MB's Articles of Interest - March 2000.

ARTICLE TITLE : Hemostatic agents and their safety.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Aug 1999, 13(4 Suppl 1) p6-11; discussion 36-7
AUTHOR(S): Levy JH
AUTHOR'S ADDRESS: Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: The pharmacologic management of hemostasis in patients undergoing cardiopulmonary bypass may be accompanied by adverse responses. Evaluating the safety profile of hemostatic agents (eg, lysine analogs, aprotinin, protamine, or even donor blood) should be done objectively. Subsequent to early anecdotal reports, the safety profile of aprotinin, a broad-spectrum serine protease inhibitor, has been thoroughly evaluated in multiple double-blind, placebo-controlled, multicenter studies. Although associated with decreased fibrinolysis, aprotinin has not been associated with an increased risk of post-cardiopulmonary bypass myocardial infarction, graft closure, stroke, or increased risk of renal dysfunction from US studies. As with any polypeptide, there is a risk of anaphylaxis, which is influenced not only by prior exposure but also by time since prior exposure. In a similar fashion, after early anecdotal reports, evaluations involving large numbers of patients have helped define adverse reactions to protamine. Adverse reactions to blood products also must be considered in any safety comparisons involving hemostatic agents.

ARTICLE TITLE : Etiology and incidence of brain dysfunction after cardiac surgery.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Aug 1999, 13(4 Suppl 1) p12-7; discussion 36-7
AUTHOR(S): Murkin JM
AUTHOR'S ADDRESS: Department of Anesthesia, University Campus, London Health Sciences Center, Ontario, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: In a 316-patient prospective study, we found no differences in outcome between pH-stat and alpha-stat strategies during moderate hypothermic CPB, except in patients who were on bypass for more than 90 minutes. Approximately 90% of these had a significant reduction in cognitive impairment with the alpha-stat method. Aprotinin, a serine protease inhibitor, has been found in two separate, randomized, placebo-controlled trials to significantly lower incidences of perioperative stroke. Further study to develop therapeutic and preemptive strategies for prevention of brain injury is required, especially in the elderly. Aprotinin and other modalities aimed at suppressing the inflammatory response to CPB may offer hope because they act to suppress injury-provoking enzymes and leukocyte activation that are, in part, responsible for organ system dysfunction following CPB.

ARTICLE TITLE : Con: beta-blockers should not be used in all patients undergoing vascular surgery [comment]
COMMENTS: Comment on: J Cardiothorac Vasc Anesth 1999 Aug; 13(4):490-5
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Aug 1999, 13(4) p496-7
AUTHOR(S): Fleisher LA
AUTHOR'S ADDRESS: Department of Anesthesiology, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE

ARTICLE TITLE : Pro: beta-blockers should be used in all patients undergoing vascular surgery [see comments]
COMMENTS: Comment in: J Cardiothorac Vasc Anesth 1999 Aug; 13(4):496-7
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Aug 1999, 13(4) p490-5
AUTHOR(S): Sutton T; Rock P
AUTHOR'S ADDRESS: Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE : Aprotinin has direct platelet protective properties: fact or fiction? [editorial; comment]
COMMENTS: Comment on: J Cardiothorac Vasc Anesth 1999 Aug; 13(4):382-7; Comment on: J Cardiothorac Vasc Anesth 1999 Aug; 13(4):388-92
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Aug 1999, 13(4) p379-81
AUTHOR(S): Shore-Lesserson L
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. They think that aprotinin reduces bleeding but does not seem to know if or how platelets might be involved.

ARTICLE TITLE : Con: every postthoracotomy patient does not deserve thoracic epidural analgesia.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Jun 1999, 13(3) p355-7
AUTHOR(S): Grant RP
AUTHOR'S ADDRESS: Department of Anaesthesia, Faculty of Medicine, University of British Columbia, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (43 references); REVIEW, TUTORIAL

ARTICLE TITLE : Pro: every postthoracotomy patient deserves thoracic epidural analgesia.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Jun 1999, 13(3) p350-4
AUTHOR(S): Slinger PD
AUTHOR'S ADDRESS: Department of Anaesthesia, University of Toronto and The Toronto Hospital, Ontario, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (43 references); REVIEW, TUTORIAL

ARTICLE TITLE : Con: All elective coronary artery bypass grafting patients are not American Society of Anesthesiologists' Physical Status IV [comment]
COMMENTS: Comment on: J Cardiothorac Vasc Anesth 1999 Apr; 13(2):225-7
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Apr 1999, 13(2) p228-30
AUTHOR(S): Wiklund RA
AUTHOR'S ADDRESS: Yale University School of Medicine, Yale-New Haven Hospital, CT 06520-8051, USA.
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE; REVIEW (19 references); REVIEW, TUTORIAL

ARTICLE TITLE : Pro: All elective coronary artery bypass grafting patients are American Society of Anesthesiologists' Physical Status IV [see comments]
COMMENTS: Comment in: J Cardiothorac Vasc Anesth 1999 Apr; 13(2):228-30
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Apr 1999, 13(2) p225-7
AUTHOR(S): Swamidoss CP; Barash PG
AUTHOR'S ADDRESS: Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06520-8051, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (19 references); REVIEW, TUTORIAL

ARTICLE TITLE : Awareness during cardiac surgery.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Apr 1999, 13(2) p214-9
AUTHOR(S): Tempe DK; Siddiquie RA
AUTHOR'S ADDRESS: Department of Anaesthesiology, G.B. Pant Hospital, New Delhi, India.
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (68 references); REVIEW, TUTORIAL

ARTICLE TITLE : Cross-sectional area of the right and left internal jugular veins.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Apr 1999, 13(2) p136-8
AUTHOR(S): Lobato EB; Sulek CA; Moody RL; Morey TE
AUTHOR'S ADDRESS: Department of Anesthesiology, University of Florida College of Medicine, Gainesville 32610-0254, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: OBJECTIVE: To compare the cross-sectional area (CSA) of the right internal jugular vein (RIJV) with the left internal jugular vein (LIJV) using two-dimensional ultrasound and to measure the response to the Valsalva maneuver in both the supine and Trendelenburg positions. DESIGN: Prospective and randomized. SETTING: University-affiliated hospital. PARTICIPANTS: Fifty healthy adult volunteers. INTERVENTIONS: The CSA of both the RIJV and LIJV was measured with a 5-MHz, two-dimensional surface transducer before and during a 10-second Valsalva maneuver with the subjects in the supine position, and then with the subjects in a 10 degree Trendelenburg tilt. MEASUREMENTS AND MAIN RESULTS: After the baseline measurements were performed, the subjects were divided into two groups based on the CSA of the RIJV and LIJV. Group 1 had an LIJV CSA equal to or greater than that of the RIJV (n = 10) and group 2 had an LIJV CSA less than that of the RIJV (n = 40). Of the latter 40 patients, 17 (34%) had an LIJV CSA less than 50% of that of the RIJV. In both groups, the CSA of both veins increased significantly with the Valsalva maneuver, Trendelenburg tilt, and both maneuvers combined. CONCLUSION: The findings suggest that in one third of adults (34%), the LIJV is significantly smaller compared with the RIJV and, combined with operator inexperience, may influence the success rate and risk for complications. Thus, the use of ultrasound and maneuvers that increase CSA is suggested during LIJV cannulation.
MB. I already routinely check with the ultrasound now. I might start applying PEEP.

