MB's Articles of Interest - October 2000

ARTICLE TITLE: Effect of intra-aortic magnesium on renal function during and after abdominal aortic surgery: a pilot study.
ARTICLE SOURCE: Acta Anaesthesiol Scand (Denmark), May 2000, 44(5) p605-11
AUTHOR(S): Backlund M; Pere P; Lepantalo M; Lehtola A; Lindgren L
AUTHOR'S ADDRESS: Department of Anaesthesia, Helsinki University Central Hospital, Finland.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: These data indicate that intra-aortic magnesium had no effect on renal function during or after aortic cross-clamping.
MB: What a relief!. I was worried they may have got a positive result. L

ARTICLE TITLE: The place of THAM in the management of acidemia in clinical practice.
ARTICLE SOURCE: Acta Anaesthesiol Scand (Denmark), May 2000, 44(5) p524-7
AUTHOR(S): Holmdahl MH; Wiklund L; Wetterberg T; Streat S; Wahlander S; Sutin K; Nahas G
AUTHOR'S ADDRESS: Department of Anesthesiology, Uppsala University, Sweden. Martin.Holmdahl@anestisi.uu.se.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (13 references); REVIEW, TUTORIAL
MB: There are almost no indications for bicarbonate. I can't imagine that they could think there is much use for THAM any more.
The full text hardly establishes anything. Martin Holmdale was in this field before I came along. I have since come to the conclusion that direct treatment of pH changes is almost never indicated.

ARTICLE TITLE: Local anaesthesia for awake fibreoptic nasotracheal intubation.
ARTICLE SOURCE: Acta Anaesthesiol Scand (Denmark), May 2000, 44(5) p511-6
AUTHOR(S): Kundra P; Kutralam S; Ravishankar M
AUTHOR'S ADDRESS: Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: Both nebulization and combined regional block (CRB) produced satisfactory anaesthesia of the upper airway, but CRB provided better patient comfort and haemodynamic stability.

ARTICLE TITLE: Peroperative cardiovascular stability during brainstem surgery. The use of high-dose methylprednisolone compared to dexamethasone. A retrospective analysis.
ARTICLE SOURCE: Acta Anaesthesiol Scand (Denmark), Apr 2000, 44(4) p378-82
AUTHOR(S): Mursch K; Buhre W; Behnke-Mursch J; Markakis E
AUTHOR'S ADDRESS: Klinik und Poliklinik fur Neurochirurgie, Georg-August-University, Gottingen, Germany. juliaetkay@aol.com.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: The retrospective analysis of the clinical data showed that the routine use of high-dose methylprednisolone was associated with a decreased incidence of haemodynamic instability in a selected group of patients undergoing brainstem surgery. This finding has to be proven in prospective double-blind controlled studies.

ARTICLE TITLE: New recommendations for uniform reporting of data following major trauma: "the Utstein style" [editorial]
ARTICLE SOURCE: Acta Anaesthesiol Scand (Denmark), Apr 2000, 44(4) p359-60
AUTHOR(S): Soreide E; Steen PA
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Management of atrial fibrillation: therapeutic options and clinical decisions.
ARTICLE SOURCE: Am J Cardiol (United States), May 25 2000, 85(10A) p3D-11D
AUTHOR(S): Prystowsky EN
AUTHOR'S ADDRESS: Clinical Electrophysiology Laboratory, St. Vincent Hospital, Indianapolis, Indiana, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (51 references); REVIEW, TUTORIAL
This article explores practical approaches to several management issues and scenarios for which there are limited relevant clinical data. These include: (1) patient selection for ventricular rate control and assessment of treatment, (2) choice of antiarrhythmic drug for maintenance of sinus rhythm, (3) inpatient versus outpatient initiation of therapy, (4) definition of antiarrhythmic drug success, (5) methods of transthoracic direct cardioversion, and (6) prediction and prevention of AF after cardiac surgery.

ARTICLE TITLE: Drug choices in the treatment of atrial fibrillation.
ARTICLE SOURCE: Am J Cardiol (United States), May 25 2000, 85(10A) p12D-19D
AUTHOR(S): Reiffel JA
AUTHOR'S ADDRESS: Electrophysiology Service, Cardiology Division, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (62 references); REVIEW, TUTORIAL
ABSTRACT: When considering therapy for atrial fibrillation (AF), the dominant issues are rate control, anticoagulation, rhythm control, and treatment of any underlying disorder. Drug choices for rate control include beta-blockers, verapamil and diltiazem, and digitalis as first-line agents, with consideration of other sympatholytics, amiodarone, or nonpharmacologic approaches in resistant cases. Anticoagulation may be accomplished with aspirin or warfarin, with the latter preferred in all older or high-risk patients. Antiarrhythmic drug therapy may be used (1) to produce cardioversion (most effective with ibutilide or class IC agents in recent onset AF); (2) to facilitate electrical conversion (class III agents); (3) to prevent early reversion after cardioversion; (4) to maintain sinus rhythm during chronic therapy; and/or (5) to facilitate conversion of fibrillation to flutter, which may then be amenable to termination or prevention with antitachypacing or ablative techniques. Antiarrhythmic drug selection for AF is guided by efficacy considerations (most drugs are similar), by convenience, cost, and discontinuation considerations; and, most importantly, by safety considerations. When possible, agents with serious organ toxicity potential and proarrhythmic risk should be avoided as first-line choices. In structurally normal hearts, class IC antiarrhythmic drugs are least proarrhythmic and least organ toxic (when considered together). In normal hearts, sotalol, dofetilide, and potentially azimilide also appear to have attractive profiles. Amiodarone has low proarrhythmic risk but can produce bradyarrhythmias and toxicity. In hypertrophied hearts, the risk of torsade de pointes with class III/IA agents is enhanced, whereas in ischemia or conditions with impaired cell contact, whether functionally (as by ischemia) or anatomically (as by fibrosis, infiltration, etc), proarrhythmic risk with class I antiarrhythmic drugs (sustained ventricular fibrillation/flutter) is greatly increased. The class I drugs should be avoided in these circumstances. Additional issues to consider are where to initiate therapy (in- or outpatient), what follow-up protocols to use, and whether to limit therapy to proprietary drugs or to allow generic formulation substitution. Each of these considerations is detailed in this article.

ARTICLE TITLE: Effect of early revascularization on mortality from cardiogenic shock complicating acute myocardial infarction in California.
ARTICLE SOURCE: Am J Cardiol (United States), May 15 2000, 85(10) p1185-8
AUTHOR(S): Edep ME; Brown DL
AUTHOR'S ADDRESS: Department of Medicine (Cardiovascular Medicine), Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
Patients referred for early revascularization had more favorable risk profiles, but after multivariate analysis early revascularization remained a powerful, independent predictor of improved survival, reducing the odds of death by 80%. This population-based study suggests that early revascularization may improve in-hospital survival of patients with cardiogenic shock complicating acute myocardial infarction (AMI), even after adjustment for baseline differences between patients who underwent early revascularization and those who did not.
MB: There is only a suggestion that it might be a good thing.

