Hemopericardium and cardiac tamponade after thrombolysis for acute ischemic stroke

Hemorrhage is the major complication of IV recombinant tissue plasminogen activator (rt-PA) treatment for stroke. We report three patients with mild or indistinct cardiac symptoms prior to thrombolysis in whom hemodynamically significant cardiac tamponade occurred after treatment with rt-PA. Acute ischemic stroke patients may have undetected myocardial or pericardial disease that may pose a risk for hemopericardium and life-threatening tamponade after treatment with rt-PA.

Predictive factors in global and anesthesia satisfaction in ambulatory surgical patients

BACKGROUND

Patient satisfaction is one of the variables that affect the outcome of health care and the use of health-care services. As more procedures are performed on an ambulatory basis, the role of the anesthesiologist becomes more important. To improve the delivery of care, the predictors of dissatisfaction with the entire process (global dissatisfaction) of ambulatory surgery and with anesthesia itself must be identified. The authors conducted a hypothesis-generating study to identify predictors; specifically, they hypothesized that satisfaction with anesthesia was a predictor of global satisfaction with ambulatory surgery and that 24-h postoperative symptoms were a predictor of satisfaction with anesthesia.

METHODS

The authors prospectively studied 5,228 consecutive patients having surgery in the ambulatory setting during a 1-yr period. Preoperative, intraoperative, and postoperative variables were gathered and patient satisfaction was assessed using a postoperative telephone questionnaire administered 24 h after operation in 2,730 respondents. Significant univariate variables and clinically important variables were entered into multiple logistic regression models. Qualitative data on dissatisfaction were obtained by asking patients' reasons for dissatisfaction.

RESULTS

Sixty-eight of the 2,730 respondents (2.5%) had global dissatisfaction with ambulatory surgery. Nine of these patients were dissatisfied with anesthesia. Dissatisfaction with anesthesia was associated with a 12-fold increase in global dissatisfaction (P = 0.0001). Thirty-one of the 2,730 respondents (1.1%) were dissatisfied with anesthesia. An increasing number of symptoms occurring 24 h after operation was associated with an exp(0.28 x N)-fold increase in dissatisfaction with anesthesia for N number of symptoms (P = 0.0001). Qualitative data showed that the most common reason for global dissatisfaction with ambulatory surgery was personal preference for inpatient care (26%), whereas intraoperative and postoperative adverse outcomes were the major causes of dissatisfaction with anesthesia (88%).

CONCLUSIONS

Dissatisfaction with anesthesia is a predictor of global dissatisfaction with ambulatory surgery. An increasing number of symptoms 24 h after operation is a predictor of dissatisfaction with anesthesia. The rate of global dissatisfaction and anesthesia dissatisfaction is very low. The predictors from this model need to be validated by a second data set from either this or another center. Given the low rate of dissatisfaction, a focused study testing specific interventions to improve patient satisfaction would be difficult.

Quantitative determination of gene expression by competitive reverse transcription-polymerase chain reaction in degraded RNA samples

Quantitative competitive reverse transcription-polymerase chain reaction has become a powerful tool for determining the amount of mRNA in cultured cells as well as in tissue. To ensure the reliability of the analysis, RNA with high purity and integrity is needed. However, when analyzing RNA samples from tumor biopsies, RNA degradation is often an inevitable problem. This causes differences in sample quality and furthermore adversely affects the quantification of gene expression. Here, we demonstrate that in partially degraded RNA samples different mRNAs are degraded to the same extent. Normalizing the expression level of a specific gene to that of a constitutively expressed gene in the same sample allows the relative quantification of this specific gene. Thus, the comparison of gene expression in RNA samples with varying integrity is possible.

Correlation between simple clinical parameters and the in vitro humidification characteristics of filter heat and moisture exchangers. Groupe de Travail sur les Respirateurs

STUDY OBJECTIVE

This study on ventilated patients in ICUs examined a large sample of heat and moisture exchanger filters (HMEFs) to determine whether simple clinical parameters are correlated with exchanger humidity output.

