadir HR and BP were recorded during the predilatation, stent delivery, and postdilatation periods. Bradycardia was defined as HR < or =60 beats/min and hypotension as systolic BP < or =100 mm Hg. Nineteen Wallstents were successfully deployed in all 19 carotid arteries. Some degree of bradycardia or hypotension occurred in 68% of carotid stent procedures, but administration of vasoactive medications was necessary in only 7 patients (37%) with more persistent hemodynamic disturbances. Hypotension or the need for continuous vasopressor therapy was significantly more common during postdilatation (32%) than in the predilatation period (5%) (p = 0.02). Bradycardia was not reduced by prophylactic atropine. In 1 patient the hemodynamic response to stenting may have contributed to an adverse neurologic and cardiac outcome. Thus, despite frequent fluctuations in HR and BP, most carotid stenting procedures were performed with excellent overall results, even in patients at high risk.

ARTICLE TITLE: Should only the squeaky wheel get the grease? The prognostic significance of silent ischemia detected by exercise treadmill testing [editorial; comment]
COMMENTS: Comment on: Am Heart J 1998 Nov; 136(5):894-904
ARTICLE SOURCE: Am Heart J (United States), Nov 1998, 136(5) p759-61
AUTHOR(S): Fearon WF; Voodi L; Atwood JE; Froelicher V
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. They suggest that you don't try to fix it. I think that would be sensible.

ARTICLE TITLE: The Canadian Registry of Atrial Fibrillation: a noninterventional follow-up of patients after the first diagnosis of atrial fibrillation.
ARTICLE SOURCE: Am J Cardiol (United States), Oct 16 1998, 82(8A) p82N-85N
AUTHOR(S): Kerr CR; Boone J; Connolly SJ; Dorian P; Green M; Klein G; Newman D; Sheldon R; Talajic M
AUTHOR'S ADDRESS: University of British Columbia, Vancouver, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
ABSTRACT: The Canadian Registry of Atrial Fibrillation (CARAF) is a nondirected, follow-up study of 1,086 patients who are enrolled at 6 centers across Canada at the time of initial electrocardiographically documented diagnosis of atrial fibrillation (AF). Enrollment commenced in 1991 with an intended 10-year follow-up. Comprehensive baseline data, including clinical history, laboratory, and echocardiographic variables were collected. The patients were treated by their own referring physicians and CARAF did not direct their care. Detailed follow-up was performed at 3 months, 1 year, then yearly, with echocardiograms repeated every 2 years. Several studies, which evaluated patient populations, predictors of events, and cardiac structure and functioning, have been performed and are ongoing. Thyroid function was evaluated at baseline, and, of 707 patients evaluated, only 6 patients were found to be hyperthyroid. Symptoms during AF were evaluated and a profile of the types of symptoms and the predictors of symptoms was compiled. Antiarrhythmic drug use is being followed. Sotalol and propafenone were the most commonly used medications, with the use of antiarrhythmic drugs increasing with recurrence of AF. The use of anticoagulants was assessed. The overall use of warfarin was relatively low, but its use increased dramatically with the presence of various risk factors including congestive heart failure, hypertension, and previous stroke. The one risk factor that did not result in increased use of warfarin was hypertension. Therefore, CARAF was able to identify that hypertension appears to be under-recognized and undertreated in its risk for thromboembolic events. CARAF is just now reaching maturity, with the majority of patients having > or=4 years of follow-up. Therefore, extensive investigations are currently under way that will evaluate the baseline characteristics and utilize these as predictors of recurrence of AF, progression to chronicity, and the occurrence of major events such as stroke and death. A very large cohort of patients with serial echocardiograms over 4 years will permit an understanding of the progression of structural and valvular disease. Therefore, CARAF offers a unique opportunity for comprehensive, nondirected follow-up of patients from their initial diagnosis of AF.

ARTICLE TITLE: Coronary thrombosis during acute myocardial infarction: Roberts was right! [editorial; comment]
COMMENTS: Comment on: Am J Cardiol 1998 Oct 1; 82(7):839-44
ARTICLE SOURCE: Am J Cardiol (United States), Oct 1 1998, 82(7) p896-7
AUTHOR(S): O'Neill WW
PUBLICATION TYPE: COMMENT; EDITORIAL
ABSTRACT: Pathologic studies have varied with clinical belief regarding the role of acute thrombotic occlusion as the inciting event during myocardial infarction. Aspiration thrombectomy, by employing a new catheter, has been performed during myocardial infarction and confirms the pathologic findings that intracoronary thrombus is absent in a substantial number of patients with acute myocardial infarction.
MB. Angioplasty rather than thrombolysis is the aim. Roberts said, "Get me to a catheter lab quick."

ARTICLE TITLE: Undetected cardiogenic shock in patients with congestive heart failure presenting to the emergency department.
ARTICLE SOURCE: Am J Cardiol (United States), Oct 1 1998, 82(7) p888-91
AUTHOR(S): Ander DS; Jaggi M; Rivers E; Rady MY; Levine TB; Levine AB; Masura J; Gryzbowski M
AUTHOR'S ADDRESS: Department of Emergency Medicine, Emory University, Atlanta, Georgia 30303, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: The purpose of this study was to examine the use of lactic acid levels and continuous central venous oxygen saturation (central venous oximetry) to stratify and treat patients with acutely decompensated end-stage chronic congestive heart failure (CHF) presenting to the emergency department. This prospective, convenience, non-outcome study was performed at an urban tertiary care hospital. Patients with end-stage CHF with an ejection fraction <30% presenting in decompensated CHF were eligible for the study. Patients were assessed using the Killip classification and New York Heart Association criteria. After lactic acid levels were obtained, patients were managed according to a standardized protocol guided by central venous oximetry. The patients were divided into high lactic acid (n = 22), low lactic acid (n = 5), and control groups (stable patients presenting to a cardiology clinic, n = 17) for comparison. There was no statistical difference in vital signs, or Killip and New York Heart Association criteria among the 3 groups. Central venous oxygen saturation was significantly lower in the high lactic acid group (32 +/- 12%) than in the normal lactic acid (51 +/- 13%) and control groups (60 +/- 6%) (p < 0.001). After treatment there was a significant decrease in lactic acid (-3.65 +/- 3.65 mM/L) and an increase in central venous oxygen saturation (32 +/- 13%) in the high lactic acid group compared with the normal lactic acid group (p < 0.001). A significant subset of patients with decompensated end-stage CHF present to the emergency department in occult shock and are clinically indistinguishable from patients with mildly decompensated CHF and stable CHF. Once identified, these patients require aggressive alternative management and disposition. Further study is necessary to identify whether this intervention impacts morbidity, mortality, and health care resource consumption.

ARTICLE TITLE: Effect of amlodipine on mode of death among patients with advanced heart failure in the PRAISE trial. Prospective Randomized Amlodipine Survival Evaluation.
ARTICLE SOURCE: Am J Cardiol (United States), Oct 1 1998, 82(7) p881-7
AUTHOR(S): O'Connor CM; Carson PE; Miller AB; Pressler ML; Belkin RN; Neuberg GW; Frid DJ; Cropp AB; Anderson S; Wertheimer JH; De Mets DL
AUTHOR'S ADDRESS: Duke Clinical Research Institute, Durham, North Carolina, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: Investigations of calcium antagonists in patients with advanced heart failure have raised concern over an increased risk of worsening heart failure and heart failure deaths. We assessed the effect of amlodipine on cause-specific mortality in such patients enrolled in a randomized, double-blind, placebo-controlled trial. In total, 1,153 patients in New York Heart Association class IIIb or IV heart failure were randomized to receive amlodipine or placebo, along with angiotensin-converting enzyme inhibitors, diuretics, and digitalis. Over a median 14.5 months of follow-up, 413 patients died. Cardiovascular deaths accounted for 89% of fatalities, 50% of which were sudden deaths and 45% of which were due to pump failure, with fewer attributed to myocardial infarction (3.3%) or other cardiovascular causes (1.6%). Amlodipine treatment resulted in a greater relative reduction in sudden deaths (21%) than in pump failure deaths (6.6%) overall. When patients were classified by etiology of heart failure (ischemic or nonischemic), cause-specific mortality did not differ significantly between treatment groups in the ischemic stratum. In the nonischemic stratum, however, sudden deaths and pump failure deaths were reduced by 38% and 45%, respectively, with amlodipine. Thus, when added to digitalis, diuretics, and angiotensin-converting enzyme inhibitors in patients with advanced heart failure, amlodipine appears to have no effect on cause-specific mortality in ischemic cardiomyopathy, but both pump failure and sudden deaths appear to be decreased in nonischemic heart failure patients treated with amlodipine.

ARTICLE TITLE: The future of antithrombotic and antiplatelet therapy for ischemic heart disease.
ARTICLE SOURCE: Am Heart J (United States), Oct 1998, 136(4 Pt 2 Su) pS66-8
AUTHOR(S): Topol EJ
AUTHOR'S ADDRESS: Cleveland Clinic Foundation, Department of Cardiology, Ohio 44195, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (12 references); REVIEW, TUTORIAL

ARTICLE TITLE: Acute effects of caffeine ingestion on signal-averaged electrocardiograms [see comments]
COMMENTS: Comment in: Am Heart J 1998 Oct; 136(4 Pt 1):574-5
ARTICLE SOURCE: Am Heart J (United States), Oct 1998, 136(4 Pt 1) p643-6
AUTHOR(S): Donnerstein RL; Zhu D; Samson R; Bender AM; Goldberg SJ
AUTHOR'S ADDRESS: Department of Pediatrics, Steele Memorial Children's Research Center, The University of Arizona College of Medicine, Tucson, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: Although moderate caffeine ingestion has not been shown to be arrhythmogenic, caffeine toxicity can cause severe cardiac arrhythmias, including atrial fibrillation and ventricular tachycardia. Atrial fibrillation and ventricular tachycardia have been associated with prolongation of P-wave and QRS complex durations on signal-averaged electrocardiograms. This study investigated acute effects of caffeine ingestion on signal-averaged P-wave and QRS complexes. METHODS AND RESULTS: Signal-averaged electrocardiograms were obtained from 12 normal subjects (6 men, 6 women; ages 21 to 26 years) before and after ingestion of caffeine (5 mg/kg body weight) or placebo in a randomized, double-blind, crossover fashion. Electrocardiograms for signal averaging were recorded from electrodes left in a constant location. After bandpass filtering (30 to 300 Hz) and amplification, signals were sampled over 7.2 minutes at 2000 Hz. Signal-averaged P-wave and QRS complex durations did not significantly change after placebo ingestion. After caffeine ingestion QRS duration prolonged in 9 of 11 subjects at 90 minutes (mean +/- SEM = 0.8+/-0.3 ms, P< .02) and in 8 of 9 after 3 hours (1.1+/-0.2 ms, P< .001). No significant change in P-wave duration or heart rate was found after caffeine ingestion at any test interval. Average caffeine level in saliva 90 minutes after ingestion was 6.6+/-1.6 (SD) microg/dL. CONCLUSIONS: Although probably not arrhythmogenic in normal subjects, moderate caffeine ingestion does produce a small but statistically significant prolongation of signal-averaged QRS complexes. Further prolongation caused by excessive caffeine intake may be a factor in the genesis of arrhythmias associated with caffeine toxicity.

ARTICLE TITLE: Caffeine ingestion: yet another wake-up call? [editorial; comment]
COMMENTS: Comment on: Am Heart J 1998 Oct; 136(4 Pt 1):643-6
ARTICLE SOURCE: Am Heart J (United States), Oct 1998, 136(4 Pt 1) p574-5
AUTHOR(S): Graboys TB; Bedell SE
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: The stent decade: 1987 to 1997. Stanford Stent Summit faculty.
ARTICLE SOURCE: Am Heart J (United States), Oct 1998, 136(4 Pt 1) p578-99
AUTHOR(S): Oesterle SN; Whitbourn R; Fitzgerald PJ; Yeung AC; Stertzer SH; Dake MD; Yock PG; Virmani R
AUTHOR'S ADDRESS: Division of Cardiovascular Medicine, Stanford University School of Medicine, Calif, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (45 references); REVIEW, TUTORIAL
ABSTRACT: In January 1997, experts from the United States, Europe, and Japan gathered at Stanford University to review their collective experience with intracoronary and noncoronary stenting and to identify and prioritize issues requiring further clinical investigation. This report summarizes the discussions that took place during this stent summit. Knowledge of stent-tissue interaction from animal and human pathologic specimens was reviewed in the context of evolving stent designs. The relative merits of coil and slotted tubular stent designs were discussed. Stent deployment routines, including self-expansion, balloon expansion, and high-pressure delivery were debated. The potential for covered stents and coated stents was explored. Problems surrounding the routine deployment of stents were identified: small vessel disease, long lesions, bifurcation stenoses, vein graft disease, ostial disease, left main stenoses, and intrastent restenosis. The value of intravascular ultrasound, as an adjunct to stenting, was explored and debated. An algorithm for "provisional stenting" based on ultrasound criteria was developed. Noncoronary stenting of the aorta, iliacs, and carotids were discussed. Clinical applications that may lead to randomized clinical trials were identified.

ARTICLE TITLE: Risk reduction in the intensive care unit [see comments]
COMMENTS: Comment in: Am J Med 1998 Dec; 105(6):551-3
ARTICLE SOURCE: Am J Med (United States), Dec 1998, 105(6) p515-23
AUTHOR(S): Saint S; Matthay MA
AUTHOR'S ADDRESS: Robert Wood Johnson Clinical Scholars Program, University of Washington, Seattle, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (117 references); REVIEW, TUTORIAL
ABSTRACT: Many potentially preventable complications occur in patients who receive intensive care. We have reviewed the epidemiology of three important complications (venous thromboembolism, stress-related upper gastrointestinal bleeding, and vascular catheter-related infection) and evaluated common preventive treatments to provide evidence-based recommendations for prevention. We used English language articles located by MEDLINE or cross-citation, giving preference to articles published in the last 10 years, meta-analyses, and clinical trials that were randomized, double-blinded, and used intention-to-treat analysis. We recommend prophylaxis against venous thromboembolism in most patients, whereas those without respiratory failure or coagulopathy may not require prophylaxis against stress-related upper gastrointestinal hemorrhage. Chlorhexidine gluconate is the preferred antiseptic for disinfecting the skin prior to and during intravascular catheterization. Central venous catheters impregnated with antibacterial or antiseptic agents should be considered in patients at high risk for vascular catheter-related infection. Finally, central venous, pulmonary arterial, and systemic arterial catheters should be changed only when clinically indicated.

ARTICLE TITLE: Systematic reviews and evidence-based critical care medicine: a step in the right direction [editorial; comment]
COMMENTS: Comment on: Am J Med 1998 Dec; 105(6):515-23
ARTICLE SOURCE: Am J Med (United States), Dec 1998, 105(6) p551-3
AUTHOR(S): Gould MK; Leonard CT; Weinacker AB; Raffin TA
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. Criticism of ICU whims.

ARTICLE TITLE: Effects of multidisciplinary case management in patients with chronic renal insufficiency [see comments]
COMMENTS: Comment in: Am J Med 1998 Dec; 105(6):546-8
ARTICLE SOURCE: Am J Med (United States), Dec 1998, 105(6) p464-71
AUTHOR(S): Harris LE; Luft FC; Rudy DW; Kesterson JG; Tierney WM
AUTHOR'S ADDRESS: Department of Medicine, Wishard Memorial Hospital and Indiana University School of Medicine, Indianapolis, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: PURPOSE: Though case management has been recommended to improve the outcomes of patients with costly or morbid conditions, it has seldom been studied in controlled trials. We performed a randomized, controlled clinical trial of an intensive, multidisciplinary case management program for patients with chronic renal insufficiency and followed patients for 5 years. PATIENTS AND METHODS: We enrolled 437 primary-care patients (73% of those eligible) with chronic renal insufficiency (estimated creatinine clearance consistently < 50 mL/min with the last serum creatinine level > 1.4 mg/dL) who were attending an urban academic general internal medicine practice. The intensive case management, administered during the first 2 years after enrollment, consisted of mandatory repeated consultations in a nephrology case management clinic staffed by two nephrologists, a renal nurse, a renal dietitian, and a social worker. Control patients received usual care. Primary outcome measurements included serum creatinine level, estimated creatinine clearance, health services use, and mortality in the 5 years after enrollment. Secondary measures included use of renal sparing and potentially nephrotoxic drugs. RESULTS: There were no differences in renal function, health services use, or mortality in the first, second, or third through fifth years after enrollment. There were significantly more outpatient visits among intervention patients, mainly because of the added visits to the nephrology case management clinic. There were also no significant differences in the use of renal sparing or selected potentially nephrotoxic drugs. The annual direct costs of the intervention were $89,355 ($484 per intervention patient). CONCLUSION: This intensive, multidisciplinary case-management intervention had no effect on the outcomes of care among primary-care patients with established chronic renal insufficiency. Such expensive and intrusive interventions, despite representing state-of-the-art care, should be tested prospectively before being widely introduced into practice.
MB. I thought that this was about multile speciality referral. It is not. The nephrologists had a lot of hanger-oners.

