Oxygen embolism after hydrogen peroxide irrigation of a vulvar abscess.

We report a case of venous oxygen embolism in a 33-yr-old healthy woman after irrigation of a vulvar abscess with 25 ml of 3% hydrogen peroxide. Venous oxygen embolism was diagnosed by the development of sudden hypoxia associated with a decrease in end-tidal carbon dioxide concentration from 5.3 kPa to 3.2 kPa, and a 'mill-wheel' sound on cardiac auscultation soon after injection of the solution. The patient responded to corrective treatment including the Trendelenburg position and 100% oxygen. She made an uneventful recovery. We discuss the possible causative mechanism of this embolism, the different diagnostic methods, and the controversial aspects of available treatments. We emphasize that hydrogen peroxide is a dangerous and unsuitable agent for routine wound irrigation and debridement.

Health status, perceptions of coping, and social support immediately after discharge of survivors of acute myocardial infarction.

BACKGROUND: The period immediately after discharge from the hospital after an acute myocardial infarction is a stressful and vulnerable time about which little is known. OBJECTIVE: To explore health status, perceptions of coping, and social support among survivors of a recent myocardial infarction in the first 3 weeks after discharge from hospitals in southwestern Sydney, Australia. METHODS: A descriptive, exploratory approach with a triangulated methodology was used to assess the experiences of 38 survivors, detect patterns in these experiences, explore the health-support needs of survivors, and determine changes in health status in the first 3 weeks after discharge. Quantitative data were collected with the Medical Outcomes Study SF-36, New York Heart Association classification, Canadian Cardiovascular Society Angina Scale, and the Jalowiec Coping Scale. A semistructured interview schedule provided additional qualitative data about the experiences of the survivors. RESULTS: The health status of participants was relatively stable during the 3-week period; most had no activity limitation due to dyspnea or angina. However, the subjects' health status was considerably lower than that of their age-matched population. The most common and most effective coping strategies adopted during this period were confrontation, optimism, and self-reliance. In addition, the subjects experienced anxiety, depression, ambiguity and uncertainty, fear of recurrence of the infarction and of deterioration in health, of boredom and of inertia. CONCLUSION: These findings can help nurses in hospital and community settings assist survivors of acute myocardial infarction to prepare for and deal effectively with experiences during convalescence.

Women recovering from first-time myocardial infarction (MI): a feminist qualitative study.

Although myocardial infarction (MI) is a leading cause of death and disablement for women internationally, little is known about women's recovery. This paper describes an exploratory descriptive study that was informed by feminist principles, and which aimed to explore the recovery experiences of a group of women survivors of first-time MI in the initial period following discharge from hospital. A total of 10 female survivors were interviewed using an open-ended semi-structured interview schedule administered at 7, 14 and 21 days post-hospital discharge. Findings revealed that recovery was experienced as a complex process, initially characterized by fear and uncertainty. Over the duration of the study these feelings were replaced with a more positive outlook, a return of energy, and a sense of confidence in the future. Participants identified an unmet need for reliable information which persisted over the duration of the study. The findings of this study have implications for nursing practice and research. Chief among these is the issue of effective provision of information to women following an acute MI. The importance of providing relevant information to be understood and retained by people experiencing crisis cannot be overstated. Equally important are the provision of opportunities for patients to have regular contact with health professionals to question and seek clarifying information. These findings should now be tested on larger populations.

Detecting tumor-related alterations in plasma or serum DNA of patients diagnosed with breast cancer.

Chromosomal abnormalities are associated with the development of breast cancer, and widespread allelic loss or imbalance is frequently found in tumor tissues taken from patients with this disease. Using different markers, we studied a total of 61 patients (divided into three groups) for the presence of microsatellite instability and loss of heterozygosity (LOH) in plasma or serum DNA. Of the initial 27 patients, 35% of the tumor samples displayed LOH, whereas 15% had identical alterations in the corresponding plasma samples. In addition, the adjacent normal breast tissue of two patients also displayed LOH. In a second group of 11 patients, 45% of the tumors displayed LOH, and 27% displayed identical plasma DNA alterations; one case displayed an identical LOH in adjacent nontumor tissue. In a third series of 23 patients also studied with tetranucleotide repeats, 81% of the tumor samples displayed LOH, whereas 48% had LOH in the corresponding serum samples. The fact that small tumors (T1) of histoprognostic grade 1 or in situ carcinomas could present DNA alterations in the plasma/serum at an early stage, allied to the widely increased range of available microsatellite markers, suggests that plasma or serum DNA may become a useful diagnostic tool for early and potentially curable breast cancer.

[The effect of different anesthetic procedures on hormone levels in women. Studies during an in vitro fertilization-embryo transfer (IVF-ET) program]. / Der Einfluss unterschiedlicher Anästhesieverfahren auf den Hormonhaushalt der Frau. Untersuchungen im Rahmen eines in vitro-Fertilisations-Embryotransfer-(IVF-ET-)Programms.