DESIGN

A total of 594 HMEFs (18 types of HMEF) were tested in nine university hospital ICUs.

PATIENTS

Each HMEF was tested on one different unselected and consecutive patient for 24 h.

INTERVENTIONS

The following parameters were rated at each tracheal aspiration on a scale of 0 to 3: secretion abundance, viscosity (Visc), suction catheter adherence (Adh) to the endotracheal tube, and the amount of water condensed in the flex tube (Cond). Individual values for each type of HMEF and each variable were averaged and correlated with the humidity output (HO) of the HMEFs, values which were supplied by the manufacturers.

RESULTS

There were significant correlations between HO and Cond (r=0.82, p<10(-3)), Visc (r=-0.67, p=0.002), and Adh (r=-0.56, p=0.01). A second study recorded the same variables, for three consecutive 24-h periods, using first a high-humidifying HMEF (DAR Hygrobac), followed by a low-humidifying one (Pall BB22-15), and again DAR Hygrobac. Visc and Adh were higher (p<0.05) and Cond was lower (p<0.05) with the Pall than with the DAR.

CONCLUSIONS

Simple clinical parameters correlate well with the efficiency of HMEFs. The apparent water condensed in the flex tubing seems to be the best indicator of the humidifying efficiency of HMEFs.

Loco-regional recurrence following mastectomy for early breast carcinoma: efficacy of radiotherapy at the time of recurrence

This study aims to define the risk factors for loco-regional relapse following mastectomy, and to assess the efficacy of radiotherapy at the time of relapse. To achieve this 272 patients with loco-regional relapse treated at a single institution with modified radical or radical mastectomy were reviewed. Tumour size, axillary node involvement and tumour grade were found to be significant risk factors for loco-regional recurrence of disease. Radiotherapy given at the time of relapse controlled disease in 61% of cases, compared with 34% of patients treated with systemic treatment only. Altogether, 146 (54%) of the 269 evaluable patients with local failure had uncontrolled disease at the same site, either at the time of death or at the date last seen. The result of this retrospective study showed that delayed radiotherapy was effective in controlling the disease in patients with developing loco-regional relapses. However, as adjuvant radiotherapy reduces the incidence of local disease recurrence it should be recommended to patients considered to be at high risk of local relapse following mastectomy; namely those with tumours bigger than 5 cm with four or more positive axillary nodes.

Fabrication of stable packed capillary reversed-phase columns for protein structural analysis

Capillary column (< or = 320-micron ID) liquid chromatography is an essential tool for the separation and concentration of low-picomole amounts of proteins and peptides for mass-spectrometric based structural analysis. We describe a detailed procedure for the fabrication of stable and efficient 50- to 180-micron ID polyimide fused-silica columns. Columns were packed by conventional slurry packing with reversed-phase silica-based supports followed by column bed consolidation with acetonitrile and sonication. PVDF membrane or internal fused-silica particles were employed for column end-frit construction. The ability of these columns to withstand high back pressures (300-400 bar) enabled their use for rapid chromatography (> 3400 cm/hr; i.e., approximately 40 microliters/min for 200-micron ID columns) and the loading of large sample volumes (up to 500 microliters). The accurate low flow rates (0.4-4.0 microliters/min) and precise gradient formation necessary to operate these columns were achieved by a simple modification of conventional HPLC systems [Moritz et al. (1992), J. Chromatogr. 599, 119-130]. Column performance was evaluated for ability to resolve low-fmol amounts of all components of a mixture of PTH-amino acids and to separate peptides for on-line LC/MS analysis of peptide mixtures derived from in situ digestion of 2-DE resolved protein spots.

Suprascapular nerve block for postoperative pain relief in arthroscopic shoulder surgery: a new modality?