ARTICLE TITLE: Evaluating the consequences of multidisciplinary case management for patients with chronic renal failure [editorial; comment]
COMMENTS: Comment on: Am J Med 1998 Dec; 105(6):464-71
ARTICLE SOURCE: Am J Med (United States), Dec 1998, 105(6) p546-8
AUTHOR(S): Wrone EM; Hornberger J
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. In spite of showing no difference in 1990 the editorial writers sensibly suggest that any progress will only occur in special clinics.

ARTICLE TITLE: Future trends in the development of safer nonsteroidal anti-inflammatory drugs.
ARTICLE SOURCE: Am J Med (United States), Nov 2 1998, 105(5A) p44S-52S
AUTHOR(S): Wolfe MM
AUTHOR'S ADDRESS: Department of Medicine, Boston University School of Medicine, Massachusetts 02118, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (68 references); REVIEW, TUTORIAL
ABSTRACT: Gastrointestinal (GI) adverse events, ranging from mild to life-threatening, are well-recognized sequelae to nonsteroidal anti-inflammatory drug (NSAID) use. Recent improvements in our knowledge of the mechanisms responsible for NSAID-associated gastropathy have enabled several experimental approaches to decreasing the risk of these events. Whereas such strategies as preassociation of NSAIDs to zwitterionic phospholipids to prevent NSAID-mucosal interactions and concomitant administration of trefoil peptides to stimulate mucosal defense pathways represent novel approaches, their clinical feasibility remains to be determined. Other strategies that appear more immediately promising in the reduction of NSAID-associated GI toxicity are the coupling of NSAIDs to nitric oxide (NO)-releasing compounds and the introduction of NSAIDs that are preferential or specific for cyclo-oxygenase-2 (COX-2), the isoform implicated in the inflammatory response. Clinical trials of several specific COX-2 inhibitors, as well as European clinical data for a preferential COX-2 inhibitor, meloxicam, suggest that COX-2 inhibitors provide an advantage over standard NSAIDs in terms of GI tolerability. However, as recent observations have implicated COX-2 as an integral component in the maintenance of physiologic homeostasis, careful scrutiny of both the beneficial and the deleterious effects of the selective COX-2 inhibitors is requisite before their approval and widespread use. Furthermore, based on the physiologic importance of COX-2, the preferential inhibitors may ultimately prove to represent the optimal compromise for the treatment of various arthritides.

ARTICLE TITLE: Nonsteroidal anti-inflammatory drug-related gastrointestinal toxicity: definitions and epidemiology.
ARTICLE SOURCE: Am J Med (United States), Nov 2 1998, 105(5A) p3S-9S
AUTHOR(S): McCarthy D
AUTHOR'S ADDRESS: Department of Veteran's Affairs and the Division of Gastroenterology, University of New Mexico School of Medicine, Albuquerque, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (65 references); REVIEW, TUTORIAL
ABSTRACT: Nonsteroidal anti-inflammatory drug (NSAID)-associated gastrointestinal (GI) toxicity is a broad topic encompassing symptoms as well as severe GI complications. GI bleeding and perforation are the 2 overlapping components that account for the majority of deaths and disability associated with these drugs. Abnormal gastric endoscopic profiles as well as symptoms such as heartburn, pain, and dyspepsia are common in NSAID users, but no correlation has been found between these factors and the occurrence of the more severe complications; therefore, neither symptoms nor endoscopic observations can necessarily be considered reliable predictors of future outcomes. Confounding factors can increase the risk of complications, and specific NSAIDs vary in the magnitude and type of risk attending their use. Recent studies have focused on the contribution of nonprescription NSAIDs to total complications, and combined with evidence suggesting that the risk is greatest during the first month of NSAID use, it is apparent that NSAID toxicity is an acute as well as a chronic problem.

ARTICLE TITLE: Nonsteroidal anti-inflammatory drug-associated toxicity of the liver, lower gastrointestinal tract, and esophagus.
ARTICLE SOURCE: Am J Med (United States), Nov 2 1998, 105(5A) p17S-21S
AUTHOR(S): Bjorkman D
AUTHOR'S ADDRESS: University of Utah Medical Center, Salt Lake City 84132, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (51 references); REVIEW, TUTORIAL
ABSTRACT: Although upper gastrointestinal (GI) adverse events are the most common consequences of nonsteroidal anti-inflammatory drug (NSAID) use, there are other GI side effects that can contribute to the morbidity and mortality associated with these drugs. NSAID-associated toxicity of the large and small bowel is increasingly recognized in clinical practice, as enteroscopic procedures become more frequently used. This lower GI toxicity may have several different manifestations: ulcerations, strictures, colitis, or exacerbation of inflammatory bowel disease. Hepatic injury, most likely due to an idiosyncratic reaction resulting from an immunologic response or altered metabolic pathways, is another sequela of NSAID use that is usually reversible. Although hepatotoxicity is listed as a class warning for NSAIDs, aspirin, diclofenac, and sulindac are most commonly associated with this problem. Surveillance for hepatic injury is not always reliable, and the low frequency of both hepatic and lower GI toxicity in NSAID users renders these events difficult to characterize. An increase in awareness, surveillance, and reporting of these events can lead to a better understanding of the risk factors and etiology associated with NSAID toxicity.
MB. Those still wanting to give ketorolac should read these reviews.

ARTICLE TITLE: Prevention of hepatitis A [editorial]
ARTICLE SOURCE: Am J Med (United States), Nov 1998, 105(5) p452-3
AUTHOR(S): Gardner P
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Septic thrombosis of the basilic, axillary, and subclavian veins caused by a peripherally inserted central venous catheter.
ARTICLE SOURCE: Am J Med (United States), Nov 1998, 105(5) p446-50
AUTHOR(S): Andes DR; Urban AW; Acher CW; Maki DG
AUTHOR'S ADDRESS: Department of Medicine, University of Wisconsin Hospitals and Clinics, University of Wisconsin Medical School, Madison 53792, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Helicobacter pylori: rational management options.
ARTICLE SOURCE: Am J Med (United States), Nov 1998, 105(5) p424-30
AUTHOR(S): Peura D
AUTHOR'S ADDRESS: University of Virginia Medical School, Division of Gastroenterology and Hepatology, Charlottesville 22906-0013, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (43 references); REVIEW, TUTORIAL
ABSTRACT: In the treatment of Helicobacter pylori-associated peptic ulcer disease, the complexity (ie, frequency and duration) of drug administration, the presence or development of bacterial antibiotic resistance, and the occurrence of side effects influence patient compliance and eradication rates, which consequently affect the costs of treatment regimens. The National Institutes of Health Consensus Conference and 1997 Digestive Health Initiative Update Conference have recommended that all patients with gastric or duodenal ulcer and H. pylori infection, whether on first presentation or recurrence, be treated with antimicrobials. However, H. pylori resistance to antimicrobials, specifically to nitroimidazole compounds, has resulted in varied and decreasing success rates of treatment regimens. Comparing the efficacy, safety, and costs of current treatment strategies for the eradication of H. pylori, a combination triple therapy with a proton pump inhibitor, amoxicillin, and clarithromycin is recommended as an effective alternative to standard bismuth-based triple therapy. When compared with other therapies, these offer more rapid symptomatic relief, improved tolerability, increased compliance and efficacy, and moderate costs.

ARTICLE TITLE: The association of intraoperative factors with the development of postoperative delirium.
ARTICLE SOURCE: Am J Med (United States), Nov 1998, 105(5) p380-4
AUTHOR(S): Marcantonio ER; Goldman L; Orav EJ; Cook EF; Lee TH
AUTHOR'S ADDRESS: Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
ABSTRACT: PURPOSE: To examine the association of intraoperative factors, including route of anesthesia, hemodynamic complications, and blood loss, with the development of postoperative delirium. PATIENTS AND METHODS: We studied 1,341 patients 50 years of age and older admitted for major elective noncardiac surgery at an academic medical center. Data on route of anesthesia, intraoperative hypotension, bradycardia and tachycardia, blood loss, number of blood transfusions, and lowest postoperative hematocrit were obtained from the medical record. Delirium was diagnosed by using daily interviews with the Confusion Assessment Method, as well as from the medical record and the hospital's nursing intensity index. RESULTS: Postoperative delirium occurred in 117 (9%) patients. Route of anesthesia and intraoperative hemodynamic complications were not associated with delirium. Delirium was associated with greater intraoperative blood loss, more postoperative blood transfusions, and postoperative hematocrit <30%. After adjusting for preoperative risk factors, postoperative hematocrit <30% was associated with an increased risk of delirium (odds ratio = 1.7, 95% confidence interval 1.1-2.7). CONCLUSIONS: Further study is required to determine whether transfusion to keep postoperative hematocrit above 30% can reduce the incidence of postoperative delirium.

ARTICLE TITLE: Advancing the cause of informed consent: moving from disclosure to understanding [editorial; comment]
COMMENTS: Comment on: Am J Med 1998 Oct; 105(4):266-74
ARTICLE SOURCE: Am J Med (United States), Oct 1998, 105(4) p354-5
AUTHOR(S): Braddock CH 3rd
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Deja vu: nosocomial hepatitis B virus transmission and fingerstick monitoring.
ARTICLE SOURCE: Am J Med (United States), Oct 1998, 105(4) p296-301
AUTHOR(S): Quale JM; Landman D; Wallace B; Atwood E; Ditore V; Fruchter G
AUTHOR'S ADDRESS: Department of Veterans Affairs Medical Center, Brooklyn, New York, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: PURPOSE: Three patients with acute hepatitis B virus infection were identified who had been hospitalized on the same medical ward during a 19-day period several months earlier. An investigation was undertaken to determine if nosocomial transmission had occurred. SUBJECTS AND METHODS: A cohort study of patients admitted to the medical ward during the 19-day period in 1995 was conducted. In addition, we reviewed medical charts and laboratory records of all patients with acute hepatitis B virus infection who had been admitted to the hospital from 1992 through October 1996 to identify other cases with possible nosocomial acquisition. RESULTS: The 3 patients who had developed acute hepatitis B infection 2 to 5 months after hospitalization on the same medical ward had diabetes mellitus but no identified risk factors for hepatitis B infection. A source patient with diabetes mellitus and hepatitis B "e" antigenemia also was present on the same medical ward at the same time; all 4 patients were infected with the same viral subtype (adw2). Diabetes mellitus and fingerstick monitoring were associated with illness (P <0.001). Through the review of medical charts and laboratory records, 11 additional cases of suspected nosocomial acquisition via fingersticks were identified in 1996, including two clusters involving an unusual subtype of hepatitis B virus (adw4). The fingerstick device employed had a reusable base onto which disposable lancet caps were inserted. There was ample opportunity for cross-contamination among patients because deficiencies in infection control practices, particularly failure to change gloves between patients, were reported by nurses and patients with diabetes mellitus. CONCLUSION: Transmission during fingerstick procedures was the most likely cause of these cases of nosocomial hepatitis B infection. Contamination probably occurred when healthcare workers failed to change gloves between patients undergoing fingerstick monitoring, although other means of contamination cannot be ruled out.

ARTICLE TITLE: What should men know about prostate-specific antigen screening before giving informed consent?
ARTICLE SOURCE: Am J Med (United States), Oct 1998, 105(4) p266-74
AUTHOR(S): Chan EC; Sulmasy DP
AUTHOR'S ADDRESS: Division of General Internal Medicine, University of Texas Health Sciences Center, Houston, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: PURPOSE: Since prostate-specific antigen (PSA) screening is controversial, some authorities recommend that patients give informed consent before testing. We identified and compared what facts experts and patients thought men should know. SUBJECTS AND METHODS: We recruited a Delphi panel of national experts (6 urologists and 6 non-urologists) and conducted 6 focus groups of couples (48 subjects) with 24 screened and unscreened men from a university hospital. We ranked key facts that experts and couples thought men ought to know before consenting to PSA screening and conducted a multidisciplinary focus group to help interpret the findings. RESULTS: All participants would disclose that false positive and false negative results can occur and that it is not known whether PSA screening reduces prostate cancer mortality. The 12 experts would disclose the uncertain benefits of treating early, localized prostate cancer. All 24 couples would disclose that the PSA test is a blood test and that patients may worry about results. The 6 urologists would disclose that prostate cancer is often incurable when symptoms appear; the 6 non-urologists, that it can be asymptomatic. The 12 couples with screened men would disclose that the PSA test can detect cancer sooner than the digital rectal examination; the 12 couples with unscreened men, that PSA testing is controversial. CONCLUSIONS: Physicians and patients agree upon some facts that men should know about PSA screening before giving informed consent. However, physicians fail to emphasize other facts that patients find important. Physicians may differ by expertise; patients, by experience. Our findings provide content for informed consent for PSA screening, and our method may be useful for other controversial tests.

ARTICLE TITLE: A solution to the problem of undictated operative reports by residents.
ARTICLE SOURCE: Am J Surg (United States), Nov 1998, 176(5) p475-80
AUTHOR(S): Cohen MM; Ammon AA
AUTHOR'S ADDRESS: Department of Surgery, Grace Hospital, Wayne State University School of Medicine, Detroit, Michigan, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: PURPOSE: The objective of this study was to reduce the number of operative reports assigned to the surgical residents but not dictated within 48 hours by 80% within 6 months. CONCLUSIONS: The performance of residents on the surgical service in respect to operative report dictation can be profoundly influenced by a carefully targeted set of interventions based on behavioral theory. The improved performance can be maintained with simple reminders and the halo effect of the intervention extends to the dictation of discharge summaries.
MB. I would have thought that the report should be done immediately after the operation.

ARTICLE TITLE: Randomized trial comparing packed red cell blood transfusion with and without leukocyte depletion for gastrointestinal surgery.
ARTICLE SOURCE: Am J Surg (United States), Nov 1998, 176(5) p462-6
AUTHOR(S): Tartter PI; Mohandas K; Azar P; Endres J; Kaplan J; Spivack M
AUTHOR'S ADDRESS: Department of Surgery, Mount Sinai Medical Center, New York, New York 10029, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: Allogeneic transfusion is associated with postoperative infections that significantly prolong hospital stays and increase costs. Recent studies suggest that filtering leukocytes from blood prior to transfusion reduces the risk of postoperative infection associated with blood transfusion. We compared the incidence of postoperative infections, hospital stays, and hospital charges of gastrointestinal surgery patients transfused with packed red cells or leukocyte-depleted cells. METHODS: Consecutive patients admitted for elective gastrointestinal surgery without previous blood transfusion were randomized to receive routine packed red cells or packed red cells filtered to remove leukocytes if transfusion was required. Multivariate analysis was used to assess the significance of the relationship between leukocyte-depleted blood and postoperative infectious complications, postoperative stay, and hospital charges. RESULTS: Fifty-nine (27%) of the 221 patients were transfused. The most significant variable related to transfusion was intraoperative blood loss (P <0.0001), followed by admission hematocrit (P <0.0001) and age (P = 0.0022). Infections were noted in 16% of the patients: 11% of untransfused patients, 16% of leukocyte-depleted blood recipients, and 44% of patients transfused with packed red cells. Both operative site and nosocomial infections were significantly (P <0.001) more frequent in patients transfused with packed red cells compared with patients transfused with leukocyte-depleted red cells. Postoperative stays averaged 9 days for untransfused patients, 12 days for leukocyte-depleted recipients, and 18 days for recipients of packed red cells. Hospital charges were $19,132, $33,954, and $41,002, respectively. Both transfusion and infection were significantly (P <0.001) related to postoperative stay in multivariate analysis. Hospital charges were significantly related to postoperative stay (P <0.001), blood loss (P <0.001), age (P <0.001), infection (P = 0.007), and randomization to packed red cells (P = 0.032). CONCLUSIONS: Filtering blood of leukocytes prior to transfusion for elective gastrointestinal surgery is associated with lower risk of postoperative infection, shorter postoperative stays, and lower hospital charges.