ARTICLE TITLE: Decline in the number of low-volume hospitals performing coronary angioplasty in California, 1989 to 1996.
ARTICLE SOURCE: Am J Cardiol (United States), Apr 15 2000, 85(8) p1026-7
AUTHOR(S): Maynard C; Every NR; Chapko MK; Ritchie JL
AUTHOR'S ADDRESS: Health Services Research and Development, Department of Veterans Affairs, Seattle, Washington, USA. cmaynard@u.washington.edu.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Hypothermia-induced coagulopathy during hemorrhagic shock.
ARTICLE SOURCE: Am Surg (United States), Apr 2000, 66(4) p348-54
AUTHOR(S): Krause KR; Howells GA; Buhs CL; Hernandez DA; Bair H; Schuster M; Bendick PJ
AUTHOR'S ADDRESS: Division of Trauma Surgery, William Beaumont Hospital, Royal Oak, Michigan 48073, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: A porcine model of hemorrhagic shock was used to study the effect of hypothermia on hemodynamic, metabolic, and coagulation parameters. <snip> We conclude that when shock and hypothermia occur together, their deleterious effect on hemodynamic and coagulation parameters are additive. The effects of hypothermia persist despite the arrest of hemorrhage and volume replacement. Thus, it is necessary to aggressively address both shock and hypothermia when they occur simultaneously.

ARTICLE TITLE: Laparoscopic colon resections: a five-year retrospective review.
ARTICLE SOURCE: Am Surg (United States), Mar 2000, 66(3) p245-8; discussion 248-9
AUTHOR(S): Gibson M; Byrd C; Pierce C; Wright F; Norwood W; Gibson T; Zibari GB
AUTHOR'S ADDRESS: Department of Surgery, Willis Knighton Hospital and Louisiana State University Medical Center, Shreveport 71130, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
We conclude that laparoscopic colectomy does show an improvement in return of bowel function, hospital cost, and shorter hospital stay. Long-term follow-up will be necessary to determine the effectiveness of laparoscopic colon resection for colorectal cancer.

ARTICLE TITLE: Severe cardiovascular depression with remifentanil.
ARTICLE SOURCE: Anesth Analg (United States), Jul 2000, 91(1) p58-61
AUTHOR(S): Elliott P; O'Hare R; Bill KM; Phillips AS; Gibson FM; Mirakhur RK
AUTHOR'S ADDRESS: Department of Clinical Anaesthesia, Royal Victoria Hospital. Belfast, United Kingdom. peter.elliott@royalhospitals.n-i.nhs.uk.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
IMPLICATIONS: This study investigates the effect on the heart and blood vessels of various rates of administration of boluses of a relatively new potent opiate, remifentanil, to patients with coronary artery disease. The results show that remifentanil should be given only by slow infusion to such patients.

ARTICLE TITLE: Tranexamic acid reduces red cell transfusion better than epsilon-aminocaproic acid or placebo in liver transplantation.
ARTICLE SOURCE: Anesth Analg (United States), Jul 2000, 91(1) p29-34
AUTHOR(S): Dalmau A; Sabate A; Acosta F; Garcia-Huete L; Koo M; Sansano T; Rafecas A; Figueras J; Jaurrieta E; Parrilla P
AUTHOR'S ADDRESS: Department of Anaesthesiology and Surgery, Princeps D'Espanya Hospital, Barcelona, Spain. antonia@servinter.com.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: We evaluated the efficacy of the prophylactic administration of epsilon-aminocaproic acid and tranexamic acid for reducing blood product requirements in orthotopic liver transplantation (OLT) in a prospective, double-blinded study performed in 132 consecutive patients. Patients were randomized to three groups and given one of three drugs prophylactically: tranexamic acid, 10 mg. kg(-1). h(-1); epsilon-aminocaproic acid, 16 mg. kg(-1). h(-1), and placebo (isotonic saline). Perioperative management was standardized. Coagulation tests, thromboelastogram, and blood requirements were recorded during OLT and in the first 24 h. There were no differences in diagnosis, Child score, or preoperative coagulation tests among groups. Administration of packed red blood cells was significantly reduced (P = 0.023) during OLT in the tranexamic acid group, but not in the epsilon-aminocaproic acid group. There were no differences in transfusion requirements after OLT. Thromboembolic events, reoperations, and mortality were similar in the three groups. Prophylactic administration of tranexamic acid, but not epsilon-aminocaproic acid, significantly reduces total packed red blood cell usage during OLT. IMPLICATIONS: In a randomized study of 132 consecutive patients undergoing liver transplantation, we found that tranexamic acid, but not epsilon-aminocaproic acid, reduced intraoperative total packed red blood cell transfusion.
MB: The difference was a mean of 4+ units of cells compared to 6+ units.

ARTICLE TITLE: Succinylcholine-induced hyperkalemia in patients with renal failure: an old question revisited.
ARTICLE SOURCE: Anesth Analg (United States), Jul 2000, 91(1) p237-41
AUTHOR(S): Thapa S; Brull SJ
AUTHOR'S ADDRESS: Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock 72205, USA. thapasushma@exchange.uams.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (43 references); REVIEW, ACADEMIC
MB: They concluded that there is little reason for thinking that sux is particularly bad in renal failure.

ARTICLE TITLE: Adsorption of lidocaine into a plastic infusion balloon.
ARTICLE SOURCE: Anesth Analg (United States), Jul 2000, 91(1) p192-4
AUTHOR(S): Takakura K; Muramatsu I; Miyamoto E; Fukuda S
AUTHOR'S ADDRESS: Departments of Anesthesiology and Reanimatology, Fukui Medical University, Matsuoka, Fukui, Japan. takakura@fmsrsa.fukui-med.ac.jp.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: An infusion balloon is a well established device used to continuously supply drugs for pain management. In this study, we determined the concentration of lidocaine that flowed out of a balloon because the balloon is made from plastics that adsorb local anesthetics.

ARTICLE TITLE: Nitrous oxide prevents movement during orotracheal intubation without affecting BIS value.
ARTICLE SOURCE: Anesth Analg (United States), Jul 2000, 91(1) p130-5
AUTHOR(S): Coste C; Guignard B; Menigaux C; Chauvin M
AUTHOR'S ADDRESS: Department of Anesthesiology, Hopital Ambroise Pare, Boulogne-Billancourt, France.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
IMPLICATIONS: We demonstrated that 0.6 minimal alveolar concentration of nitrous oxide combined with a potent anesthetic and an opioid prevents movement after orotracheal intubation without affecting the bispectral index. This demonstrates that the bispectral index is not a useful neurophysiologic variable to monitor the level of anesthesia when nitrous oxide is added to a general anesthetic regimen using propofol and remifentanil.