Arthroscopic shoulder surgery has a 45% incidence of severe postoperative pain. Opiates and interscalene nerve blocks have a high incidence of side effects, and intraarticular local anesthetic has been shown to be ineffective when used for postoperative pain relief. The suprascapular nerve supplies 70% of the sensory nerve supply to the shoulder joint, and local anesthetic block of this nerve is effective in certain shoulder pain disorders. To determine the efficacy of a suprascapular nerve block, subcutaneous saline was compared with a suprascapular nerve block using 10mL of 0.5% bupivacaine with 1:200,000 epinephrine before general anesthesia was induced. In the immediate postoperative period, a 51% reduction in demand and a 31% reduction in consumption of morphine delivered by a patient-controlled analgesic system was demonstrated. There was more than fivefold reduction in the incidence of nausea, as well as reduced visual analog and verbal pain scores for patients who received a suprascapular nerve block. The duration of hospital stay was reduced by 24% in the suprascapular nerve block group. A 24-h phone call interview revealed a 40% reduction in analgesic consumption and a reduction in verbal pain scores at rest and on abduction. There were no complications from the suprascapular nerve block. This study demonstrates that a suprascapular nerve block for pain relief in arthroscopic shoulder surgery is an effective and safe modality of postoperative pain relief.

Recall after total intravenous anaesthesia due to an equipment misuse

PURPOSE

To present a case of recall after total intravenous anaesthesia (TIVA) with propofol-alfentanil infusions to point out an uncommon misuse of the Bard InfusOR syringe driver.

CLINICAL FEATURES

A healthy patient underwent diagnostic dilatation and curettage and laparoscopy for lysis of peritoneal adhesions. After induction, anaesthesia was maintained with propofol-alfentanil infusions using the Bard InfusOR syringe drivers. Ten minutes into maintenance, the patient was moving. The flashing green light confirmed delivery of the medication and the alarms were not activated. However, the latch of the movable lever in the propofol syringe driver was found to be improperly positioned at the top of the plunger and only a small amount of propofol had been delivered. Postoperatively, the patient could recall the abdomen being touched during laparoscopy. An explanation was given and the patient was satisfied.

CONCLUSION

The Bard InfusOR syringe driver is not designed to detect a malposition of the lever on the syringe plunger. The anaesthetist must ensure proper placement of the lever and visual confirmation of medication delivery in order to prevent awareness due to this particular problem.

Are operative delivery procedures in Greece socially conditioned?

Caesarean section rates have increased in Greece by almost 50% during the last 13 years. We conducted a study in Athens, Greece, to assess the importance of a series of medical and socioeconomic factors in the use of Caesarean section or operative vaginal procedures, rather than a non-operative process, for the delivery of singleton, liveborn babies of primiparous mothers. We used a case control approach to compare 444 babies delivered through a Caesarean section and 130 delivered through operative vaginal delivery with 1235 normally delivered babies in a public and a private hospital. Data were analysed through multiple logistic regression. Caesarean section was more commonly performed in older, shorter or overweight mothers and for high and low birth-weight babies, as well as in response to several obstetric complications and following in-vitro fertilization. A similar pattern was noted with respect to operative vaginal delivery, except that this procedure was not unusually frequent among overweight women and was not encountered in this study among children born after in-vitro fertilization. Caesarean section was performed twice as often in the public teaching hospital as in a private maternity hospital, and operative vaginal delivery was several times more common in the former than in the latter, after controlling for biomedical risk factors. The unequal distribution of operative delivery procedures between the public and the private hospital raises questions about the justification of their performance in a substantial fraction of deliveries, and indicates that social factors condition their use.

