ARTICLE TITLE: Randomised controlled trial of inhaled
corticosteroids in patients with chronic obstructive pulmonary
disease.
ARTICLE SOURCE: Thorax (England), Jun 1998, 53(6) p477-82
AUTHOR(S): Bourbeau J; Rouleau MY; Boucher S
AUTHOR'S ADDRESS: McGill University Health Centre, McGill University,
Montreal, Canada.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
CONCLUSIONS: Inhaled corticosteroids, even at high doses, were of no
physiological or functional benefit in these patients with advanced
COPD.
ARTICLE TITLE: Health effects of passive smoking. 8. Passive smoking
and risk of adult asthma and COPD: an update.
ARTICLE SOURCE: Thorax (England), May 1998, 53(5) p381-7
AUTHOR(S): Coultas DB
AUTHOR'S ADDRESS: Department of Internal Medicine, University of New
Mexico Health Sciences Center, Albuquerque, New Mexico 87131,
USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (51 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Randomised placebo controlled trial of daytime
function after continuous positive airway pressure (CPAP) therapy for
the sleep apnoea/hypopnoea syndrome.
ARTICLE SOURCE: Thorax (England), May 1998, 53(5) p341-5
AUTHOR(S): Engleman HM; Martin SE; Kingshott RN; Mackay TW; Deary IJ;
Douglas NJ
AUTHOR'S ADDRESS: Respiratory Medicine Unit, University of Edinburgh,
UK.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
CONCLUSIONS: These findings provide further evidence for clinically
significant benefits to daytime function from CPAP.
ARTICLE TITLE: Reduced mortality in association with the acute
respiratory distress syndrome (ARDS).
ARTICLE SOURCE: Thorax (England), Apr 1998, 53(4) p292-4
AUTHOR(S): Abel SJ; Finney SJ; Brett SJ; Keogh BF; Morgan CJ; Evans
TW
AUTHOR'S ADDRESS: Unit of Critical Care, Imperial College School of
Medicine, Royal Brompton Hospital, London, UK.
ABSTRACT: BACKGROUND: A study was undertaken to investigate possible
reductions in mortality and/or changes in outcome predictive factors
in patients with the acute respiratory distress syndrome (ARDS)
managed in a single centre. METHODS: The study was a prospective
observational cohort study of two patient populations with ARDS.
Group 1 comprised 41 patients enrolled between May 1990 and April
1993, and group 2 consisted of 78 patients enrolled between June 1993
and March 1997. The end points of the study were mortality and
various factors predictive of death. RESULTS: There was a marked
reduction in mortality between groups 1 and 2 (66% versus 34%;
relative risk 1.77; CI 1.23 to 2.55). There were no significant
differences between the groups in terms of age (40.6 (3.3) versus
45.5 (2.2) years), APACHE score (14.5 (0.72) versus 13.6 (0.1)), lung
injury score (2.95 (0.07) versus 2.8 (0.1)), incidence of multi-organ
failure (29% versus 32%), incidence of sepsis (31% versus 39%), or
PaO2/FIO2 (kPa) ratio (11.8 (0.67) versus 12.0 (0.6)). There was a
significantly lower proportion of men in group 1 (51% versus 74%).
The case mix of the two groups was closely matched: following
elective surgery 48% versus 48%, trauma 17% versus 16%, primary lung
injury 12% versus 24%. Patients in group 1 were supported using
several ventilatory and other modes (volume preset, non-inverse ratio
ventilation, n = 15; pressure controlled inverse ratio ventilation
(PC-IRV), n = 11; ultra high frequency jet ventilation (UHFJV), n =
13; an intravascular oxygenation device (IVOX) and extracorporeal gas
exchange (ECGE), n = 2). Within group 1 no significant difference in
mortality was observed between the patients on volume controlled
ventilation and the remainder. In group 2 all patients received
PC-IRV (n = 78) but, in addition, some received other support
techniques (UHFJV n = 4, ECGE n = 2). In group 1 only sepsis on
admission (21% (survivors) versus 56% (non-survivors)) predicted
death. In group 2 age of survivors and non-survivors (41.2 (2.6)
versus 52.6 (3.5)), APACHE score (12.2 (0.6) versus 15.8 (0.9)), and
PaO2/FIO2 (12.8 (0.86) versus 10.5 (0.72)) predicted survival, but
not the incidence of sepsis or multi-organ failure. CONCLUSIONS: In
recent years a highly significant reduction in mortality associated
with ARDS has been observed between two groups of patients well
matched for disease severity and case mix. Changes in ICU
organisation rather than specific interventions may account for this
reduction, although different ventilatory and other management
strategies used in the two groups may also be relevant.
MB. Brian Keogh was registrar here the early 1980s. He completed his
training in London and has stayed there as a Consultant.
ARTICLE TITLE: Improved survival in ARDS: chance, technology or
experience? [editorial]
ARTICLE SOURCE: Thorax (England), Apr 1998, 53(4) p237-8
AUTHOR(S): Baudouin S
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: EDITORIAL
MB. The last sentence of the editorial suggests what I think is the
answer. "Perhaps---concentrating groups of complex, critically ill
patients into experienced centres improves survival."
The study and the editorial do not answer the question proposed by
the editorial but that last suggestion seems to be the obvious answer
to me. I have said so many times before.
I have seen the rise and fall of ARDS. The disease must have been due
to iatrogenic factors, which have now gone away. The disease was very
common in ICU 25y ago and is now rare. It would be interesting to
know the `medical' age of the editorial writer.
ARTICLE TITLE: Determinants of management errors in acute severe
asthma.
ARTICLE SOURCE: Thorax (England), Jan 1998, 53(1) p14-20
AUTHOR(S): Kolbe J; Vamos M; Fergusson W; Elkind G
AUTHOR'S ADDRESS: Department of Respiratory Medicine, Green Lane
Hospital, Auckland, New Zealand.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: It is hypothesised that, despite recent
initiatives to improve asthma self-management including asthma
education, detailed investigation of the sequence of events
culminating in hospital admission will lead to the identification of
important management errors and thus the likelihood that the majority
of severe asthma attacks are preventable by currently available
strategies, and that psychological, health care and socioeconomic
factors are risk factors for such management errors. METHODS: A cross
sectional study was undertaken of 138 patients aged 15-50 years
admitted to hospital (general ward or intensive care unit) with acute
severe asthma who were assessed within 24-72 hours of admission using
a number of previously validated instruments. A detailed history of
events of the attack was assessed against predetermined criteria for
non or delayed use of oral corticosteroids and non or delayed use of
emergency ambulance services. RESULTS: Subjects had evidence of
severe chronic asthma and had acute severe asthma at presentation (n
= 90, pH = 7.3 (0.2), PaCO2 = 7.2 (5.0) kPa) but duration of hospital
stay was short (3.7 (2.6) days). Serious management errors occurred
very frequently and most were deemed to have been made by the
patient. Forward stepwise regression revealed that delayed or non-use
of oral corticosteroids was predicted independently by lack of paying
job (p = 0.02), high total use of inhaled beta agonists in the 24
hours before index admission (p = 0.04), loss of a job in the last
year (p = 0.04), low frequency of use of oral corticosteroids in the
last year (p = 0.06), concerns during the index attack about medical
expenses (p = 0.07), and delay in the use of ambulance services (p =
0.05)--the model being responsible for 23% of the variance. Delayed
or non-summoning of emergency ambulance services was predicted
independently by total life events (p = 0.03), having something
stolen in the last year (p = 0.003), panic during the index attack (p
= 0.01), and concerns during the index attack about taking time off
work (p = 0.07)--the model being responsible for 21% of the variance.
CONCLUSIONS: The results of this study show that, despite recent
educational advances, serious management errors are common in those
admitted to hospital with acute severe asthma and that most
management errors relate to patient self-management behaviour.
Serious management errors are predicted by a variety of
socio-economic and psychological factors. While the results of this
study are consistent with the widely held view that most acute severe
attacks are theoretically preventable, the challenge for the future
is to change patients' behaviour in the face of considerable adverse
socioeconomic and psychological factors.
MB.Asthma mortality has remained high or increased especially in
Australia and NZ at least since 1970. The people involved do not seem
to be able to entertain the hypothesis that they might be the cause
of the persistent mortality in spite of their `improved therapy'. The
first thing that should be investigated is that maybe the therapy is
actually making things worse. Some of the article blames the
patients.
ARTICLE TITLE: The rise of asthma and atopy [editorial]
ARTICLE SOURCE: QJM (England), Mar 1998, 91(3) p169-70
AUTHOR(S): Hopkin JM
MINOR SUBJECT HEADING(S): Asthma [epidemiology]
[genetics] [immunology]; Developed Countries;
Hypersensitivity [genetics]; Life Style; Prevalence; Th1
Cells [immunology]; Th2 Cells [immunology];
Tuberculin Test
MB. Seems speculative to me. Grasping for straws to explain asthma
prevalence
ARTICLE TITLE: Outcomes research and surgeons.
ARTICLE SOURCE: Surgery (United States), Sep 1998, 124(3) p477-83
AUTHOR(S): Birkmeyer JD
AUTHOR'S ADDRESS: Department of Veterans Affairs Medical Center,
White River Junction, Vt, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (31 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Acute lower limb ischemia: determinants of
outcome.
ARTICLE SOURCE: Surgery (United States), Aug 1998, 124(2) p336-41;
discussion 341-2
AUTHOR(S): Ouriel K; Veith FJ
AUTHOR'S ADDRESS: Department of Surgery, University of Rochester, NY
14642, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ABSTRACT: BACKGROUND: Previous studies have documented high rates of
morbidity and death after acute peripheral arterial occlusion. To
date, however, few studies have identified parameters predictive of
successful therapy. METHODS: The Thrombolysis or Peripheral Arterial
Surgery Trial of intraarterial recombinant urokinase or immediate
operation for acute lower extremity arterial occlusion provided data
on 544 patients randomized at 113 centers. A Cox proportional hazards
multifactor analysis was performed to identify those main effects
predictive of amputation-free survival and to document any baseline
variables useful in deciding whether a patient would be treated best
initially with thrombolysis or operation. RESULTS: Of 28 variables
analyzed, eight main effects were predictive of amputation-free
survival. These included two demographic factors: white race (risk
ratio [RR] = 1.75; p = 0.003) and younger age (RR = 1.015; p
= 0.046). Comorbidities comprised four of the main effects: history
of central nervous system disease (RR = 1.726; p = 0.005), history of
malignancy (RR = 1.615; p = 0.024), congestive heart failure (RR =
2.202; p 0.001), or low body weight (RR = 1.007 per pound; p =
0.006). The severity of the process was also predictive, as gauged by
the presence of skin color changes (RR = 1.585, p = 0.007) or pain at
rest (RR = 0.503; p = 0.003). All eight effects were similar in the
two treatment groups; none of these variables predicted improved
outcome with one form of initial therapy over the other (i.e., there
was no therapy-by-variable interaction). The length of occlusion,
however, predicted whether a patient would fare better with
thrombolysis or operation. With a threshold occlusion length of 30
cm, the RR for longer occlusions to shorter occlusions was 43% better
in patients who received thrombolysis, whereas the situation was
reversed for those who were randomized to operation. CONCLUSIONS: A
variety of baseline variables can be identified that are predictive
of outcome after treatment for acute lower extremity ischemia. In
addition, the length of the occlusive process appears to predict
whether a patient will be best served with thrombolysis or operative
intervention; longer occlusions appear to respond best with an
initial thrombolytic strategy.
ARTICLE TITLE: Assessing residents' clinical performance: cumulative
results of a four-year study with the Objective Structured Clinical
Examination.
ARTICLE SOURCE: Surgery (United States), Aug 1998, 124(2) p307-12
AUTHOR(S): Schwartz RW; Witzke DB; Donnelly MB; Stratton T; Blue AV;
Sloan DA
AUTHOR'S ADDRESS: Department of Surgery, University of Kentucky
Chandler Medical Center, Lexington 40536-0084, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: The Objective Structural Clinical Examination
(OSCE) is an objective method for assessing clinical skills and can
be used to identify deficits in clinical skill. During the past 5
years, we have administered 4 OSCEs to all general surgery residents
and interns. METHODS: Two OSCEs (1993 and 1994) were used as
broad-based examinations of the core areas of general surgery;
subsequent OSCEs (1995 and 1997) were used as needs assessments. For
each year, the reliability of the entire examination was calculated
with Cronbach's alpha. A reliability-based minimal competence score
(MCS) was defined as the mean performance (in percent) minus the
standard error of measurement for each group in 1997 (interns, junior
residents, and senior residents). RESULTS: The reliability of each
OSCE was acceptable, ranging from 0.63 to 0.91. The MCS during the
4-year period ranged from 45% to 65%. In 1997, 4 interns, 2 junior
residents, and 2 senior residents scored below their group's MCS. MCS
for the groups increased across training levels in developmental
fashion (P .05). CONCLUSIONS: Given the relatively stable findings
observed, we conclude (1) the OSCE can be used to identify group and
individual differences reliably in clinical skills, and (2) we
continue to use this method to develop appropriate curricular
remediation for deficits in both individuals and groups.
MB. Strange thought process. They equate the result of an OSCE
examination with competence. They more or less admit that this is
arbitrary and incomplete.
ARTICLE TITLE: Transient ischaemic attacks: new treatments, new
questions [editorial]
ARTICLE SOURCE: QJM (England), Jun 1998, 91(6) p377-9
AUTHOR(S): Sandercock P
PUBLICATION TYPE: EDITORIAL
ARTICLE TITLE: Outcome from a rapid-assessment chest pain clinic.
ARTICLE SOURCE: QJM (England), May 1998, 91(5) p339-43
AUTHOR(S): Davie AP; Caesar D; Caruana L; Clegg G; Spiller J;
Capewell S; Starkey IR; Shaw TR; McMurray JJ
AUTHOR'S ADDRESS: MRC Clinical Research Initiative in Heart Failure,
University of Glasgow, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Chest pain accounts for much of the rising numbers of
emergency admissions, but in-patient assessment is not necessarily
the best way of dealing with these patients. We ran a
'rapid-assessment chest pain clinic' to provide an alternative route
of assessment, and audited its outcome. General practitioners
referred patients with recent-onset chest pain, increasing chest
pain, chest pain at rest, or other chest pain of concern, on the
understanding that they would be seen within 24 h. During 8 1/2
months, 334 patients were referred and 317 patients were seen, most
of whom had exercise electrocardiography. A median of 6 months later,
278 patients were personally contacted to determine outcome. Of
these, 18% had been admitted immediately with acute coronary
syndromes, and 49% had been diagnosed as non-coronary chest pain
(none of whom subsequently infarcted or died). Continuing symptoms
were infrequent, and satisfaction was high, although 13% of patients
had been revascularized. A significant number of patients required
immediate admission and/or ultimate revascularization, but many more
did not. The majority of these patients had non-coronary chest pain,
and this diagnosis was substantiated by their excellent outcome and
(in some cases) by further investigation.
MB. The chest pain clinic was useless.
ARTICLE TITLE: Medical treatment of acute tubular necrosis
[editorial]
ARTICLE SOURCE: QJM (England), May 1998, 91(5) p321-3
AUTHOR(S): Firth JD
MINOR SUBJECT HEADING(S): Diuretics [therapeutic use];
Dopamine [therapeutic use]; Drug Therapy, Combination
PUBLICATION TYPE: EDITORIAL
MB. Although frusemide blindly did not alter outcome except to
increase urine flow the editorial writer cannot bring himself to
conclude that therapy does not benefit tubular necrosis.
ARTICLE TITLE: Bicarbonate-based haemofiltration in the management of
acute renal failure with lactic acidosis.
ARTICLE SOURCE: QJM (England), Apr 1998, 91(4) p279-83
AUTHOR(S): Hilton PJ; Taylor J; Forni LG; Treacher DF
AUTHOR'S ADDRESS: Department of Renal Medicine, St Thomas' Hospital,
London, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Continuous haemofiltration with lactate-based replacement
fluid is widely used for the treatment of acute renal failure (ARF).
