Beta-endorphin, cortisol and postoperative delirium: a preliminary report.

A transient delirium, including hallucinations and disorientation, occurred at some time during a 48 to 72 hr postoperative period in patients recovering from elective surgery in an intensive care unit. The occurrence of delirium in these patients was associated with a significant and unusually prolonged postoperative increase in circulating levels of beta-endorphin (B-endorphin) and cortisol, and a total disruption of normal plasma circadian rhythms of B-endorphin and cortisol. Postoperative mean 24-hr plasma levels of B-endorphin and cortisol were not significantly different from preoperative baseline levels in those patients who did not exhibit post-surgical delirium. Circadian rhythms of B-endorphin and cortisol in the non-delirious patients also remained normal following surgery, although peak plasma concentrations were significantly phase-shifted to later in the day. A disruption in circadian rhythms of the endogenous opiate/hypothalamic-pituitary-adrenal axis may represent an important component of post-operative psychological changes that are frequently observed in the intensive care unit setting.

Hyperparathyroidism in the elderly.

A survey was made on the records of 40 patients aged 60 or older who were operated on at Boston University Medical Center over a 10-year period for suspected primary hyperparathyroidism. Mild or "asymptomatic" presentation was virtually the rule, with many patients having become accustomed to some degree of decreased well-being. The findings were compared with those in other reviews of the clinical manifestations of hyperparathyroidism, in both general and elderly populations of patients. Issues of screening for mild or asymptomatic disease, especially among the elderly, are discussed.

Species differences in insulin secretory responses during hemorrhagic shock.

Insulin secretory rates (ISR) during intravenous glucose tolerance tests (IVGTT's) were measured in six dogs subjected to hemorrhagic shock and were compared to ISR's from five monkeys subjected to shock of comparable severity. ISR's also were measured in normotensive control dogs and monkeys subjected to the same blood sampling protocol. A sixfold increase in ISR occurred in shocked dogs after glucose loading; however, no ISR response occurred in monkeys subjected to hemorrhage. It is concluded that marked species differences exist in the insulin-glucose metabolic responses to shock. In addition, the dog would appear to be an inappropriate experimental animal as applied to trauma-insulin metabolism in man.

Effects of beta-hydroxybutyrate, glycerol, and free fatty acid infusions on glucagon and epinephrine secretion in dogs during acute hypoglycemia.

The importance of glucagon in the regulation of carbohydrate metabolism is clearly established. However, the role played by this hormone in the regulation of the overall fuel economy is less certain, particularly with respect to such nonglucose fuels as free fatty acids, glycerol, and ketoacids. In order to elucidate glucagon's role with respect to the latter substrates, dogs were infused with solutions of these three fuels, and their A-cell responses to concomitant insulin-induced hypoglycemia were studied. In addition, epinephrine levels were also monitored. It was found that while these infusions failed to suppress glucagon release, the ketoacid infusion did significantly reduce epinephrine secretion during the insulin-induced hypoglycemic period. It was therefore concluded that glucagon secretion under these experimental conditions is not responsive to prevailing non-glucose fuel levels. Indeed, these data suggest that the sympathetic nervous system may play an important role in the regulation of the over-all fuel economy.

Persisting structural abnormalities in liver, kidney, and muscle tissues following hemorrhagic shock.

Hemorrhagic shock-induced abnormalities of liver, kidney, and muscle morphology were studied sequentially for eight days following shock and resuscitation in rabbits. The findings revealed marked structural changes, some of which became more pronounced between one and three days after shock and all of which persisted for at least three days. All of the tissue changes reverted to near normal by eight days. The specific findings included hepatic sinusoidal compression with cellular swelling and vacuolization one day after shock; renal vacuolization and swelling of proximal tubular convolutions, culminating in widespread cellular damage three days after shock; and separation of myofibrils and disruption of the band pattern in muscle tissue. These findings demonstrated the prolongation of the morphological abnormalities induced by shock, previously observed only in the acute phase, and the capacity for structural repair by the tissues after reversible hemorrhagic shock.

The effects of surgery on the circadian rhythms of cortisol.

The circadian rhythms of plasma cortisol levels are studied extensively. Frequent sampling techniques are used to examine the effects of surgical trauma on the circadian pattern of plasma cortisol in man. Five patients were studied, 48 hours before and 48 hours after major surgery. The normal preoperative cortisol rhythms of these patients did not disappear after surgical trauma but they were significantly phase-shifted. In addition, the mean cortisol concentrations were significantly elevated and the intracircadian cycles suffered complex changes in the postoperative period.

Should we shrink the health care system?

As this director of a large eastern medical center has traveled about the country, talked many times on the subject of health cost management, and examined various cost-containment plans, he has come to realize that most, if not all, of those isolated programs stand little chance of more than marginal success. True cost management can come only from a hospital system shrinkage that involves loss of jobs and closings. There is no simple way out of that box, he argues, and people should begin to realize it. Whether there is the national resolve to put the lid on accelerating health costs is questionable, but at least a clear understanding of that fact and its consequences may lead to a few successful hardheaded programs and provide preventive medicine for the numerous trivial programs that no doubt will continue to spring up.