ARTICLE TITLE: The effects of hyperbaric oxygen on normal and ischemic colon anastomoses.
ARTICLE SOURCE: Am J Surg (United States), Nov 1998, 176(5) p458-61
AUTHOR(S): Hamzaoglu I; Karahasanoglu T; Aydin S; Sahin DA; Carkman S; Sariyar M; Alemdaroglu K
AUTHOR'S ADDRESS: Department of Surgery, Istanbul University Cerrahpasa and Istanbul Medical Schools, Turkey.
INDEXING CHECK TAG(S): Animal; Male
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Leakage from colonic anastomoses is a major complication causing increased mortality and morbidity, and ischemia is a well-known cause of this event. Inadequate tissue oxygenation could be reversed by using hyperbaric oxygen. This study was designed to investigate the effects of hyperbaric oxygen on the healing of ischemic and normal colon anastomoses in the rat model. METHODS: Standardized left colon resection 3 cm above the peritoneal reflection and colonic anastomosis were performed in 40 Wistar rats divided into four groups. The control group (I) received no further treatment. To mimic ischemia, 2 cm mesocolon was ligated on either site of the anastomosis in group II and IV rats. Hyperbaric oxygen therapy was started immediately after surgery in group III and IV rats (therapeutic groups). All animals were sacrificed on the fourth postoperative day. After careful relaparotomy, in situ bursting pressure was measured. The hydroxyproline contents of the anastomotic segments in equal length were determined. RESULTS: The hydroxyproline assay revealed that rats in group II with ischemic colonic anastomosis have significantly lower levels (P <0.05). The highest levels are in the group III rats with normal colonic anastomosis treated by hyperbaric oxygen (P <0.05). There was no significant difference in hydroxyproline levels between group II and group IV animals (P >0.05). Group III animals had significantly higher bursting pressures than any other group (P <0.05). Group II rats had lowest bursting pressures (P <0.05). Group IV animals had significantly higher levels than group II (P <0.05). Mean bursting pressure values both in groups III and IV and hydroxyproline levels in group III were significantly increased by hyperbaric oxygen therapy (P <0.05). CONCLUSIONS: Ischemia impairs anastomotic healing. Hyperbaric oxygen increases anastomotic healing of both normal and ischemic colonic anastomosis and reverses ischemic damage. This study demonstrated that hyperbaric oxygen improves anastomotic healing.
MB. I hope surgeons don't read this.

ARTICLE TITLE: Groin hernia and surgical truth [editorial]
ARTICLE SOURCE: Am J Surg (United States), Oct 1998, 176(4) p301-4
AUTHOR(S): McGreevy JM
PUBLICATION TYPE: EDITORIAL; REVIEW (22 references); REVIEW, TUTORIAL
ABSTRACT: BACKGROUND: Surgeons have used many methods to repair groin hernia since 1889. In that year, both Halsted and Bassini described the first effective operation. All operative solutions to groin hernia since then have used a suture repair. The differences have been related to the anatomic structures that are joined by the sutures. Recently, laparoscopy has forced most surgeons to question their approach to groin hernia. Common questions are: Is laparoscopy superior? When should mesh be used? Which of the many available techniques give superior results? DATA SOURCES: This review presents an opinion-based review of the classical and recent literature. In addition, this review considers the manner in which surgeons search for answers to such questions. CONCLUSION: The result of this search, for the author, is an acceptance of the mesh plug repair as superior to all others currently available.

ARTICLE TITLE: The futility of chest roentgenograms following routine central venous line changes.
ARTICLE SOURCE: Am J Surg (United States), Sep 1998, 176(3) p283-5
AUTHOR(S): Cullinane DC; Parkus DE; Reddy VS; Nunn CR; Rutherford EJ
AUTHOR'S ADDRESS: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37212, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: To demonstrate chest roentgenograms after central venous line changes over a guidewire delay the use of the central lines and increases charges with no change of morbidity or the rate of complication. METHODS: Retrospective study using the Surgical Intensive Care database followed by a nonrandomized, prospective study of central venous line changes. The total time from the catheter change until chest radiograph confirmation and an analysis of charges was done. RESULTS: The retrospective study of 1,201 central line changes demonstrated no pneumothorax and two central lines malpositioned. The prospective study of 100 patients demonstrated no pneumothorax and one catheter malpositioned. The average time from completion of the central line change until the radiographic confirmation was 60.2 minutes. The charge for the chest x-ray film was $156. CONCLUSIONS: The combined studies composed of 1,301 patients demonstrated no pneumothorax and three malpositioned catheters. This study demonstrates that radiographic confirmation of central venous line placement after routine line change is of no benefit as the malpositioned catheters caused no morbidity, produces significant delays and increases medical charges to the patient. Extrapolation predicts an annual reduction of $46,800 in the Vanderbilt Surgical Intensive Care Unit.
MB, NB This applies to CHANGING lines.

ARTICLE TITLE: A prospective randomized trial of intraoperative bupivacaine irrigation for management of shoulder-tip pain (STP) following laparoscopy.
ARTICLE SOURCE: Am J Surg (United States), Sep 1998, 176(3) p258-61
AUTHOR(S): Cunniffe MG; McAnena OJ; Dar MA; Calleary J; Flynn N
AUTHOR'S ADDRESS: Department of Surgery, University College Hospital, Galway, Ireland.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: CONCLUSION: Intraperitoneal irrigation with bupivacaine to both hemidiaphragms at the end of surgery significantly reduces both frequency and intensity of STP following laparoscopic procedures thus reducing patient morbidity.

ARTICLE TITLE: A randomized controlled trial of extraperitoneal bupivacaine analgesia in laparoscopic hernia repair.
ARTICLE SOURCE: Am J Surg (United States), Sep 1998, 176(3) p254-7
AUTHOR(S): O'Riordain DS; Kelly P; Horgan PG; Keane FB; Tanner WA
AUTHOR'S ADDRESS: Department of Surgery, Trinity College Dublin, Meath Hospital, Ireland.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSION: Extraperitoneal bupivacaine minimizes pain following day-care totally extraperitoneal laparoscopic inguinal hernia repair (TEP) repair, facilitates recovery, and increases patient satisfaction. Benefits persist beyond the pharmacological action of bupivacaine.

ARTICLE TITLE: Characteristics of women surgeons in the United States.
ARTICLE SOURCE: Am J Surg (United States), Sep 1998, 176(3) p244-50
AUTHOR(S): Frank E; Brownstein M; Ephgrave K; Neumayer L
AUTHOR'S ADDRESS: Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA 30303-3219, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Women surgeons are becoming increasingly prevalent. Despite this, there have been few studies of personal or professional characteristics of US surgeons of either gender. METHODS: Data were taken from the Women Physicians' Health Study, a nationally representative random sample (n = 4,501 respondents) of US women physicians, and data were analyzed in SUDAAN. RESULTS: Surgeons were younger, and more likely to be US born, white, unmarried, and childless than were other women physicians; their personal health behaviors were similar to those of others. They worked significantly more clinical hours and call nights, but were not more likely to report feeling that they worked too much, had too much work stress, or had less control of their work environment. Their career satisfaction was similar to that of other women physicians, and satisfaction with their specialty was greater. They were less avid preventionists than were primary care practitioners, and somewhat less avid than other specialists. CONCLUSIONS: Women surgeons differ in interesting and important ways from other women physicians.

ARTICLE TITLE: Prospective, randomized, double-blind study of prophylactic antibiotics in axillary lymph node dissection. (ALND).
ARTICLE SOURCE: Am J Surg (United States), Sep 1998, 176(3) p239-43
AUTHOR(S): Bold RJ; Mansfield PF; Berger DH; Pollock RE; Singletary SE; Ames FC; Balch CM; Hohn DC; Ross MI
AUTHOR'S ADDRESS: Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: We demonstrated a trend toward fewer overall infections and significantly fewer severe infections in patients given prophylactic antibiotics, which translated into a decrease in the cost of treatment for infectious complications. These findings support antibiotic prophylaxis for patients undergoing ALND.

ARTICLE TITLE: Vena cava occlusion with balloon to control blood pressure during deployment of transluminally placed endovascular graft.
ARTICLE SOURCE: Am J Surg (United States), Sep 1998, 176(3) p233-4
AUTHOR(S): Nishikimi N; Usui A; Ishiguchi T; Matsushita M; Sakurai T; Nimura Y
AUTHOR'S ADDRESS: First Department of Surgery, Nagoya University School of Medicine, Japan.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Transluminally placed endovascular graft (TPEG) replacement has been applied to treat various aortic diseases. At the moment of deployment, TPEG receives a pressure pulse force to shove it distally, which possibly results in misplacement. Moreover, deploying the TPEG in the aorta increases cardiac afterload, which may damage myocardial function. To avoid these risks, we developed a new technique to control blood pressure by almost complete venous return occlusion. Two occlusion balloon catheters are inserted into the superior and inferior vena cava via the femoral vein. TPEG is deployed at the proper position during inflation of the vena cava balloon to maintain a blood pressure as low as 60 mm Hg by cardiac preload blockage. We, thus far, have not experienced even a trivial sequela with this technique.
MB. We have the greatest world experience of this operation. Having the systolic pressure not > 120 mm Hg is enough. Adenosine arrest is easier for the small number of thoracic aortas.

ARTICLE TITLE: Successful outcome in Swan-Ganz catheter-induced rupture of pulmonary artery.
ARTICLE SOURCE: Am Surg (United States), Nov 1998, 64(11) p1062-5
AUTHOR(S): Stancofski ED; Sardi A; Conaway GL
AUTHOR'S ADDRESS: Department of Surgery, St. Agnes HealthCare, Baltimore, Maryland, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Swan-Ganz catheter-induced pulmonary artery (PA) rupture is rare, with an incidence of 0.016 to 0.2 per cent, but it remains the most dreaded complication in the placement of these catheters with a mortality above 50 per cent. We report two cases of PA rupture after catheter placement. Both patients were managed nonoperatively and without any invasive procedure. They both stopped bleeding after the initial episode and were discharged a few days later. We believe that in the absence of high-risk factors, such as pulmonary hypertension and systemic anticoagulation, PA rupture from a Swan-Ganz catheter can be successfully treated by withdrawal of the catheter and supportive care.
MB. My 2 died.

ARTICLE TITLE: Meta-analysis of effectiveness of intermittent pneumatic compression devices with a comparison of thigh-high to knee-high sleeves.
ARTICLE SOURCE: Am Surg (United States), Nov 1998, 64(11) p1050-8
AUTHOR(S): Vanek VW
AUTHOR'S ADDRESS: Department of Surgery, St. Elizabeth Health Center, Youngstown, Ohio 44501, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
ABSTRACT: This meta-analysis used all original articles from 1966 to June 1996 that fit the preset inclusion criteria to examine the clinical effectiveness of intermittent pneumatic compression (IPC) devices in preventing deep vein thrombosis (DVT) and pulmonary embolism and to compare the results of knee-high sleeves to thigh-high sleeves. IPC devices decreased the relative risk of DVT by 62 per cent when compared with placebo, 47 per cent compared with graduated compression stockings, and 48 per cent compared with mini-dose heparin. IPC devices significantly decreased the relative risk of DVT compared with placebo in high-risk patients such as neurosurgery and major orthopedic surgery patients and in modest risk patients such as general surgery patients. In major orthopedic surgery patients, the incidence of DVT was similar for IPC- and warfarin-treated patients; however, IPC was significantly better than warfarin at decreasing the incidence of calf only DVT, whereas warfarin seemed to be better at decreasing proximal DVT. IPC devices are effective in decreasing the incidence of DVT in patients at moderate to high risk and are probably more efficacious than graduated compression stockings or mini-dose heparin; however, IPC devices are not protective against pulmonary embolism. The data directly comparing the various methods of compression (knee-high versus thigh-high sleeves and graded-sequential versus uniform compression) are sparse and conflicting.

ARTICLE TITLE: Update in hepatology.
ARTICLE SOURCE: Ann Intern Med (United States), Jan 5 1999, 130(1) p52-7
AUTHOR(S): Schiff ER
AUTHOR'S ADDRESS: University of Miami School of Medicine, Florida 33136, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (0 references); REVIEW, TUTORIAL

ARTICLE TITLE: Occupational exposures to body fluids among medical students. A seven-year longitudinal study [see comments]
COMMENTS: Comment in: Ann Intern Med 1999 Jan 5; 130(1):66-7
ARTICLE SOURCE: Ann Intern Med (United States), Jan 5 1999, 130(1) p45-51
AUTHOR(S): Osborn EH; Papadakis MA; Gerberding JL
AUTHOR'S ADDRESS: Palo Alto Medical Foundation, California 94301, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Medical students may be at high risk for occupational exposures to blood. OBJECTIVE: To measure the frequency of medical students' exposure to infectious body substances, to identify factors that affect the probability of such exposure, and to suggest targets for the prevention of such exposure. DESIGN: Review of all exposures reported by medical students at the University of California, San Francisco, School of Medicine. SETTING: Teaching hospitals affiliated with the University of California, San Francisco. PARTICIPANTS: Third- and fourth-year medical students from the classes of 1990 through 1996 at the University of California, San Francisco, School of Medicine. INTERVENTIONS: A needlestick hotline service was instituted at teaching hospitals affiliated with the University of California, San Francisco, and a required course was created to train students in universal precautions and clinical skills before the beginning of the third-year clerkship. MEASUREMENTS: Reports of exposures made to the needlestick hotline service, including type of exposure, training site, clerkship, and time of year. RESULTS: 119 of 1022 medical students sustained 129 exposures. Of these exposures, 82% occurred on four services: obstetrics-gynecology, surgery, medicine, and emergency medicine. The probability of exposure was not related to graduation year, clerkship location, previous clerkship experience, or training site. Surveys of two graduating classes at the beginning and end of the study showed that the percentage of exposures reported increased from 45% to 65% over the 7-year study period. Thus, the reported injury rates represent minimum estimates of actual occurrences. Human immunodeficiency virus infection and hepatitis were not reported, although follow-up was limited. CONCLUSIONS: Instruction in universal precautions and clinical procedures is not sufficient to prevent exposures to blood during medical training. Medical schools must assume greater responsibility for ensuring that students are proficient in the safe conduct of clinical procedures and must develop systems that protect students so that they can report and learn from their mistakes.
MB. Most anaesthetists and registrars become worse environmental hazard when they put on gloves. Nearly all central lnes have patient blood all over the external connections.

ARTICLE TITLE: Protecting the future of medicine--from themselves [editorial; comment]
COMMENTS: Comment on: Ann Intern Med 1999 Jan 5; 130(1):45-51
ARTICLE SOURCE: Ann Intern Med (United States), Jan 5 1999, 130(1) p66-7
AUTHOR(S): Federman DD
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Probable transmission of HIV from an orthopedic surgeon to a patient in France [see comments]
COMMENTS: Comment in: Ann Intern Med 1999 Jan 5; 130(1):64-5
ARTICLE SOURCE: Ann Intern Med (United States), Jan 5 1999, 130(1) p1-6
AUTHOR(S): Lot F; Seguier JC; Fegueux S; Astagneau P; Simon P; Aggoune M; van Amerongen P; Ruch M; Cheron M; Brucker G; Desenclos JC; Drucker J
AUTHOR'S ADDRESS: Reseau National de Sante Publique, Saint-Maurice, France. Lot@b3e.jussieu.fr.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Transmission of HIV from infected health care workers to patients has been documented in only one cluster involving 6 patients of a dentist in Florida. In October 1995, the French Ministry of Health offered HIV testing to patients who had been operated on by an orthopedic surgeon in whom AIDS was recently diagnosed. OBJECTIVE: To determine whether the surgeon transmitted HIV to patients during operations. DESIGN: Epidemiologic investigation. SETTING: The practice of an orthopedic surgeon in a French public hospital. PARTICIPANTS: 1 surgeon and 983 of his former patients. MEASUREMENTS: 3004 patients who had undergone invasive procedures were contacted by mail for counseling and HIV testing. One HIV-positive patient was interviewed, and DNA sequence analysis was performed to compare the genetic relation of the patient's and the surgeon's viruses. Infection-control precautions and the surgeon's practices were assessed. RESULTS: Of 983 patients in whom serologic status was ascertained, 982 were HIV negative and 1 was HIV positive. The HIV-positive patient, a woman born in 1925, tested negative for HIV before placement of a total hip prosthesis with bone graft (a prolonged operation) performed by the surgeon in 1992. She had no identified risk for HIV exposure. Molecular analysis indicated that the viral sequences obtained from the surgeon and the HIV-infected woman were closely related. Infection-control precautions were in accordance with recommendations, but blood contact between the surgeon and his patients occurred commonly during surgical procedures. CONCLUSIONS: An HIV-infected surgeon may have transmitted HIV to one of his patients during surgery.