ARTICLE TITLE: The effects of plasma fentanyl concentrations on propofol requirement, emergence from anesthesia, and postoperative analgesia in propofol-nitrous oxide anesthesia.
ARTICLE SOURCE: Anesth Analg (United States), Jun 2000, 90(6) p1365-71
AUTHOR(S): Han T; Kim D; Kil H; Inagaki Y
AUTHOR'S ADDRESS: Department of Anesthesiology, Samsung Medical Center, SungKyunKwon University School of Medicine, Seoul, Korea. athan@samsung.co.kr.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: To determine the effects of plasma fentanyl concentrations on intraoperative propofol requirements, emergence from anesthesia, and relief of postoperative pain, we studied 60 ASA physical status I and II patients undergoing spine fusion. The patients were randomly assigned to four study groups according to the expected intraoperative plasma fentanyl concentrations. Group I received an infusion of saline, and Groups II, III, and IV received fentanyl infusions to maintain the blood levels at 1.5, 3.0, and 4.5 ng/mL, respectively. An infusion rate of propofol was adjusted to keep the mean arterial pressure within 15% of the control value. Inspired nitrous oxide concentrations were maintained at 67%. The following were investigated in each group: 1) an average propofol infusion rate, 2) time to spontaneous eye opening and recovery of orientation (name, date, and place), and 3) total dose of fentanyl used for 24 h after admission to the postanesthetic care unit. Average propofol infusion rates were 10.1 +/- 2.5 (mean +/- SD), 7.5 +/- 1.2, 5.7 +/- 1.1, and 4.9 +/- 1.2 mg. kg(-1). h(-1), in Groups I, II, III, and IV, respectively. Groups receiving fentanyl infusion had significantly smaller infusion rates of propofol (P < 0.01) than the group receiving saline. Among the three fentanyl infusion groups, Group II (P < 0.01) had more than Groups III and IV. The time to spontaneous eye opening and the recovery of orientation were directly related to plasma fentanyl concentrations. The plasma fentanyl levels between Groups III and IV were the same. The total amount of IV patient-controlled analgesia fentanyl during postoperative 24 h increased significantly when the order of plasma fentanyl concentrations was reversed, 913.1 +/- 58.4, 553.4 +/- 129, 222.7 +/- 73.4, and 135.1 +/- 69.5 microg in Groups I, II, III, and IV, respectively. These results suggest that the addition of fentanyl infusions had ceiling effects that reduce the intraoperative propofol requirements according to the plasma fentanyl concentrations. The ceiling effect was demonstrated in the recovery of consciousness but not in the fentanyl requirements for postoperative analgesia. Implications: The addition of fentanyl, a potent opioid, reduced the intraoperative requirement of propofol, an IV anesthetic, in the order of the plasma fentanyl concentrations. The ceiling effects of fentanyl were demonstrated in the reduction of propofol requirements and recovery of consciousness but not in the fentanyl requirements for postoperative analgesia
MB: Their idea of 'requirement of propofol' is adjusting the blood pressure by fiddling with the propofol infusion.

ARTICLE TITLE: Can succinylcholine be abandoned?
ARTICLE SOURCE: Anesth Analg (United States), May 2000, 90(5 Suppl) pS24-8
AUTHOR(S): Cook DR
AUTHOR'S ADDRESS: Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh School of Medicine, and the Children's Hospital of Pittsburgh, Pennsylvania 15213-2583, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (32 references); REVIEW, TUTORIAL
ABSTRACT: The elective use of succinylcholine in anesthesia has largely been abandoned because of unwanted side effects. Alternatives now exist for short, intermediate, or long elective surgical procedures. NMBDs are frequently used only to facilitate tracheal intubation; rapacuronium fills an important niche particularly for a short elective case (e.g., same-day surgery). However, an equally critical issue is whether there is a reliable replacement for succinylcholine for the treatment of laryngospasm or for rapid sequence induction in patients with "full stomachs." Succinylcholine produces more intense block in a shorter time at the laryngeal muscles, compared with the adductor pollicis, compared with vecuronium, rocuronium, mivacurium, and rapacuronium (30). Although most intubations can be facilitated with 80%-90% neuromuscular block, the ideal relaxant for a rapid sequence induction should produce uniformly complete neuromuscular blockade in 1 min. Variability in the degree of neuromuscular blockade and onset time can be compared for various relaxants by using the standard deviation (Table 1), the coefficient of variation (Table 2), or a plot of the degree of maximum neuromuscular block and the time to maximum block. Figure 1 shows such a plot for mivacurium (13). There is less variability in the maximum block at the larger dose of rapacuronium but still variability in onset time. Further studies will be important in defining the role of rapacuronium for rapid sequence induction in various clinical settings.
MB: The first statement above is wrong. When something as good as sux comes along we will know. In the mean time sux is alright when profound & quick paralysis is wanted.

ARTICLE TITLE: Neuromuscular blocking drugs for the new millennium: current practice, future trends--comparative pharmacology of neuromuscular blocking drugs.
ARTICLE SOURCE: Anesth Analg (United States), May 2000, 90(5 Suppl) pS2-6
AUTHOR(S): Donati F
AUTHOR'S ADDRESS: Department of Anesthesia, University of Montreal, Quebec, Canada. donatif@medclin.umontreal.ca.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (24 references); REVIEW, TUTORIAL
MB: I don't think we need more of the same.

ARTICLE TITLE: Intrathecal fentanyl is superior to intravenous ondansetron for the prevention of perioperative nausea during cesarean delivery with spinal anesthesia.
ARTICLE SOURCE: Anesth Analg (United States), May 2000, 90(5) p1162-6
AUTHOR(S): Manullang TR; Viscomi CM; Pace NL
AUTHOR'S ADDRESS: Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: This study compares intrathecal (IT) fentanyl with IV ondansetron for preventing intraoperative nausea and vomiting during cesarean deliveries performed with spinal anesthesia. Thirty healthy parturients presenting for elective cesarean delivery with standardized bupivacaine spinal anesthesia were randomized to receive 20 microg IT fentanyl (Group F) or 4 mg IV ondansetron (Group O) by using double-blinded methodology. At eight specific intervals during the surgery, a blinded observer questioned the patient about nausea (1 = nausea, 0 = no nausea), observed for the presence of retching or vomiting (1 = vomiting or retching, 0 = no vomiting or retching), and recorded a verbal pain score (0-10, 0 = no pain, 10 = worst pain imaginable). Cumulative nausea, vomiting, and pain scores were calculated as the sum of the eight measurements. Intraoperative nausea was decreased in the IT fentanyl group compared with the IV ondansetron group: the median (interquartile range) difference in nausea scores was 1 (1, 2), P = 0.03. The incidence of vomiting and treatment for vomiting was not different (P = 0.7). The IT fentanyl group had a lower cumulative perioperative pain score than the IV ondansetron group; the median difference in the cumulative pain score was 12 (8, 16) (P = 0.0007). The IT fentanyl group required less supplementary intraoperative analgesia. The median difference in the cumulative fentanyl dose was 100 (75, 100) microg fentanyl, (P = 0.0002).
MB: It must have been annoying to be asked 8 times about nausea. I would have thought that the repeated asking might have increased any feeling of nuasea. I would not have thought that nausea during caesarian section was of the type likely to respond to antiemetics.

ARTICLE TITLE: The use of citrated whole blood in thromboelastography.
ARTICLE SOURCE: Anesth Analg (United States), May 2000, 90(5) p1086-8
AUTHOR(S): Bowbrick VA; Mikhailidis DP; Stansby G
AUTHOR'S ADDRESS: Academic Surgical & Regional Vascular Units, Imperial College School of Medicine, St. Mary's Hospital, London, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
MB: There were no differences if blood was stored for 150 minutes at 4degC. That would have damaged the platelets. Thus they think the test would be no good for looking at platelet function. The anaesthetic literature thinks the opposite but has not established that.