In the presence of lactic acidosis, such treatment exacerbates rather
than improves the clinical state. Continuous haemofiltration using a
locally-prepared bicarbonate-based replacement fluid was performed in
200 patients over 7 years. All the patients had ARF with concomitant
lactic acidosis, or demonstrated lactate intolerance after starting
haemofiltration with lactate-based replacement fluids. In every case
it was possible to correct the acidosis without inducing either
extracellular volume expansion or hypernatraemia. In 89 patients
(45%), the lactic acidosis resolved while being treated with
bicarbonate-based haemofiltration. Fifty-seven patients (28.5%)
survived. Significant differences at presentation in the group who
survived, compared with those who died, were seen in age (50.8 vs.
57.1), mean arterial pressure (68.5 vs. 60.0 mmHg) and APACHE II
score (32.1 vs. 38.9). Neither the severity of the presenting
acidosis nor the arterial blood lactate appeared to predict outcome.
Patients who developed ARF and lactic acidosis after cardiac surgery
had a low survival rate. The combination of ARF and lactic acidosis
that cannot safely be treated by haemofiltration using lactate-based
replacement fluids can be managed with bicarbonate-based
haemofiltration.
ARTICLE TITLE: Digoxin revisited.
ARTICLE SOURCE: QJM (England), Apr 1998, 91(4) p259-64
AUTHOR(S): Li-Saw-Hee FL; Lip GY
AUTHOR'S ADDRESS: University Department of Medicine, City Hospital,
Birmingham, UK.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (43 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Cloning and ethics.
ARTICLE SOURCE: QJM (England), Feb 1998, 91(2) p165-6
AUTHOR(S): Benatar D
AUTHOR'S ADDRESS: Department of Philosophy, University of Cape Town,
South Africa.
PUBLICATION TYPE: JOURNAL ARTICLE
ARTICLE TITLE: The prognostic significance of acute renal failure
after renal transplantation in patients treated with cyclosporin.
ARTICLE SOURCE: QJM (England), Jan 1998, 91(1) p27-40
AUTHOR(S): Perez Fontan M; Rodriguez-Carmona A; Bouza P; Valdes F
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: We studied 733 cadaveric renal transplant patients (747
transplants) under cyclosporin immunosuppression, to: (i) establish
the risk profile for acute renal failure (ARF) after renal
transplantation in a unit using many sub-optimal donors; (ii) assess
the long-term prognostic relevance of ARF; and (iii) explore the
synergistic prognostic significance of delayed graft function and
acute rejection during the early post-transplant period.
Transplanting from a non-heart-beating or elderly donor, protracted
cold ischaemia, haemodialysis immediately before transplant surgery,
poor HLA matching, and grafting to a hypersensitized recipient
without residual renal function, all independently predicted delayed
graft function. This delay had no detrimental effect on patient or
graft survival, but prolonged ARF was associated with increased
mortality from infection. Late markers of graft dysfunction (poor
graft function, proteinuria, hypertension) were highly prevalent
among grafts affected by ARF, specially in prolonged ARF. Delayed
graft function and early acute rejection showed a definite, albeit
not strong, additive impact on late graft survival, and also on the
prevalence of late markers of graft dysfunction.
ARTICLE TITLE: The molecular mechanisms of drug action
[editorial]
ARTICLE SOURCE: QJM (England), Jan 1998, 91(1) p1-3
AUTHOR(S): MacDermot J
PUBLICATION TYPE: EDITORIAL
ARTICLE TITLE: Patient-controlled versus staff-controlled analgesia
with pethidine after allogeneic bone marrow transplantation.
ARTICLE SOURCE: Pain (Netherlands), Apr 1998, 75(2-3) p305-12
AUTHOR(S): Zucker TP; Flesche CW; Germing U; Schroter S; Willers R;
Wolf HH; Heyll A
AUTHOR'S ADDRESS: Department of Clinical Anaesthesiology,
Heinrich-Heine-University, Dusseldorf, Germany.
zucker@uni-duesseldorf.de.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ABSTRACT: Patients treated by allogeneic bone marrow transplantation
(aBMT) suffer prolonged oropharyngeal mucositis pain. The aim of this
study was to prospectively compare patient-controlled analgesia (PCA)
with an established regimen of staff-controlled analgesia using
pethidine (meperidine). Twenty patients undergoing aBMT for
haematologic neoplasias or malignant lymphomas randomly received
pethidine intravenously either continuously plus supplemental bolus
doses on request through the transplant unit staff or by PCA. Pain
intensity was assessed by patient self report using a visual analogue
scale (VAS) and daily pethidine intake was documented. In addition,
the pethidine consumption of 20 aBMT-patients receiving
staff-controlled analgesia prior to initiation of the study, but not
reporting pain, was compared retrospectively with that of patients
receiving the same analgesia regimen under study conditions. PCA
significantly diminished both pethidine consumption and pain
intensity compared with staff-controlled analgesia. The maximum
pethidine intake was 440.1 +/- 111.8 mg/24 h in the
patient-controlled and 640.9 +/- 128.9 mg/24 h in the
staff-controlled analgesia group (mean +/- 95% CI). Mean pain scores
remained under 50% but reached 70% in the staff-controlled analgesia
group. Pethidine dosage by staff-controlled analgesia increased under
study conditions, suggesting that mere pain-assessment and a
'competing' analgesic method motivated the BMT-unit staff to
administer higher pethidine doses. This observation is discussed as a
possible Hawthorne effect. Previous studies using morphine
demonstrated that PCA diminishes opioid requirement compared to
continuous or staff-controlled application in bone marrow recipients.
In contrast to these studies, PCA additionally improved pain relief
in the present investigation.
MB. I don't think this was blinded. I have not checked the full
article.
ARTICLE TITLE: Patient empowerment and feedback did not decrease pain
in seriously ill hospitalized adults.
ARTICLE SOURCE: Pain (Netherlands), Apr 1998, 75(2-3) p237-46
AUTHOR(S): Desbiens NA; Wu AW; Yasui Y; Lynn J; Alzola C; Wenger NS;
Connors AF Jr; Phillips RS; Fulkerson W
AUTHOR'S ADDRESS: The University of Tennessee Memphis, Chattanooga
Unit of the College of Medicine, 37403, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ABSTRACT: We tested a nurse clinician-mediated intervention to
relieve pain in a group of seriously ill hospitalized adults using a
randomized controlled trial at five tertiary care academic centers in
the US. The study included 4804 patients admitted between January
1992 and January 1994 with one or more of nine high mortality
diagnoses; 2652 were allocated to the intervention and 2152 to usual
care. Specially-trained nurse clinicians assessed patients' pain,
educated them and their families about pain control, empowered
patients to expect pain relief, informed patients' nurses and
physicians about level of pain and suggested or used other pain
management resources. Patients' pain was determined from hospital
interviews with patients and surrogates. Pain 2 and 6 months later or
after death and satisfaction with its control at all time periods
were also assessed. All analyses were adjusted for baseline risk of
being in pain and propensity to be in the intervention group.
Overall, 50.9% of patients reported some pain. After adjustment for
other variables associated with pain, comparing the intervention to
the control group, there was not a statistically significant
difference in level of pain (OR for higher levels of pain 1.15; CI
1.00-1.32) or satisfaction with control of pain during the
hospitalization (OR for higher levels of pain 1.12; CI 0.91-1.39), 2
or 6 months after discharge, or during the last 3 days of life. A
multifaceted intervention using information, empowerment, advocacy,
counseling and feedback was ineffective in ameliorating pain in
seriously ill patients. Control of pain in these patients remains an
important problem. More intensive pain treatment strategies
addressing the needs of seriously ill hospitalized adults must be
evaluated.
MB I wonder how they measured empowerment.
ARTICLE TITLE: Prediction and assessment of the severity of
post-operative pain and of satisfaction with management.
ARTICLE SOURCE: Pain (Netherlands), Apr 1998, 75(2-3) p177-85
AUTHOR(S): Thomas T; Robinson C; Champion D; McKell M; Pell M
AUTHOR'S ADDRESS: St Vincent's Private Hospital, Darlinghurst, NSW,
Australia.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: A prospective observational study of cohorts of patients
undergoing hip replacement (30), knee replacement (31), and spinal
nerve root decompressive surgery (30) were interviewed
pre-operatively to identify factors which might correlate with and
potentially predict severe post-operative pain and dissatisfaction
with analgesic management. The hip patients comprised 33% females and
averaged 64 years, while the knee patients were 45% female and older
(mean 71 years) and the spinal patients were 43% female and averaged
50 years. The three groups were similar with respect to all other
pre-operative variables. Pain intensity was assessed mainly by
self-report using the Present Pain Intensity (PPI) and Visual
Analogue Scales (VAS) of the McGill Pain Questionnaire. The PPI was
preferred by patients and nurses and, as there were no analytical
advantages for the VAS, the PPI data are presented. The average
post-operative pain during routine management mainly with patient
controlled intravenous opiate, was mild to moderate and declined over
days 1-5, declined further at discharge but rose slightly 1 month
after discharge. The hip replacement patients experienced
significantly (P 0.01) less pain overall than the patients in the
other two groups. Nurses' assessments of pain severity from observed
behaviour were low and agreed poorly with the patients' self reports.
Assessed on Likert Scales (0-6), the patients generally indicated
good or excellent pain control, better than expected pain experience,
and high levels of satisfaction with analgesic management.
Significant (P or = 0.01) multivariate correlates of severe
post-operative pain assessed by logistic regression analysis of 11
variables were female gender, high pre-operative pain severity, and
younger age. Significant (P or = 0.01) multivariate correlates of
both worse than expected pain experience and low satisfaction were
female gender, high pre-operative pain severity, high anxiety about
risks and problems, low expected pain severity, age (younger) and
high willingness to report pain. These variables may reasonably be
tested in further studies as potential predictors of adverse
post-operative pain experience.
MB. Small samples.
ARTICLE TITLE: Learning to live with the pain: acceptance of pain
predicts adjustment in persons with chronic pain.
ARTICLE SOURCE: Pain (Netherlands), Jan 1998, 74(1) p21-7
AUTHOR(S): McCracken LM
AUTHOR'S ADDRESS: The University of Chicago, Department of
Psychiatry, IL 60637, USA. lmccrack@yoda.bsd.uchicago.edu.
PUBLICATION TYPE: CLINICAL TRIAL; CONTROLLED CLINICAL TRIAL; JOURNAL
ARTICLE
ABSTRACT: When patients find their pain unacceptable they are likely
to attempt to avoid it at all costs and seek readily available
interventions to reduce or eliminate it. These efforts may not be in
their best interest if the consequences include no reductions in pain
and many missed opportunities for more satisfying and productive
functioning. The purpose of this study was to examine acceptance of
pain. One hundred and sixty adults with chronic pain provided
responses to a questionnaire assessing acceptance of pain, and a
number of other questionnaires assessing their adjustment to pain.
Correlational analyses showed that greater acceptance of pain was
associated with reports of lower pain intensity, less pain-related
anxiety and avoidance, less depression, less physical and
psychosocial disability, more daily uptime, and better work status. A
relatively low correlation between acceptance and pain intensity
showed that acceptance is not simply a function of having a low level
of pain. Regression analyses showed that acceptance of pain predicted
better adjustment on all other measures of patient function,
independent of perceived pain intensity. These results are
preliminary. Further study will be needed to show for whom and under
what circumstances, accepting some aspects of the pain experience may
be beneficial.
ARTICLE TITLE: Selection bias in pain research
[editorial]
ARTICLE SOURCE: Pain (Netherlands), Jan 1998, 74(1) p1-3
AUTHOR(S): Crombie IK; Davies HT
PUBLICATION TYPE: EDITORIAL
ARTICLE TITLE: A life-threatening anaphylactoid reaction to
polyvalent snake antivenom despite pretreatment.
ARTICLE SOURCE: Med J Aust (Australia), Sep 7 1998, 169(5) p257-8
AUTHOR(S): Arunanthy S; Hertzberg SR
AUTHOR'S ADDRESS: Westmead Hospital and Community Health Services,
NSW. emedwest@wm.general.wsahs.nsw.gov.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: A 44-year-old man suffered a life-threatening anaphylactoid
reaction to polyvalent snake antivenom, although he had been given
the recommended pretreatment. Further research is needed to determine
if pretreatment is necessary.
ARTICLE TITLE: Rebuilding the English National Health Service:
doctors in the driving seat? [editorial]
ARTICLE SOURCE: Med J Aust (Australia), Jul 20 1998, 169(2) p71-2
AUTHOR(S): Braithwaite J; Hindle D; Degeling PJ
PUBLICATION TYPE: EDITORIAL
MB Utopian.
ARTICLE TITLE: Prostate-specific antigen testing for prostate cancer:
the case for informed consent [editorial; comment]
COMMENTS: Comment on: Med J Aust 1998 Jul 6; 169(1):17-20; Comment
on: Med J Aust 1998 Jul 6; 169(1):21-4; Comment on: Med J Aust 1998
Jul 6; 169(1):25-8; Comment on: Med J Aust 1998 Jul 6;
169(1):29-31
ARTICLE SOURCE: Med J Aust (Australia), Jul 6 1998, 169(1) p9-10
AUTHOR(S): McCredie M; Cox B
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Prostate-specific antigen testing in Australia and
association with prostate cancer incidence in New South Wales
[see comments]
COMMENTS: Comment in: Med J Aust 1998 Jul 6; 169(1):9-10
ARTICLE SOURCE: Med J Aust (Australia), Jul 6 1998, 169(1) p17-20
AUTHOR(S): Smith DP; Armstrong BK
AUTHOR'S ADDRESS: Cancer Control Information Centre, New South Wales
Cancer Council, Sydney. dsmith@nswcc.org.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: To describe patterns and trends in
prostate-specific antigen (PSA) testing in Australia and assess its
role in the increasing incidence of prostate cancer. DESIGN:
Descriptive analysis of (i) Medicare records of PSA testing in
Australia, and (ii) prostate cancer recorded incidence in New South
Wales. DATA: (i) Medicare data for all males who received a
Medicare-reimbursed PSA test between August 1989 and December 1996.
(ii) NSW Central Cancer Registry data for all males in NSW with
prostate cancer diagnosed between 1988 and 1995. MAIN OUTCOME
MEASURES: (i) Number of PSA tests, age-standardised rates of PSA
tests by State and Territory, and proportions of males who had a PSA
test. (ii) Recorded incidence of prostate cancer in NSW. RESULTS: (i)
More than 2.2 million PSA tests were done on more than 1.1 million
Australians between 1989 and 1996. The annual number of males tested
increased fivefold in this period and peaked in 1995. Twenty-seven
per cent of Australian men aged 50 years or over had at least one PSA
test in 1995 or 1996; 33% of men aged 60-69 years had a test in this
period. (ii) In NSW the number of PSA tests per quarter was highly
correlated with the number of new cases of prostate cancer (R2 =
0.92). CONCLUSIONS: Although no organised program for prostate cancer
screening exists, and despite repeated advice against it,
opportunistic screening has been occurring at high rates. There was a
high correlation between PSA testing and prostate cancer incidence
between 1990 and 1995 in NSW.
ARTICLE TITLE: Management of localised prostate cancer: state of the
art [editorial]
ARTICLE SOURCE: Med J Aust (Australia), Jul 6 1998, 169(1) p11-2
AUTHOR(S): Frydenberg M; Duchesne G; Stricker PD
PUBLICATION TYPE: EDITORIAL; REVIEW (16 references); REVIEW
LITERATURE
ARTICLE TITLE: Feasibility of prescribing injectable heroin and
methadone to opiate-dependent drug users: associated health gains and
harm reductions [see comments]
COMMENTS: Comment in: Med J Aust 1998 Jun 15; 168(12):590-1
ARTICLE SOURCE: Med J Aust (Australia), Jun 15 1998, 168(12)
p596-600
AUTHOR(S): Metrebian N; Shanahan W; Wells B; Stimson GV
AUTHOR'S ADDRESS: Department of Social Science and Medicine, Imperial
College School of Medicine, London, United Kingdom.
n.metrebian@cxwms.ac.uk.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Injectable heroin is not always the drug of choice. This
intervention retained most patients in treatment with substantial
benefits to both patients and the community. Prescribing injectable
opiates to long term injecting drug users is a feasible treatment
option.
ARTICLE TITLE: Prescribing heroin: nothing to fear but fear itself?