Different anaesthetic procedures that were used during an in vitro fertilisation and embryo transfer (IVF-ET) program have been analysed in order to determine their influence on plasma levels of estradiol, progesterone, prolactin, and beta-endorphin and results of IVF-ET. METHODS. Fifty-four patients awaiting transvaginal oocyte aspiration were randomised into three groups: (1) anaesthesia with ketamine as an induction agent and analgesic (n = 20); (2) general intubation anaesthesia using thiopentone for induction and enflurane for maintenance (n = 18); and (3) no anaesthesia (n = 16). Estradiol, progesterone, prolactin, and beta-endorphin were measured from day 3 to 14 referring to follicle aspiration. Differences between preoperative hormone levels and their intra- and postoperative peaks were analysed using the Kruskal-Wallis test (P < 0.03). The results were corrected using the Holms method (alpha = 0.05). RESULTS. No differences were observed in estradiol and progesterone levels (Figs. 1, 2). Prolactin levels were 1.4 times higher (P < 0.001) when ketamine was used and 2.2 times higher (P < 0.001) after short general anaesthesia than in the control group (Fig.3). Similar results were observed with respect to beta-endorphin: in comparison with the control group we found significant elevation by a factor of 2.1 when ketamine was used (P < 0.001). The discrepancy became even more marked with general anaesthesia: beta-endorphin was 3.9 times higher compared to the controls (P < 0.001) (Fig.4). Comparing the two groups who were given anaesthetics, prolactin and beta-endorphin levels were also significantly different (P < 0.001). The IVF procedure itself did not appear to be affected by different anaesthetic procedures during oocyte aspiration (Table 2). CONCLUSIONS. The increased prolactin and beta-endorphin plasma levels associated with ketamine and general anaesthesia reflect a significant alteration of the observed hormone levels. When anaesthesia is indicated, we try to avoid general intubation anaesthesia in favor of ketamine.

[Effect of different follicle puncture methods on hormone homeostasis in the woman. Studies within the scope of an in vitro fertilization-embryo transfer program]. / Der Einfluss unterschiedlicher Follikelpunktionsmethoden auf den Hormonhaushalt der Frau. Untersuchungen im Rahmen eines In-vitro-Fertilisation-Embryotransfer-Programmes.

Different methods for follicular puncture which were used in an in vitro fertilization-embryo transfer program have been analyzed in order to determine their influence on plasma levels of estradiol, progesterone, prolactin and beta-endorphins. Thirty-eight patients awaiting oocyte aspiration were randomized into a laparoscopic (n = 20) and an ultrasound-guided oocyte aspiration group (n = 18). No differences were observed as far as estradiol and progesterone levels and embryo transfer rates were concerned. When using the laparoscopic technique, prolactin levels were found to be elevated 1.5 times in comparison with the ultrasound-guided aspiration procedure, which is highly significant (p < 0.001). Also, beta-endorphins peaked at a significantly higher level during laparoscopy (27.8 vs. 20.7 mol/l, p < 0.001). The enhanced prolactin and beta-endorphin levels reflect an increased stress response during laparoscopy. With respect to less trauma and shorter duration of the procedure, we now perform the sonographically guided transvaginal aspiration technique in our program almost exclusively.

General anaesthesia versus epidural anaesthesia for primary caesarean section--a comparative study.

Forty-seven healthy parturients undergoing elective Caesarean section were randomly allocated to either general anaesthesia (n = 24) or epidural anaesthesia (n = 23) under standardized anaesthetic and surgical conditions. Seven women of the epidural group required additional systemic analgesia or sedation following delivery of the neonate. Nine of 24 newborns obtained 1-min Apgar scores below 7 after general anaesthesia compared to only 3/23 after epidural anaesthesia. The time period to establish normal colour in the babies was 2.2 min after epidural and 4.9 min after general anaesthesia. Three of the 24 general-anaesthesia newborns demonstrated a tendency to hypotonia compared to only one in the epidural group. Twenty-four hours and 7 days after delivery all infants of both groups were completely normal. At the time of delivery maternal PO2 was higher in the general anaesthesia compared to the epidural group, due to higher inspired oxygen concentrations. Comparable results were obtained in umbilical PO2 venous values; lower pH values, however, were observed in the umbilical artery after general anaesthesia. There were no significant differences in the glucose levels between the groups. A significant correlation was established between uterine incision-delivery interval and 1-min neonatal Apgar scores in the general-anaesthesia group, but not in the epidural group. Our investigation did not show either the incision-delivery interval or the start of operation-delivery interval to play a role in neonatal outcome. Epidural anaesthesia is superior to general anaesthesia in Caesarean section under normal conditions with regard to neonatal outcome. Whether this is also true for critical conditions cannot be concluded from this study.