ARTICLE TITLE: Choice of surgical technique influences perioperative outcomes in liver transplantation.
ARTICLE SOURCE: Ann Surg (United States), Jun 2000, 231(6) p814-23
AUTHOR(S): Hosein Shokouh-Amiri M; Osama Gaber A; Bagous WA; Grewal HP; Hathaway DK; Vera SR; Stratta RJ; Bagous TN; Kizilisik T
AUTHOR'S ADDRESS: Departments of Surgery (Division of Transplantation) and Anesthesia and the College of Nursing, University of Tennessee-Memphis, Memphis, Tennessee 38125, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: To examine how the choice of surgical technique influenced perioperative outcomes in liver transplantation. SUMMARY BACKGROUND DATA: The standard technique of orthotopic liver transplantation with venovenous bypass (VVB) is commonly used to facilitate hemodynamic stability. However, this traditional procedure is associated with unique complications that can be avoided by using the technique of liver resection without caval excision (the piggyback technique). METHODS: A prospective comparison of the two procedures was conducted in 90 patients (34 piggyback and 56 with VVB) during a 2.5-year period. Although both groups had similar donor and recipient demographic characteristics, posttransplant outcomes were significantly better for the patients undergoing the piggyback technique. The effect of surgical technique was examined using a stepwise approach that considered its impact on two levels of perioperative and postoperative events. RESULTS: The analysis of the first level of perioperative events found that the piggyback procedure resulted in a 50% decrease in the duration of the anhepatic phase. The analysis of the second level of perioperative events found a significant relation between the anhepatic phase and the duration of surgery and between the anhepatic phase and the need for blood replacement. The analysis of the first level of postoperative events found that the intensive care unit stay was significantly related to both the duration of surgery and the need for blood replacement. The intensive care unit stay was in turn related to the second level of postoperative events, namely the length of hospital stay. Finally, total charges were directly related to length of hospital stay. The overall 1-year actuarial patient and graft survival rates were 94% in the piggyback and 96% in the VVB groups, respectively. CONCLUSIONS: These data demonstrate that surgical choices in complex procedures such as orthotopic liver transplantation trigger a chain of events that can significantly affect resource utilization. In the current healthcare climate, examination of the sequence of events that follow a specific treatment may provide a more complete framework for choosing between treatment alternatives.
MB: There are too many variables to conclude anything.

ARTICLE TITLE: Laparoscopic donor nephrectomy with a 23-hour stay: a new standard for transplantation surgery.
ARTICLE SOURCE: Ann Surg (United States), May 2000, 231(5) p772-9
AUTHOR(S): Kuo PC; Johnson LB; Sitzmann JV
AUTHOR'S ADDRESS: Departments of Surgery, Georgetown University Medical Center, Washington, DC 20007, USA. kuop@gunet.georgetown.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Laparoscopic donor nephrectomy (LDN) can be performed as a 23-hour stay procedure without incurring additional complications or donor dissatisfaction. By further decreasing opportunity costs and disincentives for donation, LDN may increase the number of potential donors appearing for evaluation.

ARTICLE TITLE: Acupressure wristbands do not prevent postoperative nausea and vomiting after urological endoscopic surgery.
ARTICLE SOURCE: Can J Anaesth (Canada), Apr 2000, 47(4) p319-24
AUTHOR(S): Agarwal A; Pathak A; Gaur A
AUTHOR'S ADDRESS: Department of Anaesthesiology & Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. aagarwal@sgpgi.ac.in.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
MB: I was not thinking about trying it.

ARTICLE TITLE: Intrathecal morphine suppresses natural killer (NK) cell activity following abdominal surgery.
ARTICLE SOURCE: Can J Anaesth (Canada), Apr 2000, 47(4) p303-8
AUTHOR(S): Yokota T; Uehara K; Nomoto Y
AUTHOR'S ADDRESS: Department of Anaesthesiology, Kanto Rohsai Hospital, Kawasaki, Kanagawa, Japan.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL

ARTICLE TITLE: Comparison of cognitive function and quality of life after endovascular or conventional aortic aneurysm repair.
ARTICLE SOURCE: Br J Surg (England), Apr 2000, 87(4) p443-7
AUTHOR(S): Lloyd AJ; Boyle J; Bell PR; Thompson MM
AUTHOR'S ADDRESS: Oxford Centre for Health Care Research and Development, Oxford Brookes University, Oxford and Department of Surgery, Leicester University, Leicester, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Endovascular aneurysm surgery had a similar impact on health-related quality of life and cognitive function compared with conventional aneurysm repair. Patients in both groups demonstrated a significant decline in cognitive function.

ARTICLE TITLE: Cost effectiveness of outpatient anticoagulant prophylaxis after total hip arthroplasty.
ARTICLE SOURCE: Orthopedics (United States), Apr 2000, 23(4) p335-8; discussion 338-9
AUTHOR(S): Wade WE; Hawkins DW
AUTHOR'S ADDRESS: College of Pharmacy, University of Georgia, Athens 30602, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (25 references); REVIEW LITERATURE
ABSTRACT: Guidelines for deep venous thrombosis (DVT) and pulmonary embolism (PE) prophylaxis have been developed for patients undergoing total hip arthroplasty (THA). Studies suggest that risk for developing these complications may exist for as long as 3 months following surgery. Cost-effectiveness analyses were performed on three pharmacoprophylaxis regimens administered over a 30-day period using literature-reported values for incidences of DVT and PE in patients postdischarge following THA. A cost savings of $21,466.89 will occur for each thromboembolic event avoided if low-dose warfarin daily is used routinely compared to enoxaparin 40 mg daily. Additionally, a cost savings of $18,618.10 is experienced if enoxaparin 40 mg daily for 4 days plus low-dose warfarin daily is administered versus enoxaparin 40 mg daily. Clinicians may choose to continue prophylaxis postdischarge with enoxaparin 40 mg daily for 4 days in combination with warfarin for 30 days in these patients until results of more definitive studies become available.

ARTICLE TITLE: Hepatitis C virus infection: knowledge in the orthopedic community.
ARTICLE SOURCE: Am J Orthop (United States), Apr 2000, 29(4) p279-81
AUTHOR(S): Flowerdew JM; McGrory BJ
AUTHOR'S ADDRESS: University of Vermont College of Medicine, Burlington, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: A survey with 14 questions pertaining to the natural history, infectiveness, and diagnosis and treatment of hepatitis C viral infection was given to all practicing orthopedic surgeons in Portland, Maine. Possible responses were "true," "false," or "don't know" to the 14 statements. A question regarding any interest in learning more about the hepatitis C virus was also posed. Most (82%, 23/28) surgeons completed the questionnaire. A total of 72% of the responses were either wrong or marked "don't know"; most (83%) of the respondents wanted to know more about the infection about hepatitis C viral infection. Not only are orthopedic surgeons at risk for exposure to this virus, but also they are often the first to notify a patient of a positive result after routine hepatitis C testing of autologous predonated blood. Education programs and journal reviews should be directed toward this goal.
MB: That might not have much effect.