ARTICLE TITLE : Endovascular aortic repair is associated with greater hemodynamic stability compared with open aortic reconstruction.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Feb 1999, 13(1) p42-6
AUTHOR(S): Kahn RA; Moskowitz DM; Manspeizer HE; Reich DL; McConville JC; Marin ML; Hollier LH
AUTHOR'S ADDRESS: Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: These results show improved hemodynamic stability during endovascular aortic repair (EAR) compared with open aortic repair (OAR).
MB. You hardly have to do a study to find this out.

ARTICLE TITLE : Toward the goal of optimal cardiac anesthesia [editorial; comment]
COMMENTS: Comment on: J Cardiothorac Vasc Anesth 1999 Feb; 13(1):3-8
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Feb 1999, 13(1) p1-2
AUTHOR(S): Reves JG
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. They obviously have a long way to go. They are only just realising that the same patients having non-cardiac surgery can be made to wake up quickly ie within 10 minutes of completing surgery and that IV based anaesthesia can delay recovery. Before CABGing there were cardiac surgery patients in severe cardiac failure. They were all fast tracked. They did not have TIVA or with me any IV anaesthesia.

ARTICLE TITLE : Pain management in cardiac surgery patients: comparison between standard therapy and patient-controlled analgesia regimen.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Dec 1998, 12(6) p654-8
AUTHOR(S): Boldt J; Thaler E; Lehmann A; Papsdorf M; Isgro F
AUTHOR'S ADDRESS: Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Germany.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSION: Because of the beneficial effects with regard to degree of pain and satisfaction, pain management using PCA systems can be recommended for cardiac surgery patients. It appears to be superior to standard nurse-based pain therapy.

ARTICLE TITLE : An alternate method for calibrating the thromboelastograph.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Dec 1998, 12(6) p639-41
AUTHOR(S): McNulty SE; Maguire DP; Arai LD
AUTHOR'S ADDRESS: Department of Anesthesiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: This study evaluated various substances that could be used to calibrate the Thrombelastograph. DESIGN: Prospective, controlled comparison. SETTING: Operating room laboratory at a tertiary care university hospital. PARTICIPANTS: None. INTERVENTIONS: Six substances commonly available in the operating room setting (ointments, creams, and gels) were analyzed by thromboelastography for 3 minutes. Sixty measurements were made for each substance. MEASUREMENTS AND MAIN RESULTS: Thromboelastographic analysis of the ointments and cream preparations had an amplitude variability that exceeded 10 mm within the 3-minute recording period. The conductive gel had the most reproducible thromboelastography tracing with a mean amplitude of 62.5 +/- 1.1 mm (analysis of variance, p < 0.0005). There was a significant correlation between the reported viscosity of the three gels and the deflection amplitude (linear regression, R2 = 0.97; p < 0.0001). CONCLUSION: Conductive gel is a useful substance for quickly checking the functional status of the Thrombelastograph at an operational stage. Calibration of the Thrombelastograph using a gel of known viscosity is clinically relevant and may be more practical than testing with thromboelastographic-defined normal and abnormal blood analogs.
MB. How silly can you get?

ARTICLE TITLE : Perioperative renal dysfunction and cardiovascular anesthesia: concerns and controversies.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Oct 1998, 12(5) p567-86
AUTHOR(S): Aronson S; Blumenthal R
AUTHOR'S ADDRESS: Department of Anesthesia and Critical Care, University of Chicago, IL 60637, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (189 references); REVIEW, TUTORIAL
ABSTRACT: In patients with renal disease undergoing cardiovascular surgery, perioperative management continues to be a challenge. Traditional answers have turned into new questions with the introduction of new agents and the redesign of old techniques. For ARF prevention, early recognition of pending deleterious compensatory changes is critical. Theoretically, therapeutic intervention designed to prevent ischemic renal failure should be designed to preserve the balance between RBF and oxygen delivery on one hand and oxygen demand on the other. Maintenance of adequate cardiac output distribution to the kidney is determined by the relative ratio of renal artery vascular resistance to systemic vascular resistance. Indeed, it should not be surprising to learn that norepinephrine (despite its vasoconstricting effect) has been reported to have no deleterious renal effects in patients with low systemic vascular resistance. Until recently, strategies for the treatment of ARF have been directed to supportive care with dialysis (to allow tubular regeneration). Various therapeutic maneuvers have been introduced in an attempt to accelerate the recovery of glomerular filtration, including dialysis, nutritional regimens, and new pharmacologic agents. A recent small prospective trial of low-dose dopamine in the prophylaxis of ARF in patients undergoing abdominal aortic aneurysm repair showed no benefit in those patients receiving dopamine. Conversely, the effects of intravenous atrial natriuretic peptide in the treatment of patients with ARF appear to offer benefit in patients with oliguria. Among 121 patients with oliguric renal failure, 63% of those who received a 24-hour infusion of atrial natriuretic peptide required dialysis within 2 weeks compared with 87% who did not. Whether this effect will be borne out in the future remains to be determined. The administration of epidermal growth factor after induction of ischemic ARF in rats has been shown to enhance tubular regeneration and accelerate recovery of kidney function. Human growth factor administration has been shown to increase GFR 130% greater than baseline in patients with chronic renal failure, but no data for clinical ARF have been reported. In addition, there have been significant improvements in dialysis technology in the treatment of ARF. Modern dialysis uses bicarbonate as a buffer as opposed to acetate, which reduces cardiovascular instability, and has more precise regulation of volume removal. Dialysate profiles and temperatures improve hemodynamics and reduce intradialytic hypotension. Techniques of hemodialysis without anticoagulation have reduced bleeding complications. Finally, dialysis membranes activate neutrophils and complement less with the biocompatible membranes used today that reduce recovery time and dialysis treatment. Evidence indicates that activation of complement and neutrophils by older dialysis membranes caused a greater incidence of hypotension, adding to ischemic renal injury. It remains to be determined whether early and frequent dialysis with biocompatible membranes, as well as other therapeutic interventions, will increase the survival of patients with perioperative ARF.
MB. I thought we solved this problem in 1966. It is sustained hydration

ARTICLE TITLE : Perioperative cardiovascular morbidity in patients with coronary artery disease undergoing vascular surgery after percutaneous transluminal coronary angioplasty.
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Oct 1998, 12(5) p501-6
AUTHOR(S): Gottlieb A; Banoub M; Sprung J; Levy PJ; Beven M; Mascha EJ
AUTHOR'S ADDRESS: Department of General Anesthesiology, Cleveland Clinic Foundation, OH 44195, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: High-risk cardiac patients undergoing vascular surgery who have had PTCA performed up to 18 months preoperatively have a low incidence of perioperative cardiac morbidity. Prophylactic percutaneous transluminal coronary angioplasty (PTCA) may be beneficial in patients with coronary artery disease (CAD who are at high risk for perioperative cardiac complications.