[editorial; comment]
COMMENTS: Comment on: Med J Aust 1998 Jun 15; 168(12):596-600
ARTICLE SOURCE: Med J Aust (Australia), Jun 15 1998, 168(12)
p590-1
AUTHOR(S): Wodak A
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Drug abuse and illicit drug trafficking
[editorial]
ARTICLE SOURCE: Med J Aust (Australia), Jun 15 1998, 168(12)
p588-9
AUTHOR(S): Manderson DR
PUBLICATION TYPE: EDITORIAL
ARTICLE TITLE: Junior doctors' working hours: an unhealthy tradition?
[editorial; comment]
COMMENTS: Comment on: Med J Aust 1998 Jun 15; 168(12):614-6; Comment
on: Med J Aust 1998 Jun 15; 168(12):616-8
ARTICLE SOURCE: Med J Aust (Australia), Jun 15 1998, 168(12)
p587-8
AUTHOR(S): Holmes G
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Prevalence of Wernicke-Korsakoff syndrome in
Australia: has thiamine fortification made a difference? [see
comments]
COMMENTS: Comment in: Med J Aust 1998 Jun 1; 168(11):534-5
ARTICLE SOURCE: Med J Aust (Australia), Jun 1 1998, 168(11)
p542-5
AUTHOR(S): Harper CG; Sheedy DL; Lara AI; Garrick TM; Hilton JM;
Raisanen J
AUTHOR'S ADDRESS: Department of Pathology, University of Sydney, NSW.
cliveh@pathology.su.oz.au.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: There has been a significant reduction in the prevalence
of WKS in Australia since the introduction of thiamine enrichment of
bread flour. While the prevalence is still higher than in most other
Western countries, further research is needed before adding thiamine
to alcoholic beverages can be recommended.
MB This article is about histoloy. I saw some patients with the
syndrome as a student at SVH medical outpatients.
ARTICLE TITLE: Wernicke's encephalopathy and thiamine fortification
of food: time for a new direction? [editorial; comment]
COMMENTS: Comment on: Med J Aust 1998 Jun 1; 168(11):542-5
ARTICLE SOURCE: Med J Aust (Australia), Jun 1 1998, 168(11)
p534-5
AUTHOR(S): Drew LR; Truswell AS
MAJOR SUBJECT HEADING(S): Food, Fortified; Thiamine
[administration & dosage]; Wernicke's Encephalopathy
[epidemiology] [prevention & control]
MINOR SUBJECT HEADING(S): Australia [epidemiology]; Beer;
Bread
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: An epidemic of renal failure among Australian
Aboriginals [see comments]
COMMENTS: Comment in: Med J Aust 1998 Jun 1; 168(11):532-3
ARTICLE SOURCE: Med J Aust (Australia), Jun 1 1998, 168(11)
p537-41
AUTHOR(S): Spencer JL; Silva DT; Snelling P; Hoy WE
AUTHOR'S ADDRESS: Menzies School of Health Research, Casuarina,
NT.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The predicted doubling of ESRD (end stage renal disease)
incidence among Aboriginal people by the year 2000 will add an
enormous burden to limited resources. Risk factors for renal disease
underlie all the excess morbidity and mortality in NT Aboriginal
adults, and arise out of accelerated lifestyle changes and
socioeconomic disadvantage. Better living conditions and education,
robust and integrated primary healthcare programs, and systematic
screening for early renal disease and treatment of those with
established disease are all matters of urgency.
MB. There was an exchange of some land rights in exchange for
dialysis facilities in NT.
ARTICLE TITLE: Kidney disease in Australian aboriginals: time for
decisive action [editorial; comment]
COMMENTS: Comment on: Med J Aust 1998 Jun 1; 168(11):537-41
ARTICLE SOURCE: Med J Aust (Australia), Jun 1 1998, 168(11)
p532-3
AUTHOR(S): Thomas MA
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: The diastolic debate: is it time to discard Korotkoff
phase IV in favour of phase V for blood pressure measurements in
pregnancy?
ARTICLE SOURCE: Med J Aust (Australia), Aug 17 1998, 169(4)
p203-5
AUTHOR(S): Walker SP; Higgins JR; Brennecke SP
AUTHOR'S ADDRESS: Department of Perinatal Medicine, Royal Women's
Hospital, Melbourne, VIC. s.walker@pgrad.unimelb.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Current guidelines recommend using Korotkoff phase IV for
measuring diastolic blood pressure in pregnant women. However, phase
IV does not approximate "true" blood pressure as closely as phase V,
is more difficult to detect, and has limited reproducibility. Many
practitioners use phase V despite the guidelines. Universal adoption
of phase V would improve the reliability of blood pressure
measurements.
MB. Phase V is loss of all sound. I have always used it. What do the
non-invasive BP monitors diastolic reading correspond to?
ARTICLE TITLE: Decision making in CPR: attitudes of hospital patients
and healthcare professionals [see comments]
COMMENTS: Comment in: Med J Aust 1998 Aug 3; 169(3):124-5
ARTICLE SOURCE: Med J Aust (Australia), Aug 3 1998, 169(3)
p128-31
AUTHOR(S): Kerridge IH; Pearson SA; Rolfe IE; Lowe M
AUTHOR'S ADDRESS: Faculty of Medicine and Health Sciences, University
of Newcastle, NSW. ikerridge@mail.newcastle.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: To examine the opinions of patients and
healthcare professionals regarding the process of making decisions
about cardiopulmonary resuscitation (CPR). DESIGN AND PARTICIPANTS: A
cross-sectional survey of 511 healthcare professionals (doctors,
nurses and allied health professionals) (64% response rate) and 152
patients (58% response rate) at the John Hunter Hospital, Newcastle,
New South Wales, in June 1994. MAIN OUTCOME MEASURES: Opinions on who
should be involved in CPR decision making; what issues are important
when making the decision; and how these decisions should be
communicated. RESULTS: 80% (95% confidence interval [CI],
72%-86%) of patients and 99% (95% CI, 98%-100%) of healthcare
professionals (P 0.001) thought patients' views should be taken into
account when making CPR decisions. More patients (29%; 95% CI,
22%-38%) than healthcare professionals (14%; 95% CI, 11%-17%)
indicated that doctors should be the main decision makers. Two-thirds
of respondents regarded the patient's wishes, diagnosis and quality
of life as important factors. Most respondents (82%) felt comfortable
discussing CPR, but only 29% (95% CI, 22%-37%) of patients and 57%
(95% CI, 52%-61%) of healthcare professionals had actually discussed
CPR with others (P 0.001). More than half of all respondents
preferred to express their wishes about CPR in writing (47% [95%
CI, 39%-55%] of patients, 69% [95% CI, 64%-73%] of
healthcare professionals; P 0.01); the others preferred to tell a
family member or close friend. Most patients (60%; 95% CI, 52%-68%)
and healthcare professionals (85%; 95% CI, 81%-88%) wanted their
views in their medical records (P 0.001). CONCLUSION: Most patients
want to be involved in CPR decision making and many want some form of
advance directive. Although there are some differences in opinions
between patients and healthcare professionals, both perceive decision
making at the end of life as a shared process, primarily involving
the patient and doctor.
MB. None of authors are anasthetists or intensivists. They are from
ethics and education. The accompaning editorial is by a
psychiatrist.
ARTICLE TITLE: Matters of life and death: the challenge of CPR
decision making: how can we improve patient involvement in this
complex process? [editorial; comment]
COMMENTS: Comment on: Med J Aust 1998 Aug 3; 169(3):128-31
ARTICLE SOURCE: Med J Aust (Australia), Aug 3 1998, 169(3) p124-5
AUTHOR(S): Ryan CJ
MAJOR SUBJECT HEADING(S): Attitude of Health Personnel;
Cardiopulmonary Resuscitation; Decision Making; Patient
Participation; Resuscitation Orders
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Resuscitation preferences among patients with severe
congestive heart failure: results from the SUPPORT project. Study to
Understand Prognoses and Preferences for Outcomes and Risks of
Treatments [see comments]
COMMENTS: Comment in: Circulation 1998 Aug 18; 98(7):619-22
ARTICLE SOURCE: Circulation (United States), Aug 18 1998, 98(7)
p648-55
AUTHOR(S): Krumholz HM; Phillips RS; Hamel MB; Teno JM; Bellamy P;
Broste SK; Califf RM; Vidaillet H; Davis RB; Muhlbaier LH; Connors AF
Jr; Lynn J; Goldman L
AUTHOR'S ADDRESS: Department of Medicine, Yale School of Medicine and
the Yale-New Haven Hospital Center for Outcomes Research and
Evaluation, Conn 06520-8025, USA. harlan.krumholz@yale.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
ABSTRACT: BACKGROUND: We sought to describe the resuscitation
preferences of patients hospitalized with an exacerbation of severe
congestive heart failure, perceptions of those preferences by their
physicians, and the stability of the preferences. CONCLUSIONS: Almost
one quarter of patients hospitalized with severe heart failure
expressed a preference not to be resuscitated. The physician's
perception of the patient's preference was not accurate in about one
quarter of the cases. but communication was not associated with
greater agreement between the patient and the physician. A
substantial proportion of patients who did not want to be
resuscitated changed their minds within 2 months of discharge.
ARTICLE TITLE: Rites and responsibility for resuscitation in heart
failure: tread gently on the thin places [editorial;
comment]
COMMENTS: Comment on: Circulation 1998 Aug 18; 98(7):648-55
ARTICLE SOURCE: Circulation (United States), Aug 18 1998, 98(7)
p619-22
AUTHOR(S): Stevenson LW
ARTICLE TITLE: D-lactic acidosis. A review of clinical presentation,
biochemical features, and pathophysiologic mechanisms.
ARTICLE SOURCE: Medicine (Baltimore) (United States), Mar 1998, 77(2)
p73-82
AUTHOR(S): Uribarri J; Oh MS; Carroll HJ
AUTHOR'S ADDRESS: Department of Medicine, Mount Sinai Medical Center,
New York, New York 10029, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (72 references); REVIEW OF
REPORTED CASES
ABSTRACT: This report describes a case of d-lactic acidosis observed
by the authors and then reviews all case reports of d-lactic acidosis
in the literature in order to define its clinical and biochemical
features and pathogenetic mechanisms. The report also reviews the
literature on metabolism of d-lactic acid in humans. The clinical
presentation of d-lactic acidosis is characterized by episodes of
encephalopathy and metabolic acidosis. The diagnosis should be
considered in a patient who presents with metabolic acidosis and high
serum anion gap, normal lactate level, negative Acetest, short bowel
syndrome or other forms of malabsorption, and characteristic
neurologic findings. Development of the syndrome requires the
following conditions 1) carbohydrate malabsorption with increased
delivery of nutrients to the colon, 2) colonic bacterial flora of a
type that produces d-lactic acid, 3) ingestion of large amounts of
carbohydrate, 4) diminished colonic motility, allowing time for
nutrients in the colon to undergo bacterial fermentation, and 5)
impaired d-lactate metabolism. In contrast to the initial assumption
that d-lactic acid is not metabolized by humans, analysis of
published data shows a substantial rate of metabolism of d-lactate by
normal humans. Estimates based on these data suggest that impaired
metabolism of d-lactate is almost a prerequisite for the development
of the syndrome.
ARTICLE TITLE: Acute respiratory failure in pregnancy. An analysis of
19 cases.
ARTICLE SOURCE: Medicine (Baltimore) (United States), Jan 1998, 77(1)
p41-9
AUTHOR(S): Karetzky M; Ramirez M
AUTHOR'S ADDRESS: Division of Pulmonary and Critical Care Medicine,
New Jersey School of Medicine, UMDNJ, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: We studied 19 peripartum patients with acute respiratory
failure associated with pregnancy. Although it is an uncommon event,
noncardiogenic pulmonary edema is the most common cause of
respiratory failure in the peripartum period. This acute lung injury
syndrome was observed to be associated with a variety of
complications of pregnancy including premature labor, the use of
tocolytics, infection, hypertension, leukoagglutinin reactions,
aspiration, abruptio placentae, and amniotic fluid embolism. From
1989 through 1992 there were 10,852 deliveries and 19 patients with
noncardiogenic pulmonary edema at our institution. Analyzing these
cases has led us to favor the hypothesis that the respiratory failure
associated with the various complications of pregnancy primarily
represents the fatal and nonfatal cases of amniotic fluid embolism
that Steiner and Lushbaugh initially believed undoubtedly to exist.
Moreover, we suggest, as have others, that the nonspecific symptom
complex of inflammation, coagulopathy, and cardiopulmonary failure
represents the release of soluble mediators into the maternal
circulation. It is not clear what the predominant mediator is, but we
have focused on platelet activating factor. It is also not
established whether the mediator(s) is of amniotic fluid origin or a
result of maternal anaphylactoid-type of response to a fetal or
amnioplacental antigen. In conclusion, monitoring maternal
oxygenation either directly or indirectly by oximetry should be
considered routinely in the peripartum period, especially in
complicated pregnancies, to detect at an early stage "asymptomatic"
or preclinical cases of noncardiogenic pulmonary edema, in hopes of
then modifying management to prevent their progression.
ARTICLE TITLE: Heparin-induced thrombocytopenia, paradoxical
thromboembolism, and other side effects of heparin therapy.
ARTICLE SOURCE: Med Clin North Am (United States), May 1998, 82(3)
p635-58
AUTHOR(S): Walenga JM; Bick RL
AUTHOR'S ADDRESS: Department of Thoracic-Cardiovascular Surgery,
Loyola University Medical Center, Maywood, Illinois 60153, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (79 references); REVIEW,
TUTORIAL
ABSTRACT: Although several new anticoagulant drugs are in
development, heparin remains the drug of choice for most
anticoagulation needs. The clinical effects of heparin are
meritorious, but side effects do exist. Important untoward effects of
heparin therapy including heparin-induced thrombocytopenia,
heparin-associated osteoporosis, eosinophilia, skin reactions,
allergic reactions other than thrombocytopenia and alopecia will be
discussed in this article.
ARTICLE TITLE: Unfractionated and low-molecular-weight heparin.
Comparisons and current recommendations.
ARTICLE SOURCE: Med Clin North Am (United States), May 1998, 82(3)
p587-99
AUTHOR(S): Pineo GF; Hull RD
AUTHOR'S ADDRESS: Thrombosis Research Unit, Foothills Hospital,
Alberta, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (84 references); REVIEW,
TUTORIAL
ABSTRACT: Intravenous heparin followed by warfarin has been the
classical anticoagulant therapy of acute venous thromboembolism for
the past 30 years. In recent years a number of low-molecular-weight
heparins have become available for clinical trials. These agents have
a number of advantages over unfractionated heparin and are now being
used internationally for the prevention and treatment of venous
thromboembolism. Low-molecular-weight heparin will undoubtedly
replace intravenous unfractionated heparin not only in the treatment
of venous thromboembolism but in other conditions where heparin
therapy is indicated. Whether or not the low-molecular-weight
heparins can decrease or eliminate some of the complications of
unfractionated heparin will depend on the outcome of future clinical
trials.
ARTICLE TITLE: Prophylaxis of deep venous thrombosis and pulmonary
embolism. Current recommendations.
ARTICLE SOURCE: Med Clin North Am (United States), May 1998, 82(3)
p477-93
AUTHOR(S): Hull RD; Pineo GF
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (96 references); REVIEW,
TUTORIAL
ABSTRACT: Pulmonary embolism is responsible for approximately 150,000
to 200,000 deaths per year in the United States. Venous
thromboembolism usually occurs as a complication in patients who are
sick and hospitalized, but it may also affect ambulant and otherwise
healthy individuals. Many patients who die from pulmonary embolism
succumb suddenly or within 2 hours after the acute event (i.e.,
before therapy can be initiated or take effect). Therefore,
prevention is the key to reducing death and morbidity from venous
thromboembolism. Effective and safe prophylactic measures against
venous thromboembolism are now available for most high-risk patients.
This article highlights practical approaches to the prevention of
venous thromboembolism.
ARTICLE TITLE: Preflight versus en route success and complications of
rapid sequence intubation in an air medical service.
ARTICLE SOURCE: J Trauma (United States), Sep 1998, 45(3) p588-92
AUTHOR(S): Slater EA; Weiss SJ; Ernst AA; Haynes M
AUTHOR'S ADDRESS: Vanderbilt University Lifeflight, Vanderbilt
University, Nashville, Tennessee, USA.
CONCLUSION: Air medical intubations, both preflight and en route, for
both scene calls and interhospital transports, can be done with a
very high success rate. Rapid sequence intubation may improve the
success rate. For scene calls, there was a significant decrease in
ground time, and there was a trend toward fewer multiple intubation
attempts when the patient was intubated en route instead of
preflight.