ARTICLE TITLE: Deep vein thrombosis prophylaxis: a comprehensive approach for total hip and total knee arthroplasty patient populations.
ARTICLE SOURCE: Am J Orthop (United States), Apr 2000, 29(4) p269-74
AUTHOR(S): Miric A; Lombardi P; Sculco TP
AUTHOR'S ADDRESS: Department of Orthopaedic Surgery, Kaiser-Permanente of Southern California, Sunset Facility, Los Angeles, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (54 references); REVIEW, TUTORIAL
ABSTRACT: One of the most catastrophic complications after total joint arthroplasty is a fatal pulmonary embolism. Thromboembolic disease is particularly a problem in lower extremity joint arthroplasty secondary to the development of deep vein thrombosis (DVT) and proximal propagation of the thrombus. The environment created during total hip and knee arthroplasty fulfills the criteria for DVT formation: vessel wall damage, venous stasis, and a hypercoagulable state. Evidence that suggests the insult and primary event in thrombogenesis occurs during surgery. Until recently, however, the main thrust of DVT prophylaxis has concentrated on the immediate postoperative period. A more global approach to patient care during the 6-week period beginning with surgery may result in more effective DVT prophylaxis. Operative interventions that have proven to be effective include hypotensive epidural anesthesia and intravenous administration of heparin. Postoperative pharmaceutical interventions range from standard doses of aspirin or warfarin to recently studied dosing regimens of low-molecular-weight heparins, antiplatelet agents, and antithrombotic agents. Mechanical prophylaxis has also proved to be a valuable adjunct in DVT prophylaxis during these periods. It is hoped that a more comprehensive approach incorporating several of the aforementioned treatments into a strategy that encompasses the intraoperative and early and late postoperative periods will maximize the effectiveness of DVT prophylaxis.
MB: We can all live in hope.

ARTICLE TITLE: Spinal anesthesia versus general anesthesia for hip fracture repair: a longitudinal observation of 741 elderly patients during 2-year follow-up.
ARTICLE SOURCE: Am J Orthop (United States), Jan 2000, 29(1) p25-35
AUTHOR(S): Gilbert TB; Hawkes WG; Hebel JR; Hudson JI; Kenzora JE; Zimmerman SI; Felsenthal G; Magaziner J
AUTHOR'S ADDRESS: Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY
ABSTRACT: The Baltimore Hip Studies, a multicenter, noninterventional, observational trial, provided an opportunity to investigate the effects of anesthetic technique on the long-term outcome of elderly patients after hip fracture repair. Detailed interviews assessing functional status and pain were conducted during the hospital stay. Out-of-hospital evaluations were repeated after the procedure at 2, 6, 12, 18, and 24 months with a portable gait and balance laboratory. Multivariate analysis was done to determine the effects of anesthetic technique on functional and other outcomes, after controlling for multiple baseline variables. Of 741 enrolled patients who completed the study, 430 and 311 patients received spinal anesthesia or general anesthesia, respectively. Subgroup analysis of three spinal anesthetics, tetracaine, lidocaine, and epinephrine, was also done. In the present large observational study, general anesthesia was at least as efficacious as spinal anesthesia, and possibly better, in affording good long-term outcome.
MB: This should settle the matter. The GAs were slightly better than the regionals. 8% of the GA s were for failed regional. Why not give a GA first always?

ARTICLE TITLE: Physostigmine reversal of midazolam-induced electroencephalographic changes in healthy subjects.
ARTICLE SOURCE: Clin Pharmacol Ther (United States), May 2000, 67(5) p538-48
AUTHOR(S): Ebert U; Oertel R; Kirch W
AUTHOR'S ADDRESS: Institute of Clinical Pharmacology, Faculty of Medicine, Technical University Dresden, Germany. uebert@rcs.urz.tu-dresden.de.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSION: Physostigmine and flumazenil antagonized midazolam-induced sedation. This suggests that a reversible central anticholinergic mechanism may be involved in the sedative action of midazolam.

ARTICLE TITLE: Living liver donor surgery: report of initial anesthesia experience.
ARTICLE SOURCE: J Clin Anesth (United States), Mar 2000, 12(2) p157-61
AUTHOR(S): Beebe DS; Carr R; Komanduri V; Humar A; Gruessner R; Belani KG
AUTHOR'S ADDRESS: Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN 55455, USA. beebe001@tc.umn.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: The charts and anesthetic records of 12 patients who donated the left lateral segment of their liver to a related infant or child to treat liver failure were retrospectively reviewed. Blood loss, need for transfusion, fluids administered, surgical length, and perioperative complications were investigated. The records also were examined to determine the hemodynamic stability of patients undergoing donor hepatectomy to assess their need for invasive monitoring. There were no episodes of hypotension or hemodynamic instability. The average operating time was 9.6 +/- 1.1 hours. The blood loss was 562 +/- 244 mL (range 300 to 1100 mL). Four patients received their own cell saver blood (200 mL, 220 mL, 300 mL, 475 mL), and one patient received 1 U (350 mL) of predonated autologous blood. The average hemoglobin decreased significantly (p = 0.001) from a preoperative value of 14.1 +/- 1.2 to 12.3 +/- 1.8 g/dL in the recovery room. All patients were extubated in the operating room or recovery room. Patients were discharged home in 6.9 +/- 1.3 days (range 5 to 9 days). Living-related liver resection can be performed with noninvasive monitoring and without the need for heterologous blood products.
MB: Some have died. The incidence is not known 'cause they have not been published. They were whispered about at the recent International Liver Transplant Congress.

ARTICLE TITLE: A multicenter comparison of isoflurane and propofol as adjuncts to remifentanil-based anesthesia.
ARTICLE SOURCE: J Clin Anesth (United States), Mar 2000, 12(2) p129-35
AUTHOR(S): Wilhelm W; Grundmann U; Van Aken H; Haus EM; Larsen R
AUTHOR'S ADDRESS: Department of Anesthesiology and Intensive Care Medicine, University of Saarland, Homburg/Saar, Germany. wolfram.wilhelm@t-online.de.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: Emergence after remifentanil-based anesthesia with 0.6 vol% of isoflurane is at least as rapid as with 0.1 mg/kg/min propofol. Both isoflurane and propofol are suitable adjuncts to remifentanil, and the applied dosages are clinically equivalent with respect to emergence and recovery. Therefore, both combinations should be appropriate, particularly in settings in which rapid recovery from anesthesia is desirable, such as fast tracking and/or ambulatory surgery.
MB: Seems like an upside-down idea of what anaesthesia is

ARTICLE TITLE: Cardiovascular homeostasis during inhalational general anesthesia: a clinical comparison between sevoflurane and isoflurane. On behalf of the Italian Research Group on sevoflurane.
ARTICLE SOURCE: J Clin Anesth (United States), Mar 2000, 12(2) p117-22
AUTHOR(S): Torri G; Casati A
AUTHOR'S ADDRESS: Department of Anesthesiology, University of Milan, Italy.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
CONCLUSIONS: Sevoflurane provided equally safe and effective control of cardiovascular homeostasis as isoflurane, with a more rapid discharge from the recovery area. Interestingly, patients over 50 years of age showed a lower risk for hemodynamic side effects when receiving sevoflurane than isoflurane.

ARTICLE TITLE: Methylprednisolone for acute spinal cord injury: an inappropriate standard of care [see comments]
COMMENTS: Comment in: J Neurosurg 2000 Jul; 93(1 Suppl):175-9
ARTICLE SOURCE: J Neurosurg (United States), Jul 2000, 93(1 Suppl) p1-7
AUTHOR(S): Hurlbert RJ
AUTHOR'S ADDRESS: University of Calgary Spine Program, Foothills Hospital and Medical Centre, Alberta, Canada. jhurlber@ucalgary.ca.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
MB: They don't like it.

ARTICLE TITLE: Adverse effects of limited hypotensive anesthesia on the outcome of patients with subarachnoid hemorrhage.
ARTICLE SOURCE: J Neurosurg (United States), Jun 2000, 92(6) p971-5
AUTHOR(S): Chang HS; Hongo K; Nakagawa H
AUTHOR'S ADDRESS: Department of Neurological Surgery, Aichi Medical University, Japan. chang@aichi-med-u.ac.jp.
PUBLICATION TYPE: JOURNAL ARTICLE
MB: They don't like that either.