Biochemical validation of self-reported caffeine consumption during caffeine fading.

Increasing concern about caffeine as a drug with potential for abuse has resulted in the development of procedures for effecting reductions in caffeine consumption among heavy users. However, the reliability of reported findings may be questioned, since previous studies have relied on subject self-report as the principal measure of caffeine use. The present study employed bioanalytic methods for assessing the reliability of self-reported caffeine intake during a caffeine-fading regime. Twelve subjects, each with a history of heavy caffeine use, provided baseline, treatment, and follow-up blood samples which were assayed for caffeine and its major metabolites. General support was provided for the reliability of self-report as a measure of caffeine consumption. The general efficacy of caffeine fading was also supported, although there were indications that maintenance effects may have been over-estimated in previous studies.

Ultrasonically guided follicle aspiration for oocyte retrieval in an in vitro fertilization program: further simplification.

Transabdominal, transvesical aspiration of oocytes was performed in 58 infertility patients under ultrasound guidance. In contrast to other groups, no particular guiding instruments were used. Wider bore needles and general anesthesia improved the oocyte recovery rate from 44% to 80%, thus approaching the one achieved by laparoscopy.

[Anesthesia-related maternal mortality during labor. Results of a survey in the Federal Republic of Germany 1971-1980]. / Anaesthesiebedingte mütterliche Mortalität während der Geburt. Ergebnisse einer Befragung in der Bundesrepublik Deutschland 1971-1980.

In order to obtain figures on the anaesthesia related maternal mortality in the Federal Republic of Germany, 707 hospitals have been addressed via questionnaire. Hospitals where obstetric departments and anaesthetic departments as well were available, were investigated for maternal mortality, anaesthetic requirements, and the complications which led to the maternal deaths during the period of 1971-1980. 38% (259 general hospitals and 10 university hospitals) responded; the geographical distribution seemed to be representative. The average maternal mortality rate was at 0.21%, which ranged from 0.21% for general hospitals to 0.16% for university hospitals. The overall anaesthesia related maternal mortality was around 6.4%. 20 of the reported 21 maternal deaths occurred under general anaesthesia and 1 under local anaesthesia; 17 patients died during caesarean section and 4 during vaginal delivery. The main complications which led to the maternal deaths were cardiac arrest and aspiration of gastric content with 38,1% each and convulsions with 4.8%. In 19% of the total maternal deaths the causes could not be determined. The importance of obstetric centres and of controlled anaesthetic methods delivery will be discussed on the basis of these and other figures which have been reported in the literature.

The early use of positive end expiratory pressure (PEEP) ventilation in emergency medicine, and some experiments on pigs.

The effects on near drowning of young pigs of positive end expiratory pressure and zero end expiratory pressure were studied. The arterial PO2 and blood gases were examined during recovery from near drowning and after haemorrhagic shock. The cardiovascular parameters were measured after shock. The findings were considered in relation to the use of positive and expiratory pressure in patients. It was recommended that it be only administered by experienced staff in hospitals, and should not exceed 10 mbars, while 5 mbar was adequate and avoided complications in most cases.

[Comparative studies on general anesthesia versus peridural anesthesia in primary cesarean section]. / Vergleichende Untersuchungen zur Allgemeinanaesthesie bzw. Periduralanaesthesie bei der primären Sectio caesarea.

In a prospective interdisciplinary study involving the departments of gynaecology, anaesthetics and paediatrics, the influence on both the mother and neonate of general as opposed to epidural anaesthesia was compared in 47 planned caesarean sections. Neither maternal or foetal risk factors were present in these cases, and the cardiotocogram was always normal before the anaesthetic was applied. Methods. Systolic and diastolic blood pressure were carefully monitored. Under an identical infusion regime the following parameters were estimated in maternal blood: blood gas and acid-base status, blood sugar, lactate, beta-hydroxybutyric acid, ACTH and cortisol. These same parameters were also estimated in cord blood taken at delivery. The Apgar score at 1, 5 and 10 minutes, and a complete paediatric assessment including neurostatus at 15 minutes, 24 hours and 7 days of age were used to assess neonatal status. Some of the women given a general anaesthetic initially had marked increases in blood pressure and pulse, while about a third of the epidural cases showed a blood pressure fall despite positioning in the left lateral position in order to prevent the aorto-caval syndrome. An increase in lactate, ACTH and cortisol was found in both groups up to the time of delivery, when the ACTH level of the general anaesthetic group was significantly higher. Acid-base and PCO2 values were not markedly influenced by either of the techniques used, but the maternal capillary PO2 levels were very much higher in the general anaesthetic group. The neonates born under general anaesthetic had a lower 1 min Apgar score, as a result of the relatively long induction-delivery time, of on average 17 min. The 5 and 10 min Apgar scores and the neurophysiological development of the babies revealed no differences between the two groups.