ARTICLE TITLE: Outcome after hemorrhagic shock in trauma
patients.
ARTICLE SOURCE: J Trauma (United States), Sep 1998, 45(3) p545-9
AUTHOR(S): Heckbert SR; Vedder NB; Hoffman W; Winn RK; Hudson LD;
Jurkovich GJ; Copass MK; Harlan JM; Rice CL; Maier RV
AUTHOR'S ADDRESS: Department of Epidemiology, University of
Washington, Seattle, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: It is essential to identify patients at high
risk of death and complications for future studies of interventions
to decrease reperfusion injury. METHODS: We conducted an inception
cohort study at a Level I trauma center to determine the rates and
predictors of death, organ failure, and infection in trauma patients
with systolic blood pressure < or = 90 mm Hg in the field or in
the emergency department. RESULTS: Among the 208 patients with
hemorrhagic shock (blood pressure < or = 90 mm Hg), 31% died
within 2 hours of emergency department arrival, 12% died between 2
and 24 hours, 11% died after 24 hours, and 46% survived. Among those
who survived > or = 24 hours, 39% developed infection and 24%
developed organ failure. Increasing volume of crystalloid in the
first 24 hours was strongly associated with increased mortality (p =
0.00001). CONCLUSION: Hemorrhage-induced hypotension in trauma
patients is predictive of high mortality (54%) and morbidity. The
requirement for large volumes of crystalloid was associated with
increased mortality.
ARTICLE TITLE: Redefining cardiovascular performance during
resuscitation: ventricular stroke work, power, and the
pressure-volume diagram.
ARTICLE SOURCE: J Trauma (United States), Sep 1998, 45(3) p470-8
AUTHOR(S): Chang MC; Mondy JS; Meredith JW; Holcroft JW
AUTHOR'S ADDRESS: Department of General Surgery, The Wake Forest
University School of Medicine, Winston-Salem, North Carolina 27157,
USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVES: (1) To compare left ventricular stroke work
index (SW) and left ventricular power output (LVP), hemodynamic
variables that encompass blood pressure as well as blood flow, with
the purely flow-derived hemodynamic and oxygen transport variables as
markers of perfusion and outcome in critically injured patients
during resuscitation. (2) To use the ventricular pressure-volume
diagram to define characteristic hemodynamic patterns in the
determinants of SW and LVP that are associated with survival.
METHODS: This was a cohort study at a university Level I trauma
center during the course of 1 year. A consecutive series of patients
was monitored with a volumetric pulmonary artery catheter during the
initial 48 hours of resuscitation. Heart rate, SW, LVP, cardiac
index, and oxygen delivery and consumption during resuscitation were
compared using multivariate logistic regression analysis with regard
to the ability to clear lactate in less than 24 hours and survival.
Receiver operating characteristic curves were constructed to
determine threshold values for SW and LVP. Ventricular
pressure-volume diagrams were used to describe characteristic
patterns in the determinants of SW and LVP in survivors and
nonsurvivors. Preload was expressed as left ventricular end-diastolic
volume index, afterload as aortic input impedance (Ea), and
contractility as ventricular end-systolic elastance (Ees). The ratio
of Ea/Ees (RATIO) was used as a measure of ventricular-arterial
coupling, which describes the efficacy of energy transfer from the
heart to the vascular system. RESULTS: One hundred eleven patients
(87 survivors, 24 nonsurvivors) met study criteria. Survivors had a
significantly higher SW (4,510 +/- 1,070 vs. 3,440 +/- 980 mm Hg x mL
x m(-2); p < 0.0001) and LVP (370 +/- 94 vs. 270 +/- 81 mm Hg x L
x min(-2) x m(-2); p < 0.0001) than nonsurvivors. Heart rate, SW,
and LVP were the only studied variables that were significantly
related to lactate clearance and survival by logistic regression.
Threshold values determined by the receiver operating characteristic
curves were 4,000 mm Hg x mL x m(-2) for SW and 320 mm Hg x L x
min(-1) x m(-2) for LVP. Survivors had better ventricular-arterial
coupling than nonsurvivors, indicated by a lower RATIO (0.32 +/- 0.22
vs. 0.54 +/- 0.38; p = 0.003). This lower RATIO was attributable to
lower levels of Ea (2.7 +/- 0.7 vs. 3.4 +/- 0.8 mm Hg x mL(-1) x
m(-2); p = 0.0003) and a trend toward higher levels of Ees (13 +/- 11
vs. 9.9 +/- 7.3 mm Hg x mL(-1) x m(-2); p = 0.12). CONCLUSION:
Thermodynamic perfusion variables that encompass both pressure and
flow, such as SW and LVP, are more closely related to perfusion and
outcome than the purely flow-derived variables. The higher SW and LVP
in survivors is related to better ventricular-arterial coupling, and
therefore more efficient cardiac function. Cutoff values for LVP of
320 mm Hg x L x min(-1) x m(-2) and for SW of 4,000 mm Hg x mL x
m(-2) may be useful thresholds for evaluating hemodynamic performance
during resuscitation.
ARTICLE TITLE: How effective is the Newport/Aspen collar? A
prospective radiographic evaluation in healthy adult volunteers.
ARTICLE SOURCE: J Trauma (United States), Aug 1998, 45(2) p374-8
AUTHOR(S): Hughes SJ
AUTHOR'S ADDRESS: Department of Surgery, University of Tennessee
Medical Center, Knoxville, USA. steven.hughes@virgin.net.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Cervical extrication collars are used in the
evacuation of the injured to minimize secondary injury. These collars
were designed for extrication and evacuation, not for longterm use,
and complications have been reported when they have been used in the
rehabilitation phase. The Newport/Aspen collar was designed
specifically for long-term use. METHODS: Using a radiographic method,
the effectiveness of the collar in restricting motion was evaluated
for the cervical spine as a whole and for constituent segments,
occiput to C7, in 15 normal volunteers. RESULTS: Combined
flexion-extension was reduced from mean 98.8 to 31.1 degrees (31.5%
of normal; p = 0.000000002), lateral bending was reduced from mean
31.1 to 15.9 degrees (51.1% of normal; p = 0.0000001), and overhead
rotation was reduced from mean 64.6 to 26.8 degrees (41% of normal; p
= 0.000000002). The cervical spine, however, does not move as one
unit; paradoxical motion, the phenomenon of "snaking," occurs.
Goniometric techniques do not demonstrate this effect. Data are
provided for motion by segmental level. CONCLUSION: Full cervical
immobilization is a myth. It would seem logical to match the
level-specific efficacy of the device to the level of injury. Data
are provided for the Aspen collar.
ARTICLE TITLE: Prehospital airway management in the acutely injured
patient: the role of surgical cricothyrotomy revisited.
ARTICLE SOURCE: J Trauma (United States), Aug 1998, 45(2) p312-4
AUTHOR(S): Gerich TG; Schmidt U; Hubrich V; Lobenhoffer HP; Tscherne
H
AUTHOR'S ADDRESS: Department of Trauma Surgery, Hannover Medical
School, Germany.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Experienced emergency medical services personnel can
effectively perform endotracheal intubation with narcotic analgesics
without the use of paralytic agents in the field. With proper
training for field airway management, cricothyrotomy in the field can
be reduced to a few indications with high success rates.
ARTICLE TITLE: Permissive hypercapnia ventilation in patients with
severe pulmonary blast injury.
ARTICLE SOURCE: J Trauma (United States), Jul 1998, 45(1) p35-8
AUTHOR(S): Sorkine P; Szold O; Kluger Y; Halpern P; Weinbroum AA;
Fleishon R; Silbiger A; Rudick V
AUTHOR'S ADDRESS: Department of Intensive Care & Anesthesiology,
Tel Aviv Sourasky Medical Center, and the Sackler Faculty of
Medicine, Tel Aviv University, Israel.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVES: To describe our experience with the use of
limited peak inspiratory pressure (PIP), volume-controlled
ventilation, and permissive hypercapnia in patients with severe
pulmonary blast injury. METHODS: Patients with pulmonary blast injury
were ventilated using volume-controlled, synchronized intermittent
mandatory ventilation. Whenever PIP exceeded 40 cm H2O, the tidal
volume was decreased to maintain PIP at less than 40 cm H2O. Whenever
the arterial pH fell below 7.2, the ventilator rate was increased in
increments of 2 breaths per minute until the arterial pH rose to
7.25. RESULTS: Between 1994 and 1996, 17 patients with severe
pulmonary blast injury (10 from enclosed space explosions and seven
from open space ones), requiring mechanical ventilatory support were
admitted to our intensive care unit. Four patients developed
increasing PaCO2 levels (to 93 +/- 12 mm Hg) associated with the
reduction in arterial pH that was corrected by increasing the
ventilator rate. There was evidence of ventilator-induced pulmonary
barotrauma. Of the 17 patients, 15 patients (88%) survived.
CONCLUSIONS: Limited PIP in a volume-controlled ventilation is a
useful and safe mode of mechanical ventilation in patients with
pulmonary blast injury.
ARTICLE TITLE: Intra-abdominal hypertension after life-threatening
penetrating abdominal trauma: prophylaxis, incidence, and clinical
relevance to gastric mucosal pH and abdominal compartment
syndrome.
ARTICLE SOURCE: J Trauma (United States), Jun 1998, 44(6) p1016-21;
discussion 1021-3
AUTHOR(S): Ivatury RR; Porter JM; Simon RJ; Islam S; John R; Stahl
WM
AUTHOR'S ADDRESS: Department of Surgery, New York Medical College,
Lincoln Medical & Mental Health Center, Bronx, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: intra-abdominal hypertension (IAH) is frequent after
major abdominal trauma. It may cause gut mucosal acidosis at lower
bladder pressures, long before the onset of clinical abdominal
compartment syndrome (ACS).. Uncorrected, it may lead to splanchnic
hypoperfusion, ACS, distant organ failure, and death. Prophylactic
mesh closure of the abdomen may facilitate the prevention and bedside
treatment of IAH and reduce these complications.
MB. We use plastic sheeting.
ARTICLE TITLE: In search of the optimal end points of resuscitation
in trauma patients: a review.
ARTICLE SOURCE: J Trauma (United States), May 1998, 44(5) p908-14
AUTHOR(S): Porter JM; Ivatury RR
AUTHOR'S ADDRESS: University of California, Davis-East Bay, Oakland
94602, USA. jpcut2cure@aol.com.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (58 references); REVIEW,
TUTORIAL
ABSTRACT: Complete resuscitation from shock is one of the primary
concerns of the surgeon taking care of injured patients.
Traditionally, the return to normalcy of blood pressure, heart rate,
and urine output has been the end point of resuscitation. Using these
end points may leave a substantial number of patients, up to 50 to
85% in some series, in "compensated" shock, which if it persists may
ultimately lead to the death of the patient. Because of this
potential other end points are being used and include supernormal
values for oxygen transport variables (cardiac index, oxygen
delivery, and oxygen consumption), lactate, base deficit, and gastric
intramucosal pH. We believe that the current data support the use of
lactate, base deficit, and/or gastric intramucosal pH as the
appropriate end points of resuscitation of trauma patients. The goal
should be to correct one or all of three of these markers of tissue
perfusion to normal within the initial 24 hours after injury.
ARTICLE TITLE: Diagnostic validity of pulmonary artery
catheterization for residents at an intensive care unit.
ARTICLE SOURCE: J Trauma (United States), May 1998, 44(5) p902-6
AUTHOR(S): Staudinger T; Locker GJ; Laczika K; Knapp S; Burgmann H;
Wagner A; Weiss K; Zimmerl M; Stoiser B; Frass M
AUTHOR'S ADDRESS: Department of Internal Medicine I, University of
Vienna, Austria. thomas.staudinger@akh-wien.ac.at.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: In a selected group of critically ill patients, the PAC
adds valuable and clinically relevant information to clinical
assessment in about 50% of cases. Its use should not be withheld in
patients with unclear hemodynamic and metabolic profiles.
ARTICLE TITLE: Importance of a reliable admission Glasgow Coma Scale
score for determining the need for evacuation of posttraumatic
subdural hematomas: a prospective study of 65 patients.
ARTICLE SOURCE: J Trauma (United States), May 1998, 44(5) p868-73
AUTHOR(S): Servadei F; Nasi MT; Cremonini AM; Giuliani G; Cenni P;
Nanni A
AUTHOR'S ADDRESS: Division of Neurosurgery, Ospedale Maurizio
Bufalini, Cesena, Italy. servadei@mbox.queen.it.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Nonoperative management for selected cases of acute
subdural hematomas is at least as safe as surgical management. GCS
scoring at the scene and in the emergency room combined with early
and subsequent CT scanning is crucial when making the decision for
nonoperative management. This strategy requires that administration
of long-lasting sedatives and paralytic medications be avoided before
the patient arrives at the neurosurgical center.
ARTICLE TITLE: Variation among trauma centers' calculation of Glasgow
Coma Scale score: results of a national survey.
ARTICLE SOURCE: J Trauma (United States), Sep 1998, 45(3) p429-32
AUTHOR(S): Buechler CM; Blostein PA; Koestner A; Hurt K; Schaars M;
McKernan J
AUTHOR'S ADDRESS: Bronson Methodist Hospital, Kalamazoo, MI 49007,
USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Wide variation in GCS scoring among Level I trauma
centers was identified. Because GCS scores are used in treatment
algorithms, trauma scoring, and outcome prediction (Trauma and Injury
Severity Score), uniform scoring is essential and should be pursued.
Use of state and national databases and outcome research may be
adversely affected by the lack of consistent GCS scoring.
ARTICLE TITLE: Hypothermic coagulopathy in trauma: effect of varying
levels of hypothermia on enzyme speed, platelet function, and
fibrinolytic activity.
ARTICLE SOURCE: J Trauma (United States), May 1998, 44(5) p846-54
AUTHOR(S): Watts DD; Trask A; Soeken K; Perdue P; Dols S; Kaufmann
C
AUTHOR'S ADDRESS: Department of Trauma Services, Inova Regional
Trauma Center, Falls Church, Virgina 22042-3300, USA.
MAJOR SUBJECT HEADING(S): Blood Coagulation Disorders
[etiology]; Hypothermia [complications]; Wounds and
Injuries [complications]
MINOR SUBJECT HEADING(S): Adolescence; Adult; Blood Coagulation
Disorders [blood]; Blood Coagulation [physiology];
Blood Platelets [physiology]; Body Temperature; Fibrinolysis;
Fluid Therapy; Hematocrit; Hypothermia [blood]; Injury
Severity Score; Multivariate Analysis; Partial Thromboplastin Time;
Prospective Studies; Thrombelastography; Wounds and Injuries
[blood] [classification]
INDEXING CHECK TAG(S): Female; Human; Male
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: The coagulopathy noted in hypothermic trauma
patients has been variously theorized to be caused by either enzyme
inhibition, platelet alteration, or fibrinolytic processes, but no
study has examined the possibility that all three processes may
simultaneously contribute to coagulopathy, but are perhaps triggered
at different levels of hypothermia. The purpose of this study was to
determine whether, at clinically common levels of hypothermia
(33.0-36.9 degrees C), there are specific temperature levels at which
coagulopathic alterations are seen in each of these processes.
METHODS: Of 232 consecutive adult trauma patients presenting to a
Level I trauma center, 112 patients met the inclusion criteria of an
Injury Severity Score of 9 or greater and time since injury of less
than 2 hours. Of the included patients, 40 were normothermic and 72
were hypothermic ( or =37 degrees C, n = 40; 36.9-36 degrees C, n =
29; 35.9-35 degrees C, n = 20; 34.9-34 degrees C, n = 16; 33.9-33
degrees C, n = 7). Included patients were prospectively studied with
thrombelastography adjusted to core body temperature. Additionally,
PT, aPTT, platelets, CO2, hemoglobin, hematocrit, and Injury Severity
Score were measured. RESULTS: Analysis by multivariate analysis of
variance of the relationship between coagulation and temperature
demonstrated that in hypothermic trauma patients, 34 degrees C was
the critical point at which enzyme activity slowed significantly (p
0.0001), and at which significant alteration in platelet activity was
seen (p 0.001). Fibrinolysis was not significantly affected at any of
the measured temperatures (p 0.25). CONCLUSIONS: Patients whose
temperature was or =34.0 degrees C actually demonstrated a
significant hypercoagulability. Enzyme activity slowing and decreased
platelet function individually contributed to hypothermic
coagulopathy in patients with core temperatures below 34.0 degrees C.