Inadequacy of iridium implant as sole radiation treatment for operable breast cancer

In order to avoid a prolonged course of external irradiation as part of breast conservation therapy, 27 patients received an iridium implant to the primary tumour bed as sole radiation treatment. Surgery was standardised comprising tumourectomy and axillary clearance. Using a rigid implant afterloading with iridium192 wires, 55 Gy was delivered on a continuous basis over 5 days. After 6 years median follow-up, relapse of cancer within the treated breast has occurred in 10 of the 27 patients (37%). Compared with historical controls treated by similar surgery and iridium192 implant (20 Gy) with external radiotherapy (46 Gy), there was a significantly increased breast relapse rate in those treated by iridium implant alone. However, the incidence of distant metastases and overall survival was similar. Thus, a continuous iridium192 implant delivering 55 Gy in 5 days is not an effective means of achieving local control in patients with operable breast cancer.

Modulation of birthweight through gestational age and fetal growth

Several factors are known to affect birthweight and their effects are variously mediated through gestational duration or through fetal growth conditional on this gestation. In order to quantify independent associations of birthweight conditional and unconditional on gestational age, all 2538 mothers of singleton babies delivered during 1993 in two Maternity Hospitals in Athens were interviewed and their obstetric records abstracted. Birthweight was modelled as outcome variable through multiple regression including 32 potentially predictive factors. The regression model was fitted with and without gestational age as an additional independent variable in order to apportion birthweight associations into those independent of, or mediated through, gestational length. The factors studied were found to be classifiable into the following categories: factors associated with birthweight mostly through increases in gestational duration, either positively (age at menarche, long menstrual cycles, parity 4 or higher), or negatively (single motherhood, maternal age, tobacco smoking); those associated with birthweight mostly through increase of birthweight conditional on gestational duration, either positively (male gender, short menstrual cycles, maternal pre-pregnancy weight, anaemia, oedema) or inversely (employment during pregnancy, stillbirth, primiparity, pregnancy induced hypertension, coffee drinking); and those associated with birthweight through apparently dual effects, either positively (maternal education) or inversely (perceived stress, bleeding during pregnancy). The other studied factors were not demonstrably related to birthweight in this data set. Identification and quantification of these relations is useful for understanding underlying physiological and pathophysiological processes and for increasing specificity in exploring the association of birthweight with adult onset diseases, like coronary heart disease or cancer.

Capital decisions. Where is the smart money being invested?

Health care executives are faced with a welter of priorities when it comes to allocating their increasingly scarce capital: they need to build information systems, organize primary care physicians, and expand outpatient services. But what are the defining issues? We asked five executives to explain how their strategies are changing as a result of managed care growth and integration. What emerges is a snapshot of the new capital allocation reality.

Birth weight and handedness in boys and girls

The association between selected demographic variables and birth weight on the one hand and a composite hand preference score based on seven hand tasks (each performed twice) on the other was investigated in a sample of 1387 male and female schoolchildren aged 5 to 10 years old. In multiple regression models left-handedness was significantly more common among boys and among children of better educated mothers and tended to decrease with age. No association was found with respect to urban or rural residence or birth order. Increased birth weight was associated with right-handedness in boys but with left-handedness in girls, and the birth weight by sex interaction term was statistically significant (p = 0.037). The demographic associations in the present study are compatible with those reported previously. The different associations of birth weight with hand preference in boys and girls indicate that the prenatal hormonal factors that affect brain lateralization and handedness are qualitatively or quantitatively different in the two sexes and may be differentially associated with birth weight.

Management and motivational factors in the control of noise induced hearing loss (NIHL)

This paper describes a study investigating attitudes to noise as an occupational hazard. The objectives of the study were to understand the individual and organizational factors which affect attitudes towards noise induced hearing loss (NIHL) and to relate these to the standards of hearing conservation achieved in industry as demonstrated by compliance with the Noise at Work Regulations. The study comprised a survey of 48 organizations across Britain, and a more detailed examination of 10 of these as case studies. Methods used included desk research, audits of hearing conservation programmes, questionnaires and interviews. Whilst there is widespread acceptance that industrial noise is a hazard, it is one that is frequently taken for granted, and measures to deal with it are often inadequate. Most organizations place the onus on the workforce to protect their own hearing through the use of personal hearing protectors. Workers reactions to noise tended however to be passive and much of the time neither managers nor the workforce are concious of the noise hazard. This is the case even where some managers are committed to good industrial housekeeping and accident prevention. As effective hearing conservation programme requires three management attributes: leadership from senior management, the ability of middle management (particularly in production and engineering) to put hearing conservation measures into practice, and specialist technical knowledge of noise and of the legislation. The study points to the need for more education and motivation of senior managers as the priority in improving standards of hearing conservation and noise control.