ARTICLE TITLE: Gender differences in the results of the final medical examination at University College Dublin [see comments]
COMMENTS: Comment in: Med Educ 2000 Jan; 34(1):2
ARTICLE SOURCE: Med Educ (England), Jan 2000, 34(1) p30-4
AUTHOR(S): McDonough CM; Horgan A; Codd MB; Casey PR
AUTHOR'S ADDRESS: UCD Department of Adult Psychiatry, Mater Misericordiae Hospital, Dublin, Ireland.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The success of females and their increased numbers at undergraduate level are not reflected at senior registrar and consultant level. As medical manpower becomes more of an issue the lack of women, particularly in certain specialties, and the possible reasons for this need to be addressed.
MB: Why should they think that the results of an undergraduate course determine the following stages' outcomes?

ARTICLE TITLE: Evaluation of medical students' performance using the anaesthesia simulator.
ARTICLE SOURCE: Med Educ (England), Jan 2000, 34(1) p42-5
AUTHOR(S): Morgan PJ; Cleave-Hogg D
AUTHOR'S ADDRESS: Department of Anaesthesia, Sunnybrook Health Science Centre, 2075 Bayview M3-200, Toronto, Ontario, Canada M4N 3 M5.
MAJOR SUBJECT HEADING(S): Anesthesiology [education]; Education, Medical, Undergraduate [methods]
MINOR SUBJECT HEADING(S): Anesthesiology [standards]; Education, Medical, Undergraduate [standards]; Pilot Projects; Program Evaluation; Videotape Recording
INDEXING CHECK TAG(S): Human; Support, Non-U.S. Gov't
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Our pilot data suggest that the simulator is a reliable assessment method for medical students' performance. Further work may justify the inclusion of the simulator as an evaluation and education tool and expanded to incorporate learning objectives of other medical disciplines.
MB: We can do without suggestions.

ARTICLE TITLE: The emperor's new clothes: from objectives to outcomes.
ARTICLE SOURCE: Med Educ (England), Mar 2000, 34(3) p168-9
AUTHOR(S): Prideaux D
AUTHOR'S ADDRESS: Flinders University, Flinders Medical Centre, Bedford Park, South Australia, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE
MB: I have always thought medical education theory was gobble-de-gook. This has not made me change my mind.

ARTICLE TITLE: Differences in teaching about the acute sore throat within one medical faculty.
ARTICLE SOURCE: Med Educ (England), Apr 2000, 34(4) p269-74
AUTHOR(S): Brooker C; Kamien M; Ward AM
AUTHOR'S ADDRESS: Department of General Practice, University of Western Australia, Western Australia, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVES: To examine the consistency of teaching about the acute sore throat in four departments in one medical faculty, and to determine whether there is agreement between what is taught and the evidence-based literature. DESIGN: Cross-sectional study. SUBJECTS: 71 undergraduates and 15 postgraduate general practice registrars and four lecturers. RESULTS: Differences were identified in teaching about the diagnostic value of a throat swab, a full blood count and clinical scoring, as well as on the use of penicillin in suspected streptococcal pharyngitis. Only one department based their teaching on the evidence-based literature. No department discussed issues of cost-effectiveness. Half of the students identified discrepancies in the teaching about the sore throat and were initially confused by them. CONCLUSION: One method of resolving disagreement between teachers from different disciplines is to rely on the evidence-based literature. This type of study can be useful in curricular development and in correcting teaching inconsistencies within a faculty.
MB: How pathetic? Do they think the students believe what they are told (taught)?

ARTICLE TITLE: Consistency of teaching in parallel surgical firms: an audit of student experience at one medical school.
ARTICLE SOURCE: Med Educ (England), Apr 2000, 34(4) p292-8
AUTHOR(S): Seabrook MA; Woodfield SJ; Papagrigoriadis S; Rennie JA; Atherton A; Lawson M
AUTHOR'S ADDRESS: Department of General Practice and Primary Care, King's College School of Medicine, Weston Education Centre, London, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
DISCUSSION: Students in so called 'parallel' clerkships did not receive comparable teaching. The traditional opportunistic nature of clinical teaching led, in effect, to individual curricula within each clerkship. The General Medical Council has called for a core curriculum to be delivered across different clinical sites within each medical school. To achieve this, medical schools may need to introduce guidelines to direct teaching in the same way that clinical protocols have been developed to achieve greater standardization in clinical practice.
MB: The medical course is just the beginning of very diverse medical lives.

ARTICLE TITLE: Virtually viewing the large bowel: the future of colorectal cancer screening? [editorial; comment]
COMMENTS: Comment on: Med J Aust 2000 May 1; 172(9):428-30
ARTICLE SOURCE: Med J Aust (Australia), May 1 2000, 172(9) p416-7
AUTHOR(S): Mendelson RM; Forbes GM
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Government policymaking, private health insurance and hospital-efficiency issues [editorial; comment]
COMMENTS: Comment on: Med J Aust 2000 May 1; 172(9):439-42
ARTICLE SOURCE: Med J Aust (Australia), May 1 2000, 172(9) p413-4
AUTHOR(S): Palmer GR
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Perspectives from a surgeon turned hospital chaplain.
ARTICLE SOURCE: Med J Aust (Australia), Apr 17 2000, 172(8) p389-90
AUTHOR(S): Faris IB
AUTHOR'S ADDRESS: Christ Church, Geelong, VIC. ifaris@ozemail.com.au.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: A metamorphosis: doctor to chaplain.
ARTICLE SOURCE: Med J Aust (Australia), Apr 17 2000, 172(8) p390-1
AUTHOR(S): Allbrook DB
AUTHOR'S ADDRESS: Swan Health Services, Midland, WA. dallbrok@cygnus.uwa.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Use of interventions to minimise perioperative allogeneic blood transfusion in Australia. A survey by the International Study of Perioperative Transfusion (ISPOT) Study Group [see comments]
COMMENTS: Comment in: Med J Aust 2000 Apr 17; 172(8):359-60
ARTICLE SOURCE: Med J Aust (Australia), Apr 17 2000, 172(8) p365-9
AUTHOR(S): Henry DA; Henderson KM; Fryer JL; Treloar CJ; McGrath KM; Deveridge SF
AUTHOR'S ADDRESS: Faculty of Medicine and Health Sciences, University of Newcastle. mddah@mail.newcastle.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Interventions to minimise the need for perioperative allogeneic blood transfusion (apart from drugs) are widely used in Australia. However, enthusiasm for intraoperative techniques of re-infusing autologous blood needs to be assessed against the evidence of their efficacy and cost-effectiveness.
MB: ...& safety

ARTICLE TITLE: Safety first: reducing exposure to allogeneic blood [editorial; comment]
COMMENTS: Comment on: Med J Aust 2000 Apr 17; 172(8):365-9
ARTICLE SOURCE: Med J Aust (Australia), Apr 17 2000, 172(8) p359-60
AUTHOR(S): Beal RW
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Medicine for the millennium: the challenge of postmodernism.
ARTICLE SOURCE: Med J Aust (Australia), Apr 3 2000, 172(7) p332-4
AUTHOR(S): Chan JJ; Chan JE
AUTHOR'S ADDRESS: Royal Perth Hospital, WA. jjchan@cyllene.uwa.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: As the new millennium dawns, Australian society is becoming more post-modern, whereas the medical system remains increasingly modernist in its outlook. In this article, we discuss the emerging prevalence of post-modernism and examine current medical education and practice strategies, such as evidence-based medicine, from a post-modern perspective. We argue that if medicine does not respond to the ideas of post-modernism, which challenges the concepts of truth and our ability to be objective, it may become increasingly irrelevant to the needs of a changing society.