All the coagulation measures affected are part of the polymerization
process of platelets and fibrin, and this process may be the
mechanism by which the alteration in coagulation occurs.
ARTICLE TITLE: Trauma mortality patterns in three nations at
different economic levels: implications for global trauma system
development.
ARTICLE SOURCE: J Trauma (United States), May 1998, 44(5) p804-12;
discussion 812-4
AUTHOR(S): Mock CN; Jurkovich GJ; nii-Amon-Kotei D; Arreola-Risa C;
Maier RV
AUTHOR'S ADDRESS: Department of Surgery, University of Science and
Technology, Kumasi, Ghana. charlie.mock@sos.washington.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Whereas organized trauma care systems have
decreased trauma mortality in the United States, trauma system design
has not been well addressed in developing nations. We sought to
determine areas in greatest need of improvement in the trauma systems
of developing nations. METHODS: We compared outcome of all seriously
injured (Injury Severity Score or = 9 or dead), nontransferred,
adults managed over 1 year in three cities in nations at different
economic levels: (1) Kumasi, Ghana: low income, gross national
product (GNP) per capita of $310, no emergency medical service (EMS);
(2) Monterrey, Mexico: middle income, GNP $3,900, basic EMS; and (3)
Seattle, Washington: high income, GNP $25,000, advanced EMS. Each
city had one main trauma hospital, from which hospital data were
obtained. Annual budgets (in US$) per bed for these hospitals were as
follows: Kumasi, $4,100; Monterrey, $68,000; and Seattle, $606,000.
Data on prehospital deaths were obtained from vital statistics
registries in Monterrey and Seattle, and by an epidemiologic survey
in Kumasi. RESULTS: Mean age (34 years) and injury mechanisms (79%
blunt) were similar in all locations. Mortality declined with
increased economic level: Kumasi (63% of all seriously injured
persons died), Monterrey (55%), and Seattle (35%). This decline was
primarily due to decreases in prehospital deaths. In Kumasi, 51% of
all seriously injured persons died in the field; in Monterrey, 40%;
and in Seattle, 21%. Mean prehospital time declined progressively:
Kumasi (102 +/- 126 minutes) Monterrey (73 +/- 38 minutes) Seattle
(31 +/- 10 minutes). Percent of trauma patients dying in the
emergency room was higher for Monterrey (11%) than for either Kumasi
(3%) or Seattle (6%). CONCLUSIONS: The majority of deaths occur in
the prehospital setting, indicating the importance of injury
prevention in nations at all economic levels. Additional efforts for
trauma care improvement in both low-income and middle-income
developing nations should focus on prehospital and emergency room
care. Improved emergency room care is especially important in
middle-income nations which have already established a basic EMS.
ARTICLE TITLE: Postintubation tracheoesophageal fistula: surgical
treatment of three cases.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Sep 1998,
116(3) p518-9
AUTHOR(S): Santini P; Dragotto A; Gigli PM; Notaristefano T; Salani
G; Regio S; Palmimiello A
AUTHOR'S ADDRESS: Thoracic and Cardiovascular Surgical Unit, Careggi
Hospital, University of Florence, Firenze, Italy.
PUBLICATION TYPE: JOURNAL ARTICLE
ARTICLE TITLE: Hematocrit value on intensive care unit entry
influences the frequency of Q-wave myocardial infarction after
coronary artery bypass grafting. The Institutions of the Multicenter
Study of Perioperative Ischemia (McSPI) Research Group.
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Sep 1998,
116(3) p460-7
AUTHOR(S): Spiess BD; Ley C; Body SC; Siegel LC; Stover EP; Maddi R;
D'Ambra M; Jain U; Liu F; Herskowitz A; Mangano DT; Levin J
AUTHOR'S ADDRESS: Department of Anesthesiology, University of
Washington, Seattle 98195, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
CONCLUSION: High hematocrit value on entry into the intensive care
unit (IHCT) is associated with a higher rate of myocardial infarction
and is an independent predictor of infarction. On the basis of the
risk of myocardial infarction, there is no rationale for transfusion
to an arbitrary level after coronary artery bypass grafting.
ARTICLE TITLE: Artificial placenta--a need for fetal surgery?
[editorial; comment]
COMMENTS: Comment on: J Thorac Cardiovasc Surg 1998 May;
115(5):1023-31
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), May 1998,
115(5) p1021-2
AUTHOR(S): Assad RS; Hanley FL
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Editorial (pro) re minimally invasive port-access
mitral valve surgery [editorial; comment]
COMMENTS: Comment on: J Thorac Cardiovasc Surg 1998 Mar;
115(3):567-74; discussionn 574-6
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Mar 1998,
115(3) p565-6
AUTHOR(S): Verrier ED
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE
ARTICLE TITLE: Editorial (con) re minimally invasive port-access
mitral valve surgery [editorial; comment]
COMMENTS: Comment on: J Thorac Cardiovasc Surg 1998 Mar;
115(3):567-74; discussion 574-6
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Mar 1998,
115(3) p563-4
AUTHOR(S): Baldwin JC
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE
ARTICLE TITLE: Minimally invasive port-access mitral valve surgery
[see comments]
COMMENTS: Comment in: J Thorac Cardiovasc Surg 1998 Mar;
115(3):563-4; Comment in: J Thorac Cardiovasc Surg 1998 Mar;
115(3):565-6
ARTICLE SOURCE: J Thorac Cardiovasc Surg (United States), Mar 1998,
115(3) p567-74; discussion 574-6
AUTHOR(S): Mohr FW; Falk V; Diegeler A; Walther T; van Son JA;
Autschbach R
AUTHOR'S ADDRESS: Department of Cardiac Surgery, Herzzentrum,
Universitat Leipzig, Germany.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: The Port-Access system allows for video-assisted
minimally invasive replacement and complex repair of the mitral valve
through a right lateral minithoracotomy. However, morbidity and
mortality associated with this novel technique were high.
ARTICLE TITLE: Effect of nitrous oxide on cerebral blood flow
velocity after induction of hypocapnia.
ARTICLE SOURCE: J Neurosurg Anesthesiol (United States), Jul 1998,
10(3) p142-5
AUTHOR(S): Watts AD; Luney SR; Lee D; Gelb AW
AUTHOR'S ADDRESS: Department of Anesthesia, London Health Sciences
Centre, Ontario, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Hyperventilation may reverse increases in cerebral blood
flow velocity caused by inhalation of nitrous oxide (N2O). This study
sought to determine whether inhalation of 50% nitrous oxide after the
induction of hyperventilation increases cerebral blood flow velocity
as measured by transcranial Doppler ultrasonography. Seven volunteers
breathed air/O2 through a modified Circle system at normocapnia
followed by air/O2 with hyperventilation, and then N2O/O2 with
hyperventilation. Expired gas concentrations were measured in the
expiratory limb of the circuit distal to a one-way valve.
Hyperventilation reduced end-tidal carbon dioxide from 38+/-1 mmHg to
26+/-1 mmHg. Hypocapnia was maintained during inhalation of N2O
(EtCO2=28+/-1 mmHg). Mean cerebral blood flow velocity decreased 34%
with hyperventilation (38+/-4 cm/second versus 59+/-9 cm/second, p
< 0.05) and returned to baseline with the addition of nitrous
oxide (58+/-7 cm/second), despite persistent hypocapnia. The addition
of nitrous oxide to the inspired gas mixture after induction of
hypocapnia reversed reductions in cerebral blood flow velocity
associated with hyperventilation. Potential benefits of induced
hypocapnia in patients with intracranial pathology may be offset by
the administration of N2O.
ARTICLE TITLE: Malignant cerebral edema in patients with hypertensive
intracerebral hemorrhage associated with hypertonic saline infusion:
a rebound phenomenon?
ARTICLE SOURCE: J Neurosurg Anesthesiol (United States), Jul 1998,
10(3) p188-92
AUTHOR(S): Qureshi AI; Suarez JI; Bhardwaj A
AUTHOR'S ADDRESS: Division of Neurosciences Critical Care, The Johns
Hopkins Hospital, Baltimore, Maryland, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Hypertonic saline was recently introduced as a new
hyperosmolar agent for treatment of intracranial hypertension and
cerebral edema. It has the potential to cause a rebound phenomenon
similar to other osmotic agents. The authors report on two patients
with cerebral edema caused by hypertensive intracerebral hemorrhage
who were treated with hypertonic saline infusion. Both patients
improved clinically after 24 hours of hypertonic saline
administration. However, both patients deteriorated clinically, 48
and 96 hours after initiation of therapy, despite continued
hypertonic saline administration. Compared with pre-treatment
computed tomographic scans, edema volume on repeat scans increased
from 131 cc to 262 cc, and from 171 cc to 239 cc in the first and
second patients, respectively, despite the lack of change in hematoma
volume. Malignant edema formation late in the course of intracerebral
hemorrhage after prolonged administration of hypertonic saline may
represent a rebound phenomenon of hyperosmolar therapy. Further
studies are warranted to identify the occurrence of this phenomenon
and the subset of patients susceptible to it.
ARTICLE TITLE: Cerebral monitoring by means of oximetry and
somatosensory evoked potentials during carotid endarterectomy.
ARTICLE SOURCE: J Neurosurg (United States), Oct 1998, 89(4)
p533-8
AUTHOR(S): Cho H; Nemoto EM; Yonas H; Balzer J; Sclabassi RJ
AUTHOR'S ADDRESS: Department of Neurological Surgery and Center for
Clinical Neurophysiology, University of Pittsburgh School of
Medicine, Pennsylvania, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ARTICLE TITLE: Selection of severely head injured patients for mild
hypothermia therapy.
ARTICLE SOURCE: J Neurosurg (United States), Aug 1998, 89(2)
p206-11
AUTHOR(S): Shiozaki T; Sugimoto H; Taneda M; Oda J; Tanaka H; Hiraide
A; Shimazu T
AUTHOR'S ADDRESS: Department of Traumatology, Osaka University
Medical School, Japan.
PUBLICATION TYPE: JOURNAL ARTICLE
ARTICLE TITLE: Improvement of cerebral oxygenation patterns and
metabolic validation of superselective intraarterial infusion of
papaverine for the treatment of cerebral vasospasm.
ARTICLE SOURCE: J Neurosurg (United States), Jul 1998, 89(1)
p93-100
AUTHOR(S): Fandino J; Kaku Y; Schuknecht B; Valavanis A; Yonekawa
Y
AUTHOR'S ADDRESS: Department of Neurosurgery and Institute of
Neuroradiology, University Hospital of Zurich, Switzerland.
PUBLICATION TYPE: JOURNAL ARTICLE
ARTICLE TITLE: A randomized, double-blind, dose-response study of
ondansetron in the prevention of postoperative nausea and
vomiting.
ARTICLE SOURCE: J Clin Anesth (United States), Jun 1998, 10(4)
p314-20
AUTHOR(S): Dershwitz M; Conant JA; Chang Y; Rosow CE; Connors PM
AUTHOR'S ADDRESS: Department of Anesthesia and Critical Care,
Massachusetts General Hospital and Harvard Medical School, Boston
02114, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ARTICLE TITLE: Central venous pressure and cardiac function during
spaceflight.
ARTICLE SOURCE: J Appl Physiol (United States), Aug 1998, 85(2)
p738-46
AUTHOR(S): White RJ; Blomqvist CG
AUTHOR'S ADDRESS: Baylor College of Medicine, Houston, Texas 77030,
USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Early in spaceflight, an apparently paradoxical condition
occurs in which, despite an externally visible headward fluid shift,
measured central venous pressure is lower but stroke volume and
cardiac output are higher, and heart rate is unchanged from reference
measurements made before flight. This paper presents a set of studies
in which a simple three-compartment, steady-state model of
cardiovascular function is used, providing insight into the
contributions made by the major mechanisms that could be responsible
for these events. On the basis of these studies, we conclude that,
during weightless spaceflight, the chest relaxes with a concomitant
shape change that increases the volume of the closed chest cavity.
This leads to a decrease in intrapleural pressure, ultimately causing
a shift of blood into the vessels of the chest, increasing the
transmural filling pressure of the heart, and decreasing the central
venous pressure. The increase in the transmural filling pressure of
the heart is responsible, through a Starling-type mechanism, for the
observed increases in heart size, left ventricular end-diastolic
volume, stroke volume, and cardiac output.
ARTICLE TITLE: Fast and slow components of cerebral blood flow
response to step decreases in end-tidal PCO2 in humans.
ARTICLE SOURCE: J Appl Physiol (United States), Aug 1998, 85(2)
p388-97
AUTHOR(S): Poulin MJ; Liang PJ; Robbins PA
AUTHOR'S ADDRESS: University Laboratory of Physiology, Parks Road,
Oxford OX1 3PT, United Kingdom.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: This study examined the dynamics of the middle cerebral
artery (MCA) blood flow response to hypocapnia in humans (n = 6) by
using transcranial Doppler ultrasound. In a control protocol,
end-tidal PCO2 (PETCO2) was held near eucapnia (1.5 Torr above
resting) for 40 min. In a hypocapnic protocol, PETCO2 was held near
eucapnia for 10 min, then at 15 Torr below eucapnia for 20 min, and
then near eucapnia for 10 min. During both protocols, subjects
hyperventilated throughout and PETCO2 and end-tidal PO2 were
controlled by using the dynamic end-tidal forcing technique.
Beat-by-beat values were calculated for the intensity-weighted mean
velocity (VIWM), signal power (P), and their instantaneous product
(P.VIWM). A simple model consisting of a delay, gain terms, time
constants (tauf,on, tauf, off) and baseline levels of flow for the
on- and off-transients, and a gain term (gs) and time constant (taus)
for a second slower component was fitted to the hypocapnic protocol.
The cerebral blood flow response to hypocapnia was characterized by a
significant (P 0.001) slow progressive adaptation in P.VIWM, with gs
= 1.26 %/Torr and taus = 427 s, that persisted throughout the
hypocapnic period. Finally, the responses at the onset and relief of
hypocapnia were asymmetric (P 0.001), with tauf,on (6.8 s) faster
than tauf,off (14.3 s).
ARTICLE TITLE: Invited editorial on "Fast and slow components of
cerebral blood flow response to step decreases in end-tidal PCO2 in
humans" [editorial]
ARTICLE SOURCE: J Appl Physiol (United States), Aug 1998, 85(2)
p386-7
AUTHOR(S): Lambertsen CJ
PUBLICATION TYPE: JOURNAL ARTICLE
ARTICLE TITLE: Analysis of tissue and arterial blood temperatures in
the resting human forearm. 1948 [classical article]
ARTICLE SOURCE: J Appl Physiol (United States), Jul 1998, 85(1)
p5-34
AUTHOR(S): Pennes HH
PUBLICATION TYPE: BIOGRAPHY; CLASSICAL ARTICLE; CLINICAL TRIAL;
HISTORICAL ARTICLE; JOURNAL ARTICLE
ARTICLE TITLE: Hypoproteinemia, strong-ion difference, and acid-base
status in critically ill patients.
ARTICLE SOURCE: J Appl Physiol (United States), May 1998, 84(5)
p1740-8
AUTHOR(S): Wilkes P
AUTHOR'S ADDRESS: University of Ottawa Heart Institute, Ottawa Civic
Hospital, Ontario, Canada. pwilkes@heartinst.on.ca.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: The present study was a prospective, nonrandomized,
observational examination of the relationship among hypoproteinemia
and electrolyte and acid-base status in a critical care population of
patients. A total of 219 arterial blood samples reviewed from 91
patients was analyzed for arterial blood gas, electrolytes, lactate,
and total protein. Plasma strong-ion difference ([SID]) was
calculated from [Na+] + [K+] - [Cl-] -
[La-]. Total protein concentration was used to derive the
total concentration of weak acid ([A]tot). [A]tot
encompassed a range of 18.7 to 9.0 meq/l, whereas [SID]
varied from 48.1 to 26.6 meq/l and was directly correlated with
[A]tot. The decline in [SID] was primarily
attributable to an increase in [Cl-]. A direct correlation
was also noted between PCO2 and [SID], but not between PCO2
and [A]tot. The decrease in [SID] and PCO2 was such
that neither [H+] nor [HCO-3] changed significantly
with [A]tot.