ARTICLE TITLE : Percutaneous transluminal coronary angioplasty before noncardiac surgery: current state of the debate [editorial]
ARTICLE SOURCE: J Cardiothorac Vasc Anesth (United States), Oct 1998, 12(5) p499-500
AUTHOR(S): Fleisher LA; Barash PG
PUBLICATION TYPE: EDITORIAL
MB. It depends on how good the local percutaneous transluminal coronary angioplasty is. In other words they have no idea

ARTICLE TITLE : Percutaneous dilatational tracheostomy: still a surgical procedure.
ARTICLE SOURCE: Am Surg (United States), Oct 1999, 65(10) p982-6
AUTHOR(S): Suh RH; Margulies DR; Hopp ML; Ault M; Shabot MM
AUTHOR'S ADDRESS: Department of Surgery, Burns and Allen Research Institute, Cedars-Sinai Medical Center and the University of California at Los Angeles School of Medicine, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Although percutaneous dilatational tracheostomy (PDT) has been shown to be a cost-effective bedside alternative to open tracheostomy (OT), prior reports of the complications of the procedure are contradictory. Reported complications range from minor events to fatal ones, in varying percentages. This prospective study was designed to identify the type and severity of complications accompanying the introduction of PDT to a tertiary medical center. Surgical and medical intensive care unit (ICU) patients requiring elective tracheostomy were identified as appropriate for PDT using approved institutional criteria. All procedures were performed at an ICU bedside in the presence of a surgeon privileged to perform OT. Demographic data, procedural information, and patient outcome (including minor and major complications, length of stay, and survival) were collected. PDT was performed in 96 ICU patients, with complete data available for 95 patients. PDT was performed in an average of 13.1+/-1.0 minutes. Twenty-three major and minor complications occurred, including two perioperative deaths, in 15 patients (15.8%). A total of 37 PDT patients (38.9%) died in the hospital, indicative of the severity of illness of patients requiring tracheostomy. Based on the experience to date, Cedars-Sinai Medical Center (Los Angeles, CA) continues to require a surgeon privileged to perform OT to participate in all PDT procedures.
MB. It looks as though intensivists should not do this procedure. Intubation is of course the acute treatment. Then get a surgeon.

ARTICLE TITLE : Clinical use of a bioartificial liver in the treatment of acetaminophen-induced fulminant hepatic failure.
ARTICLE SOURCE: Am Surg (United States), Oct 1999, 65(10) p934-8
AUTHOR(S): Detry O; Arkadopoulos N; Ting P; Kahaku E; Watanabe FD; Rozga J; Demetriou AA
AUTHOR'S ADDRESS: Department of Surgery, Cedars Sinai Medical Center, University of California at Los Angeles School of Medicine, 90048, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
Eight patients were treated. Three patients were bridged to liver transplantation, and five patients recovered without a transplant. All patients experienced neurological and metabolic improvement after treatments with the BAL support system. The extracorporeal bioartificial liver (BAL) support system seems to improve the outcome of high-risk patients with acetaminophen-induced fulminant hepatic failure (FHF), even in the absence of liver transplantation. Avoiding liver transplantation is particularly important in an era of organ shortage and high cost of transplants.

ARTICLE TITLE : The first anatomists/artists.
ARTICLE SOURCE: Am Surg (United States), Sep 1999, 65(9) p899-900
AUTHOR(S): Xie C; O'Leary JP
AUTHOR'S ADDRESS: Department of Surgery, Louisiana State University Medical Center, New Orleans 70112, USA.
PUBLICATION TYPE: BIOGRAPHY; HISTORICAL ARTICLE; JOURNAL ARTICLE

ARTICLE TITLE : An overview of remifentanil.
ARTICLE SOURCE: Anesth Analg (United States), Oct 1999, 89(4 Suppl) pS1-3
AUTHOR(S): Rosow CE
AUTHOR'S ADDRESS: Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston 02114-2696, USA. rosow@etherdome.mgh.harvard.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (15 references); REVIEW, TUTORIAL

ARTICLE TITLE : Intravenous infusion of phenytoin relieves neuropathic pain: a randomized, double-blinded, placebo-controlled, crossover study.
ARTICLE SOURCE: Anesth Analg (United States), Oct 1999, 89(4) p985-8
AUTHOR(S): McCleane GJ
AUTHOR'S ADDRESS: Pain Clinic, Craigavon Area Hospital, Northern Ireland.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
IMPLICATIONS: Oral phenytoin can relieve neuropathic pain. The aim of this study was to examine the effect of IV phenytoin on neuropathic pain. The results indicate that IV phenytoin may be used to treat flare-ups of chronic neuropathic pain.

ARTICLE TITLE : Refractory hypotension after induction of anesthesia in a patient chronically treated with angiotensin receptor antagonists.
ARTICLE SOURCE: Anesth Analg (United States), Oct 1999, 89(4) p887-8
AUTHOR(S): Brabant SM; Eyraud D; Bertrand M; Coriat P
AUTHOR'S ADDRESS: Department of Anesthesiology, University Hospital Pitie-Salpetriere, Paris, France.
INDEXING CHECK TAG(S): Case Report; Human; Male
PUBLICATION TYPE: JOURNAL ARTICLE
MB. We may have to use vasopressin agonists (Interlipresin or triglycyl-lysine vasopressin)

ARTICLE TITLE : ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography.
ARTICLE SOURCE: Anesth Analg (United States), Oct 1999, 89(4) p870-84
AUTHOR(S): Shanewise JS; Cheung AT; Aronson S; Stewart WJ; Weiss RL; Mark JB; Savage RM; Sears-Rogan P; Mathew JP; Quinones MA; Cahalan MK; Savino JS
AUTHOR'S ADDRESS: Division of Cardiac Anesthesia and Critical Care, Emory University School of Medicine, Atlanta, Georgia, USA.
PUBLICATION TYPE: GUIDELINE; JOURNAL ARTICLE;

ARTICLE TITLE : A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopedic surgery. International Study of Perioperative Transfusion (ISPOT) Investigators.
ARTICLE SOURCE: Anesth Analg (United States), Oct 1999, 89(4) p861-9
AUTHOR(S): Huet C; Salmi LR; Fergusson D; Koopman-van Gemert AW; Rubens F; Laupacis A
AUTHOR'S ADDRESS: INSERM U-330, Universite Victor Segalen Bordeaux, France.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
.IMPLICATIONS: This meta-analysis of all published randomized trials provides the best current estimate of the effectiveness of cell salvage and is useful in guiding clinical practice. We conclude that cell salvage in orthopedic surgery decreases the proportion of patients requiring allogeneic blood transfusion perioperatively, but postoperative cell salvage is only marginally effective in cardiac surgery.

ARTICLE TITLE : Perioperative- and long-term mortality rates after major vascular surgery: the relationship to preoperative testing in the medicare population.
ARTICLE SOURCE: Anesth Analg (United States), Oct 1999, 89(4) p849-55
AUTHOR(S): Fleisher LA; Eagle KA; Shaffer T; Anderson GF
AUTHOR'S ADDRESS: Department of Anesthesiology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA. lfleishe@welchlink.welch.jhu.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
Stress testing, with or without coronary revascularization, was associated with improved short-and long-term survival in aortic surgery. The use of stress testing with coronary revascularization was not associated with reduced perioperative mortality after infrainguinal surgery. Stress testing alone was associated with reduced long-term mortality in patients undergoing infrainguinal revascularization. IMPLICATIONS: Analysis of the Medicare Claims database suggests that vascular surgery is associated with substantial perioperative and long-term mortality. The reduced long-term mortality in patients who had previously undergone preoperative testing and coronary revascularization reinforces the need for a prospective evaluation of these practices.
MB. Stress testing is not treatment. How could is inprove the results of surgery.