ARTICLE TITLE: Provider-to-patient HIV transmission: how to keep it exceedingly rare [editorial; comment]
COMMENTS: Comment on: Ann Intern Med 1999 Jan 5; 130(1):1-6
ARTICLE SOURCE: Ann Intern Med (United States), Jan 5 1999, 130(1) p64-5
AUTHOR(S): Gerberding J
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Fifty years of death certificates: the Framingham Heart Study [editorial; comment]
COMMENTS: Comment on: Ann Intern Med 1998 Dec 15; 129(12):1020-6
ARTICLE SOURCE: Ann Intern Med (United States), Dec 15 1998, 129(12) p1066-7
AUTHOR(S): Lenfant C; Friedman L; Thom T
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Accuracy of death certificates for coding coronary heart disease as the cause of death [see comments]
COMMENTS: Comment in: Ann Intern Med 1998 Dec 15; 129(12):1066-7
ARTICLE SOURCE: Ann Intern Med (United States), Dec 15 1998, 129(12) p1020-6
AUTHOR(S): Lloyd-Jones DM; Martin DO; Larson MG; Levy D
AUTHOR'S ADDRESS: National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Death certificates are widely used in epidemiologic and clinical investigations and for national statistics. CONCLUSIONS: Coronary heart disease may be overrepresented as a cause of death on death certificates. National mortality statistics, which are based on death certificate data, may overestimate the frequency of coronary heart disease by 7.9% to 24.3% overall and by as much as two-fold in older persons.

ARTICLE TITLE: Compliance with do-not-resuscitate orders for hospitalized patients transported to radiology departments [see comments]
COMMENTS: Comment in: Ann Intern Med 1998 Nov 15; 129(10):831-3
ARTICLE SOURCE: Ann Intern Med (United States), Nov 15 1998, 129(10) p801-5
AUTHOR(S): Heffner JE; Barbieri C
AUTHOR'S ADDRESS: Mercy Health Services Research Group, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85001, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Little is known about the effectiveness of do-not-resuscitate (DNR) orders during transport of hospitalized patients away from their rooms. OBJECTIVE: To determine compliance with DNR orders in radiology departments. DESIGN: Observational study. SETTING: 248 hospital-based radiology departments. PARTICIPANTS: 248 radiology department representatives. MEASUREMENTS: 10-item questionnaire examining the response of radiology personnel to patients with DNR orders who experience cardiopulmonary arrest. RESULTS: Written DNR protocols and structured procedures for communicating DNR status were used by 18.5% (CI, 13.7% to 23.4%) and 18.1% (CI, 13.3% to 23.0%) of departments, respectively. Medical chart review was the only source of information on DNR status for 41.5% (CI, 35.4% to 47.7%) of departments. It was found that 20.2% of respondents (CI, 15.2% to 25.2%) would resuscitate patients with DNR orders and that 38.3% (CI, 32.3% to 44.4%) had resuscitated patients with DNR orders in the past. CONCLUSIONS: Most radiology departments do not have formal procedures to prevent patients from undergoing unwanted or inappropriate resuscitative interventions, and DNR orders are frequently overruled.

ARTICLE TITLE: Resuscitation and the radiologist [editorial] [comment]
COMMENTS: Comment on: Ann Intern Med 1998 Nov 15; 129(10):801-5
ARTICLE SOURCE: Ann Intern Med (United States), Nov 15 1998, 129(10) p831-3
AUTHOR(S): McDermott VG
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. It is impossible for people casually seeing patients to interpret bald `Do not resuscitate orders'.

ARTICLE TITLE: The magic white coat.
ARTICLE SOURCE: Ann Intern Med (United States), Nov 1 1998, 129(9) p743
AUTHOR(S): Druss RG
AUTHOR'S ADDRESS: Columbia P&S, New York, NY 10128, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
MB. No one seems to wear white coats here any more.

ARTICLE TITLE: Deconstructing the white coat [editorial; comment]
COMMENTS: Comment on: Ann Intern Med 1998 Nov 1; 129(9):734-7
ARTICLE SOURCE: Ann Intern Med (United States), Nov 1 1998, 129(9) p740-2
AUTHOR(S): Branch WT Jr
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: On white coats and professional development: the formal and the hidden curricula [see comments]
COMMENTS: Comment in: Ann Intern Med 1998 Nov 1; 129(9):740-2
ARTICLE SOURCE: Ann Intern Med (United States), Nov 1 1998, 129(9) p734-7
AUTHOR(S): Wear D
AUTHOR'S ADDRESS: Northeastern Ohio Universities College of Medicine, Rootstown 44272, USA. dw@neoucom.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: White coat ceremonies are a recent phenomenon in medical education. Selected as a symbol by the Arnold P. Gold Foundation to impress upon medical students the importance of compassion and humility, the white coat has had a long association with all things medical, scientific, and healing. It is also associated with the attributes of purity and goodness traditionally symbolized by the color white. Thus, its selection as the material focus of the white coat ceremony seems natural. This article situates the white coat ceremony as a curricular event and suggests that, in addition to having the meanings cited above, the white coat has other meanings that fall into the realm of the hidden curriculum--it can symbolize caregiving hierarchies and spheres of practice, the social and economic privilege of physicians, and medicine's well-established practices of determining membership in the profession. Finally, this paper suggests several other ceremonies or rituals that may be better than the white coat ceremony for encouraging compassion and humility in medical students.
MB. I don't think that anyone will become better after such rituals.
The last 3 articles are amazing.

ARTICLE TITLE: Temporary abdominal closure: a prospective evaluation of its effects on renal and respiratory physiology.
ARTICLE SOURCE: J Trauma (United States), Nov 1998, 45(5) p914-21
AUTHOR(S): Sugrue M; Jones F; Janjua KJ; Deane SA; Bristow P; Hillman K
AUTHOR'S ADDRESS: Department of Surgery, Liverpool Hospital, Sydney, Australia. m.sugrue@unsw.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT. The mean number of abdominal operations after mesh insertion was 2.6+/-2.4. There were 21 deaths, for a standardized mortality rate of 0.80. Although it achieved significant reductions in abdominal pressures and improved lung dynamic compliance, TAC did not result in improved renal function or patient oxygenation.

ARTICLE TITLE: Lactated ringer's is superior to normal saline in a model of massive hemorrhage and resuscitation.
ARTICLE SOURCE: J Trauma (United States), Nov 1998, 45(5) p894-9
AUTHOR(S): Healey MA; Davis RE; Liu FC; Loomis WH; Hoyt DB
AUTHOR'S ADDRESS: Department of Surgery, University of Saskatchewan, Saskatoon, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: With moderate hemorrhage, NS and LR are equivalent, but in the setting of massive hemorrhage and resuscitation, significantly more physiologic derangement and mortality occurs with NS than LR. LR is superior to NS for use in massive resuscitation.

ARTICLE TITLE: Empiric therapy of sepsis in the surgical intensive care unit with broad-spectrum antibiotics for 72 hours does not lead to the emergence of resistant bacteria.
ARTICLE SOURCE: J Trauma (United States), Nov 1998, 45(5) p887-91
AUTHOR(S): Namias N; Harvill S; Ball S; McKenney MG; Salomone JP; Sleeman D; Civetta JM
AUTHOR'S ADDRESS: University of Miami School of Medicine, Jackson Memorial Hospital, FL 33101, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: It is our practice to treat suspected sepsis with imipenem/cilastatin and gentamicin (IMP/GENT) for 72 hours while awaiting culture results. CONCLUSION: This protocol did not lead to the emergence of resistant bacteria.

ARTICLE TITLE: Base deficit in the elderly: a marker of severe injury and death.
ARTICLE SOURCE: J Trauma (United States), Nov 1998, 45(5) p873-7
AUTHOR(S): Davis JW; Kaups KL
AUTHOR'S ADDRESS: Tampa General Hospital, University of South Florida, Tampa 33606, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: A base deficit of < or = -6 is a marker of severe injury and significant mortality in all trauma patients, but it is particularly ominous in patients 55 years and older. Patients older than 55 years may have significant injuries and mortality risk without manifesting a base deficit out of the normal range.

ARTICLE TITLE: Is resection of pulmonary and hepatic metastases warranted in patients with colorectal cancer?
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Jan 1999, 117(1) p66-75; discussion 75-6
AUTHOR(S): Robinson BJ; Rice TW; Strong SA; Rybicki LA; Blackstone EH
AUTHOR'S ADDRESS: Departments of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Younger patients with solitary metachronous metastases to the liver, then the lung, and long disease-free intervals are more likely to benefit from resection of both liver and lung metastases. Patients with risk factors also had better survival with resection than without resection.

ARTICLE TITLE: Comparison of the effects of transfusions of cryopreserved and liquid-preserved platelets on hemostasis and blood loss after cardiopulmonary bypass.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Jan 1999, 117(1) p172-83; discussion 183-4
AUTHOR(S): Khuri SF; Healey N; MacGregor H; Barnard MR; Szymanski IO; Birjiniuk V; Michelson AD; Gagnon DR; Valeri CR
AUTHOR'S ADDRESS: Department of Surgery, Brockton/West Roxbury Veterans Administration Medical Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: OBJECTIVE: The aim of the study was to compare the clinical effects and hemostatic efficiency of transfusions of platelets preserved in the frozen state for as long as 2 years with transfusions of platelets preserved in the conventional manner for as long as 5 days in patients undergoing cardiopulmonary bypass. METHODS: Seventy-three patients were prospectively randomly assigned to receive transfusions of cryopreserved or liquid-preserved platelets. Nonsurgical blood loss was measured during and after the operation. Bleeding time, hematologic variables, and the bleeding time site shed blood were assayed before cardiopulmonary bypass and at 30 minutes and 2, 4, and 24 hours after transfusion. In vitro platelet function tests were conducted on platelets obtained from healthy volunteers. RESULTS: No adverse sequelae of the transfusions were observed. Blood loss and the need for postoperative blood product transfusions were lower in the group receiving cryopreserved platelets. Lower posttransfusion platelet increments and a tendency toward decreased platelet survival were observed in patients receiving cryopreserved platelets. Hematocrit and plasma fibrinogen were significantly higher in this group, and the duration of intubation was shorter. In vitro, cryopreserved platelets demonstrated less aggregation, lower pH, and decreased response to hypotonic stress but generated more procoagulant activity and thromboxane. CONCLUSIONS: (1) Cryopreserved platelet transfusions are superior to liquid-preserved platelets in reducing blood loss and the need for blood product transfusions after cardiopulmonary bypass. (2) The reduction in blood loss in the patients receiving cryopreserved platelet transfusions after cardiopulmonary bypass probably reflects improved in vivo hemostatic function of cryopreserved platelets. (3) Some in vitro measures of platelet quality (aggregation, pH, hypotonic stress) may not reflect in vivo quality of platelet transfusions after cardiopulmonary bypass, whereas other in vitro measures (platelet procoagulant activity and thromboxane) do.

ARTICLE TITLE: Neuropsychologic outcome after deep hypothermic circulatory arrest in adults.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Jan 1999, 117(1) p156-63
AUTHOR(S): Reich DL; Uysal S; Sliwinski M; Ergin MA; Kahn RA; Konstadt SN; McCullough J; Hibbard MR; Gordon WA; Griepp RB
AUTHOR'S ADDRESS: Departments of Anesthesiology, Cardiothoracic Surgery, and Rehabilitation Medicine, The Mount Sinai-New York University Medical Center, New York, NY 10029-6574, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: INTRODUCTION: Pediatric patients undergoing prolonged periods of deep hypothermic circulatory arrest have been found to experience long-term deficits in cognitive function. However, there is limited information of this type in adult patients who are undergoing deep hypothermic circulatory arrest for thoracic aortic repairs. METHODS: One hundred forty-nine patients undergoing elective cardiac or thoracic aortic operations were evaluated preoperatively; 106 patients were evaluated early in the postoperative period (EARLY), and 77 patients were evaluated late in the postoperative period (LATE) with a battery of neuropsychologic tests. Seventy-three patients had routine cardiac operations without deep hypothermic circulatory arrest, and 76 patients with deep hypothermic circulatory arrest were divided into 2 subgroups: those with 1 to 24 minutes of deep hypothermic circulatory arrest (n = 36 patients) and those with 25 minutes or more of deep hypothermic circulatory arrest (n = 40 patients). The neuropsychologic test battery consisted of 8 tests encompassing 5 domains: attention, processing speed, memory, executive function, and fine motor function. Data were normalized to baseline values, and changes from baseline were analyzed by analysis of covariance, multivariate logistic regression, and survival functions. RESULTS: In all domains, poor performance or inability to be tested EARLY were significant predictors of poor performance LATE (odds ratio, 5.27; P <.01). Deep hypothermic circulatory arrest of 25 minutes or more and advanced age were significant predictors of poor performance LATE for the memory and fine motor domains. Deep hypothermic circulatory arrest of 25 minutes or more (odds ratio, 4. 0; P =.02) was a determinant of prolonged hospital stay (>21 days). CONCLUSION: Deep hypothermic circulatory arrest of 25 minutes or more and advanced age were associated with memory and fine motor deficits and with prolonged hospital stay.

ARTICLE TITLE: Atherosclerosis of the ascending aorta is a predictor of renal dysfunction after cardiac operations.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Jan 1999, 117(1) p111-6
AUTHOR(S): Davila-Roman VG; Kouchoukos NT; Schechtman KB; Barzilai B
AUTHOR'S ADDRESS: Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine and Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: An atherosclerotic ascending aorta is an important predictor of postoperative renal dysfunction, possibly because atheroembolism to the kidneys occurs in the perioperative period (ie, during surgical manipulation of an atherosclerotic aorta) or because the diseased aorta may be a marker of widespread atherosclerotic disease that may predispose to perioperative renal dysfunction.

ARTICLE TITLE: Policy statement: minimally invasive coronary artery bypass surgery. STS/AATS Ad Hoc Committee on New Technology Assessment. American Association for Thoracic Surgery.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Nov 1998, 116(5) p887-8
AUTHOR(S): Cohn LH; Chitwood WR; Dralle JG; Emery RW; Esposito RA; Fonger JD; Heitmiller RF; Kaiser LK; Landreneau RJ; Lerut TE; Lytle BW; Mack M; McBride LR; Reitz BA; Schaff HV; Subramanian VA; Svennevig JL; Swain JA; Ullyot DJ
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Postischemic hyperthermia exacerbates neurologic injury after deep hypothermic circulatory arrest.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Nov 1998, 116(5) p780-92
AUTHOR(S): Shum-Tim D; Nagashima M; Shinoka T; Bucerius J; Nollert G; Lidov HG; du Plessis A; Laussen PC; Jonas RA
AUTHOR'S ADDRESS: Department of Cardiovascular Surgery, Children's Hospital, Harvard Medical School, Boston, Mass 02115, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Mild postischemic hyperthermia significantly exacerbates functional and structural neurologic injury after deep hypothermic circulatory arrest and should therefore be avoided.

ARTICLE TITLE: Transmyocardial laser revascularization fails to prevent left ventricular functional deterioration and aneurysm formation after acute myocardial infarction in sheep.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Nov 1998, 116(5) p752-62
AUTHOR(S): Malekan R; Kelley ST; Suzuki Y; Reynolds C; Plappert T; Sutton MS; Edmunds LH Jr; Bridges CR
AUTHOR'S ADDRESS: Department of Surgery, University of Pennsylvania, Philadelphia, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Transmyocardial laser perforations do not revascularize acute myocardial infarction in sheep.

ARTICLE TITLE: Aprotinin and vein graft occlusion--the controversy continues [editorial]
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Nov 1998, 116(5) p731-3
AUTHOR(S): Westaby S; Katsumata T
PUBLICATION TYPE: EDITORIAL
Occluded CABGs is a high price to pay for an average saving of 250 ml blood.

ARTICLE TITLE: The efficacy and safety of aprotinin use in cardiac surgery.
ARTICLE SOURCE: Ann Thorac Surg (United States), Nov 1998, 66(5 Suppl) pS6-11; discussion S25-8
AUTHOR(S): Rich JB
AUTHOR'S ADDRESS: Department of Surgery, Eastern Virginia Medical School, Sentara Norfolk General Hospital, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (20 references); REVIEW, TUTORIAL
ABSTRACT: BACKGROUND: The serine protease inhibitor aprotinin has received much attention in cardiac surgical practice as a pharmacologic intervention to improve the hemostatic derangement associated with cardiopulmonary bypass. This review highlights the major studies undertaken to investigate the efficacy and safety of aprotinin use in both primary and repeat coronary artery bypass graft surgical procedures. METHODS: There have been at least 45 controlled studies in more than 7,000 patients in a variety of patient populations. These have ranged from primary coronary artery bypass graft and valve operations to complex reoperation procedures, including aortic arch reconstructions and thoracic organ transplantation. The recently completed International Multicenter Graft Patency Experience trial, the largest study to date, involved 870 patients at 13 international sites. The study examined the effects of aprotinin on graft patency, incidence of myocardial infarction, and blood loss in patients undergoing primary coronary artery bypass graft operations with cardiopulmonary bypass. RESULTS: Twenty-one studies in approximately 5,000 patients undergoing primary coronary artery bypass graft or valve operations reported 33% to 66% reduction in blood loss with full-dose aprotinin therapy; 15 of the same studies reported significant reductions in transfusion requirements, ranging from 31% to 85%. The recently completed International Multicenter Graft Patency Experience study observed a significant reduction in thoracic-drainage volume of 43% (p < 0.0001) and a 49% (p < 0.001) reduction in the requirement for allogeneic blood transfusions. Aprotinin did not affect the occurrence of definite myocardial infarction (aprotinin, 2.9% versus placebo, 3.8%) or mortality (aprotinin, 1.4% versus placebo, 1.6%). There was no observed difference in the patency of internal mammary artery bypass grafts from all study sites in aprotinin- versus placebo-treated patients (aprotinin, 98.2% versus placebo, 98.0%). CONCLUSIONS: Given the risks and costs associated with excessive bleeding and transfusions and the limited supply of banked blood, aprotinin represents an important and safe approach to blood conservation.