ARTICLE TITLE: Age alters the cardiovascular response to direct
passive heating.
ARTICLE SOURCE: J Appl Physiol (United States), Apr 1998, 84(4)
p1323-32
AUTHOR(S): Minson CT; Wladkowski SL; Cardell AF; Pawelczyk JA; Kenney
WL
AUTHOR'S ADDRESS: Noll Physiological Research Center, Pennsylvania
State University, University Park, Pennsylvania 16802-6900, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: During direct passive heating in young men, a dramatic
increase in skin blood flow is achieved by a rise in cardiac output
(Qc) and redistribution of flow from the splanchnic and renal
vascular beds. To examine the effect of age on these responses, seven
young (Y; 23 +/- 1 yr) and seven older (O; 70 +/- 3 yr) men were
passively heated with water-perfused suits to their individual limit
of thermal tolerance. Measurements included heart rate (HR), Qc (by
acetylene rebreathing), central venous pressure (via peripherally
inserted central catheter), blood pressures (by brachial
auscultation), skin blood flow (from increases in forearm blood flow
by venous occlusion plethysmography), splanchnic blood flow (by
indocyanine green clearance), renal blood flow (by p-aminohippurate
clearance), and esophageal and mean skin temperatures. Qc was
significantly lower in the older than in the young men (11.1 +/- 0.7
and 7.4 +/- 0.2 l/min in Y and O, respectively, at the limit of
thermal tolerance; P 0. 05), despite similar increases in esophageal
and mean skin temperatures and time to reach the limit of thermal
tolerance. A lower stroke volume (99 +/- 7 and 68 +/- 4 ml/beat in Y
and O, respectively, P 0.05), most likely due to an attenuated
increase in inotropic function during heating, was the primary factor
for the lower Qc observed in the older men. Increases in HR were
similar in the young and older men; however, when expressed as a
percentage of maximal HR, the older men relied on a greater
proportion of their chronotropic reserve to obtain the same HR
response (62 +/- 3 and 75 +/- 4% maximal HR in Y and O, respectively,
P 0.05). Furthermore, the older men redistributed less blood flow
from the combined splanchnic and renal circulations at the limit of
thermal tolerance (960 +/- 80 and 720 +/- 100 ml/min in Y and O,
respectively, P 0. 05). As a result of these combined attenuated
responses, the older men had a significantly lower increase in total
blood flow directed to the skin.
ARTICLE TITLE: The alcohol breath test--a review.
ARTICLE SOURCE: J Appl Physiol (United States), Feb 1998, 84(2)
p401-8
AUTHOR(S): Hlastala MP
AUTHOR'S ADDRESS: Department of Physiology and Biophysics, University
of Washington, Seattle 98195-6522, USA.
mike@colossus.pulmcc.washington.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (61 references); REVIEW,
TUTORIAL
ABSTRACT: The alcohol breath test (ABT) is evaluated for variability
in response to changes in physiological parameters. The ABT was
originally developed in the 1950s, at a time when understanding of
pulmonary physiology was quite limited. Over the past decade,
physiological studies have shown that alcohol is exchanged entirely
within the conducting airways via diffusion from the bronchial
circulation. This is in sharp contrast to the old idea that alcohol
exchanges in the alveoli in a manner similar to the lower solubility
respiratory gases (O2 and CO2). The airway alcohol exchange process
is diffusion (airway tissue) and perfusion (bronchial circulation)
limited. The dynamics of airway alcohol exchange results in a
positively sloped exhaled alveolar plateau that contributes to
considerable breathing pattern-dependent variation in measured breath
alcohol concentration measurements.
ARTICLE TITLE: Control of breathing during sleep assessed by
proportional assist ventilation.
ARTICLE SOURCE: J Appl Physiol (United States), Jan 1998, 84(1)
p3-12
AUTHOR(S): Meza S; Giannouli E; Younes M
AUTHOR'S ADDRESS: Department of Medicine, University of Manitoba,
Winnipeg, Canada.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: We used proportional assist ventilation (PAV) to evaluate
the sources of respiratory drive during sleep. PAV increases the
slope of the relation between tidal volume (VT) and respiratory
muscle pressure output (Pmus). We reasoned that if respiratory drive
is dominated by chemical factors, progressive increase of PAV gain
should result in only a small increase in VT because Pmus would be
downregulated substantially as a result of small decreases in PCO2.
In the presence of substantial nonchemical sources of drive
[believed to be the case in rapid-eye-movement (REM) sleep]
PAV should result in a substantial increase in minute ventilation and
reduction in PCO2 as the output related to the chemically insensitive
drive source is amplified severalfold. Twelve normal subjects
underwent polysomnography while connected to a PAV ventilator.
Continuous positive air pressure (5.2 +/- 2.0 cmH2O) was administered
to stabilize the upper airway. PAV was increased in 2-min steps from
0 to 20, 40, 60, 80, and 90% of the subject's elastance and
resistance. VT, respiratory rate, minute ventilation, and end-tidal
CO2 pressure were measured at the different levels, and Pmus was
calculated. Observations were obtained in stage 2 sleep (n = 12),
slow-wave sleep (n = 11), and REM sleep (n = 7). In all cases, Pmus
was substantially downregulated with increase in assist so that the
increase in VT, although significant (P 0.05), was small 0.08 liter
at the highest assist). There was no difference in response between
REM and non-REM sleep. We conclude that respiratory drive during
sleep is dominated by chemical control and that there is no
fundamental difference between REM and non-REM sleep in this regard.
REM sleep appears to simply add bidirectional noise to what is
basically a chemically controlled respiratory output.
ARTICLE TITLE: Low molecular weight heparin as an adjunct to
thrombolysis for acute myocardial infarction: the FATIMA study.
Fraxiparin Anticoagulant Therapy in Myocardial Infarction Study
Amsterdam (FATIMA) Study Group.
ARTICLE SOURCE: Heart (England), Jul 1998, 80(1) p35-9
AUTHOR(S): Chamuleau SA; de Winter RJ; Levi M; Adams R; Buller HR;
Prins MH; Lie KI; Peters RJ
AUTHOR'S ADDRESS: Department of Cardiology, University of Amsterdam,
Netherlands.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: This small study indicates that low molecular weight
heparin (LMWH) is feasible as an adjunct to thrombolysis in patients
with acute myocardial infarction. The aXa levels were within the
target range and patency rates at three to five days were around 80%,
with no major bleeding complications.
ARTICLE TITLE: Heparin for coronary angioplasty: high dose, low dose,
or no dose? [editorial]
ARTICLE SOURCE: Heart (England), Jul 1998, 80(1) p3-4
AUTHOR(S): Garachemani A; Meier B
PUBLICATION TYPE: EDITORIAL
ARTICLE TITLE: Low-molecular-weight heparins: an intriguing new twist
with profound implications [editorial; comment]
COMMENTS: Comment on: Circulation 1998 Jul 28; 98(4):294-9
ARTICLE SOURCE: Circulation (United States), Jul 28 1998, 98(4)
p287-9
AUTHOR(S): Antman EM; Handin R
PUBLICATION TYPE: COMMENT; EDITORIAL; REVIEW (22 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Better outcome for women compared with men undergoing
coronary revascularization: a report from the bypass angioplasty
revascularization investigation (BARI).
ARTICLE SOURCE: Circulation (United States), Sep 29 1998, 98(13)
p1279-85
AUTHOR(S): Jacobs AK; Kelsey SF; Brooks MM; Faxon DP; Chaitman BR;
Bittner V; Mock MB; Weiner BH; Dean L; Winston C; Drew L; Sopko G
AUTHOR'S ADDRESS: Evans Memorial Department of Clinical Research and
the Section of Cardiology, Department of Medicine, Boston Medical
Center, Boston, MA, USA. alice.jacobs@bmc.org.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ABSTRACT: BACKGROUND: Numerous studies have shown that women
undergoing coronary revascularization procedures do so at a higher
risk for an adverse outcome compared with men. However, the impact of
advances in technology and improvements in techniques on in-hospital
and long-term outcome after revascularization in women is unclear.
METHODS AND RESULTS: We evaluated 1829 patients with symptomatic
multivessel coronary disease randomized to CABG or PTCA in the Bypass
Angioplasty Revascularization Investigation (BARI), of whom 27% were
women. As expected, women were older (64.0 versus 60.5 years), with
more congestive heart failure (14% versus 7%), hypertension (68%
versus 42%), treated diabetes mellitus (31% versus 15%), and unstable
angina (67% versus 61%) than men but had similar preservation of left
ventricular function and extent of multivessel disease. Women
assigned to surgery received the same number of total grafts but
fewer internal mammary artery grafts (72% versus 85%, P<0. 01),
and those assigned to angioplasty had more intended lesions (76%
versus 71%, P<0.01) successfully dilated than men. At an average
of 5.4 years' follow-up, crude mortality rates were similar in women
(12.8%) and men (12.0%). The Cox regression model adjusting for
baseline differences revealed that women had a significantly lower
risk of death (relative risk, 0.60; 95% CI, 0.43 to 0.84; P=0. 003)
but not a significantly lower risk of death plus myocardial
infarction (relative risk, 0.84; 95% CI, 0.66 to 1.07; P=0.16) than
men. CONCLUSIONS: Although the unadjusted mortality rate suggests
that women and men undergoing CABG and PTCA have a similar 5-year
mortality, women have higher risk profiles; consequently, contrary to
previous reports, female sex is an independent predictor of improved
5-year survival after we control for multiple risk factors.
ARTICLE TITLE: Clinical effects of beta-adrenergic blockade in
chronic heart failure: a meta-analysis of double-blind,
placebo-controlled, randomized trials.
ARTICLE SOURCE: Circulation (United States), Sep 22 1998, 98(12)
p1184-91
AUTHOR(S): Lechat P; Packer M; Chalon S; Cucherat M; Arab T; Boissel
JP
AUTHOR'S ADDRESS: Service de Pharmacologie, Hopital
Pitie-Salpetriere, Paris, France.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; META-ANALYSIS
CONCLUSIONS: These analyses indicate that there is persuasive
evidence supporting a favorable effect of beta-blockade on ejection
fraction and the combined risk of death and hospitalization for heart
failure. In contrast, the effect of these drugs on other end points
requires additional study.
ARTICLE TITLE: Impact of atrial fibrillation on the risk of death:
the Framingham Heart Study [see comments]
COMMENTS: Comment in: Circulation 1998 Sep 8; 98(10):943-5
ARTICLE SOURCE: Circulation (United States), Sep 8 1998, 98(10)
p946-52
AUTHOR(S): Benjamin EJ; Wolf PA; D'Agostino RB; Silbershatz H; Kannel
WB; Levy D
AUTHOR'S ADDRESS: National Heart, Lung, and Blood Institute's
Framingham Heart Study, National Institutes of Health, Mass, USA.
emelia@fram.nhlbi.nih.gov.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: In subjects from the original cohort of the Framingham
Heart Study, AF was associated with a 1.5- to 1.9-fold mortality risk
after adjustment for the preexisting cardiovascular conditions with
which AF was related. The decreased survival seen with AF was present
in men and women and across a wide range of ages.
ARTICLE TITLE: Epidemiological and mechanistic studies of atrial
fibrillation as a basis for treatment strategies [editorial;
comment]
COMMENTS: Comment on: Circulation 1998 Sep 8; 98(10):946-52
ARTICLE SOURCE: Circulation (United States), Sep 8 1998, 98(10)
p943-5
AUTHOR(S): Bigger JT Jr
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Atrial fibrillation and congestive heart failure: the
intersection of two common diseases [editorial; comment]
COMMENTS: Comment on: Circulation 1998 Sep 8; 98(10):953-60
ARTICLE SOURCE: Circulation (United States), Sep 8 1998, 98(10)
p941-2
AUTHOR(S): Scheinman MM
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Images in cardiovascular medicine. Left main coronary
artery disease: cardiac arrest following stress echocardiography.
ARTICLE SOURCE: Circulation (United States), Sep 8 1998, 98(10)
p1038
AUTHOR(S): Kaji EH; Bednarz J; Spencer KT; Lang RM
AUTHOR'S ADDRESS: University of Chicago Medical Center, Department of
Medicine, Ill 60637, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ARTICLE TITLE: Physician noncompliance with the 1993 National
Cholesterol Education Program (NCEP-ATPII) guidelines.
ARTICLE SOURCE: Circulation (United States), Sep 1 1998, 98(9)
p851-5
AUTHOR(S): Frolkis JP; Zyzanski SJ; Schwartz JM; Suhan PS
AUTHOR'S ADDRESS: Lipid Research Center, PHS Mount Sinai Medical
Center, Cleveland, Ohio, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
. CONCLUSIONS: Physicians are poorly compliant with National
Cholesterol Education Program (NCEP-ATPII) guidelines for risk factor
assessment and counseling, even in patients at high risk for coronary
heart disease. Physicians follow National Cholesterol Education
Program (NCEP-ATPII) algorithms for obtaining an LDL value, a key
step in evaluating the need for treatment, only 50% of the time. NCEP
criteria seem to influence the decision to initiate lipid-lowering
therapy, but significant numbers of eligible patients remain
untreated.
ARTICLE TITLE: Accuracy and impact of presumed cause in patients with
cardiac arrest.
ARTICLE SOURCE: Circulation (United States), Aug 25 1998, 98(8)
p766-71
AUTHOR(S): Kurkciyan I; Meron G; Behringer W; Sterz F; Berzlanovich
A; Domanovits H; Mullner M; Bankl HC; Laggner AN
AUTHOR'S ADDRESS: Department of Emergency Medicine, General Hospital
of Vienna, University of Vienna, Austria.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: International guidelines recommend
differentiation between cardiac and noncardiac causes of cardiac
arrest. The aim of this study was to find the rate of agreement
between primarily postulated and definitive causes of cardiac arrest.
METHODS AND RESULTS: We retrospectively analyzed the primarily
presumed cause of cardiac arrest as determined by the emergency room
physician on admission in all patients admitted to the emergency
department of one urban tertiary care hospital. This was compared
with the definitive cause as established by clinical evidence or
autopsy. Within 4 years, the initially presumed cause was unclear in
24 (4%) of 593 patients. In the remaining 569 patients, the presumed
cause was correct in 509 (89%) and wrong in 60 (11%) cases. Cardiac
origin was presumed in 421 (71%) and the definitive cause in 408
(69%) cases. Noncardiac origin was presumed in 148 (25%) and the
definitive cause in 185 (31%) patients. Presumed cardiac cause was
sensitive (96%) but less specific (77%). Noncardiac causes such as
pulmonary embolism, cerebral disorders, or exsanguination were those
most frequently overlooked. Asystole occurred significantly more
often in patients in whom presumed cause remained undetermined or
differed from the definitive cause. CONCLUSIONS: Cause of cardiac
arrest is not as easily recognized as anticipated, especially when
the initial rhythm is different from ventricular fibrillation. This
might affect comparability of study results, therapeutic strategies,
prognosis, and outcome. Patients in whom the presumed cause was
confirmed as being correct had significantly better survival and
neurological outcome.
ARTICLE TITLE: Landmarks in the development of coronary artery bypass
surgery.
ARTICLE SOURCE: Circulation (United States), Aug 4 1998, 98(5)
p466-78
AUTHOR(S): Favaloro RG
AUTHOR'S ADDRESS: Institute of Cardiology and Cardiovascular Surgery,
Favaloro Foundation, Buenos Aires, Argentina.
refav@ffinme.edu.ar.
PUBLICATION TYPE: HISTORICAL ARTICLE; JOURNAL ARTICLE; REVIEW (110
references); REVIEW, ACADEMIC
ARTICLE TITLE: Vessel dilator enhances sodium and water excretion and
has beneficial hemodynamic effects in persons with congestive heart
failure.
ARTICLE SOURCE: Circulation (United States), Jul 28 1998, 98(4)
p323-9
AUTHOR(S): Vesely DL; Dietz JR; Parks JR; Baig M; McCormick MT;
Cintron G; Schocken DD
AUTHOR'S ADDRESS: Department of Medicine, James A. Haley Veterans
Hospital, and the University of South Florida Health Sciences Center,
Tampa 33612, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Vessel dilator, a 37-amino acid peptide hormone
synthesized in the heart, enhances urine flow 4- to 12-fold and
sodium excretion 3- to 6-fold in healthy humans. The present
investigation was designed to determine whether vessel dilator might
have similar beneficial effects in persons with congestive heart
failure (CHF). CONCLUSIONS: These results indicate that vessel
dilator has significant beneficial diuretic, natriuretic, and
hemodynamic properties in humans with congestive heart failure.