ARTICLE TITLE : A demonstration of the concentration and second gas effects in humans anesthetized with nitrous oxide and desflurane.
ARTICLE SOURCE: Anesth Analg (United States), Sep 1999, 89(3) p774-80
AUTHOR(S): Taheri S; Eger EI 2nd
AUTHOR'S ADDRESS: Department of Anesthesia, University of California, San Francisco 94143-0464, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: In the present study, we explored both the existence of and the basis for the concentration and second gas effects. Groups of six normocapnic patients were given one of three gas mixtures via a nonrebreathing system: 65% nitrous oxide (N2O) plus 4% desflurane; 5% N2O plus 4% desflurane; or 65% N2O plus 0.5% desflurane plus 2% xenon (Xe). End-tidal carbon dioxide (CO2) was held constant by adjustments in ventilation. Confirming the existence of the concentration effect, the end-tidal (F(A)) concentration of N2O increased toward the inspired (F(I)) concentration more rapidly (i.e., F(A)/F(I) increased more rapidly) when the inspired concentration was 65% than when it was 5%. The F(A)/F(I) for desflurane also increased more rapidly when desflurane was given with 65% rather than 5% N2O, confirming the existence of the second gas effect. The small uptake of the second gas (desflurane) did not influence its own F(A)/F(I) or that of N2O; that is, the administration of 4%, rather than 0.5%, desflurane did not increase the rate of rise of F(A)/F(I) of either N2O or desflurane. One of the bases of the concentration and second gas effects, a concentrating of residual gases, was confirmed: administration of Xe with 65% N2O produced an F(A)/F(I) for Xe that exceeded 1.0. Patient sex did not seem to influence the rate of rise of F(A)/F(I) of either N2O or desflurane. Finally, we unexpectedly found that, despite an equal solubility in blood, the rise in F(A)/F(I) for N2O exceeded that for desflurane, perhaps because of differences in tissue solubilities and intertissue diffusion. IMPLICATIONS: As predicted by the concentration and second gas effects, increasing the inspired concentration of nitrous oxide accelerated its rate of rise and the rate of rise of concurrently administered desflurane in humans.
MB. Eger was spurred on by an article from China (Sun et al., Anesth Analges1999;88:188-92) saying that these effects did not occur. That paper used a volume set ventilator so the increased increased inspred volume due to nitrous being taken up could not occur. Eger contriolled the end tidal CO2 and in fact kept the expired volume constant. Very obtuse writing. These 2 concepts are not very important but do exist. Diffusion hypoxia is in the same class. They are all due to differences in solubilities of gases being exchanged between the external world and the physiological fluid spaces.
See Aug 1999 articles of interest for Sun & al. Also more commentary from me.

ARTICLE TITLE : The effectiveness of preemptive analgesia varies according to the type of surgery: a randomized, double-blind study.
ARTICLE SOURCE: Anesth Analg (United States), Sep 1999, 89(3) p711-6
AUTHOR(S): Aida S; Baba H; Yamakura T; Taga K; Fukuda S; Shimoji K
AUTHOR'S ADDRESS: Department of Anesthesiology, Niigata University School of Medicine, Japan. aae62360@pop21.odn.ne.jp.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: The reliability of preemptive analgesia is controversial. Its effectiveness may vary among anatomical areas or surgical types. We evaluated preemptive analgesia by epidural morphine in six surgery types in a randomized, double-blind manner. Pain intensity was rated using a visual analog scale, a verbal report, and a measurement of postsurgical morphine consumption. Preemptive analgesia was effective in limb surgery and mastectomy, but ineffective for gastrectomy, hysterectomy, herniorrhaphy, and appendectomy. Relief of postsurgical pain in hemiorrhaphy was more rapid than that in the other surgery types. Preemptive analgesia was effective in limb surgery and mastectomy, but not in surgeries involving laparotomy, regardless of whether the surgery was major (gastrectomy and hysterectomy) or minor (herniorrhaphy and appendectomy). These results suggest that viscero-peritoneal nociception is involved in postsurgical pain. The abdominal viscera and peritoneum are innervated both heterosegmentally (in duplicate or triplicate by the vagus and/or phrenic nerves) and segmentally (by the spinal nerves). Therefore, supraspinal and/or cervical spinal neurons might be sensitized, despite the blockade of the segmental nerves with epidural morphine. The rapid retreat of the pain after hemiorrhaphy suggests that central sensitization remits soon after minor surgery, but that in appendicitis, it may be protracted by additional noxious stimuli, such as infection. IMPLICATIONS: Epidural preemptive analgesia was reliably effective in limb and breast surgeries but ineffective in abdominal surgery, suggesting involvement of the brainstem and cervical spinal cord via the vagus and phlenic nerves.

ARTICLE TITLE : Anesthetic and perioperative management of adult transplant recipients in nontransplant surgery.
ARTICLE SOURCE: Anesth Analg (United States), Sep 1999, 89(3) p613-22
AUTHOR(S): Kostopanagiotou G; Smyrniotis V; Arkadopoulos N; Theodoraki K; Papadimitriou L; Papadimitriou J
AUTHOR'S ADDRESS: Anesthesiology Unit, Aretaieion Hospital, University of Athens School of Medicine, Greece. narkado@otenet.gr.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (147 references); REVIEW, ACADEMIC
MB. I suppose there is some value in this review but I don't think that having had a trasnplant presents many specific problems at least in liver or kidney trasnplants. Adequate hydration in renal trasnplants shoud be similar to that desirable always. It would be a pity to mess up a transplanted kidney by giving some of the common applied renal protections.

ARTICLE TITLE : Reduction of blood loss and transfusion requirement by aprotinin in posterior lumbar spine fusion.
ARTICLE SOURCE: Anesth Analg (United States), Sep 1999, 89(3) p590-7
AUTHOR(S): Lentschener C; Cottin P; Bouaziz H; Mercier FJ; Wolf M; Aljabi Y; Boyer-Neumann C; Benhamou D
AUTHOR'S ADDRESS: Department of Anesthesiology, Hopital Antoine-Beclere, Universite Paris-Sud, Clamart, France. claude.lentschener@abc.ap-hop.paris.fr.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: Aprotinin reduces blood loss in many orthopedic procedures. In posterior lumbar spine fusion, blood loss results primarily from large vein bleeding and also occurs after the wound is closed. Seventy-two patients undergoing posterior lumbar spine fusion were randomly assigned to large-dose aprotinin therapy or placebo. All patients donated three units of packed red blood cells (RBCs) preoperatively. Postoperative blood loss was harvested from the surgical wound in patients undergoing two- and/or three-level fusion for reinfusion. The target hematocrit for RBC transfusion was 26% if tolerated. Total (intraoperative and 24 h postoperative) blood loss, transfusion requirements, and percentage of transfused patients per treatment group were significantly smaller in the aprotinin group than in the placebo group (1935 +/- 873 vs 2809 +/- 973 mL per patient [P = 0.007]; 42 vs 95 packed RBCs per group [P = 0.001]; 40% vs 81% per group [P = 0.02]). Hematological assessments showed an identically significant (a) intraoperative increase in both thrombin-antithrombin III complexes (TAT) and in activated factor XII (XIIa) and (b) decrease in activated factor VII (VIIa), indicating a similar significant effect on coagulation in patients of both groups (P = 0.9 for intergroup comparisons of postoperative VIIa, XIIa, and TAT). Intraoperative activation of fibrinolysis was significantly less pronounced in the aprotinin group than in the placebo group (P < 0.0001 for intergroup comparison of postoperative D-dimer levels). No adverse drug effects (circulatory disturbances, deep venous thrombosis, alteration of serum creatinine) were detected. Although administered intraoperatively, aprotinin treatment dramatically reduced intraoperative and 24-h postoperative blood loss and autologous transfusion requirements but did not change homologous transfusion in posterior lumbar spine fusion. IMPLICATIONS: In our study, aprotinin therapy significantly decreased autologous, but not homologous, transfusion requirements in posterior lumbar spine fusion.
MB. It is strange that only autologous transfusion was reduced. I would have thought the best wine would be used first.