ARTICLE TITLE: Analyses of coronary graft patency after aprotinin use: results from the International Multicenter Aprotinin Graft Patency Experience (IMAGE) trial.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Nov 1998, 116(5) p716-30
AUTHOR(S): Alderman EL; Levy JH; Rich JB; Nili M; Vidne B; Schaff H; Uretzky G; Pettersson G; Thiis JJ; Hantler CB; Chaitman B; Nadel A
AUTHOR'S ADDRESS: Division of Cardiovascular Medicine, Stanford University Medical Center, Calif 94305, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: In this study, the probability of early vein graft occlusion was increased by aprotinin, but this outcome was promoted by multiple risk factors for graft occlusion.

ARTICLE TITLE: The "first generation" of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Nov 1998, 116(5) p689-703; discussion 703-4
AUTHOR(S): Dake MD; Miller DC; Mitchell RS; Semba CP; Moore KA; Sakai T
AUTHOR'S ADDRESS: Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Calif, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: Our goal was to determine whether endovascular stent-grafting is feasible and effective for patients with aneurysms of the descending thoracic aorta. METHODS: Starting in July 1992, we conducted a prospective, uncontrolled clinical trial in 103 patients (mean age 69 years [range 34-89 years]) who underwent endovascular treatment of aneurysms of the descending thoracic aorta using a custom-fabricated, self-expanding stent-graft device. Follow-up was 100% complete and averaged 22 months. Sixty-two patients (60%) were judged not to be reasonable candidates for a conventional "open" surgical procedure. RESULTS: Complete thrombosis of the aneurysm was ultimately achieved in 86 (83%) patients. The early mortality rate was 9% +/- 3% (+/- 70% CL). Multivariable analysis revealed that myocardial infarction or stroke was linked with a higher likelihood of early death (P = .001). Early serious complications included paraplegia in 3% +/- 2% and stroke in 7% +/- 3%. Actuarial survival estimates at 1 year and 2 years were 81% +/- 4% and 73% +/- 5% (+/- 1 SE), respectively; being judged not to be a surgical candidate portended a higher probability of death (P = .003). According to the intent-to-treat principle, "treatment failure" (including all late sudden unexplained deaths) occurred in 38 patients; 53% +/- 10% of patients were free from treatment failure at 3.7 years. Stent-graft related complications occurred commonly and were linked with several anatomic, technical, and patient-related risk factors. CONCLUSIONS: This 5-year clinical trial involving use of a "first generation" device indicates that endovascular stent-grafting of descending thoracic aortic aneurysms is feasible with acceptable medium-term results. More refined, commercially developed devices available today offer less traumatic and more precise stent-graft deployment; these major technical advantages, coupled with important lessons we have learned over time and better patient selection, should be associated with more salutary clinical results in the future.

ARTICLE TITLE: Long-term survival of patients with coronary artery disease and left ventricular dysfunction: implications for the role of myocardial viability assessment in management decisions.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Dec 1998, 116(6) p997-1004
AUTHOR(S): Di Carli MF; Maddahi J; Rokhsar S; Schelbert HR; Bianco-Batlles D; Brunken RC; Fromm B
AUTHOR'S ADDRESS: Division of Nuclear Medicine, Department of Medical and Molecular Pharmacology, UCLA School of Medicine, Los Angeles, CA, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Patients with low ejection fraction and evidence of viable myocardium by positron emission tomography have improved survival and symptoms with coronary bypass grafting compared with medical therapy. In patients without evidence of viability, survival and symptom improvement with bypass grafting are apparent only among those patients with severe angina.

ARTICLE TITLE: Management of vasodilatory shock after cardiac surgery: identification of predisposing factors and use of a novel pressor agent.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Dec 1998, 116(6) p973-80
AUTHOR(S): Argenziano M; Chen JM; Choudhri AF; Cullinane S; Garfein E; Weinberg AD; Smith CR Jr; Rose EA; Landry DW; Oz MC
AUTHOR'S ADDRESS: Departments of Surgery and Medicine, Columbia University College of Physicians and Surgeons, New York, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Low ejection fraction and angiotensin-converting enzyme inhibitor use are risk factors for postbypass vasodilatory shock, and this syndrome is associated with vasopressin deficiency. In patients exhibiting this syndrome after high-risk cardiac operations, replacement of arginine vasopressin increases blood pressure and reduces catecholamine pressor requirements.

ARTICLE TITLE: Assessing disability after head injury: improved use of the Glasgow Outcome Scale.
ARTICLE SOURCE: J Neurosurg (United States), Dec 1998, 89(6) p939-43
AUTHOR(S): Pettigrew LE; Wilson JT; Teasdale GM
AUTHOR'S ADDRESS: Department of Neurosurgery, University of Glasgow, United Kingdom.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Pitfalls of bungee jumping. Case report and review of the literature.
ARTICLE SOURCE: J Neurosurg (United States), Dec 1998, 89(6) p1040-2
AUTHOR(S): Louw D; Reddy KK; Lauryssen C; Louw G
AUTHOR'S ADDRESS: Department of Neurological Surgery, Oregon Health Sciences University, Portland 97201-3098, USA. louwd@ohsu.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (08 references); REVIEW OF REPORTED CASES

ARTICLE TITLE: Methylprednisolone or tirilazad mesylate administration after acute spinal cord injury: 1-year follow up. Results of the third National Acute Spinal Cord Injury randomized controlled trial.
ARTICLE SOURCE: J Neurosurg (United States), Nov 1998, 89(5) p699-706
AUTHOR(S): Bracken MB; Shepard MJ; Holford TR; Leo-Summers L; Aldrich EF; Fazl M; Fehlings MG; Herr DL; Hitchon PW; Marshall LF; Nockels RP; Pascale V; Perot PL Jr; Piepmeier J; Sonntag VK; Wagner F; Wilberger JE; Winn HR; Young W
AUTHOR'S ADDRESS: Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut 06520-8034, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL

ARTICLE TITLE: Application of cryoprecipitate as a hematostatic glue.
ARTICLE SOURCE: J Cardiovasc Surg (Torino) (Italy), Oct 1998, 39(5) p609-12
AUTHOR(S): Shiono N; Koyama N; Watanabe Y; Tokuhiro K; Suzuki N; Fujii T; Ozawa T; Sakuragawa H; Ohsawa H; Iwashita Y; Sensui S; Yamazaki S
AUTHOR'S ADDRESS: Department of Thoracic and Cardiovascular Surgery, Toho University, School of Medicine, Tokyo, Japan.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: The effectiveness of cryoprecipitate, harvested from a patient's own fresh frozen plasma, for use in cardiac surgery as a hematostatic glue was studied in 32 randomized elective adult cardiac surgery patients from January 1993 to July 1994. MATERIALS AND METHODS: Patients from the Toho Sakura Hospital were randomly allocated to two groups: Group 1 (n=11) received conventional fibrin glue presently available in our institution; while Group 2 (n=21) received autologous cryoprecipitate as a hematostatic glue. Surgical procedures broken down by group were as follows: Group 1: 4 CABG, 5 valvular surgeries and 2 other. Group 2: 11 CABG, 6 valvular surgery, 4 other. We preserved the patient's own blood and stored pure red cell and fresh frozen plasma (FFP). Cryoprecipitate was prepared from the FFP and preserved until required. RESULTS: Cryoprecipitate had a 5-fold increase in fibrinogen activity (1190+/-311 mg/dl vs 238+/-34 mg/dl p<0.001), a 10-fold increase in factor VIII activity (362+/-219% vs 34+/-11%, p=0.001), and 4.5-fold increase in factor XIII activity (538+/-213% vs 119+/-50%, p<0.001), compared to serum. The amount of bleeding postoperatively was slightly lower in the cryoprecipitate glue group compared to the conventional glue group, but this was not significantly different. CONCLUSIONS: We conclude that autologous samples of human cryoprecipitate prepared from a patient's own FFP had a strong hematostatic effect compared to conventional fibrin glue and was a very valuable hematostatic agent during cardiac surgery.

ARTICLE TITLE: Endotoxemia after elective surgery for abdominal aortic aneurysm and the effect of early oral feeding.
ARTICLE SOURCE: J Cardiovasc Surg (Torino) (Italy), Oct 1998, 39(5) p547-9
AUTHOR(S): Sugita T; Watarida S; Katsuyama K; Nakajima Y; Yamamoto R; Matsuno S; Tabata R; Mori A
AUTHOR'S ADDRESS: Second Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Japan.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: A low concentration of systemic endotoxins can be observed after surgery for abdominal aortic aneurysm, and early oral feeding prevented this elevation.

ARTICLE TITLE: The influence of cardiopulmonary function on outcome of veterans undergoing resectional therapy for lung cancer.
ARTICLE SOURCE: J Cardiovasc Surg (Torino) (Italy), Aug 1998, 39(4) p497-501
AUTHOR(S): Canver CC; Cooler SD; Nichols RD
AUTHOR'S ADDRESS: Section of Cardiothoracic Surgery, William S. Middleton Memorial Veterans Hospital, University of Wisconsin School of Medicine, Madison 53792, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Preoperative cardiopulmonary risk for veterans with bronchogenic cancer is acceptable and lung resection can be performed with good outcomes in this distinct patient population.

ARTICLE TITLE: Surgical results for thoraco-abdominal aneurysm by modified DeBakey method using centrifugal biopump and renal cryopreservation.
ARTICLE SOURCE: J Cardiovasc Surg (Torino) (Italy), Aug 1998, 39(4) p399-404
AUTHOR(S): Yamashita C; Okada M; Ataka K; Yoshida M; Nohara H; Azami T; Yamashita T; Ozaki N
AUTHOR'S ADDRESS: Department of Surgery, Kobe University School of Medicine, Japan.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: In conclusion, by using different techniques for spinal cord and visceral protection, including the Gott shunt, Biomedicus pump, renal cryopreservation, and separate revascularization of viscera and intercostal arteries, good results could be obtained.
MB. Not a controlled trial. 2 of 22 became paraplegic

ARTICLE TITLE: Effect of beverage osmolality on intestinal fluid absorption during exercise.
ARTICLE SOURCE: J Appl Physiol (United States), Nov 1998, 85(5) p1941-8
AUTHOR(S): Gisolfi CV; Summers RW; Lambert GP; Xia T
AUTHOR'S ADDRESS: Departments of Exercise Science and Internal Medicine, University of Iowa, Iowa City, Iowa 52242-1111, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT. We conclude that total fluid absorption of 6% CHO-electrolyte beverages from the duodenojejunum during exercise, within the osmotic range studied, is not different from water placebo.

ARTICLE TITLE: Susceptibility to periodic breathing with assisted ventilation during sleep in normal subjects.
ARTICLE SOURCE: J Appl Physiol (United States), Nov 1998, 85(5) p1929-40
AUTHOR(S): Meza S; Mendez M; Ostrowski M; Younes M
AUTHOR'S ADDRESS: Respiratory Medicine, University of Manitoba, Winnipeg, Manitoba, Canada R3A 1R8.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We conclude that 1) a PCO2 apneic threshold exists during sleep at 1.5-5.8 Torr below eupneic PCO2, 2) the development of periodic breathin during assisted ventilation with pressure support (PSV) is entirely predictable during sleep, and 3) the inherent susceptibility to PB varies considerably among normal subjects.

ARTICLE TITLE: Kinetics of oxygen uptake at the onset of exercise in boys and men.
ARTICLE SOURCE: J Appl Physiol (United States), Nov 1998, 85(5) p1833-41
AUTHOR(S): Hebestreit H; Kriemler S; Hughson RL; Bar-Or O
AUTHOR'S ADDRESS: Universitats-Kinderklinik, 97080 Wurzburg, Germany. KINK085@mail.uni-wuerzburg.de.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: In conclusion, O2 deficit and fast-component O2 uptake on-transients are similar in boys and men, even at high exercise intensities, which is in contrast to the findings of other studies employing simpler methods of analysis. The previous interpretation that children rely less on nonoxidative energy pathways at the onset of heavy exercise is not supported by our findings.

ARTICLE TITLE: Maintained exercise pressor response in heart failure.
ARTICLE SOURCE: J Appl Physiol (United States), Nov 1998, 85(5) p1793-9
AUTHOR(S): Shoemaker JK; Kunselman AR; Silber DH; Sinoway LI
AUTHOR'S ADDRESS: Section of Cardiology, Pennsylvania State University College of Medicine, The Milton S. Hershey Medical Center, Hershey, 17033, Pennsylvania.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: These data suggest that muscle reflex activation of the pressor response is intact in heart failure subjects but the resulting improvement in perfusion pressure does not appear to enhance muscle oxidative metabolism or muscle blood flow, possibly because of associated increases in sympathetic vasoconstriction of active skeletal muscle.

ARTICLE TITLE: Recovery from mild hypothermia can be accelerated by mechanically distending blood vessels in the hand.
ARTICLE SOURCE: J Appl Physiol (United States), Nov 1998, 85(5) p1643-8
AUTHOR(S): Grahn D; Brock-Utne JG; Watenpaugh DE; Heller HC
AUTHOR'S ADDRESS: Department of Biological Sciences, School of Medicine, Stanford University, Stanford, California 94305, USA. dagrahn@leland.stanford.edu.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: Peripheral vasoconstriction decreases thermal conductance of hypothermic individuals, making it difficult to transfer externally applied heat to the body core. We hypothesized that increasing blood flow to the skin of a hypothermic individual would enhance the transfer of exogenous heat to the body core, thereby increasing the rate of rewarming. External auditory meatus temperature (TEAM) was monitored in hypothermic subjects during recovery from general anesthesia. In 10 subjects, heat (45-46 degreesC, water-perfused blanket) was applied to a single forearm and hand that had been placed in a subatmospheric pressure environment (-30 to -40 mmHg) to distend the blood vessels. Heat alone was applied to control subjects (n = 6). The application of subatmospheric pressure resulted in a 10-fold increase in rewarming rates as determined by changes in TEAM [13.6 +/- 2.1 (SE) degreesC/h in the experimental group vs. 1.4 +/- 0.1 degreesC/h in the control group; P < 0.001]. In the experimental subjects, the rate of change of TEAM decreased sharply as TEAM neared the normothermic range.

ARTICLE TITLE: Effect of sodium in a rehydration beverage when consumed as a fluid or meal.
ARTICLE SOURCE: J Appl Physiol (United States), Oct 1998, 85(4) p1329-36
AUTHOR(S): Ray ML; Bryan MW; Ruden TM; Baier SM; Sharp RL; King DS
AUTHOR'S ADDRESS: Exercise Biochemistry Laboratory, Department of Health and Human Performance, Iowa State University, Ames, Iowa 50011, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: To investigate the impact of fluid composition on rehydration effectiveness, 30 subjects (15 men and 15 women) were studied during 2 h of rehydration after a 2.5% body weight loss. In a randomized crossover design, subjects rehydrated with water (H2O), chicken broth (CB: 109.5 mmol/l Na, 25.3 mmol/l K), a carbohydrate-electrolyte drink (CE: 16.0 mmol/l Na, 3.3 mmol/l K), and chicken noodle soup (Soup: 333.8 mmol/l Na, 13.7 mmol/l K). Subjects ingested 175 ml at the start of rehydration and 20 min later; H2O was given every 20 min thereafter for a total volume equal to body weight loss during dehydration. At the end of the rehydration period, plasma volume was not significantly different from predehydration values in the CB (-1.6 +/- 1.1%) and Soup (-1.4 +/- 0.9%) trials. In contrast, plasma volume remained significantly (P < 0.01) below predehydration values in the H2O (-5.6 +/- 1.1%) and CE (-4.2 +/- 1.0%) trials after the rehydration period. Urine volume was greater in the CE (310 +/- 30 ml) than in the CB (188 +/- 20 ml) trial. Urine osmolality was higher in the CB and Soup trials than in the CE trial. Urinary sodium concentration was higher in the Soup and CB trials than in the CE and H2O trials. These results provide evidence that the inclusion of sodium in rehydration beverages, as well as consumption of a sodium-containing liquid meal, increases fluid retention and improves plasma volume restoration.
MB This is what I thought. Gatorade contains 18 mmol/litre & 3 mmol/litre

ARTICLE TITLE: Exertional fatigue, sleep loss, and negative energy balance increase susceptibility to hypothermia.
ARTICLE SOURCE: J Appl Physiol (United States), Oct 1998, 85(4) p1210-7
AUTHOR(S): Young AJ; Castellani JW; O'Brien C; Shippee RL; Tikuisis P; Meyer LG; Blanchard LA; Kain JE; Cadarette BS; Sawka MN
AUTHOR'S ADDRESS: United States Army Research Institute of Environmental Medicine, Natick, Massachusetts 01760, USA. ayoung@natick-ccmail.army.mil.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: The purpose of this study was to determine how chronic exertional fatigue and sleep deprivation coupled with negative energy balance affect thermoregulation during cold exposure. Thus chronic exertional fatigue and sleep loss, combined with underfeeding, reduced tissue insulation and blunted metabolic heat production, which compromised maintenance of body temperature. A short period of rest, sleep, and refeeding restored the thermogenic response to cold, but thermal balance in the cold remained compromised until after several weeks of recovery when tissue insulation had been restored.