ARTICLE TITLE: Low-dose dopamine and oxygen transport by the lung
[editorial; comment]
COMMENTS: Comment on: Circulation 1998 Jul 14; 98(2):126-31
ARTICLE SOURCE: Circulation (United States), Jul 14 1998, 98(2)
p97-9
AUTHOR(S): Johnson RL Jr
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Circadian variations in the occurrence of cardiac
arrests: initial and repeat episodes.
ARTICLE SOURCE: Circulation (United States), Jul 7 1998, 98(1)
p31-9
AUTHOR(S): Peckova M; Fahrenbruch CE; Cobb LA; Hallstrom AP
AUTHOR'S ADDRESS: Department of Biostatistics, University of
Washington, Seattle 98105-4689, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Patterns of temporal variation of cardiac
arrests may be important for understanding mechanisms leading to the
onset of acute cardiovascular disorders. Previous studies reported
diurnal variation of the onset of cardiac arrests, with high
incidence in the morning and in the evening, lack of daily variation
during the week, and some seasonal variation. The association between
the time of day and recurrent cardiac arrests has not been previously
examined. CONCLUSIONS: Cardiac arrests do not occur randomly during
the day, but rather follow certain periodic patterns. These patterns
are probably associated with patterns of daily activities. The
hypothesis that cardiac arrests are triggered by a person's activity
rather than by some underlying characteristics of his or her disease
is supported by the lack of association between the times of the
first and second arrests in the patients with recurrent arrests.
ARTICLE TITLE: Proceedings of the Brenot Memorial Symposium on the
Pathogenesis of Primary Pulmonary Hypertension. Corisca, July 29-31,
1997.
ARTICLE SOURCE: Chest (United States), Sep 1998, 114(3 Suppl)
p183S-247S
PUBLICATION TYPE: BIOGRAPHY; FESTSCHRIFT; HISTORICAL ARTICLE; MEETING
REPORT; OVERALL
ARTICLE TITLE: MRI of central venous anatomy: implications for
central venous catheter insertion.
ARTICLE SOURCE: Chest (United States), Sep 1998, 114(3) p820-6
AUTHOR(S): Aslamy Z; Dewald CL; Heffner JE
AUTHOR'S ADDRESS: Mercy Health Services Research Group, St. Joseph's
Hospital and Medical Center, Phoenix, Arizona, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: STUDY OBJECTIVES: To determine normative values for
superior vena cava (SVC) length and the utility of radiographic
landmarks for identifying the boundaries of the SVC for assisting
central line placement. DESIGN: Cross-sectional study. SETTING: Urban
tertiary care medical centers. PATIENTS: Patients undergoing thoracic
MRI scanning for various indications. INTERVENTIONS: None.
MEASUREMENTS AND RESULTS: The SVC dimensions and relationship to
radiographic landmarks were determined from MRI scans of 42 patients
(22 men, 20 women; median age, 57 years). The median length of the
SVC was 6.8 cm (range, 4.4 to 10.0 cm) and did not correlate with
gender or other measured cardiovascular dimensions. The right
tracheobronchial angle was the best radiographic landmark for
determining the cephalad origin of the SVC being always caudad and
within a median of 1.5 cm (range, 0.1 to 3.8 cm) of the upper SVC. It
was always at least 2.9 cm above the atriocaval junction. The right
superior heart border was formed by the left atrium in 38% (95%
confidence interval, 23 to 53%) of patients and did not reliably
identify the atriocaval junction. CONCLUSIONS: The right
tracheobronchial angle is the most reliable landmark for the upper
margin of the SVC. Venous catheters placed caudad to this landmark
and cephalad to the right superior cardiac silhouette or no more than
2.9 cm caudad to the tracheobronchial angle result in catheter tips
within the SVC.
ARTICLE TITLE: The safety of brachial artery puncture for arterial
blood sampling.
ARTICLE SOURCE: Chest (United States), Sep 1998, 114(3) p748-51
AUTHOR(S): Okeson GC; Wulbrecht PH
AUTHOR'S ADDRESS: Scott & White Clinic and Memorial Hospital,
Scott, Sherwood and Brindley Foundation, Texas A&M University
Health Science Center, College of Medicine, Temple, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: This study was designed to determine the
incidence of complications in a sample of 6,185 brachial artery
punctures for arterial blood gas analysis. RESULTS: The overall
incidence of all complications was 2.0%. Immediate limb pain or
parenthesias occurred in 1.1%, while the onset of symptoms was
delayed up to 24 h in 0.9%. Hematoma formation occurred in only
0.06%. None of the complications was considered to be of major
impact, in that none was associated with limb ischemia or other
objective abnormalities. Only one subject required analgesic
medication to control pain that ultimately subsided spontaneously
without deficit. CONCLUSION: We believe that brachial artery
puncture, when properly performed, is a safe and reliable alternative
route for obtaining arterial blood for gas analysis.
ARTICLE TITLE: Specialists achieve better outcomes than generalists
for lung cancer surgery [see comments]
COMMENTS: Comment in: Chest 1998 Sep; 114(3):663-4
ARTICLE SOURCE: Chest (United States), Sep 1998, 114(3) p675-80
AUTHOR(S): Silvestri GA; Handy J; Lackland D; Corley E; Reed CE
AUTHOR'S ADDRESS: Department of Medicine, The Center for Health Care
Research, Medical University of South Carolina, Charleston, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Mortality is lower for lung cancer resection when the
surgery is performed by a thoracic surgeon.
MB. How surprising?
ARTICLE TITLE: Weaning from mechanical ventilation: what have we
learned and what do we still need to know? [editorial;
comment]
COMMENTS: Comment on: Chest 1998 Sep; 114(3):886-901
ARTICLE SOURCE: Chest (United States), Sep 1998, 114(3) p672-4
AUTHOR(S): Mador MJ
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Managing cough as a defense mechanism and as a
symptom. A consensus panel report of the American College of Chest
Physicians.
ARTICLE SOURCE: Chest (United States), Aug 1998, 114(2 Suppl
Managing) p133S-181S
AUTHOR(S): Irwin RS; Boulet LP; Cloutier MM; Fuller R; Gold PM;
Hoffstein V; Ing AJ; McCool FD; O'Byrne P; Poe RH; Prakash UB;
Pratter MR; Rubin BK
PUBLICATION TYPE: CONSENSUS DEVELOPMENT CONFERENCE; GUIDELINE;
JOURNAL ARTICLE; PRACTICE GUIDELINE; REVIEW (325 references)
ARTICLE TITLE: Out-of-hospital prophylaxis with low-molecular-weight
heparin in hip surgery: the Swedish study.
ARTICLE SOURCE: Chest (United States), Aug 1998, 114(2 Suppl
Evidence) p130S-132S
AUTHOR(S): Davidson BL
AUTHOR'S ADDRESS: Division of Pulmonary and Critical Care Medicine,
Medical College of Pennsylvania and Hahnemann University, Allegheny
University of the Health Sciences, Philadelphia, USA.
brucedavidson@pobox.com.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED
ARTICLE TITLE: The incidence of symptomatic venous thromboembolism
after enoxaparin prophylaxis in lower extremity arthroplasty: a
cohort study of 1,984 patients. Canadian Collaborative Group.
ARTICLE SOURCE: Chest (United States), Aug 1998, 114(2 Suppl
Evidence) p115S-118S
AUTHOR(S): Leclerc JR; Gent M; Hirsh J; Geerts WH; Ginsberg JS
AUTHOR'S ADDRESS: The Montreal General Hospital, McGill University,
Quebec, Canada.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER
STUDY
ARTICLE TITLE: The timing of tracheotomy: a systematic review
[see comments]
COMMENTS: Comment in: Chest 1998 Aug; 114(2):361-5
ARTICLE SOURCE: Chest (United States), Aug 1998, 114(2) p605-9
AUTHOR(S): Maziak DE; Meade MO; Todd TR
AUTHOR'S ADDRESS: Division of Thoracic Surgery, University of
Toronto, Ontario, Canada.
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. :-(
ARTICLE TITLE: Timing tracheotomy: calendar watching or
individualization of care? [editorial; comment]
COMMENTS: Comment on: Chest 1998 Aug; 114(2):605-9
ARTICLE SOURCE: Chest (United States), Aug 1998, 114(2) p361-3
AUTHOR(S): Heffner JE
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Does positive end-expiratory pressure ventilation
improve left ventricular function? A comparative study by
transesophageal echocardiography in cardiac and noncardiac
patients.
ARTICLE SOURCE: Chest (United States), Aug 1998, 114(2) p556-62
AUTHOR(S): Fellahi JL; Valtier B; Beauchet A; Bourdarias JP; Jardin
F
AUTHOR'S ADDRESS: Respiratory Intensive Care Unit, Hopital Ambroise
Pare, University of Paris V, France.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: STUDY OBJECTIVES: Positive end-expiratory pressure (PEEP)
has been proposed to improve cardiac output in patients with left
ventricular (LV) dysfunction. This study was designed to compare
quantitative global and regional LV performance in response to PEEP
in patients with normal and poor LV function. DESIGN: A prospective
clinical trial. SETTING: Adult medical ICU in a university hospital.
PATIENTS: Twelve critically ill patients requiring respiratory
support and divided into two groups according to baseline
transesophageal echocardiographic (TEE) measurements: normal LV
dimensions and fractional area of contraction (FAC=61+/-5%) (n=7) and
dilated cardiomyopathy with reduced FAC (21+/-1%) (n=5). MEASUREMENTS
AND RESULTS: All patients were studied when two successive levels of
PEEP (best PEEP as the highest value of respiratory compliance and
high PEEP as best PEEP+10 cm H2O) were applied. Global systolic LV
performance and quantitative regional wall motion analysis performed
by the centerline method were assessed on the TEE transgastric
short-axis view. End-systolic wall stress (ESWS) was used as a
reliable indication of LV afterload. PEEP reduced LV dimensions
asymmetrically in both groups of patients and septolateral diameter
significantly decreased without affecting global LV systolic
performance. Additionally, high PEEP produced a significant
impairment in septal kinetics as evidenced by the centerline method.
High PEEP also decreased ESWS for all patients (-27% in normal group
and -23% in cardiac group, p 0.05) without significant improvement in
global systolic LV performance (FAC: +2% in normal group and +0% in
cardiac group; not significant). CONCLUSIONS: PEEP cannot be
recommended routinely to improve LV performance in patients with
severe dilated cardiomyopathy.
MB. I would think that they should have maximised the cardiac
out-put/PEEP ratio. I would be surprised if any particular level of
PEEP would maximise contractility for all patients. Using TEE would
give only subjective not a quantitative result.
ARTICLE TITLE: The use of continuous i.v. sedation is associated with
prolongation of mechanical ventilation [see comments]
COMMENTS: Comment in: Chest 1998 Aug; 114(2):360-1
ARTICLE SOURCE: Chest (United States), Aug 1998, 114(2) p541-8
AUTHOR(S): Kollef MH; Levy NT; Ahrens TS; Schaiff R; Prentice D;
Sherman G
AUTHOR'S ADDRESS: Department of Medicine, Washington University
School of Medicine, St. Louis, MO 63110, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: We conclude from these preliminary observational data
that the use of continuous i.v. sedation may be associated with the
prolongation of mechanical ventilation. This study suggests that
strategies targeted at reducing the use of continuous i.v. sedation
could shorten the duration of mechanical ventilation for some
patients. Prospective randomized clinical trials, using well-designed
sedation guidelines and protocols, are required to determine whether
patient-specific outcomes (eg, duration of mechanical ventilation,
patient comfort) can be improved compared with conventional sedation
practices.
MB. When I was running ventilated patients alone (before we had ICU
---1972---15+ years after everyone else) I did not paralyse or sedate
anyone.
ARTICLE TITLE: Maximum cardiac output during incremental exercise by
first-pass radionuclide ventriculography.
ARTICLE SOURCE: Chest (United States), Aug 1998, 114(2) p457-61
AUTHOR(S): Maroni JM; Oelberg DA; Pappagianopoulos P; Boucher CA;
Systrom DM
AUTHOR'S ADDRESS: Pulmonary and Critical Care Unit, Massachusetts
General Hospital and Harvard Medical School, Boston 02114, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: noninvasive first-pass radionuclide ventriculographic
(FPRV) can reasonably estimate maximum cardiac output during
incremental exercise in patients for whom the technique has ruled out
left-sided cardiac regurgitant lesions.
ARTICLE TITLE: Duration of glucocorticoid treatment and outcome in
sepsis: is the right drug used the wrong way? [editorial;
comment]
COMMENTS: Comment on: Chest 1998 Aug; 114(2):426-51
ARTICLE SOURCE: Chest (United States), Aug 1998, 114(2) p355-60
AUTHOR(S): Meduri GU; Chrousos GP
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Early extubation following coronary artery bypass
surgery: a prospective randomized controlled trial. The Fast Track
Cardiac Care Team.
ARTICLE SOURCE: Chest (United States), Jun 1998, 113(6) p1481-8
AUTHOR(S): Silbert BS; Santamaria JD; O'Brien JL; Blyth CM; Kelly WJ;
Molnar RR
AUTHOR'S ADDRESS: Department of Anaesthesia, St. Vincent's Hospital,
Melbourne, Victoria, Australia.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ABSTRACT: STUDY OBJECTIVES: To determine the safety of early
extubation (EE) after coronary artery surgery. DESIGN: Prospective
randomized controlled trial. SETTING: The cardiac surgery operating
room and ICU of a university-affiliated teaching hospital. PATIENTS:
One hundred eligible patients presenting for elective coronary artery
surgery. INTERVENTIONS: Patients randomized to the EE group were
administered a reduced dose of fentanyl (15 microg/kg) and an
anesthetic compatible with EE, while patients randomized to the
conventional extubation (CE) group were given fentanyl (50
microg/kg). MEASUREMENTS AND RESULTS: The time to extubation in the
EE group (median, 240 min; range, 30 to 930 min) was significantly
less than the CE group (median, 420 min; range, 125 to 1,140 min) (p
0.01). Twenty patients were withdrawn from the study according to
protocol guidelines. There were no cases of reintubation or
complications attributable to EE. CONCLUSIONS: By using an
appropriate anesthetic technique and postoperative management, EE can
be achieved following coronary artery bypass surgery without major
complications
ARTICLE TITLE: Anesthetic management is a major determinant of early
extubation after elective cardiac surgery [letter]
ARTICLE SOURCE: Chest (United States), Jul 1998, 114(1) p348
AUTHOR(S): Guarracino F; De Stefani R; Zussa C; Polesel E
PUBLICATION TYPE: CLINICAL TRIAL; LETTER; RANDOMIZED CONTROLLED
TRIAL
MB. A rather small number in study.
ARTICLE TITLE: Central vein catheter-related thrombosis in intensive
care patients: incidence, risks factors, and relationship with
catheter-related sepsis.
ARTICLE SOURCE: Chest (United States), Jul 1998, 114(1) p207-13
AUTHOR(S): Timsit JF; Farkas JC; Boyer JM; Martin JB; Misset B;
Renaud B; Carlet J
AUTHOR'S ADDRESS: Division of Reanimation Polyvalente, Hopital Saint
Joseph, Paris, France.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
ABSTRACT: OBJECTIVE: To evaluate the incidence and risk factors for
catheter-related central vein thrombosis in ICU patients. DESIGN:
Observational prospective multicenter study. SETTING: An 8-bed
surgical ICU, a 10-bed surgical cardiovascular ICU, and a 10-bed
medical-surgical ICU. PATIENTS: During an 18-month period, 265
internaljugular or subclavian catheters were included. Veins were
explored by duplex scanning performed just before or 24 h after
catheter removal. Suspected risk factors of catheter-related central
vein thrombosis were recorded. INTERVENTIONS: None. MEASUREMENTS AND
MAIN RESULTS: Fifty-seven catheters were excluded from the analysis.