ARTICLE TITLE : Aortic and radial pulse contour: different effects of nitroglycerin and prostacyclin.
ARTICLE SOURCE: Anesth Analg (United States), Sep 1999, 89(3) p566-72
AUTHOR(S): Soderstrom S; Sellgren J; Ponten J
AUTHOR'S ADDRESS: Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Goteborg, Sweden.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
. IMPLICATIONS: We studied ascending aortic and radial pulse contours in patients scheduled for coronary artery surgery. The radial pulse wave can be used for interpretation of central hemodynamic changes during nitroglycerin-, but not prostacyclin-, induced hypotension.
MB. Arterial traces are rarely optimally shaped as we don't make sure there are no small bubbles etc.

ARTICLE TITLE : Adverse cardiac outcomes after noncardiac surgery in patients with prior percutaneous transluminal coronary angioplasty.
ARTICLE SOURCE: Anesth Analg (United States), Sep 1999, 89(3) p553-60
AUTHOR(S): Posner KL; Van Norman GA; Chan V
AUTHOR'S ADDRESS: Department of Anesthesiology, University of Washington, Seattle 98195-6540, USA. posner@u.washington.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
Present findings do not lend support to a role for prophylactic percutaneous transluminal coronary angioplasty (PTCA to improve noncardiac surgery outcomes. This investigation did not control for coronary artery disease (CAD severity, medical management, or comorbidities. Study of these factors is needed before the clinical implications of PTCA for noncardiac surgical risk can be completely assessed. IMPLICATIONS: Hospital records showed patients with prior percutaneous transluminal coronary angioplasty were twice as likely as healthy patients to have an adverse cardiac outcome after noncardiac surgery, although their risk was reduced by half compared with patients with untreated coronary artery disease. Further study of the role of percutaneous transluminal coronary angioplasty in modulating noncardiac surgery risk is needed.

ARTICLE TITLE : Cardiac output is a determinant of the initial concentrations of propofol after short-infusion administration [see comments]
COMMENTS: Comment in: Anesth Analg 1999 Sep; 89(3):541-4
ARTICLE SOURCE: Anesth Analg (United States), Sep 1999, 89(3) p545-52
AUTHOR(S): Upton RN; Ludbrook GL; Grant C; Martinez AM
AUTHOR'S ADDRESS: Department of Anaesthesia and Intensive Care, Royal Adelaide Hospital, University of Adelaide, Australia, SA rupton@health.adelaide.edu.au.
IMPLICATIONS: The initial arterial concentrations of propofol after IV administration were shown to be inversely related to cardiac output. This implies that cardiac output may be a determinant of the induction of anesthesia with propofol.
MB. I would have thought this was pretty obvious. If the cardiac output was already low it is not a surprise that IV induction agents can depress it further. It's classical.

ARTICLE TITLE : What determines anesthetic induction dose? It's the front-end kinetics, doctor! [editorial; comment]
COMMENTS: Comment on: Anesth Analg 1999 Sep; 89(3):545-52
ARTICLE SOURCE: Anesth Analg (United States), Sep 1999, 89(3) p541-4
AUTHOR(S): Krejcie TC; Avram MJ
AUTHOR'S ADDRESS: Department of Anesthesiology, Northwestern University Medical School, Chicago, Illinois, USA.
PUBLICATION TYPE: COMMENT; EDITORIAL; REVIEW (19 references); REVIEW, TUTORIAL

ARTICLE TITLE : Assessing the relative quality of anesthesiology and critical care medicine Internet mailing lists [see comments]
COMMENTS: Comment in: Anesth Analg 1999 Aug; 89(2):271-2
ARTICLE SOURCE: Anesth Analg (United States), Aug 1999, 89(2) p520-5
AUTHOR(S): Hernandez-Borges AA; Macias-Cervi P; Gaspar-Guardado MA; Torres-Alvadez de Arcaya ML; Ruiz-Rabaza A; Ormazabal-Ramos C
AUTHOR'S ADDRESS: Pediatric Intensive Care Unit, Hospital Universitario de Canarias, Tenerife, Spain. borges@redkbs.com.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: We studied the relative quality of a subset of anesthesiology and critical care medicine Internet mailing lists regarding the publishing capacity of their members to compare them with the major journals and conferences regarding these specialties. Using systematic searches on MEDLINE and according to the Science Citation Index 1995, we investigated the impact factor of mailing list subscribers, of the first authors of the selected articles, and of the first authors of published abstracts from conferences. We studied six mailing lists, seven journals, and four conferences. Journals and conferences showed a higher percentage of published authors and higher average impact factor among their first authors than the mailing lists did per subscriber. However, when only the subset of publishing authors from the three media was considered, no significant differences were found. We conclude that qualified authors may be found among the subscribers of Internet medical mailing lists on anesthesiology and critical care medicine. These professional discussion groups could complement peer-reviewed publications and conferences in professional information exchange and continuing medical education. Implications: Internet publishing is not governed by rules that assure certain basic quality standards. Methods for assessing these standards are needed. We compared discussion groups with medical journals and conferences on anesthesiology and critical care medicine by calculating the impact factor of their members and first authors, respectively. Our study shows that qualified authors may be found in all three media.
MB. I don't think gasnetters would care.

ARTICLE TITLE : How can we cope with the Internet? [editorial; comment]
COMMENTS: Comment on: Anesth Analg 1999 Aug; 89(2):520-5
ARTICLE SOURCE: Anesth Analg (United States), Aug 1999, 89(2) p271-2
AUTHOR(S): Tramer MR
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. They say that one should be cautious. That is a great help. It applies to all other sources of medical information except anatomy text-books.

ARTICLE TITLE : Influenza prevention and treatment: current practices and new horizons [editorial]
ARTICLE SOURCE: Ann Intern Med (United States), Oct 19 1999, 131(8) p621-4
AUTHOR(S): Belshe RB
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE : Learning medicine through the closet door.
ARTICLE SOURCE: Ann Intern Med (United States), Sep 21 1999, 131(6) p470-1
AUTHOR(S): Curtis JR
AUTHOR'S ADDRESS: Harborview Medical Center, Seattle, WA 98104, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
MB. About a closeted gay medical student in 1986 when he encountered a friend as a patient with AIDs fungal meningitis.

ARTICLE TITLE : Infection-control measures reduce transmission of vancomycin-resistant enterococci in an endemic setting.
ARTICLE SOURCE: Ann Intern Med (United States), Aug 17 1999, 131(4) p269-72
AUTHOR(S): Montecalvo MA; Jarvis WR; Uman J; Shay DK; Petrullo C; Rodney K; Gedris C; Horowitz HW; Wormser GP
AUTHOR'S ADDRESS: Division of Infectious Diseases, New York Medical College and Westchester Medical Center, Valhalla 10595, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Vancomycin-resistant enterococci (VRE) are nosocomial pathogens in many U. S. hospitals. OBJECTIVE: To determine whether enhanced infection-control strategies reduce transmission of VRE in an endemic setting. DESIGN: Prospective cohort study. SETTING: Adult oncology inpatient unit. PATIENTS: 259 patients evaluated during use of enhanced infection-control strategies and 184 patients evaluated during use of standard infection-control practices. INTERVENTIONS: Patient surveillance cultures were taken, patients were assigned to geographic cohorts, nurses were assigned to patient cohorts, gowns and gloves were worn on room entry, compliance with infection-control procedures was monitored, patients were educated about VRE transmission, patients taking antimicrobial agents were evaluated by an infectious disease specialist, and environmental surveillance was performed. MEASUREMENTS: VRE infection rates, VRE colonization rates, and changes in antimicrobial use. RESULTS: During use of enhanced infection-control strategies, incidence of VRE bloodstream infections decreased significantly (0.45 patients per 1000 patient-days compared with 2.1 patients per 1000 patient-days; relative rate ratio, 0.22 [95% CI, 0.05 to 0.92]; P = 0.04), as did VRE colonization (10.3 patients per 1000 patient-days compared with 20.7 patients per 1000 patient-days; relative rate ratio, 0.5 [CI, 0.33 to 0.75]; P < 0.001). Use of all antimicrobial agents except clindamycin and amikacin was significantly reduced. CONCLUSION: Enhanced infection-control strategies reduced VRE transmission in an oncology unit in which VRE were endemic.