ARTICLE TITLE: Continuous measurement of tympanic temperature with a new infrared method using an optical fiber.
ARTICLE SOURCE: J Appl Physiol (United States), Sep 1998, 85(3) p921-6
AUTHOR(S): Shibasaki M; Kondo N; Tominaga H; Aoki K; Hasegawa E; Idota Y; Moriwaki T
AUTHOR'S ADDRESS: Laboratory for Applied Human Physiology, Faculty of Human Development, Kobe University, Kobe 657-8501, Japan. mshiba@kobe-u.ac.jp.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: The purpose of this study was to investigate the utility of an infrared tympanic thermometry by using an optical fiber for measuring tympanic temperature (Tty). In the head cooling and facial fanning tests during normothermia, right Tty measured by this method (infrared-Tty) and esophageal temperature (Tes) were not affected by decreased temple and forehead skin temperatures, suggesting that the infrared sensor in this system measured the infrared radiation from the tympanic membrane selectively. Eight male subjects took part in passive-heat-stress and progressive-exercise tests. No significant differences among infrared-Tty, the left Tty measured by thermistor (contact-Tty), and Tes were observed at rest or at the end of each experiment, and there was no significant difference in the increase in these core temperatures from rest to the end. Furthermore, there were no significant differences in the core temperature threshold at the onset of sweating and slope (the relationship of sweating rate vs. infrared-Tty and vs. contact-Tty). These results suggest that this method makes it possible to measure Tty accurately, continuously, and more safely.
MB. I could not see if if this is about the tympanic membrane temperature devices we have.

ARTICLE TITLE: Fundamental concepts in statistics: elucidation and illustration.
ARTICLE SOURCE: J Appl Physiol (United States), Sep 1998, 85(3) p775-86
AUTHOR(S): Curran-Everett D; Taylor S; Kafadar K
AUTHOR'S ADDRESS: Departments of Pediatrics and of Preventive Medicine and Biometrics, School of Medicine, University of Colorado Health Sciences Center, Denver, 80217-3364, USA. dcurranevere@castle.cudenver.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (51 references); REVIEW, TUTORIAL
ABSTRACT: Fundamental concepts in statistics form the cornerstone of scientific inquiry. If we fail to understand fully these fundamental concepts, then the scientific conclusions we reach are more likely to be wrong. This is more than supposition: for 60 years, statisticians have warned that the scientific literature harbors misunderstandings about basic statistical concepts. Original articles published in 1996 by the American Physiological Society's journals fared no better in their handling of basic statistical concepts. In this review, we summarize the two main scientific uses of statistics: hypothesis testing and estimation. Most scientists use statistics solely for hypothesis testing; often, however, estimation is more useful. We also illustrate the concepts of variability and uncertainty, and we demonstrate the essential distinction between statistical significance and scientific importance. An understanding of concepts such as variability, uncertainty, and significance is necessary, but it is not sufficient; we show also that the numerical results of statistical analyses have limitations.
MB. Makes a big deal on the difference between significance and importance.

ARTICLE TITLE: O2 extraction maintains O2 uptake during submaximal exercise with beta-adrenergic blockade at 4,300 m.
ARTICLE SOURCE: J Appl Physiol (United States), Sep 1998, 85(3) p1092-102
AUTHOR(S): Wolfel EE; Selland MA; Cymerman A; Brooks GA; Butterfield GE; Mazzeo RS; Grover RF; Reeves JT
AUTHOR'S ADDRESS: Cardiovascular Pulmonary Research Laboratory, Division of Cardiology, University of Colorado Health Sciences Center, Denver, Colorado 80262, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: Whole body O2 uptake (VO2) during maximal and submaximal exercise has been shown to be preserved in the setting of beta-adrenergic blockade at high altitude, despite marked reductions in heart rate during exercise. An increase in stroke volume at high altitude has been suggested as the mechanism that preserves systemic O2 delivery (blood flow x arterial O2 content) and thereby maintains VO2 at sea-level values. To test this hypothesis, we studied the effects of nonselective beta-adrenergic blockade on submaximal exercise performance in 11 normal men (26 +/- 1 yr) at sea level and on arrival and after 21 days at 4,300 m. Six subjects received propranolol (240 mg/day), and five subjects received placebo. At sea level, during submaximal exercise, cardiac output and O2 delivery were significantly lower in propranolol- than in placebo-treated subjects. Increases in stroke volume and O2 extraction were responsible for the maintenance of VO2. At 4,300 m, beta-adrenergic blockade had no significant effect on VO2, ventilation, alveolar PO2, and arterial blood gases during submaximal exercise. Despite increases in stroke volume, cardiac output and thereby O2 delivery were still reduced in propranolol-treated subjects compared with subjects treated with placebo. Further reductions in already low levels of mixed venous O2 saturation were responsible for the maintenance of VO2 on arrival and after 21 days at 4,300 m in propranolol-treated subjects. Despite similar workloads and VO2, propranolol-treated subjects exercised at greater perceived intensity than subjects given placebo at 4,300 m. The values for mixed venous O2 saturation during submaximal exercise in propranolol-treated subjects at 4,300 m approached those reported at simulated altitudes >8,000 m. Thus beta-adrenergic blockade at 4,300 m results in significant reduction in O2 delivery during submaximal exercise due to incomplete compensation by stroke volume for the reduction in exercise heart rate. Total body VO2 is maintained at a constant level by an interaction between mixed venous O2 saturation, the arterial O2-carrying capacity, and hemodynamics during exercise with acute and chronic hypoxia.

ARTICLE TITLE: Adrenaline dosage and buffers in cardiac arrest.
ARTICLE SOURCE: Heart (England), Oct 1998, 80(4) p412-4
AUTHOR(S): Adgey AA
AUTHOR'S ADDRESS: Regional Medical Cardiology Centre, Royal Victoria Hospital, Belfast, UK.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (10 references); REVIEW, TUTORIAL

ARTICLE TITLE: Antiarrhythmic drugs in resuscitation.
ARTICLE SOURCE: Heart (England), Oct 1998, 80(4) p408-11
AUTHOR(S): Chamberlain DA
MINOR SUBJECT HEADING(S): Combined Modality Therapy; Electric Countershock; Emergency Treatment [methods]; Lidocaine [therapeutic use]; Magnesium Sulfate [therapeutic use]; Potassium Chloride [therapeutic use]; Time Factors; Ventricular Fibrillation [drug therapy]
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (45 references); REVIEW, TUTORIAL

ARTICLE TITLE: Approaches to modern management of cardiac arrest.
ARTICLE SOURCE: Heart (England), Oct 1998, 80(4) p397-401
AUTHOR(S): Adgey AA; Johnston PW
AUTHOR'S ADDRESS: Regional Medical Cardiology Centre, Royal Victoria Hospital, Belfast, UK.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (64 references); REVIEW, TUTORIAL

ARTICLE TITLE: Reproducibility and responsiveness of quality of life assessment and six minute walk test in elderly heart failure patients.
ARTICLE SOURCE: Heart (England), Oct 1998, 80(4) p377-82
AUTHOR(S): O'Keeffe ST; Lye M; Donnellan C; Carmichael DN
AUTHOR'S ADDRESS: Department of Geriatric Medicine, University of Liverpool, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: MAIN OUTCOME MEASURES: Subjects underwent a standardised six minute walk test and completed the chronic heart failure questionnaire (CHQ), a heart failure specific quality of life questionnaire. CONCLUSIONS: Quality of life assessment and a six minute walk test are reproducible and responsive measures of cardiac status in frail, very elderly patients with heart failure.

ARTICLE TITLE: Endoluminal vessel reconstruction by stent placement in patients with obstructive coronary artery disease who are poor surgical candidates.
ARTICLE SOURCE: Heart (England), Oct 1998, 80(4) p355-8
AUTHOR(S): Eeckhout E; Stauffer JC; Vogt P; Kappenberger L; Goy JJ
AUTHOR'S ADDRESS: Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Percutaneous reconstruction of diseased coronary arteries in patients with single or multivessel disease turned down for surgical revascularisation may be considered as a valuable treatment option. On follow up, more events seem to be encountered than after elective de novo stenting of discrete coronary lesions. This is probably related to higher clinical restenosis rates.

ARTICLE TITLE: Stethoscopes.
ARTICLE SOURCE: Heart (England), Oct 1998, 80(4) p318
AUTHOR(S): Davies MK; Hollman A
PUBLICATION TYPE: HISTORICAL ARTICLE; JOURNAL ARTICLE

ARTICLE TITLE: Successful radiofrequency catheter ablation of atrial trigeminy in a young patient.
ARTICLE SOURCE: Heart (England), Sep 1998, 80(3) p301-2
AUTHOR(S): Dobran IJ; Niebch V; Vester EG
AUTHOR'S ADDRESS: Department of Cardiology, Pneumology, and Angiology, Heinrich-Heine-University, Dusseldorf, Germany. galnedr@uni-duesseldorf.de.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: A case is reported of a 35 year old man with atrial parasystolic trigeminy. The patient presented with a 10 year history of sustained supraventricular extrasystole causing symptoms leading to several hospitalisations and continuous unemployment. He had been treated ineffectively with several drug combinations. Radiofrequency catheter ablation of a right atrial focus completely suppressed the ectopic activity. This is the first report to demonstrate the efficacy and safety of radiofrequency catheter ablation in atrial ectopic trigeminy.
MB. Maybe I should go to Dusseldorf.

ARTICLE TITLE: Heart rate variability and cardiac failure [editorial]
ARTICLE SOURCE: Heart (England), Sep 1998, 80(3) p213-4
AUTHOR(S): Lombardi F; Mortara A
PUBLICATION TYPE: EDITORIAL; REVIEW (17 references); REVIEW, TUTORIAL

ARTICLE TITLE: The falling mortality from coronary heart disease: a clinicopathological perspective. The United Kingdom Heart Attack Study (UKHAS) Collaborative Group [see comments]
COMMENTS: Comment in: Heart 1998 Aug; 80(2):112-3
ARTICLE SOURCE: Heart (England), Aug 1998, 80(2) p121-6
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: (1) To compare mortality estimates based on clinicopathological diagnoses of death from acute coronary heart disease with official estimates of coronary heart disease mortality; (2) to compare present day mortality figures with those from earlier reports. DESIGN: Prospective community study over the two years 1994 and 1995. CONCLUSIONS: There are differences, most noticeable in elderly subjects, between estimates of coronary mortality made according to strict clinical and pathological definitions and official rates based on death certification. Recognition of these differences will be important for future epidemiological studies.

ARTICLE TITLE: Effect of time from onset to coming under care on fatality of patients with acute myocardial infarction: effect of resuscitation and thrombolytic treatment. The United Kingdom Heart Attack Study (UKHAS) Collaborative Group.
ARTICLE SOURCE: Heart (England), Aug 1998, 80(2) p114-20
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
ABSTRACT: OBJECTIVE: To examine the relation between time from onset of symptoms and coming under ambulance and hospital care on fatality in patients with evolving acute myocardial infarction, and on the proportions who survive because of resuscitation and thrombolytic treatment. CONCLUSIONS: Results of treatment are strongly related to delay in coming under care. Reduction in delay can reduce mortality from acute myocardial infarction.

ARTICLE TITLE: Diabetes and coronary artery disease: time to stop taking the tablets? [editorial]
ARTICLE SOURCE: Heart (England), Aug 1998, 80(2) p108-9
AUTHOR(S): Connaughton M; Webber J
PUBLICATION TYPE: EDITORIAL
MB Oral hypoglycaemic agents may be a cardiac `risk factor'

ARTICLE TITLE: Benzodiazepine use and cognitive function among community-dwelling elderly.
ARTICLE SOURCE: Clin Pharmacol Ther (United States), Dec 1998, 64(6) p684-92
AUTHOR(S): Hanlon JT; Horner RD; Schmader KE; Fillenbaum GG; Lewis IK; Wall WE Jr; Landerman LR; Pieper CF; Blazer DG; Cohen HJ
AUTHOR'S ADDRESS: Department of Medicine, Duke University Medical Center, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The results suggested that current benzodiazepine use, especially in recommended or higher doses, is associated with worse memory among community-dwelling elderly. ;

ARTICLE TITLE: The substance P receptor antagonist CP-99,994 reduces acute postoperative pain.
ARTICLE SOURCE: Clin Pharmacol Ther (United States), Nov 1998, 64(5) p562-8
AUTHOR(S): Dionne RA; Max MB; Gordon SM; Parada S; Sang C; Gracely RH; Sethna NF; MacLean DB
AUTHOR'S ADDRESS: Pain and Neurosensory Mechanisms Branch, National Institute of Dental Research, National Institutes of Health, Bethesda, MD 20892-1258, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: Animal studies suggest that substance P, a peptide that preferentially activates the neurokinin-1 (NK1) receptor, is involved in pain transmission, with particular importance in pain after inflammation. METHODS: The analgesic efficacy of CP-99,994, a NK1 receptor antagonist, was compared with ibuprofen and placebo in 78 subjects undergoing third molar extraction. CONCLUSIONS: This replicate demonstration that a NK1 receptor blocker relieves clinical pain supports the hypothesis that substance P contributes to the generation of pain in humans. The reduction in postoperative pain at doses not producing side effects suggests that NK1 antagonists may be clinically useful.

ARTICLE TITLE: Inhibiting tissue angiotensin-converting enzyme: a pound of flesh without the blood? [editorial; comment]
COMMENTS: Comment on: Circulation 1998 Dec 22-29; 98(25):2842-8
ARTICLE SOURCE: Circulation (United States), Dec 22-29 1998, 98(25) p2788-90
AUTHOR(S): Zisman LS

ARTICLE TITLE: Ten-year follow-up of the first megatrial testing thrombolytic therapy in patients with acute myocardial infarction: results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto-1 study. The GISSI Investigators [see comments]
COMMENTS: Comment in: Circulation 1998 Dec 15; 98(24):2649-51
ARTICLE SOURCE: Circulation (United States), Dec 15 1998, 98(24) p2659-65
AUTHOR(S): Franzosi MG; Santoro E; De Vita C; Geraci E; Lotto A; Maggioni AP; Mauri F; Rovelli F; Santoro L; Tavazzi L; Tognoni G
AUTHOR'S ADDRESS: GISSI Coordinating Center, Milano and Ospedale Niguarda Ca Granda. franzosi@irfmm.mnegri.it.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: We conducted a 10-year follow-up of the 11 712 patients with acute myocardial infarction randomized in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto-1 study, the first large trial assessing thrombolytic therapy. CONCLUSIONS: The benefits of a single intravenous infusion of 1.5 million units of streptokinase in prolonging survival of patients with acute myocardial infarction is sustained up to 10 years, with a still-evident trend in favor of the patients admitted earlier.

ARTICLE TITLE: Ten years of benefit from a one-hour intervention [editorial; comment]
COMMENTS: Comment on: Circulation 1998 Dec 15; 98(24):2659-65
ARTICLE SOURCE: Circulation (United States), Dec 15 1998, 98(24) p2649-51
AUTHOR(S): Califf RM
PUBLICATION TYPE: COMMENT; EDITORIAL
The acute management of myocardial infarction is a big mess, Outcome studies are required. Some drugs turned out to make things worse.

