[Fast track surgery]. / Chirurgie fast track.

Fast track (FT) surgery is a multimodal concept aiming to reduce postoperative pain and stress-induced organ dysfunction. Key elements are perioperative fluid restriction, epidural analgesia, early oral nutrition and early mobilization. Therefore, multidisciplinary teamwork is required in order to obtain the optimal outcome of reduced postoperative complications and a hospital stay of only three or four days after open colectomy. Most of the patients undergoing colorectal surgery qualify for FT surgery. Meanwhile, FT principles are applied in a variety of open and laparoscopic procedures. The aim of this review is to highlight the principles of FT and to answer the question why FT surgery should nowadays be considered as standard care.

How do humans control physiological strain during strenuous endurance exercise?

BACKGROUND: Distance running performance is a viable model of human locomotion. METHODOLOGY/PRINCIPAL FINDINGS: To evaluate the physiologic strain during competitions ranging from 5-100 km, we evaluated heart rate (HR) records of competitive runners (n = 211). We found evidence that: 1) physiologic strain (% of maximum HR (%HRmax)) increased in proportional manner relative to distance completed, and was regulated by variations in running pace; 2) the %HRmax achieved decreased with relative distance; 3) slower runners had similar %HRmax response within a racing distance compared to faster runners, and despite differences in pace, the profile of %HRmax during a race was very similar in runners of differing ability; and 4) in cases where there was a discontinuity in the running performance, there was evidence that physiologic effort was maintained for some time even after the pace had decreased. CONCLUSIONS/SIGNIFICANCE: The overall results suggest that athletes are actively regulating their relative physiologic strain during competition, although there is evidence of poor regulation in the case of competitive failures.

[Peri-operative stress response and peri-operative analgesia in children].

Peri-operative surgical stress (SS) is characterized by increased secretion of pituitary hormones and sympathetic activation and is correlated with changed blood levels of stress hormones and metabolites. Adverse effects of perioperative stress include mortality and morbidity and a negative nitrogen balance. Although peri-operative analgesia and stress response-free period are commonly considered as synonyms, pain seems not to be the only factor determining the hormonal-metabolic response to surgery. Other factors playing a role in the creation of SS in newborns include blood loss, site of surgery, superficial and visceral trauma, surgery duration, hypothermia, infection, prematurity and factors related to cardiac surgery. Potent semi-synthetic opioids attenuate the SS better than morphine. However, supplementation of general anesthesia (GA) with local anesthetics either by way of regional or local anesthesia seems to decrease SS more effectively than GA with IV opioids. Hemodynamic monitoring may not suffice for SS or analgesia quality estimation. The most accessible laboratory measure for the monitoring of the stress response for non-cardiac surgery and pre-bypass phase of cardiac surgery may be blood glucose. Blood glucose increases with stress and when analgesia is inadequate; it is easily measured and treated almost immediately once an excessive response is identified. This individualized approach and real-time feedback may be far better than using either excessive opioid doses (hoping to ablate stress response) or minimal opioid dosages.

Efficacy of dog-appeasing pheromone in reducing stress associated with social isolation in newly adopted puppies.

This study was designed to determine the potential value of dog-appeasing pheromone (dap) in reducing stress in puppies newly adopted from a pet shop. The trial was triple-blinded and placebo-controlled. After their arrival at the pet shop, 32 puppies were fitted with a dap collar and 34 were fitted with a control collar, according to a randomisation protocol. Adopting owners were contacted by telephone, three and 15 days after they had adopted a puppy, to obtain information about the puppy's integration into the family, and particularly about any signs of distress shown by the puppy when it was socially isolated. All the isolated puppies from the control group vocalised during the first night. Signs of distress, particularly vocalisation, were significantly lower in the dap group on day 3 and throughout the rest of the study, and vocalisation during the night ceased significantly sooner in this group. These differences were observed in puppies of small, medium and large breeds. The dap collars had no effect on the incidence of house soiling.

[Sedation an acute respiratory distress syndrome]. / Sédation du patient présentant un syndrome de détresse respiratoire aiguë.

AIM: To assess the role of sedation and myorelaxant agents in acute respiratory distress syndrome (ARDS) and to propose an updated management according to recent literature. EXTRACTION OF DATA: From Medline and Cochrane database of English and French language articles. Keywords were: acute respiratory distress syndrome, acute lung injury, general anaesthetics, inhalation, intravenous anaesthetics and intensive care. Selection of original articles, reviews and expert reports. Case reports have been included. TOPIC: ARDS is a clinical picture in which respiratory constraints are major because of hypoxemia. To insure correct haematosis, mechanical ventilation has to be considered. It constitutes, then, the most frequent indication of sedation in the intensive care unit. The objectives are to help the ventilation of lungs and to improve gas exchange, by controlling agitation, fight against ventilation and to reduce mechanical ventilation associated injuries. In this situation, use of myorelaxant agents is aimed at facilitating synchronization of the patient with his/her ventilator and serves to improve oxygenation during the early inflammatory phase of ARDS. Several mechanisms may enflame this improvement of oxygenation. One of the most probable effect on optimization is the possibility of optimize protective ventilation at the cares phase of ARDS and to reduce mechanical ventilation-associated injuries. CONCLUSION: With regard to benefits and inconvenient, sedation is considered as a treatment of ARDS. Its goals are the well being of patient and his/her adaptation to ventilator, but also the prevention on mechanical ventilation associated injuries. Hence, most authors suggest using a deep sedation at the early phase of ARDS. In this contact, use of myorelaxant agent is an intersecting adjuvant if sedation is not enough. The benefit is terms of survival and outcome remains to show.