ARTICLE TITLE : Brief encounters: speaking with patients.
ARTICLE SOURCE: Ann Intern Med (United States), Aug 3 1999, 131(3) p231-4
AUTHOR(S): Balint JA
AUTHOR'S ADDRESS: Center For Medical Ethics, Education and Research, Albany Medical Center, NY 12208, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE : Rapacuronium (Org 9487): do we have a replacement for succinylcholine? [editorial; comment]
COMMENTS: Comment on: Br J Anaesth 1999 Apr; 82(4):537-41
ARTICLE SOURCE: Br J Anaesth (England), Apr 1999, 82(4) p489-92
AUTHOR(S): Goulden MR; Hunter JM
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. The answer is NO.

ARTICLE TITLE : Patients' vs nurses' assessments of postoperative pain and anxiety during patient- or nurse-controlled analgesia.
ARTICLE SOURCE: Br J Anaesth (England), Mar 1999, 82(3) p374-8
AUTHOR(S): Rundshagen I; Schnabel K; Standl T; Schulte am Esch J
AUTHOR'S ADDRESS: Department of Anaesthesiology, University Hospital Eppendorf, Hamburg, Germany.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We have compared patients' and nurses' assessments of postoperative pain and anxiety after different analgesic treatments. Sixty orthopaedic patients were allocated randomly to receive i.v. piritramide (either nurse-controlled or patient-controlled) or subarachnoid bupivacaine (nurse-controlled or patient-controlled). Patients and nurses assessed pain and anxiety using a visual analogue scale (VAS; 1-100 mm). Pain and anxiety ratings of patients and nurses were significantly correlated (Spearman's r > or = 0.69; P < 0.001). In general, patients' pain scores were higher than nurses' scores (patients' median VAS = 34 (range 1-76) mm; nurses VAS 21 (1-59) mm) and for all groups except the patient-controlled subarachnoid bupivacaine group, where they were significantly higher (P < 0.01). Discrepancy in pain estimates between patients and nurses increased with the level of pain. The relationship between patients' and nurses' anxiety scores was less clearly defined and did not depend on the level of anxiety.
MB. There is no definition of anxiety---just what the word means. They even have an analogue scale for it. L

ARTICLE TITLE : Cardiac surgery in the elderly [comment]
COMMENTS: Comment on: Heart 1999 Aug; 82(2):134-7; Comment on: Heart 1999 Aug; 82(2):138-42; Comment on: Heart 1999 Aug; 82(2):143-8
ARTICLE SOURCE: Heart (England), Aug 1999, 82(2) p119-20
AUTHOR(S): Harris J
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE

ARTICLE TITLE : Carotid baroreflex function during prolonged exercise.
ARTICLE SOURCE: J Appl Physiol (United States), Jul 1999, 87(1) p339-47
AUTHOR(S): Norton KH; Gallagher KM; Smith SA; Querry RG; Welch-O'Connor RM; Raven PB
AUTHOR'S ADDRESS: Department of Integrative Physiology and Cardiovascular Research Institute, University of North Texas Health Science Center, Fort Worth, Texas 76107-2609, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: The present investigation was designed to uncouple the hemodynamic physiological effects of thermoregulation from the effects of a progressively increasing central command activation during prolonged exercise. Subjects performed two 1-h bouts of leg cycling exercise with 1) no intervention and 2) continuous infusion of a dextran solution to maintain central venous pressure constant at the 10-min pressure. Volume infusion resulted in a significant reduction in the decrement in mean arterial pressure seen in the control exercise bout (6.7 +/- 1.8 vs. 11.6+/- 1.3 mmHg, respectively). However, indexes of central command such as heart rate and ratings of perceived exertion rose to a similar extent during both exercise conditions. In addition, the carotid-cardiac baroreflex stimulus-response relationship, as measured by using the neck pressure-neck suction technique, was reset from rest to 10 min of exercise and was further reset from 10 to 50 min of exercise in both exercise conditions, with the operating point being shifted toward the reflex threshold. We conclude that the progressive resetting of the carotid baroreflex and the shift of the reflex operating point render the carotid-cardiac reflex ineffectual in counteracting the continued decrement in mean arterial pressure that occurs during the prolonged exercise.
MB. Is that why they sometimes die?

ARTICLE TITLE : Sodium-free fluid ingestion decreases plasma sodium during exercise in the heat.
ARTICLE SOURCE: J Appl Physiol (United States), Jun 1999, 86(6) p1847-51
AUTHOR(S): Vrijens DM; Rehrer NJ
AUTHOR'S ADDRESS: School of Physical Education, Otago University, Dunedin, New Zealand.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
The results show that decreased plasma sodium concentration can result from replacement of sweat losses with plain water, when sweat losses are large, and can precipitate the development of hyponatremia, particularly in individuals who have a decreased urine production during exercise. Exercise performance is also reduced with a decrease in plasma sodium concentration. We, therefore, recommend consumption of a sodium-containing beverage to compensate for large sweat losses incurred during exercise.
MB. I have known that since I was a student. The common fluid touted to be used during pathological exercise dose not contain much sodium. (Gatorasde has Na18 mmol /litre & K 3mmol/litre. Sweet has Na about 70mmol/litre.)Why is it thought to be all right? During sweat soaked dance parties many carry the fashionable bottles of water ie with no sodium. L

ARTICLE TITLE : The unintended consequences of measuring quality on the quality of medical care.
ARTICLE SOURCE: N Engl J Med (United States), Oct 7 1999, 341(15) p1147-50
AUTHOR(S): Casalino LP
AUTHOR'S ADDRESS: Stanford Coastside Medical Clinic, Half Moon Bay, CA 94019, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE : The prevention of obesity [editorial; comment]
COMMENTS: Comment on: N Engl J Med 1999 Oct 7; 341(15):1097-105
ARTICLE SOURCE: N Engl J Med (United States), Oct 7 1999, 341(15) p1140-1
AUTHOR(S): Williamson DF
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE : Managed care and medical education.
ARTICLE SOURCE: N Engl J Med (United States), Sep 30 1999, 341(14) p1092-6
AUTHOR(S): Kuttner R
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE : Apnea and periodic breathing during sleep [editorial; comment]
COMMENTS: Comment on: N Engl J Med 1999 Sep 23; 341(13):949-54
ARTICLE SOURCE: N Engl J Med (United States), Sep 23 1999, 341(13) p985-7
AUTHOR(S): Cherniack NS
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE : The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators [see comments]
COMMENTS: Comment in: N Engl J Med 1999 Sep 2; 341(10):753-5
ARTICLE SOURCE: N Engl J Med (United States), Sep 2 1999, 341(10) p709-17
AUTHOR(S): Pitt B; Zannad F; Remme WJ; Cody R; Castaigne A; Perez A; Palensky J; Wittes J
AUTHOR'S ADDRESS: Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: Blockade of aldosterone receptors by spironolactone, in addition to standard therapy, substantially reduces the risk of both morbidity and death among patients with severe heart failure.