Therefore 208 catheters were analyzed. Mean age of patients was
64+/-15 years, simplified acute physiologic score was 12+/-5, organ
system failure score at insertion was 1+/-1, and mean duration of
catheterization was 9+/-5 days. A catheter-related internal jugular
or subclavian vein thrombosis occurred in 33% of the cases (42%
[95% confidence interval (CI), 34 to 49%] and 10% [95%
CI, 3 to 18%], respectively). Thrombosis was limited in 8%, large
in 22%, and occlusive in 3% of the cases. Internal jugular route
(relative risk [RR], 4.13; 95% CI, 1.72 to 9.95), therapeutic
heparinization (RR 0.47; 95% CI, 0.23 to 0.99), and age 64 years (RR,
2.44; 95% CI, 2.05 to 3.19) were independently associated with
catheter-related thrombosis. Moreover, the risk of catheter-related
sepsis was 2.62-fold higher when thrombosis occurred (p=0.011).
CONCLUSIONS: Catheter-related central vein thrombosis is a frequent
complication of central venous catheterization in ICU patients and is
closely associated with catheter-related sepsis.
ARTICLE TITLE: Left ventricular filling pressures during exercise: a
cardiological blind spot?
ARTICLE SOURCE: Chest (United States), Jun 1998, 113(6) p1695-7
AUTHOR(S): West JB
AUTHOR'S ADDRESS: Department of Medicine, University of California
San Diego, La Jolla, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
MB. L ventricular filling pressure can rise in exercise without
implying cardiac failure.
ARTICLE TITLE: Prediction of mortality in febrile medical patients:
How useful are systemic inflammatory response syndrome and sepsis
criteria? [see comments]
COMMENTS: Comment in: Chest 1998 Jun; 113(6):1442-3
ARTICLE SOURCE: Chest (United States), Jun 1998, 113(6) p1533-41
AUTHOR(S): Bossink AW; Groeneveld J; Hack CE; Thijs LG
AUTHOR'S ADDRESS: Department of Internal Medicine, Free University
Hospital, Amsterdam, The Netherlands.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: STUDY OBJECTIVES: The aim was to evaluate demographic,
clinical, and laboratory variables in febrile patients, with or
without a microbiologically confirmed infection, for prediction of
death, in comparison to the systemic inflammatory response syndrome
(SIRS) and its criteria, such as abnormal temperature, tachycardia,
tachypnea, and abnormal WBC count, and to sepsis, that includes SIRS
and an infection. DESIGN: A prospective cohort study. SETTING:
Department of internal medicine at a university hospital. PATIENTS:
In 300 consecutive, hospitalized medical patients with new onset of
fever, demographic, clinical, and laboratory variables were obtained
during the 2 days after inclusion, while microbiological results for
a follow-up period of 7 days were collected. Patients were followed
up for survival or death, up to a maximum of 28 days after inclusion.
MEASUREMENTS AND RESULTS: Of all patients, 95% had SIRS, 44% had
sepsis with a microbiologically confirmed infection, and 9% died. A
model with a set of variables all significantly (p 0.01) contributing
to the prediction of mortality was derived. The set included the
presence of hospital-acquired fever, the peak respiratory rate, the
nadir score on the Glasgow coma scale, and the nadir albumin plasma
level within the first 2 days after inclusion. This set of variables
predicted mortality for febrile patients with microbiologically
confirmed infection even better. The predictive values for mortality
of SIRS and sepsis were less than that of our set of variables.
CONCLUSIONS: In comparison to SIRS and sepsis, the new set of
variables predicted mortality better for all patients with fever and
also for those with microbiologically confirmed infection only. This
type of effort may help in refining definitions of SIRS and sepsis,
based on prognostically important demographic, clinical, and
laboratory variables that are easily obtainable at the bedside.
ARTICLE TITLE: The uncertain value of the definition for SIRS.
Systemic inflammatory response syndrome [editorial;
comment]
COMMENTS: Comment on: Chest 1998 Jun; 113(6):1533-4
ARTICLE SOURCE: Chest (United States), Jun 1998, 113(6) p1442-3
AUTHOR(S): Opal SM
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. I thought the idea or SIRS was silly from the beginning. This
editorial NOW agrees. I attended a seminar in Berlin last year to
commerorate Bone, the inventor or the term. All his other proposals
were proved wrong after being adopted by the ICU community. :-(
ARTICLE TITLE: A comparison between systolic aortic root pressure and
finger blood pressure.
ARTICLE SOURCE: Chest (United States), Jun 1998, 113(6) p1466-74
AUTHOR(S): Philippe EG; Hebert JL; Coirault C; Zamani K; Lecarpentier
Y; Chemla D
AUTHOR'S ADDRESS: Service de Physiologie Cardio-Respiratoire, CHU de
Bicetre, Le Kremlin Bicetre, France.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: As expected, systolic finger (FBP) was almost always
higher than between systolic aortic root pressure (IAoBP).
Importantly, the differences in systolic pressure did not correlate
with known determinants of the pulse wave amplification phenomenon.
The device must be used cautiously if one wants to noninvasively
track spontaneous or induced changes in IAoBP.
ARTICLE TITLE: Physiology of lung resection: no rules, just...Rx
[editorial; comment]
COMMENTS: Comment on: Chest 1998 Jun; 113(6):1511-6
ARTICLE SOURCE: Chest (United States), Jun 1998, 113(6) p1438-9
AUTHOR(S): Olsen GN
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. This subject, as it says in this editorial, is a mess and that we
should press ahead doing what we do best. That is hopeless.
ARTICLE TITLE: Pulmonary arterial hypertension: dipping into the
reserve [editorial; comment]
COMMENTS: Comment on: Chest 1998 Jun; 113(6):1459-65
ARTICLE SOURCE: Chest (United States), Jun 1998, 113(6) p1436-8
AUTHOR(S): Olman MA
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Underuse of venous thromboembolism prophylaxis for
general surgery patients: physician practices in the community
hospital setting.
ARTICLE SOURCE: Arch Intern Med (United States), Sep 28 1998, 158(17)
p1909-12
AUTHOR(S): Bratzler DW; Raskob GE; Murray CK; Bumpus LJ; Piatt DS
AUTHOR'S ADDRESS: Oklahoma Foundation for Medical Quality Inc.,
Clinical Epidemiology Unit, Veterans Administration Medical Center,
Oklahoma City 73118-7472, USA. okpro.dbratzler@sdps.org.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Venous thromboembolism is a common complication
of surgery. Although surveys of physician self-reported practices
have suggested near universal support for routine use of measures to
prevent venous thromboembolism, medical record auditing has
demonstrated underuse. OBJECTIVE: To assess physician practices of
venous thromboembolism prophylaxis in the community hospital setting.
METHODS: Retrospective review of the medical records from 20
hospitals in Oklahoma of 419 Medicare patients aged 65 years or older
undergoing major abdominothoracic surgery between April 1 and
December 31, 1995. Utilization rates of prophylaxis stratified
according to patient risk for venous thromboembolism were measured.
RESULTS: Prophylaxis measures were implemented for only 160 (38%) of
419 patients studied (95% confidence interval, 33%-43%). There was
little variation in the use of prophylaxis based on the risk for
venous thromboembolism. Only 97 (39%) of 250 patients (95% confidence
interval, 33%-45%) at very high risk received any form of prophylaxis
and of these 97, only 64 patients (66%) received appropriate measures
(95% confidence interval, 56%-75%). CONCLUSIONS: Despite widely
disseminated, evidence-based recommendations, venous thromboembolism
prophylaxis is underused in Medicare patients undergoing major
abdominothoracic surgery in community hospitals in Oklahoma.
ARTICLE TITLE: National patterns and predictors of beta-blocker use
in patients with coronary artery disease.
ARTICLE SOURCE: Arch Intern Med (United States), Sep 28 1998, 158(17)
p1901-6
AUTHOR(S): Wang TJ; Stafford RS
AUTHOR'S ADDRESS: Institute for Health Policy, Massachusetts General
Hospital, and the Department of Medicine, Harvard Medical School,
Boston 02114, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Prior studies suggest underuse of beta-blockers
in patients with coronary artery disease, but these studies have been
based on selected populations of recently hospitalized patients.
OBJECTIVE: To describe national patterns and determinants of
beta-blocker use in the ambulatory setting. METHODS: We analyzed
11745 visits by patients with coronary artery disease to randomly
selected, office-based physicians in the National Ambulatory Medical
Care Surveys for 1980, 1981, 1985, and 1989 through 1996. We used
multiple logistic regression to determine the independent effect of
sociodemographic and clinical factors on beta-blocker use. OUTCOME
MEASURE: Beta-blocker use at patient visits. RESULTS: Beta-blocker
use was reported in only 20.9% of office visits by patients with
coronary artery disease and no strong contraindications between 1993
and 1996. In multivariate analyses, age younger than 75 years,
residence in the Northeast, and visits to cardiologists and
internists compared with family and general practitioners predicted
greater use of beta-blocker therapy. White race and private insurance
also were significant predictors of beta-blocker use between 1980 and
1996. Longitudinal analyses revealed a significant decline in
beta-blocker use from 1980 to 1990, followed by a gradual increase in
recent years. CONCLUSIONS: Beta-blockers appear to be underused in
ambulatory patients with coronary artery disease. Our data suggest
that nonclinical factors may influence rates of use, indicating the
need for closer scrutiny of variations in physician prescribing
practices.
ARTICLE TITLE: Calcium antagonists and mortality risk in men and
women with hypertension in the Framingham Heart Study.
ARTICLE SOURCE: Arch Intern Med (United States), Sep 28 1998, 158(17)
p1882-6
AUTHOR(S): Abascal VM; Larson MG; Evans JC; Blohm AT; Poli K; Levy
D
AUTHOR'S ADDRESS: National Heart, Lung, and Blood Institute's
Framingham Heart Study, Mass 01702, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Several recent studies have suggested that
calcium antagonist drugs, which are widely used for the treatment of
hypertension, are associated with increased risk of cardiovascular
disease. These studies have cast doubts on the long-term safety of
calcium antagonists. CONCLUSIONS: In this cohort of 3539 subjects
with hypertension there were no differences in mortality among
subjects with hypertension using a calcium antagonist compared with
those who were not. Results were similar among subjects with
hypertension with and without coronary heart disease. The results of
ongoing long-term, randomized clinical trials will provide more
definitive data on the safety of calcium antagonists.
ARTICLE TITLE: Concepts of fever.
ARTICLE SOURCE: Arch Intern Med (United States), Sep 28 1998, 158(17)
p1870-81
AUTHOR(S): Mackowiak PA
AUTHOR'S ADDRESS: Medical Care Clinical Center, Maryland Veterans
Affairs Health Care System, Baltimore 21201, USA.
PUBLICATION TYPE: HISTORICAL ARTICLE; JOURNAL ARTICLE; REVIEW (171
references); REVIEW, TUTORIAL
ABSTRACT: If asked to define fever, most physicians would offer a
thermal definition, such as "fever is a temperature greater than...."
In offering their definition, many would ignore the importance of the
anatomic site at which temperature measurements are taken, as well as
the diurnal oscillations that characterize body temperature. If
queried about the history of clinical thermometry, few physicians
could identify the source or explain the pertinacity of the belief
that 98.6 degrees F (37.0 degrees C) has special meaning vis-a-vis
normal body temperature. Fewer still could cite the origin of the
thermometer or trace the evolution of modern concepts of clinical
thermometry. Although many would have some knowledge of the
fundamentals of thermoregulation and the role played by exogenous and
endogenous pyrogens in the induction of fever, few would have more
than a superficial knowledge of the broad biological activities of
pyrogenic cytokines or know of the existence of an equally complex
and important system of endogenous cryogens. A distinct minority
would appreciate the obvious paradoxes inherent in an enlarging body
of data concerned with the question of fever's adaptive value. The
present review considers many of these issues in the light of current
data.
ARTICLE TITLE: National trends in the use of antibiotics by primary
care physicians for adult patients with cough.
ARTICLE SOURCE: Arch Intern Med (United States), Sep 14 1998, 158(16)
p1813-8
AUTHOR(S): Metlay JP; Stafford RS; Singer DE
AUTHOR'S ADDRESS: General Medicine Division, Massachusetts Division,
Massachusetts General Hospital and Harvard Medical School, Boston,
USA. jmetlay@cceb.med.upenn.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Increased antibiotic use for outpatient
illnesses has been identified as an important determinant of the
recent rise in antibiotic resistance among common respiratory
pathogens. Efforts to reduce the inappropriate use will need to be
evaluated against current trends in the outpatient use of
antibiotics. OBJECTIVES: To examine national trends in the use of
antibiotics by primary care physicians in the care of adult patients
with cough and identify patient factors that may influence antibiotic
use for these patients. RESULTS: Overall, an antibiotic was
prescribed 66% of the time during office visits for patients with
cough: 59% of patient visits in 1980 rising to 70% of visits in 1994
(P = .002 for trend). In every study year, white, non-Hispanic
patients and patients younger than 65 years were more likely to
receive antibiotics compared with nonwhite patients and patients 65
years or older, respectively. CONCLUSIONS: The rate of antibiotic use
by primary care physicians for patients with cough remained high from
1980 to 1994, and was influenced by nonclinical characteristics of
patients.
ARTICLE TITLE: Suicide: the public health crisis of our time.
ARTICLE SOURCE: Aust N Z J Med (Australia), Jun 1998, 28(3)
p295-300
AUTHOR(S): Singh BS
AUTHOR'S ADDRESS: Department of Psychiatry, University of Melbourne,
Vic.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (32 references); REVIEW,
TUTORIAL
ARTICLE TITLE: Rediscovering ionised calcium [editorial;
comment]
COMMENTS: Comment on: Aust N Z J Med 1998 Apr; 28(2):173-8
ARTICLE SOURCE: Aust N Z J Med (Australia), Apr 1998, 28(2)
p155-7
AUTHOR(S): Need AG; Nordin BE
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Surgical standby for coronary interventions
[editorial; comment]
COMMENTS: Comment on: Aust N Z J Med 1998 Apr; 28(2):165-71
ARTICLE SOURCE: Aust N Z J Med (Australia), Apr 1998, 28(2)
p153-4
AUTHOR(S): Farnsworth AE
PUBLICATION TYPE: COMMENT; EDITORIAL
ARTICLE TITLE: Prospective, randomized comparison of extrapleural
versus epidural analgesia for postthoracotomy pain.
ARTICLE SOURCE: Ann Thorac Surg (United States), Aug 1998, 66(2)
p367-72
AUTHOR(S): Kaiser AM; Zollinger A; De Lorenzi D; Largiader F; Weder
W
AUTHOR'S ADDRESS: Department of Surgery and Institute for
Anesthesiology, University Hospital, Zurich, Switzerland.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
CONCLUSIONS: These results led us to suggest that extrapleural
intercostal analgesia might be a valuable alternative to thoracic
epidural analgesia for pain control after thoracotomy and should
particularly be considered in patients who do not qualify for
thoracic epidural analgesia.
ARTICLE TITLE: Impact of gender on coronary bypass operative
mortality.
ARTICLE SOURCE: Ann Thorac Surg (United States), Jul 1998, 66(1)
p125-31
AUTHOR(S): Edwards FH; Carey JS; Grover FL; Bero JW; Hartz RS
AUTHOR'S ADDRESS: Division of Cardiothoracic Surgery, University of
Florida Health Science Center, Jacksonville 32209-6511, USA.
fhe@mediaone.net.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: In spite of many reports investigating the
influence of gender on coronary artery operations, it is still
uncertain whether gender is an independent risk factor for operative
mortality. A major problem of previous reports has centered around
the fact that men and women constitute quite different populations,
thereby making direct comparisons difficult. METHODS: The Society of
Thoracic Surgeons National Cardiac Surgery Database was used to
retrospectively examine 344,913 patients undergoing coronary artery
bypass graft operations from 1994 through the most recent data
harvest. The operative mortality of male and female patients was
compared for a variety of single risk factors and combinations of
risk factors. A logistic risk model was used to account for all
important patient parameters so that individuals could be stratified
into comparable categories allowing for direct comparisons of
risk-matched male and female patients. RESULTS: The univariate
analysis showed that the 97,153 women carried a significantly higher
mortality for each of the risk factors examined. The multivariate
analysis and the risk model stratification showed that women had
significantly higher mortality as compared to equally matched men in
the low- and medium-risk part of the spectrum, but in high-risk
patients, there was no difference between male and female mortality.
CONCLUSIONS: Gender is an independent predictor of operative
mortality except for patients in very high-risk categories.