Survival from childhood leukemia depending on socioeconomic status in Athens

One hundred and twenty children first diagnosed as having acute leukemia between 1988 and 1992 in Athens, Greece, were followed until May 15, 1993. The socioeconomic status of the children's families was assessed by means of paternal occupation, paternal schooling, maternal schooling, ownership of a car, ability to choose a private medical facility and freedom in the choice of the attending physician. The analysis was done by proportional-hazards modelling, controlling for age and gender. All six socioeconomic indicators, alternatively evaluated, showed that fatality rates were higher in the lower socioeconomic groups, although nominal statistical significance was reached for only one of them. With respect to family ownership of a private car, the fatality rate ratio between children of families who own a car and children of families who do not was 0.29 with a 95% confidence interval of 0.13-0.62 (p = 0.002). These results suggest that in Greece, socially disadvantaged children have a less favorable survival from childhood leukemia.

Trends and geographical distribution of childhood leukemia in Greece in relation to the Chernobyl accident

Parts of Greece have been exposed to fallout radiation from the Chernobyl accident as much as any of the countries boardering with the former Soviet Union, because of the direction of the prevailing winds after the accident. Although fallout radiation did not reach levels expected to be associated with measurable effects, there is widespread concern in Greece that the incidence of childhood leukemia may be rising in the more heavily affected parts of Greece. Patient discharge data from all Greek hospitals treating childhood leukemia were used to calculate the annual incidence of the disease from January 1980 to June 1986 (preaccident period), from July 1986 to June 1988 (immediate postaccident period) and from July 1988 to June 1991 ("relevant" post-accident period, that accommodates the presumed latent period of the disease). Fallout radiation measurements (in Bq/kg Cs-137) were used to create 17 regions of similar (within regions) but highly variable (between regions) levels of fallout deposition. Background radiation (in Bq/kg Ra-226) and annual incidence of childhood leukemia by region were also estimated. There was no evidence of increased incidence of childhood leukemia during the immediate or the "relevant" post-Chernobyl period in any part of the country. Furthermore, regression analyses did not show any significant or suggestive association of childhood leukemia by region with either background or fallout radiation. These results indicate that the Chernobyl accident did not affect noticeably the incidence of childhood leukemia in Greece during the five-year post accident period.

Evaluation of 0.75% metronidazole gel in acne--a double-blind study

Metronidazole, an imidazole, is an antibiotic with established efficacy against anaerobic bacteria. To date, however, there are no published data concerning the efficacy of topical metronidazole in the treatment of acne. This randomized, double-blind prospective clinical study of 96 patients was performed to investigate the efficacy and tolerability of 0.75% metronidazole gel vs. placebo in the treatment of mild to moderate acne. The results of this study showed no significant benefit in using 0.75% metronidazole gel over placebo in reducing counts of inflamed and non-inflamed lesions of acne. There was also no statistically significant difference between the two groups at any stage in the trial when skin tolerability was assessed.

Dental management of a child on anticoagulant therapy and the International Normalized Ratio: case report

A 7-year-old girl with a history of four prosthetic heart valve replacements and daily anticoagulant therapy was treated with modification of the anticoagulant regimen and hospitalization. Coagulation times now are being expressed using the International Normalized Ratio (INR), a move by the international medical community to standardized laboratory values worldwide. This report describes this new measure and its role in patient assessment.