ARTICLE TITLE: Prostate cancer: what should be the sequel to diagnosis? [editorial; comment]
COMMENTS: Comment on: Med J Aust 2000 Mar 20; 172(6):270-4
ARTICLE SOURCE: Med J Aust (Australia), Mar 20 2000, 172(6) p256-7
AUTHOR(S): Gardiner RA
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Deaths due to brain injury among footballers in Victoria, 1968-1999.
ARTICLE SOURCE: Med J Aust (Australia), Mar 6 2000, 172(5) p217-9
AUTHOR(S): McCrory PR; Berkovic SF; Cordner SM
AUTHOR'S ADDRESS: Department of Medicine (Neurology), University of Melbourne, Austin and Repatriation Medical Centre, VIC. pmccrory@compuserve.com.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVES: To determine the frequency and nature of fatal brain injuries occurring in Australian football. SETTING: State of Victoria, January to July 1999. DESIGN: Retrospective case series of football-related deaths identified from the coronial autopsy records of the Victorian Institute of Forensic Medicine (1990-1999) and newspaper reports (1968-1989). MAIN OUTCOME MEASURES: Coronial autopsy findings and circumstances of injury. RESULTS: 25 deaths associated with Australian football were identified, nine due to brain injury. Coronial findings in the brain-injury deaths were intracranial haemorrhage in eight patients and infarct in the territory of the middle cerebral artery in one. In three of four cases of subarachnoid haemorrhage, vertebral artery trauma was noted. In all but one case, injury occurred as an accidental part of play. CONCLUSIONS: The most common findings in deaths due to brain injury in Australian football were intracranial haemorrhage, including subarachnoid haemorrhage from vertebral artery injury.
MB: 25 death in 10 y due to Australian Rules! Is it worse in NSW?
There were 22 in Australian Rules & 3 in Rugby. 9 had head injuries, one a ruptired liver and most of the rest were cardiac.

ARTICLE TITLE: Genetically modified food: consternation, confusion, and crack-up [editorial; comment] ]
COMMENTS: Comment on: Med J Aust 2000 Feb 21; 172(4):170-3; Comment on: Med J Aust 2000 Feb 21; 172(4):173-4
ARTICLE SOURCE: Med J Aust (Australia), Feb 21 2000, 172(4) p148-9
AUTHOR(S): Horton R
PUBLICATION TYPE: COMMENT; EDITORIAL; REVIEW (14 references); REVIEW, TUTORIAL

ARTICLE TITLE: Genetically modified foods--food for thought [see comments]
COMMENTS: Comment in: Med J Aust 2000 Feb 21; 172(4):148-9
ARTICLE SOURCE: Med J Aust (Australia), Feb 21 2000, 172(4) p173-4
AUTHOR(S): Leeder SR
AUTHOR'S ADDRESS: Faculty of Medicine, University of Sydney, NSW. steve@medicine.usyd.edu.au.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (14 references); REVIEW, TUTORIAL
ABSTRACT: We would be wise to hold off until we know more about the health, ecological and economic effects of genetically modified food.

ARTICLE TITLE: Genetically modified foods--safety and regulatory issues [see comments]
COMMENTS: Comment in: Med J Aust 2000 Feb 21; 172(4):148-9
ARTICLE SOURCE: Med J Aust (Australia), Feb 21 2000, 172(4) p170-3
AUTHOR(S): Huppatz JL; Fitzgerald PA
AUTHOR'S ADDRESS: CSIRO Plant Industry, Canberra, ACT.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (15 references); REVIEW, TUTORIAL
ABSTRACT: Gene technology is a new form of biotechnology with much greater potential applications.

ARTICLE TITLE: Is acupuncture effective for the treatment of chronic pain? A systematic review.
ARTICLE SOURCE: Pain (Netherlands), Jun 2000, 86(3) p217-25
AUTHOR(S): Ezzo J; Berman B; Hadhazy VA; Jadad AR; Lao L; Singh BB
AUTHOR'S ADDRESS: Complementary Medicine Program at the University of Maryland School of Medicine, Kernan Hospital Mansion, 2200 Kernan Drive, Baltimore, MD 21207-6697, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
We conclude there is limited evidence that acupuncture is more effective than no treatment for chronic pain; and inconclusive evidence that acupuncture is more effective than placebo, sham acupuncture or standard care. However, we have found an important relationship between the methodology of the studies and their results that should guide future research.

ARTICLE TITLE: Perils in the pursuit of mechanisms [editorial]
ARTICLE SOURCE: Pain (Netherlands), May 2000, 86(1-2) p1-2
AUTHOR(S): Loeser JD
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Simple pain rating scales hide complex idiosyncratic meanings.
ARTICLE SOURCE: Pain (Netherlands), Apr 2000, 85(3) p457-63
AUTHOR(S): de CWilliams AC; Davies HT; Chadury Y
AUTHOR'S ADDRESS: King's, Guy's and St. Thomas' Medical School, University of London, London, UK. amanda.williams@kcl.ac.uk.
MAJOR SUBJECT HEADING(S): Pain Measurement [standards]; Pain [psychology]
MINOR SUBJECT HEADING(S): Adult; Aged; Individuality; Interview, Psychological; Middle Age; Pilot Projects
INDEXING CHECK TAG(S): Female; Human; Male
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: Assumptions of reliability and consistency of self-report of pain by patients using visual analogue scales (VAS) and numerical rating scales (NRS) are based on narrow considerations of possible sources of error. This study examined patients' use of VASs and NRSs, by their own description, with particular attention to rating of multiple pains, of different dimensions of pain, and of interpretation and use of lower and upper endpoints and increments on the scales. These have implications for the approximation of the scales to psychometric requirements. An interview developed from a small pilot project was given to 78 volunteer chronic pain patients embarking on a pain management course, and consisted of both forced choice questions and free response. Data are described with reference to lack of concordance between patients and of consistency within patients; responses suggested that ratings incorporate multiple partially differentiated dimensions of pain, with particular importance placed on function or mobility. Labels assigned to scale endpoints by researchers, whether lexical or numerical, appeared to affect their use; however, covert relabelling of scale points was revealed in free response. The action of arriving at a rating is better conceptualised as an attempt to construct meaning, influenced by and with reference to a range of internal and external factors and private meanings, rather than as a task of matching a distance or number to a discrete internal stimulus.
MB: I think this means that the scales are useless but it could mean anything.

ARTICLE TITLE: The use of non-pharmacological therapies by pain specialists [editorial]
ARTICLE SOURCE: Pain (Netherlands), Apr 2000, 85(3) p313-5
AUTHOR(S): Berman BM; Bausell RB
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Beta-blockers for heart failure--time to think the unthinkable?
ARTICLE SOURCE: QJM (England), Nov 1999, 92(11) p673-8
AUTHOR(S): Davies CH; Bashir Y
AUTHOR'S ADDRESS: Departments of Cardiovascular Medicine and Cardiology, John Radcliffe Hospital, Oxford, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
MB: The unthinkable being that gradually applied beta-blockers are good in cardiac failure.