ARTICLE TITLE : How to resolve an ethical dilemma concerning randomized clinical trials.
ARTICLE SOURCE: N Engl J Med (United States), Aug 26 1999, 341(9) p691-3
AUTHOR(S): Marquis D
AUTHOR'S ADDRESS: University of Kansas, Lawrence 66045, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE : Early revascularization in cardiogenic shock--a positive view of a negative trial [editorial; comment]
COMMENTS: Comment on: N Engl J Med 1999 Aug 26; 341(9):625-34
ARTICLE SOURCE: N Engl J Med (United States), Aug 26 1999, 341(9) p687-8
AUTHOR(S): Ryan TJ
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE : Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock [see comments]
COMMENTS: Comment in: N Engl J Med 1999 Aug 26; 341(9):687-8
ARTICLE SOURCE: N Engl J Med (United States), Aug 26 1999, 341(9) p625-34
AUTHOR(S): Hochman JS; Sleeper LA; Webb JG; Sanborn TA; White HD; Talley JD; Buller CE; Jacobs AK; Slater JN; Col J; McKinlay SM; Le Jemtel TH
AUTHOR'S ADDRESS: St. Luke's-Roosevelt Hospital Center and Columbia University, New York, NY 10025, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: In patients with cardiogenic shock, emergency revascularization did not significantly reduce overall mortality at 30 days. However, after six months there was a significant survival benefit. Early revascularization should be strongly considered for patients with acute myocardial infarction complicated by cardiogenic shock.

ARTICLE TITLE : Disseminated intravascular coagulation.
ARTICLE SOURCE: N Engl J Med (United States), Aug 19 1999, 341(8) p586-92
AUTHOR(S): Levi M; Ten Cate H
AUTHOR'S ADDRESS: Department of Vascular Medicine and Internal Medicine, Academic Medical Center, University of Amsterdam, The Netherlands. m.m.levi@amc.uva.nl.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (52 references); REVIEW, TUTORIAL
MB. I assume that this is as good as it gets in DIC literature. DIC is a common invoked surgical/anaesthetic diagnosis in bleeding situations. There is little of use that I could find in this review. I have always been suspicious of DIC. The review confirms my doubts. In surgical situations almost always uncontrolable haemorrhage is a surgical excuse. In massive trauma usually inappropriate IV fluids are given after arrival in hospital. Of course little should be given before that.

ARTICLE TITLE : Hormones and hemodynamics in heart failure.
ARTICLE SOURCE: N Engl J Med (United States), Aug 19 1999, 341(8) p577-85
AUTHOR(S): Schrier RW; Abraham WT
AUTHOR'S ADDRESS: Department of Medicine, University of Colorado School of Medicine, Denver 80262, USA. robertschrier@uchsc.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (60 references); REVIEW, TUTORIAL
MB. I thought that this review article would solve my dilemma of wondering why the CV system appear to improve when the compensation mechanisms it puts in place to help it cope with muscle inadequacy are counteracted. I can cope with diuretics because the extra fluid required to keep the myocardium stretched so that it will contract more vigorously involves extra water retention. The extra weight puts an extra physical load on the CV system. I suppose extra exercise should work if you don't die while doing it. Some do of course.
Beta blockers and ACE inhibitors are my big problem. It used to be thought that at least the beta blockers could be bad in cardiac failure. I have never been able to get my mind around the angiotsin system for it looks to be compensatory but blocking it is good. They are supposed to be mainly vasodilatory but that is obviously wrong. The review failed to help me. There is a vague remake about the mounting evidence that ---the ACE inhibitors benefit in CCF due to actions on myocardium in addition to decreases in after load ie blood pressure. (Paraphrase of a long sentence pp580-1). There is only one reference (1992) to indicate the mountain (of evidence). (My ACE inhibitor dose has been doubled. I don't know if I/my heart am/is better yet. I felt all right already on the lower dose. My blood pressure has not changed. ?????)
I was talking about this to a bright resident while I was having coffee after finishing reading this review. He thought that we must have the wrong model of cardiac failure. It seems to be getting worse with the mounting need for ad hoc hypotheses to accommodate empirical evidence, which does fit the model. This is the classical of a failing model. Unfortunately we don't have purely theoretical physiologists (like physicist). Maybe I am one.
Don't waste your time reading the review. It is full of however, may, suggests, unfortunately, on the other hand, has been implicated etc etc. These are fairly good signs that the whole thing is gobbledegook.

ARTICLE TITLE : Intravenous albumin for spontaneous bacterial there peritonitis in patients with cirrhosis [editorial; comment]
COMMENTS: Comment on: N Engl J Med 1999 Aug 5; 341(6):403-9
ARTICLE SOURCE: N Engl J Med (United States), Aug 5 1999, 341(6) p443-4
AUTHOR(S): Bass NM
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE : Clinical problem-solving. A little math helps the medicine go down.
ARTICLE SOURCE: N Engl J Med (United States), Aug 5 1999, 341(6) p435-9
AUTHOR(S): Kopelman RI; Wong JB; Pauker SG
AUTHOR'S ADDRESS: Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE : Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis [see comments]
COMMENTS: Comment in: N Engl J Med 1999 Aug 5; 341(6):443-4
ARTICLE SOURCE: N Engl J Med (United States), Aug 5 1999, 341(6) p403-9
AUTHOR(S): Sort P; Navasa M; Arroyo V; Aldeguer X; Planas R; Ruiz-del-Arbol L; Castells L; Vargas V; Soriano G; Guevara M; Gines P; Rodes J
AUTHOR'S ADDRESS: Liver Unit, Institut de Malalties Digestives, Hospital Clinic, Barcelona, Catalunya, Spain.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: In patients with cirrhosis and spontaneous bacterial peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone.
MB. This is common in patients waiting for liver transplants.

ARTICLE TITLE : Palliation of pain in chronic pancreatitis. Use of neural blocks and neurotomy.
ARTICLE SOURCE: Surg Clin North Am (United States), Aug 1999, 79(4) p873-93
AUTHOR(S): Wong GY; Sakorafas GH; Tsiotos GG; Sarr MG
AUTHOR'S ADDRESS: Department of Anesthesiology, Mayo Clinic and Foundation, Rochester, Minnesota, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (71 references); REVIEW, TUTORIAL
ABSTRACT: Effective management of the pain of chronic pancreatitis may require a multidisciplinary approach involving gastroenterologists, anesthesiologists, psychologists or counselors for chemical addiction (alcohol, narcotics), and surgeons. Viable approaches use pharmacologic analgesics with selected psychotropic medications, celiac plexus blocks, and possibly thoracoscopic splanchnic nerve transections. If these management techniques that preserve pancreatic parenchyma and function, fail, resective surgical therapy may be indicated. For most of these patients, all attempts at nonresective therapy should be exhausted before operative intervention.

ARTICLE TITLE : Palliation of pain in chronic pancreatitis. Use of enzymes.
ARTICLE SOURCE: Surg Clin North Am (United States), Aug 1999, 79(4) p861-72, xi
AUTHOR(S): Mossner J
AUTHOR'S ADDRESS: Department of Internal Medicine, University of Leipzig, Germany.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (64 references); REVIEW, TUTORIAL
ABSTRACT: According to the concept of negative feedback regulation of pancreatic enzyme secretion by proteases, treatment with pancreatic extracts has been proposed to lower pain in chronic pancreatitis by decreasing pancreatic duct pressure. <snip> . In a meta-analysis, which included the author's study, six randomized, double-blind, placebo-controlled studies were evaluated. Statistical analysis demonstrated no benefit of the application of porcine pancreatic extracts to relieve pain in chronic pancreatitis. The author concluded that pancreatic extracts neither inhibit pancreatic enzyme secretion nor are they efficient in lowering pain in chronic pancreatitis.