ARTICLE TITLE: Endothelium as a therapeutic target in heart failure [editorial]
ARTICLE SOURCE: Circulation (United States), Dec 15 1998, 98(24) p2652-5
AUTHOR(S): Drexler H
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Effects of continuous positive airway pressure on obstructive sleep apnea and left ventricular afterload in patients with heart failure.
ARTICLE SOURCE: Circulation (United States), Nov 24 1998, 98(21) p2269-75
AUTHOR(S): Tkacova R; Rankin F; Fitzgerald FS; Floras JS; Bradley TD
AUTHOR'S ADDRESS: Sleep Research Laboratories of the Rehabilitation Institute of Toronto and Mount Sinai Hospital and the Department of Medicine of the University of Toronto, Toronto, Ontario, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: In CHF patients with obstructive sleep apnea (OSA) LV afterload increases from wakefulness to stage 2 sleep. By alleviating OSA, continuous positive airway pressure (CPAP) reduces LV afterload and heart rate, unloads inspiratory muscles, and improves arterial oxygenation during stage 2 sleep. CPAP is a nonpharmacological means of further reducing afterload and heart rate during sleep in pharmacologically treated CHF patients with OSA.

ARTICLE TITLE: Short-term oral endothelin-receptor antagonist therapy in conventionally treated patients with symptomatic severe chronic heart failure.
ARTICLE SOURCE: Circulation (United States), Nov 24 1998, 98(21) p2262-8
AUTHOR(S): Sutsch G; Kiowski W; Yan XW; Hunziker P; Christen S; Strobel W; Kim JH; Rickenbacher P; Bertel O
AUTHOR'S ADDRESS: Divisions of Cardiology, Departments of Medicine, University Hospital Zurich, Switzerland.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: The vasoconstrictor peptide endothelin-1 (ET-1) is important for increased vascular tone in patients with chronic heart failure, but the effects of endothelin-receptor blockade in addition to conventional triple therapy are unknown CONCLUSIONS: Additional short-term oral endothelin-receptor antagonist therapy improved systemic and pulmonary hemodynamics in heart failure patients who were symptomatic with standard triple-drug therapy (diuretics, digoxin, and ACE inhibitors). Further investigations are warranted to characterize the effects of long-term endothelin-receptor antagonist therapy on symptoms, morbidity, and mortality in such patients.

ARTICLE TITLE: ACE (I/D) genotype as a predictor of the magnitude and duration of the response to an ACE inhibitor drug (enalaprilat) in humans.
ARTICLE SOURCE: Circulation (United States), Nov 17 1998, 98(20) p2148-53
AUTHOR(S): Ueda S; Meredith PA; Morton JJ; Connell JM; Elliott HL
AUTHOR'S ADDRESS: University Department of Medicine and Therapeutics, Western Infirmary, Glasgow, Scotland.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: We have investigated the possible effects of contrasting ACE (I/D) genotypes on the responses to the ACE inhibitor enalaprilat in normotensive men. METHODS AND RESULTS: Subjects with DD (n=12) and II (n=11) ACE genotypes received an intravenous infusion of enalaprilat or placebo. Pressor responses to stepwise, incremental doses of angiotensin I were measured at 1 and 10 hours after dosing. The dose required to raise mean blood pressure by 20 mm Hg (PD20) was calculated individually, and the ratio of PD20 during enalaprilat to that during placebo (dose ratio, DR) was used for assessment of the extent of ACE inhibition. The pressor response was significantly attenuated at 1 hour after enalaprilat in both groups, but significant attenuation was evident at 10 hours after dose only in the II subjects. The DRs at both 1 hour (median, 5.43 versus 2.82, P=0.0035) and 10 hours (2.06 versus 0.84, P=0.0008) after enalaprilat were significantly higher in II subjects than in DD subjects. CONCLUSIONS: The effect of enalaprilat was significantly greater and lasted longer in normotensive men homozygous for the II ACE genotype. By multivariate analysis, ACE (I/D) genotype and plasma angiotensin II levels were predictive of >50% of the variation in response to ACE inhibition.

ARTICLE TITLE: Effect of payer status on outcomes of coronary artery bypass surgery in blacks.
ARTICLE SOURCE: Circulation (United States), Nov 10 1998, 98(19 Suppl) pII46-9; discussion II49-50
AUTHOR(S): Higgins RS; Paone G; Borzak S; Jacobsen G; Peterson E; Silverman NA
AUTHOR'S ADDRESS: Division of Cardiac and Thoracic Surgery, Henry Ford Hospital, Detroit, MI 48202, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Black patients with coronary artery disease have a higher mortality rate than white Americans. They also have a higher prevalence of hypertension, diabetes mellitus, and renal disease, which may have an effect on mortality rates. CONCLUSIONS: These data on CABG surgery in black patients suggest that early death is due to associated risk factors and not due to race or insurance payer status.

ARTICLE TITLE: Hospital readmission after cardiac surgery. Does "fast track" cardiac surgery result in cost saving or cost shifting?
ARTICLE SOURCE: Circulation (United States), Nov 10 1998, 98(19 Suppl) pII35-40
AUTHOR(S): Lahey SJ; Campos CT; Jennings B; Pawlow P; Stokes T; Levitsky S
AUTHOR'S ADDRESS: Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass., USA. s14cabg@aol.com.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Intense medical and economic pressures have created "fast track" cardiac surgery in which clinical services are streamlined and early discharge is encouraged. Does this strategy promote significant cost saving or merely cost shifting? In a global system of reimbursement, the economic benefit of decreasing patient length of stay may be offset by high rates of patient readmission. This study was undertaken to determine the 30-day readmission rate after cardiac surgery and to analyze trends of readmission diagnoses. METHODS AND RESULTS: From October 1, 1996 to July 31, 1997, 460 consecutive cardiac surgical operations were performed at 1 institution. There were 25 deaths and 8 patients who remained as inpatients at the 30-day postoperative deadline for readmission. Two patients had 2 operations. Therefore, 527 operations were performed on 525 patients. There were 110 readmissions after 527 operations for a readmission rate of 20.9%. A significant number of readmissions (49%) were to outside hospitals. Readmission diagnoses were: atrial fibrillation (23%); angina, congestive heart failure, or ventricular tachycardia (20%); leg wound (15%); sternal wound (5%); pneumonia (5%); gastrointestinal complaints (5%); neurologic event (2%); and miscellaneous (25%). Patients discharged > or = 7 days postoperatively were twice as likely to be readmitted as those discharged on postoperative days 4, 5, or 6. CONCLUSIONS: Readmission after cardiac surgery is common and frequently (49%) to outside institutions. Patients discharged > or = 7 days postoperatively represent the patients at greatest risk of readmission and, therefore, warrant closer scrutiny before discharge.

ARTICLE TITLE: Impact of managed waiting for coronary artery bypass graft surgery on patients' perceived quality of life.
ARTICLE SOURCE: Circulation (United States), Nov 10 1998, 98(19 Suppl) pII29-33; discussion II33-4
AUTHOR(S): Teo KK; Spoor M; Pressey T; Williamson H; Calder P; Gelfand ET; Koshal A
AUTHOR'S ADDRESS: Division of Cardiology, University of Alberta Hospitals, Edmonton, Canada. kkt@tachy.uah.ualberta.ca.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Current demand for CABG surgery remains high, often exceeds available resources, and has led to the development of managed waiting lists. This study was designed to determine how being placed on a managed waiting list for > 6 weeks for CABG surgery affected patients' perceived quality of life in a Canadian center. METHODS AND RESULTS: Telephone interviews were carried out in the setting of a large urban hospital in northern Alberta. All participants were identified from 3 waiting lists of adult patients waiting for open heart surgery. A master list of patient statements was compiled to formulate the 47-item Waiting List Impact Questionnaire (WLIQ). A total of 102 patients completed the WLIQ by telephone interview. Patients (87.5%) indicated that their quality of life had deteriorated since being placed on the waiting list. None of the patients perceived an improvement in their quality of life. Frequency data for the WLIQ provided a broad, multidimensional perspective of the experience of waiting for CABG surgery and its impact on perceived quality of life. Negative impact was found in each of 5 main themes: employment and income, physical stress, social support, frustration, and quality of life. CONCLUSIONS: This study indicates that patients perceived a negative impact on their quality of life after being placed on a managed waiting list for CABG surgery. In the allocation of healthcare resources, attention should be paid to the impact of waiting on patients' physical well-being as well as on quality of life.

ARTICLE TITLE: Evidence for unconscious memory processing during elective cardiac surgery.
ARTICLE SOURCE: Circulation (United States), Nov 10 1998, 98(19 Suppl) pII289-92; discussion II292-3
AUTHOR(S): Adams DC; Hilton HJ; Madigan JD; Szerlip NJ; Cooper LA; Emerson RG; Smith CR; Rose EA; Oz MC
AUTHOR'S ADDRESS: Department of Anesthesiology, Columbia-Presbyterian Medical Center, New York, NY, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Many anesthetic drugs have been shown to disrupt conscious recall (explicit memory) in volunteers. However, unconscious processing (implicit memory) of intraoperative auditory material may occur during general anesthesia and may provide an opportunity for intraoperative therapeutic intervention. In this study, we examined patients undergoing elective cardiac surgery for evidence of intraoperative implicit and explicit memory. METHODS AND RESULTS: Twenty-five subjects provided written informed consent and underwent general anesthesia and cardiopulmonary bypass for cardiac surgery. During the operation, patients were randomized to receive 1 of 2 different audiotapes of associated word pairs. Postoperatively, a blinded observer conducted a standardized interview to determine the extent of intraoperative implicit and explicit memory. With the use of free association, significant intraoperative implicit memory was found. In contrast, no patient had spontaneous or directed recall of intraoperative events, and we did not find evidence of intraoperative explicit memory with a recognition task. CONCLUSIONS: Patients undergoing general anesthesia for cardiac surgery were reliably able to reinforce associations between word pairs solely on the basis of their intraoperative presentation. This provides further evidence that patients are capable of processing intraoperative auditory information.
MB. Don't talk about patient when the patient is anaesthetised.

ARTICLE TITLE: How do we best treat patients with ischemic heart disease? [editorial; comment]
COMMENTS: Comment on: Circulation 1998 Nov 10; 98(19):2017-23
ARTICLE SOURCE: Circulation (United States), Nov 10 1998, 98(19) p1985-6
AUTHOR(S): Pepine CJ; Deedwania PC
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Cardiovascular outcome in white-coat versus sustained mild hypertension: a 10-year follow-up study [see comments]
COMMENTS: Comment in: Circulation 1998 Nov 3; 98(18):1834-6
ARTICLE SOURCE: Circulation (United States), Nov 3 1998, 98(18) p1892-7
AUTHOR(S): Khattar RS; Senior R; Lahiri A
AUTHOR'S ADDRESS: Department of Cardiovascular Medicine, Northwick Park, and St Mark's Hospital NHS Trust and Institute for Medical Research, Harrow, Middlesex, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: The aim of this study was to compare the risk conferred by white-coat versus sustained mild hypertension for the development of cardiovascular disease. METHODS AND RESULTS: Patients (n=479) who underwent 24-hour intra-arterial ambulatory blood pressure monitoring on the basis of a persistently elevated clinic systolic blood pressure of 140 to 180 mm Hg were followed up for the development of subsequent cardiovascular events during a 9.1+/-4. 2-year period. White-coat hypertension, defined as a clinic systolic blood pressure of 140 to 180 mm Hg associated with a 24-hour ambulatory systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg, was present in 126 patients, and the remainder had sustained mild hypertension. A subgroup of patients without complications underwent follow-up echocardiography and carotid ultrasound. CONCLUSIONS: These findings indicate a relatively benign outcome in white-coat hypertension compared with sustained mild hypertension.

ARTICLE TITLE: White coat hypertension: time for action [editorial; comment]
COMMENTS: Comment on: Circulation 1998 Nov 3; 98(18):1892-7
ARTICLE SOURCE: Circulation (United States), Nov 3 1998, 98(18) p1834-6
AUTHOR(S): Pickering TG
PUBLICATION TYPE: COMMENT; EDITORIAL; REVIEW (17 references); REVIEW, TUTORIAL

ARTICLE TITLE: Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting. The full anticoagulation versus aspirin and ticlopidine (fantastic) study.
ARTICLE SOURCE: Circulation (United States), Oct 20 1998, 98(16) p1597-603
AUTHOR(S): Bertrand ME; Legrand V; Boland J; Fleck E; Bonnier J; Emmanuelson H; Vrolix M; Missault L; Chierchia S; Casaccia M; Niccoli L; Oto A; White C; Webb-Peploe M; Van Belle E; McFadden EP
AUTHOR'S ADDRESS: Dept de Cardiologie B, Hopital Cardiologique, 59037 Lille, France. bertrandme@aol.com.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: Antiplatelet therapy after coronary stenting significantly reduced rates of bleeding and subacute stent occlusion compared with conventional anticoagulation.

ARTICLE TITLE: Low-molecular-weight heparin : A review of the results of recent studies of the treatment of venous thromboembolism and unstable angina.
ARTICLE SOURCE: Circulation (United States), Oct 13 1998, 98(15) p1575-82
AUTHOR(S): Hirsh J
AUTHOR'S ADDRESS: Hamilton Civic Hospitals Research Centre, Hamilton, Ontario, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (44 references); REVIEW, TUTORIAL

ARTICLE TITLE: Percutaneous tracheostomy: is it really better?
ARTICLE SOURCE: Chest (United States), Dec 1998, 114(6) p1771-2
AUTHOR(S): Malthaner RA; Telang H; Miller JD; McFadden S; Inculet RI
AUTHOR'S ADDRESS: Department of Surgery, University of Western Ontario, London Health Sciences Centre, Canada. richard.malthaner@lhsc.on.ca.
MAJOR SUBJECT HEADING(S): Intraoperative Complications; Surgical Procedures, Minimally Invasive; Tracheostomy [adverse effects] [methods]
PUBLICATION TYPE: JOURNAL ARTICLE
MB. Better than elective trachostomy. The 2 complicatios are the type of complicaions that electivr trachostomy avoids.

ARTICLE TITLE: Multicenter study of noninvasive monitoring systems as alternatives to invasive monitoring of acutely ill emergency patients [see comments]
COMMENTS: Comment in: Chest 1998 Dec; 114(6):1511-3
ARTICLE SOURCE: Chest (United States), Dec 1998, 114(6) p1643-52
AUTHOR(S): Shoemaker WC; Belzberg H; Wo CC; Milzman DP; Pasquale MD; Baga L; Fuss MA; Fulda GJ; Yarbrough K; Van De Water JP; Ferraro PJ; Thangathurai D; Roffey P; Velmahos G; Murray JA; Asensio JA; El Tawil K; Dougherty WR; Sullivan MJ; Patil RS; Adibi J; James CB; Demetriades D
AUTHOR'S ADDRESS: Department of Surgery, University of Southern California School of Medicine, Los Angeles, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
ABSTRACT: BACKGROUND: Recent reports showed lack of effectiveness of pulmonary artery catheterization in critically ill medical patients and relatively late-stage surgical patients with organ failure. Since invasive monitoring requires critical care environments, the early hemodynamic patterns may have been missed. Ideally, early noninvasive hemodynamic monitoring systems, if reliable, could be used as the "front end" of invasive monitoring to supply more complete descriptions of circulatory pathophysiology. OBJECTIVES: To evaluate the accuracy and reliability of noninvasive hemodynamic monitoring consisting of a new bioimpedance method for estimating cardiac output combined with arterial BP, pulse oximetry, and transcutaneous PO2 and PCO2; we compared this system of noninvasive monitoring with simultaneous invasive measurements to evaluate circulatory deficiencies in acutely ill patients shortly after hospital admission where invasive monitoring was not readily available. We also preliminarily explored early differences in temporal hemodynamic patterns of survivors and nonsurvivors. DESIGN AND SETTING: Prospective comparison of simultaneous invasive and noninvasive measurements of circulatory function with retrospective analysis of data in university-run county hospitals, university hospitals and affiliated teaching hospitals, and a community private hospital. PATIENTS: We studied 680 patients, including 139 severely injured or hemorrhaging patients in the emergency department (ED), 129 medical (nontrauma) patients on admission to the ED, 274 high-risk surgical patients intraoperatively, and 138 patients recently admitted to the ICU. RESULTS: A new noninvasive impedance device provided cardiac output estimations under conditions in which invasive thermodilution measurements were not usually applied. There were 2,192 simultaneous bioimpedance and thermodilution cardiac index measurements; the correlation coefficient, r = 0.85, r2 = 0.73, p < 0.001. The precision and bias was -0.124+/-0.75 L/min/m2. Both invasive and noninvasive monitoring systems provide similar information and identified episodes of hypotension, low cardiac index, arterial hemoglobin desaturation, low transcutaneous O2, high transcutaneous CO2, and low oxygen consumption before and during initial resuscitation. The limitations of noninvasive systems were described. CONCLUSIONS: Noninvasive monitoring systems gave continuous displays of physiologic data that provided information allowing early recognition of low flow and poor tissue perfusion that were more pronounced in the nonsurvivors. Noninvasive systems may be acceptable alternatives where invasive monitoring is not available.