[General anesthesia or peridural anesthesia in primary cesarean section; a comparative study]. / Allgemeinanästhesie oder Periduralanästhesie bei der primären Sectio, eine vergleichende Untersuchung.

In a prospective cooperative study of gynecologists, anaesthesiologists and pediatricians we compared the effect of continuous epidural anaesthesia (23 cases) and of general anaesthesia (24 cases) on mother and newborn. All patients were delivered in the 39. to 41. week of an uncomplicated pregnancy by primary caesarean section for breech presentation or disproportion. Nearly one third of the patients with epidural anaesthesia showed an initial transitory decrease in blood pressure- up to 25%. The mean pO2 was higher (155 mmHg) in the group with the general anaesthesia than in the group with epidural anaesthesia (88 mmHg). Corresponding values for pO2 were found in the umbilical artery (22,8 mmHg after general anaesthesia, 16,6 mmHg after epidural anaesthesia). Concerning the pH in the umbilical artery, the better results were obtained in the group with continuous epidural anaesthesia (7,3 versus 7,27). After general anaesthesia 9 children had a one minute Apgar-score below 8 versus 3 children after epidural anaesthesia; five and ten minutes after birth the Apgar scores were practically identical. The neurologic examination 15 min after delivery revealed a pathologic muscle tone in three cases after general anaesthesia and in one case after epidural anaesthesia. After 7 days all children showed a normal neurobehavior. As no severe differences between the two types of anaesthesia in the effect on mother or newborn could be seen, in uncomplicated pregnancies the choice should be left to the mother.

[Peridural morphine analgesia: effects and pharmacokinetics. A double-blind study in vaginal hysterectomy patients]. / Peridurale Morphinanalgesie: Wirkung und Pharmakokinetic. Eine Doppelblindstudie bei vaginalen Hysterektomien.

In a controlled prospective double-blind-study we were able to show that the analgesic duration of epidurally applied morphine is more than four fold longer lasting than intravenous morphine. We found similar pharmacokinetics in both groups, suggesting a rapid absorption of epidurally applied morphine into the vascular system. The identical pharmacokinetics of intravenous and epidurally applied morphine suggest that only small amounts of morphine diffuse across the dura to the spinal cord, where it produces a long lasting analgesia at the opiate receptors. The comparison of serum morphine levels in patients who reported a very short lasting and very long lasting analgesia gave us no pharmacokinetic explanation for this difference.

[A comparative study on the obstetric aspects of epidural anaesthesia]. / Geburtshilfliche Aspekte der Katheterperiduralanästhesie. Eine vergleichende Studie.

A retrospective analysis of 2,130 deliveries in 1980 was done. 42.21% of the women had epidural anaesthesia (EDA). They were compared with the 57.79% of the women, who did not have EDA. Decisive differences in both groups concerning age, fetal malposition, birth weight, umbilical artery pH and the Apgar score after one minute were not noted. There were more primiparous women in the EDA group and more women with a nationality other than German in the control group. Frequency of instrumental vaginal deliveries was extremely high in the EDA group as compared with the control group. In the EDA group a prolongation of labour especially the third stage was observed. A cesarian section due to an arrest in the process of labour was more often performed in the EDA group than in the control group. The suggestion is made that the relaxation of the pelvic floor and the diminuation of the bearing down reflex in EDA leads to a prolongation of labour and an increased instrumental delivery rate.

[Effectiveness of obstetric epidural analgesia. II. Caesarean section]. / Untersuchungen zur Effektivität der geburtshilflichen Periduralanaesthesie. II. Sectio caeserea.

A questionnaire was sent to 260 women who in 1979 had undergone a caesarean section under either epidural or general anaesthesia. Those women who had an epidural for their caesarean section were on average very well informed about the procedure. In contrast, those who had been given a general anaesthetic felt that they had been badly or inadequately informed. Over 90% of the patients of both the epidural and the general anaesthetic groups described the type of anaesthesia which they had received as "very good" to "adequate". In the epidural group, 80% of the patients described the experience of the birth as very intense. Headache, back pain and other complaints such as abdominal pain and wound pain were significantly more frequent in the general anaesthetic as compared to the epidural group. 85.8% of the women given an epidural said that they would choose the same again for a future caesarean, 12.1% would not. Of the group given a general anaesthetic, 29.9% said that in the future they would choose an epidural, and 62.3% that they would prefer to have a general anaesthetic again. The Apgar score at one minute, and the umbilical artery pH values of the newborn of the epidural group were significantly better than those of the general anaesthetic group, whereas at 5 and 10 min the Apgar scores of the babies of both groups showed no differences.