ARTICLE TITLE : Medical students' knowledge of smoking [letter]
ARTICLE SOURCE: Thorax (England), Jul 1999, 54(7) p657-8
AUTHOR(S): Bowen EF; Rayner CF
PUBLICATION TYPE: LETTER
MEDLINE INDEXING DATE: 199910

ARTICLE TITLE : Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease.
ARTICLE SOURCE: Thorax (England), Jul 1999, 54(7) p581-6
AUTHOR(S): Bestall JC; Paul EA; Garrod R; Garnham R; Jones PW; Wedzicha JA
AUTHOR'S ADDRESS: Division of Physiological Medicine, St George's Hospital Medical School, London SW17 0RE, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Methods of classifying chronic obstructive pulmonary disease (COPD) depend largely upon spirometric measurements but disability is only weakly related to measurements of lung function. With the increased use of pulmonary rehabilitation, a need has been identified for a simple and standardised method of categorising disability in COPD. This study examined the validity of the Medical Research Council (MRC) dyspnoea scale for this purpose. METHODS: One hundred patients with COPD were recruited from an outpatient pulmonary rehabilitation programme. Assessments included the MRC dyspnoea scale, spirometric tests, blood gas tensions, a shuttle walking test, and Borg scores for perceived breathlessness before and after exercise. Health status was assessed using the St George's Respiratory Questionnaire (SGRQ) and Chronic Respiratory Questionnaire (CRQ). The Nottingham Extended Activities of Daily Living (EADL) score and Hospital Anxiety and Depression (HAD) score were also measured. RESULTS: Of the patients studied, 32 were classified as having MRC grade 3 dyspnoea, 34 MRC grade 4 dyspnoea, and 34 MRC grade 5 dyspnoea. Patients with MRC grades 1 and 2 dyspnoea were not included in the study. There was a significant association between MRC grade and shuttle distance, SGRQ and CRQ scores, mood state and EADL. Forced expiratory volume in one second (FEV1) was not associated with MRC grade. Multiple logistic regression showed that the determinants of disability appeared to vary with the level of disability. Between MRC grades 3 and 4 the significant covariates were exercise performance, SGRQ and depression score, whilst between grades 4 and 5 exercise performance and age were the major determinants. CONCLUSIONS: The MRC dyspnoea scale is a simple and valid method of categorising patients with COPD in terms of their disability that could be used to complement FEV1 in the classification of COPD severity.
MB. The abstract does not tell us what the scale is.

ARTICLE TITLE : Selling bits and pieces of humans to make babies: The gift of the magi revisited.
ARTICLE SOURCE: J Med Philos (Netherlands), Jun 1999, 24(3) p288-306
AUTHOR(S): Cohen CB
AUTHOR'S ADDRESS: The Kennedy Institute of Ethics, Georgetown University, Washington, DC 20007, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Reproductive medicine, a sector of a health care system increasingly captured by the demands of the marketplace, is enmeshed in a drive to sell certain human bits and pieces, such as gametes, cells, fetal eggs, and fetal ovaries, for reproductive purposes. The ethical objection raised by Kant and Radin to the sale of human organs - that this is incompatible with human dignity and worth - also applies to these sales. Moreover, such sales nullify the reproductive paradigm, irretrievably replacing it with a manufacturing paradigm. This represents a change in kind, not just of degree, in the way that we view our capacity to generate children and destroys our concept of reproduction as an essentially human activity. In the face of a struggle to retain those common ethical values at the foundation of reproductive medicine, this form of commodification of the human body should be viewed as ethically unacceptable.

ARTICLE TITLE : A basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients.
ARTICLE SOURCE: J Med Philos (Netherlands), Feb 1999, 24(1) p77-97
AUTHOR(S): McCullough LB
AUTHOR'S ADDRESS: Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA. mccullou@bcm.tmc.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Managed care employs two business tools of managed practice that raise important ethical issues: paying physicians in ways that impose conflicts of interest on them; and regulating physicians' clinical judgment, decision making, and behavior. The literature on the clinical ethics of managed care has begun to develop rapidly in the past several years. Professional organizations of physicians have made important contributions to this literature. The statements on ethical issues in managed care of four such organizations are considered here, the American Medical Association, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. Three themes common to these statements are identified and critically assessed: the primacy of meeting the medical needs of each individual patient; disclosure of conflicts of interest in how physicians are paid; and opposition to gag orders. The paper concludes with an argument for a basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients.

ARTICLE TITLE : Informed consent to septoplasty: an anecdote from the field.
ARTICLE SOURCE: J Med Philos (Netherlands), Feb 1999, 24(1) p11-7
AUTHOR(S): Erde EL
AUTHOR'S ADDRESS: Department of Family Medicine, University of Medicine and Dentistry of New Jersey, Stratford 08004-1350, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: This paper tells the story of events that led up to a septoplasty and the consequences that followed it. The patient is a medical ethicist. After scratching the inside of a nostril in 1976, he suffered with occasional bleeding and irritation for almost two decades. He tried topical treatment. As this failed, he sought help from an ENT specialist. The paper relates the conduct of the patient and others (friends in the medical field, the patient's spouse, nurses and anesthesiologists) vis-a-vis informed consent.

ARTICLE TITLE : A transcultural, preventive ethics approach to critical-care medicine: restoring the critical care physician's power and authority [comment]
COMMENTS: Comment on: J Med Philos 1998 Dec; 23(6):563-80; Comment on: J Med Philos 1998 Dec; 23(6):581-600; Comment on: J Med Philos 1998 Dec; 23(6):601-15; Comment on: J Med Philos 1998 Dec; 23(6):616-27
ARTICLE SOURCE: J Med Philos (Netherlands), Dec 1998, 23(6) p628-42
AUTHOR(S): McCullough LB
AUTHOR'S ADDRESS: Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA.
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE
ABSTRACT: This article comments on the treatment of critical-care ethics in four preceding articles about critical-care medicine and its ethical challenges in mainland China, Hong Kong, Japan, and the Philippines. These articles show how cultural values can be in both synchrony and conflict in generating these ethical challenges and in the constraints that they place on the response of critical-care ethics to them. To prevent ethical conflict in critical care the author proposes a two-step approach to the ethical justification of critical-care management: (1) the decision to resuscitate and initiate critical-care management, which is based on the obligation to prevent imminent mortality without permanent loss of consciousness; and (2) the decision to continue critical-care management, which is based on the obligation both to prevent imminent death without permanent loss of consciousness and to avoid unnecessary, significant iatrogenic costs to the patient and psychosocial costs to the family when the reduction of mortality risk is marginal. Physicians and hospitals should restore the critical-care physician's authority and power -- against prevailing cultural values, if necessary -- to control when critical-care intervention is offered, when it is recommended to continue, and when it is recommended to be discontinued and the patient allowed to die.
MB. I think that they have that authority.

ARTICLE TITLE : Abandoning informed consent: an idea whose time has not yet come.
ARTICLE SOURCE: J Med Philos (Netherlands), Aug 1998, 23(5) p477-99
AUTHOR(S): White BC; Zimbelman J
AUTHOR'S ADDRESS: Department of Philosophy, California State University at Chico, 95929-0730, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: In a recent critique of informed consent, Robert Veatch argues that the practice is in principle unable to attain the goals for which it was developed. We argue that Veatch's focus on the theoretical impossibility of determining patients' best interests is misapplied to the practical discipline of medicine, and that he wrongly assumes that the patient-physician communication fails to provide the knowledge needed to insure the patient's best interests. We further argue that Veatch's suggested alternative, value-based patient-professional pairing, is, on his own terms, impossible to implement. Finally, we reexamine the philosophical and practical justifications for informed consent and conclude that the practice should be retained.