ARTICLE TITLE: Echocardiography in stroke and thromboembolism: transoesophageal imaging for all? [editorial]
ARTICLE SOURCE: QJM (England), Nov 1999, 92(11) p619-21
AUTHOR(S): Channon KM; Banning AP
PUBLICATION TYPE: EDITORIAL

ARTICLE TITLE: Factors associated with hospital admissions and repeat emergency department visits for adults with asthma.
ARTICLE SOURCE: Thorax (England), Jul 2000, 55(7) p566-73
AUTHOR(S): Adams RJ; Smith BJ; Ruffin RE
AUTHOR'S ADDRESS: Department of Medicine, The University of Adelaide, The Queen Elizabeth Hospital, Woodville, South Australia. robert.adams@channing.harvard.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: In addition to factors relating to severity, not possessing a written asthma action plan, avoidance coping, and attitudes to self-management were related to acute use of health services in this at risk group. Interventions need to address or take these factors into account to reduce asthma morbidity.
MB: My father, an old time pharmacist, used to say that asthmatics were always running out of their therapy but the diabetics did not.

ARTICLE TITLE: An antibiotic policy to prevent emergence of resistant bacilli [see comments]
COMMENTS: Comment in: Lancet 2000 Mar 18; 355(9208):946-7
ARTICLE SOURCE: Lancet (England), Mar 18 2000, 355(9208) p973-8
AUTHOR(S): de Man P; Verhoeven BA; Verbrugh HA; Vos MC; van den Anker JN
AUTHOR'S ADDRESS: Department of Medical Microbiology and Infection Control, Erasmus University Medical Centre, Rotterdam, The Netherlands. peter_de_man@franciscus.nl.
PUBLICATION TYPE: JOURNAL ARTICLE
INTERPRETATION: Policies regarding the empiric use of antibiotics do matter in the control of antimicrobial resistance. A regimen avoiding amoxicillin and cefotaxime restricts the resistance problem.
MB: They were saying this when I was a medical student.

ARTICLE TITLE: Mortality rates after surgery for congenital heart defects in children and surgeons' performance [see comments]
COMMENTS: Comment in: Lancet 2000 Mar 18; 355(9208):948
ARTICLE SOURCE: Lancet (England), Mar 18 2000, 355(9208) p1004-7
AUTHOR(S): Stark J; Gallivan S; Lovegrove J; Hamilton JR; Monro JL; Pollock JC; Watterson KG
AUTHOR'S ADDRESS: Institute of Child Health, London, UK. jarda@freeuk.com.
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
INTERPRETATION: The participating departments seemed to reach high standards of care for children with congenital heart defects, although more data would be needed to assess performance of individual surgeons. The development of quality standards will be difficult because of the complexity of defects, the different types of operations, and few patients in each subgroup. Collection of larger sets of data for more patients and centres are needed.

ARTICLE TITLE: Inhaled corticosteroid use and bone-mineral density in patients with asthma [see comments]
COMMENTS: Comment in: Lancet 2000 Apr 22; 355(9213):1385
ARTICLE SOURCE: Lancet (England), Apr 22 2000, 355(9213) p1399-403
AUTHOR(S): Wong CA; Walsh LJ; Smith CJ; Wisniewski AF; Lewis SA; Hubbard R; Cawte S; Green DJ; Pringle M; Tattersfield AE
AUTHOR'S ADDRESS: Division of Respiratory Medicine, City Hospital, Nottingham, UK. czwong@middlemore.co.nz.
PUBLICATION TYPE: JOURNAL ARTICLE
INTERPRETATION: This study provides evidence of a negative relation between total cumulative dose of inhaled corticosteroid and bone-mineral density in patients with asthma.

ARTICLE TITLE: Inhaled corticosteroids, bone density, and risk of fracture [comment]
COMMENTS: Comment on: Lancet 2000 Apr 22; 355(9213):1399-403
ARTICLE SOURCE: Lancet (England), Apr 22 2000, 355(9213) p1385
AUTHOR(S): Sambrook PN
AUTHOR'S ADDRESS: Institute of Bone & Joint Research, University of Sydney, Royal North Shore Hospital, St Leonards, Australia.
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: COMMENT; JOURNAL ARTICLE

ARTICLE TITLE: Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. HAEST Study Group. Heparin in Acute Embolic Stroke Trial.
ARTICLE SOURCE: Lancet (England), Apr 8 2000, 355(9211) p1205-10
AUTHOR(S): Berge E; Abdelnoor M; Nakstad PH; Sandset PM
AUTHOR'S ADDRESS: Department of Haematology, Ulleval University Hospital, Oslo, Norway. eivind.berge@ulleval.no.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED CONTROLLED TRIAL
INTERPRETATION: The present data do not provide any evidence that low-molecular-weight heparin (LMWH, dalteparin 100 IU/kg subcutaneously twice a day) is superior to aspirin for the treatment of acute ischaemic stroke in patients with atrial fibrillation. However, the study could not exclude the possibility of smaller, but still worthwhile, effects of either of the trial drugs.

ARTICLE TITLE: The antioxidant paradox.
ARTICLE SOURCE: Lancet (England), Apr 1 2000, 355(9210) p1179-80
AUTHOR(S): Halliwell B
AUTHOR'S ADDRESS: Department of Biochemistry, Medical Faculty, National University of Singapore, Singapore. bchbh@nus.edu.sg.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (26 references); REVIEW, TUTORIAL

ARTICLE TITLE: Consequences of discharges from intensive care at night [see comments]
COMMENTS: Comment in: Lancet 2000 Apr 1; 355(9210):1111
ARTICLE SOURCE: Lancet (England), Apr 1 2000, 355(9210) p1138-42
AUTHOR(S): Goldfrad C; Rowan K
AUTHOR'S ADDRESS: Intensive Care National Audit & Research Centre, London, UK.
PUBLICATION TYPE: JOURNAL ARTICLE
INTERPRETATION: Night discharges from ICU are increasing in the UK. This practice is of concern because patients discharged at night fare significantly worse than those discharged during the day. Night discharges are more likely to be "premature" in the view of the clinicians involved. The implication of these results is that many hospitals have insufficient intensive-care beds. In deciding whether or not to invest more resources in intensive care we must, however, consider the cost-utility of this particular service compared with other ways that additional resources could be used.

ARTICLE TITLE: Red cells I: inherited anaemias [see comments]
COMMENTS: Comment in: Lancet 2000 Apr 1; 355(9210):1118
ARTICLE SOURCE: Lancet (England), Apr 1 2000, 355(9210) p1169-75
AUTHOR(S): Weatherall DJ; Provan AB
AUTHOR'S ADDRESS: Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, UK.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (26 references); REVIEW, TUTORIAL
ABSTRACT: Examination of the genetic mechanisms underlying the thalassaemias has led to a clearer understanding of the control of eukaryotic genes in general. Inherited disorders of haemoglobin synthesis are an important cause worldwide of morbidity and mortality, and place a large burden on patients, families, and ultimately communities. The haemoglobin disorders can be controlled, by counseling and prenatal diagnosis. Treatment is usually symptomatic, though bone-marrow transplantation for beta-thalassaemia may be successful in suitable patients.
MB: I can't see how the disorder could be controlled by counseling and prenatal diagnosis.