ARTICLE TITLE: Monitor wizards can be dangerous [editorial; comment]
COMMENTS: Comment on: Chest 1998 Dec; 114(6):1643-52
ARTICLE SOURCE: Chest (United States), Dec 1998, 114(6) p1511-3
AUTHOR(S): Robin ED; McCauley RF
INDEXING CHECK TAG(S): Human; Support, Non-U.S. Gov't
MB. Critical if of excessive ICU .

ARTICLE TITLE: The AtBCs of lung cancer screening [editorial; comment]
COMMENTS: Comment on: Chest 1998 Dec; 114(6):1514-8
ARTICLE SOURCE: Chest (United States), Dec 1998, 114(6) p1502-5
AUTHOR(S): Strauss GM
MAJOR SUBJECT HEADING(S): Lung Neoplasms [radiography]; Mass Screening
MINOR SUBJECT HEADING(S): Bias (Epidemiology); Lung Neoplasms [mortality] [prevention & control]; Survival Analysis

ARTICLE TITLE: Comparing two heat and moisture exchangers, one hydrophobic and one hygroscopic, on humidifying efficacy and the rate of nosocomial pneumonia.
ARTICLE SOURCE: Chest (United States), Nov 1998, 114(5) p1383-9
AUTHOR(S): Thomachot L; Viviand X; Arnaud S; Boisson C; Martin CD
AUTHOR'S ADDRESS: Intensive Care Unit and Trauma Center, Hopital Nord, Marseilles University Hospital System, Marseilles Medical School, France.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSION: Despite differences in their components, the two HMEFs tested achieved similar performances in terms of humidification and heating of inspired gases. Only one episode of endotracheal tube occlusion was detected and very few patients (one in each group) had to be switched to an active heated humidifier. No difference was observed either in the rate of tracheal colonization or of ventilator-associated pneumonia. These data show that the hygroscopic HME (Humid-Vent Filter Light) and the hydrophobic HME (Pall BB 100) are suited for use in ICU patients.

ARTICLE TITLE: The effect of positive pressure airway support on mortality and the need for intubation in cardiogenic pulmonary edema: a systematic review.
ARTICLE SOURCE: Chest (United States), Oct 1998, 114(4) p1185-92
AUTHOR(S): Pang D; Keenan SP; Cook DJ; Sibbald WJ
AUTHOR'S ADDRESS: Aberdeen Medical School, Scotland.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (23 references); REVIEW, MULTICASE
CONCLUSIONS: A modest amount of favorable experimental evidence exists to support the use of CPAP in patients with cardiogenic pulmonary edema. CPAP appears to decrease intubation rates and data suggest a trend toward a decrease in mortality, although the potential for harm has not been excluded. The role of NPPV in this setting requires further study before it can be widely recommended.

ARTICLE TITLE: Acupuncture for back pain: a meta-analysis of randomized controlled trials.
ARTICLE SOURCE: Arch Intern Med (United States), Nov 9 1998, 158(20) p2235-41
AUTHOR(S): Ernst E; White AR
AUTHOR'S ADDRESS: Department of Complementary Medicine, Postgraduate Medical School, University of Exeter, England. E.Ernst@ex.ac.uk.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
ABSTRACT: BACKGROUND: Acupuncture is commonly used to treat back pain, but there is no published meta-analysis of trials of its effectiveness for this condition. OBJECTIVE: To perform a meta-analysis of trials of acupuncture for the treatment of back pain. METHODS: A systematic literature search was conducted to retrieve all randomized controlled trials of any form of acupuncture for any type of back pain in humans. The adequacy of the acupuncture treatment was assessed by consulting 6 experienced acupuncturists. The main outcome measure for the meta-analysis was numbers of patients whose symptoms were improved at the end of treatment. RESULTS: Twelve studies were included, of which 9 presented data suitable for meta-analysis. The odds ratio of improvement with acupuncture compared with control intervention was 2.30 (95% confidence interval, 1.28-4.13). For sham-controlled, evaluator-blinded studies, the odds ratio was 1.37 (95% confidence interval, 0.84-2.25). CONCLUSION: Acupuncture was shown to be superior to various control interventions, although there is insufficient evidence to state whether it is superior to placebo.

ARTICLE TITLE: "Conventional" and "unconventional" medicine: can they be integrated? [editorial]
ARTICLE SOURCE: Arch Intern Med (United States), Nov 9 1998, 158(20) p2179-81
AUTHOR(S): Dalen JE
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Rate control and sinus rhythm maintenance in atrial fibrillation: national trends in medication use, 1980-1996.
ARTICLE SOURCE: Arch Intern Med (United States), Oct 26 1998, 158(19) p2144-8
AUTHOR(S): Stafford RS; Robson DC; Misra B; Ruskin J; Singer DE
AUTHOR'S ADDRESS: General Medicine Division, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
CONCLUSIONS: Despite changes in the treatment of atrial fibrillation, digoxin remains the dominant rate control medication. Medications for sinus rhythm maintenance are not widely used. Quinidine use declined prominently in the 1980s, possibly because of concerns about proarrhythmic effects. The use of sinus rhythm agents, however, is now rising.

ARTICLE TITLE: Efficacy of ondansetron and prochlorperazine for the prevention of postoperative nausea and vomiting after total hip replacement or total knee replacement procedures: a randomized, double-blind, comparative trial.
ARTICLE SOURCE: Arch Intern Med (United States), Oct 26 1998, 158(19) p2124-8
AUTHOR(S): Chen JJ; Frame DG; White TJ
AUTHOR'S ADDRESS: Department of Pharmacy, Rush-Presbyterian-St Luke's Medical Center, Chicago, Ill 60612-3833, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSION: Prochlorperazine is associated with superior efficacy and significant cost savings compared with ondansetron for the prevention of PONV in patients undergoing total hip and total knee replacement procedures.

ARTICLE TITLE: Determinants of mortality in elderly patients with heart failure: the role of angiotensin-converting enzyme inhibitors.
ARTICLE SOURCE: Arch Intern Med (United States), Oct 12 1998, 158(18) p2024-8
AUTHOR(S): Havranek EP; Abrams F; Stevens E; Parker K
AUTHOR'S ADDRESS: Colorado Foundation for Medical Care, Aurora, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Underinvestigation and undertreatment of chronic heart failure persists. Failure to treat elderly patients with ACE-I is associated with a mortality that appears to be greater than that seen in the placebo arms of large clinical trials of ACE-I therapy. Within the population studied, older patients are less likely to be treated. Failure of age to significantly add to prediction of mortality implies that the apparent bias against treating older patients with chronic heart failure with ACE-I is not justified. Because mortality is dependent on provider and site of treatment, further reductions in mortality from chronic heart failure may require intensive and selective local efforts, or development of regional heart failure centers.

ARTICLE TITLE: Deep venous thrombosis: thinking inside out [editorial; comment]
COMMENTS: Comment on: Arch Intern Med 1998 Oct 12; 158(18):2001-3
ARTICLE SOURCE: Arch Intern Med (United States), Oct 12 1998, 158(18) p1964
AUTHOR(S): Liebowitz RS
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Central nervous system effects of cardiopulmonary bypass.
ARTICLE SOURCE: Ann Thorac Surg (United States), Nov 1998, 66(5 Suppl) pS20-4; discussion S25-8
AUTHOR(S): Taylor KM
AUTHOR'S ADDRESS: Department of Surgery, National Heart and Lung Institute, Hammersmith Hospital, London, England.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (11 references); REVIEW, TUTORIAL
ABSTRACT: BACKGROUND: The spectrum of approaches to the issue of brain injury in cardiac surgical practice ranges from refusal to acknowledge that the problem exists to an overemphasis on cerebral risks that can unduly frighten patients. An appropriate approach to therapeutic and preventive strategies requires a fitting sense of proportion and an understanding of the mechanisms of cerebral injury. METHODS: This article reviews the incidence and severity of cerebral injury during cardiopulmonary bypass, the identification of high-risk patients, and the mechanisms of injury, including hypoperfusion, microemboli, and inflammatory response. It discusses the influences of alpha-stat and pH-stat strategies on cerebral blood flow during cardiopulmonary bypass; the use of retinal angiography to image the retinal circulation, thus providing a window on the cerebral microcirculation during bypass; magnetic resonance imaging evidence of an inflammatory response in the brain during bypass; and current efforts to gain better understanding of the molecular mechanisms involved in the inflammatory response. RESULTS: The current incidence of stroke during cardiopulmonary bypass is somewhat lower than in the 1980s but still remains a significant problem. Levels of cognitive impairment also are unacceptably high. Recognized predictors enable us to identify patients at particularly high risk of stroke. Hypertensive patients are particularly susceptible to ischemic injury during bypass and should be perfused at mean perfusion pressures higher than those for normotensive patients. Under conditions of hypothermia, a pH-stat strategy causes loss of cerebral blood flow autoregulation, and the cerebral blood flow becomes pressure-passive. With both the pH-stat and alpha-stat strategies, cooling of the patient greatly increases the flow to metabolism ratio of the cerebral blood flow; however, this luxury perfusion brings to the brain not just an excess supply of oxygen but also an increased quantity of microemboli. Current investigative efforts are focused on the endothelial cell-leukocyte adhesion cascade, attempting to characterize beta2 and beta1 adhesion molecule expression in patients undergoing cardiac surgery. Hammersmith Hospital is about to complete a study of the effects of high-dose aprotinin on the inflammatory response pattern and on cerebral infarction. CONCLUSIONS: Further progress in the development of therapeutic and preventive strategies with respect to cerebral injury during cardiac bypass depends on an increase in the understanding of the mechanisms involved. Current strategies should include optimizing cerebral perfusion and minimizing macroembolic and microembolic damage. The possibility of modifying the systemic inflammatory response is the most interesting challenge of the next few years.

ARTICLE TITLE: Outcomes after vascular operations: federal and private perspectives.
ARTICLE SOURCE: Ann Thorac Surg (United States), Oct 1998, 66(4) p1485
AUTHOR(S): Moskowitz J
AUTHOR'S ADDRESS: Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1023, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Combined carotid endarterectomy and coronary revascularization operation [comment]
COMMENTS: Comment on: Ann Thorac Surg 1998 Oct; 66(4):1480-2
ARTICLE SOURCE: Ann Thorac Surg (United States), Oct 1998, 66(4) p1483-4
AUTHOR(S): Akins CW
AUTHOR'S ADDRESS: Cardiac Surgical Unit, Massachusetts General Hospital, Boston 02114, USA.
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE
ABSTRACT: The increasing risk of perioperative stroke after coronary artery bypass grafting can in part be attributed to the increased incidence of carotid stenosis with increasing patient age. The efficacy of carotid endarterectomy has been demonstrated for both symptomatic and asymptomatic patients. Combined operations yield acceptable mortality and stroke risks, provide good freedom from late events, and cost less than staged operations.

ARTICLE TITLE: Carotid endarterectomy and coronary artery bypass: the staged approach [see comments]
COMMENTS: Comment in: Ann Thorac Surg 1998 Oct; 66(4):1483-4
ARTICLE SOURCE: Ann Thorac Surg (United States), Oct 1998, 66(4) p1480-2
AUTHOR(S): Johnson RG
AUTHOR'S ADDRESS: Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Results of a regional study of modes of death associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group.
ARTICLE SOURCE: Ann Thorac Surg (United States), Oct 1998, 66(4) p1323-8
AUTHOR(S): O'Connor GT; Birkmeyer JD; Dacey LJ; Quinton HB; Marrin CA; Birkmeyer NJ; Morton JR; Leavitt BJ; Maloney CT; Hernandez F; Clough RA; Nugent WC; Olmstead EM; Charlesworth DC; Plume SK
AUTHOR'S ADDRESS: Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA. gerald.t.o'connor@dartmouth.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
ABSTRACT: BACKGROUND: It is well known that surgeon-specific in-hospital mortality rates for coronary artery bypass grafting vary, but this aggregate measure does not suggest specific opportunities for improvement. METHODS: We performed a regional prospective study of 8,641 consecutive patients undergoing isolated coronary artery bypass grafting by all of the 23 cardiothoracic surgeons practicing in northern New England during the study period. Mode of death was assigned by an end points committee using predetermined definitions. Surgeons were ranked according to risk-adjusted mortality rates and grouped in terciles, and cause-specific mortality rates were determined. RESULTS: The mortality rate was 3.3% in the lowest surgeon mortality tercile and 5.8% in the highest tercile. Fatal heart failure accounted for 80.0% of the difference in aggregate mortality rates, ranging from 1.9% in lowest surgeon mortality tercile to 4.0% in the highest tercile (p < 0.001). Rates of other causes did not differ significantly across surgeon mortality terciles. Differences in rates of fatal heart failure could not be explained by differences in preoperative left ventricular dysfunction or other patient characteristics. CONCLUSIONS: Most of the difference in observed mortality rates across surgeons is attributable to differences in rates of heart failure.

ARTICLE TITLE: A national study of postoperative mortality associated with coronary artery bypass grafting in Israel. ISCAB Consortium. Israel Coronary Artery Bypass Study.
ARTICLE SOURCE: Ann Thorac Surg (United States), Oct 1998, 66(4) p1254-62; discussion 1263
AUTHOR(S): Mozes B; Olmer L; Galai N; Simchen E
AUTHOR'S ADDRESS: Unit for Quality Assurance, The Gertner Institute for Epidemiology and Health Policy Research, Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel. benjamin@post.tau.ac.il.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
ABSTRACT: BACKGROUND: Investigation of observed differences in outcomes among medical centers is of major interest to the medical community and the public and has a substantial impact on efforts to improve the quality of medical care. METHODS: This study analyzed data from consecutive patients who underwent isolated coronary artery bypass grafting at 14 medical centers. Data included demographic and clinical information, comorbidity, cardiac catheterization results, and 30-day postoperative vitality status. Logistic regression analysis was used to identify variables associated with mortality. An outlier hospital was defined as one having an observed mortality outside the 95% confidence interval boundaries around the expected mortality rate calculated, given the patient risk factors. RESULTS: The overall crude 30-day mortality rate for isolated coronary artery bypass grafting among the 4,835 patients in this study was 3.1%. The rate varied among centers, ranging from 0.85% to 7.05%. Predictors of 30-day mortality included advanced age, female sex, diabetes mellitus, poor left ventricular function, high creatinine level, high priority of operation, and three-vessel disease (with or without left main coronary artery disease). After adjustment for risk factors, two hospitals were defined as outliers. CONCLUSIONS: The observed disparity in early mortality among patients undergoing coronary artery bypass grafting is not due solely to differences in case mix.
MB.It looks as though there were 2 out of line Hospitals on Israel and none in New England.

ARTICLE TITLE: Partial liquid ventilation in adult patients with ARDS: a multicenter phase I-II trial. Adult PLV Study Group.
ARTICLE SOURCE: Ann Surg (United States), Nov 1998, 228(5) p692-700
AUTHOR(S): Hirschl RB; Conrad S; Kaiser R; Zwischenberger JB; Bartlett RH; Booth F; Cardenas V
AUTHOR'S ADDRESS: Department of Surgery, University of Michigan, Ann Arbor 48109-0245, USA.
PUBLICATION TYPE: CLINICAL TRIAL; CLINICAL TRIAL, PHASE I; CLINICAL TRIAL, PHASE II; JOURNAL ARTICLE; MULTICENTER STUDY
CONCLUSIONS: These data suggest that PLV may be performed safely with few related severe adverse effects. Improvement in gas exchange was observed in this series of adult patients over the 48 hours after initiation of PLV.

ARTICLE TITLE: Virtual reality applied to hepatic surgery simulation: the next revolution.
ARTICLE SOURCE: Ann Surg (United States), Nov 1998, 228(5) p627-34
AUTHOR(S): Marescaux J; Clement JM; Tassetti V; Koehl C; Cotin S; Russier Y; Mutter D; Delingette H; Ayache N
AUTHOR'S ADDRESS: Department of Digestive and Endocrine Surgery, Universite Louis Pasteur, Strasbourg, France.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Three-dimensional visualization of the organ in relation to the pathology is of great help to appreciate the complex anatomy of the liver. Using virtual reality concepts (navigation, interaction, and immersion), surgical planning, training, and teaching for this complex surgical procedure may be possible. The ability to practice a given gesture repeatedly will revolutionize surgical training, and the combination of surgical planning and simulation will improve the efficiency of intervention, leading to optimal care delivery.