Alzheimer's disease, amnestic mild cognitive impairment, and age-associated memory impairment: current understanding and progress toward integrative prevention.

Alzheimer's disease, AD, is the most common form of dementia. AD initially targets memory and progressively destroys the mind. The brain atrophies as the neocortex suffers neuronal, synaptic, and dendritic losses, and the hallmark amyloid plaques and neurofibrillary tangles proliferate. Pharmacological management, at best, is palliative and transiently effective, with marked adverse effects. Certain nutrients intrinsic to human biochemistry (orthomolecules) match or exceed pharmacological drug benefits in double-blind, randomized, controlled trials, with superior safety. Early intervention is feasible because its heritability is typically minimal and pathological deterioration is detectable years prior to diagnosis. The syndrome amnestic mild cognitive impairment exhibits AD pathology and to date has frustrated attempts at intervention. The condition age-associated memory impairment is a nonpathological extreme of normal brain aging, but with less severe cognitive impairment than amnestic mild cognitive impairment. Age-associated memory impairment is a feasible target for early intervention against AD, beginning with the modifiable AD risk factors - smoking, hypertension, homocysteine, type 2 diabetes, insulin resistance, and obesity. Stress reduction, avoidance of toxins, and mental and physical exercise are important aspects of prevention. The diet should emphasize omega-3 fatty acids docosahexaenoic acid and eicosapentaenoic acid; flavonoids and other antioxidant nutrients; and B vitamins, especially folate, B6 and B12. Dietary supplementation is best focused on those proven from randomized, controlled trials: the phospholipids phosphatidylserine and glycerophosphocholine, the energy nutrient acetyl-L-carnitine, vitamins C and E, and other antioxidants. A comprehensive integrative strategy initiated early in cognitive decline is the most pragmatic approach to controlling progression to Alzheimer's disease.

[Effect of highway driving on the health of factory workers].

Commuting transportation is one of the important factors in the administration of safety management in industries. Most workers commute to work by car and are certain to make use of highways, mainly because of the special condition of factory locations. In this study, we investigated the effect of communicating by car on the health of factory workers. The proportion of males was significantly higher in the highway (HW) group than in the non-highway (NHW) group, and the former was younger than the latter. BMI, systolic blood pressure, diastolic blood pressure, and total cholesterol deteriorated significantly in the NHW group after 5-year periodic medical checkups. However, in the HW group, those factors did not change except for systolic blood pressure and significant improvements in triglyceride. The percentage of those who follow a good lifestyle regarding excise and nutrition, and have a solution for stress, was lower in the HW group than in the NHW group. Nevertheless, the percentage of those who did not feel stress was significantly higher in the HW group than in the NHW group, suggesting a stress-relieving effect of highway driving. Highway driving might have an unexpectedly good impact on the health of factory workers.

Stress management in the difficult patient encounter.

Patient care and management can present a significant source of stress for the practicing dentist. This article presents the various facets and underpinnings of stress, followed by an overview of the physiologic phenomena attending the classic stress response, with an examination of the interplay between the psychologic components of stress and its influences on the development or exacerbation of somatic disorders. In addition, the characteristics that can be attributed to the patient and the practitioner that give rise to difficult encounters are explored, with an eye toward proper professional management. Further, the motivations of select patient personae are examined, including discussions regarding the angry patient, the anxious or demanding patient, and the noncompliant and addicted patient. The article offers suggestions for management of such patients, with short- and long-term stress management techniques.

Building physician resilience.

OBJECTIVE: To explore the dimensions of family physician resilience. DESIGN: Qualitative study using in-depth interviews with family physician peers. SETTING: Hamilton, Ont. PARTICIPANTS: Purposive sample of 17 family physicians. METHOD: An iterative process of face-to-face, in-depth interviews that were audiotaped and transcribed. The research team independently reviewed each interview for emergent themes with consensus reached through discussion and comparison. Themes were grouped into conceptual categories. MAIN FINDINGS: Four main aspects of physician resilience were identified: 1) attitudes and perspectives, which include valuing the physician role, maintaining interest, developing self-awareness, and accepting personal limitations; 2) balance and prioritization, which include setting limits, taking effective approaches to continuing professional development, and honouring the self;3) practice management style, which includes sound business management, having good staff, and using effective practice arrangements; and 4) supportive relations, which include positive personal relationships, effective professional relationships, and good communication. CONCLUSION: Resilience is a dynamic, evolving process of positive attitudes and effective strategies.

Impact of environmental factors and poverty on pregnancy outcomes.

Studies have indicated that various societal factors such as toxicant exposure, maternal habits, occupational hazards, psychosocial factors, socioeconomic status, racial disparity, chronic stress, and infection may impact pregnancy outcomes. These outcomes include spontaneous abortion, preterm birth, alterations in the development of the fetus, and long-term health of offspring. Although much is known about individual pregnancy outcomes, little is known about the associations between societal factors and pregnancy outcomes. This manuscript reviews some of the literature available on the effects of the above-mentioned societal factors on pregnancy outcomes and examines some potential remedies for preventing adverse pregnancy outcomes in the future.

Stress and burnout in anaesthesia.

PURPOSE OF REVIEW: Recently, many researchers have been studying stress and burnout in anaesthesia. Some researchers have examined the effects of stress in the workplace. Others have identified some job characteristics that have an impact on anaesthetist's well-being. Yet, few studies use the same measure of stress and/or define the concept of stress in the same way, making comparison and aggregation of results difficult, and therefore minimizing the general impact of these research findings. RECENT FINDINGS: The following review focuses on the increasing recent research on stress and burnout in anaesthesia regarding the existing stress models and shows where the progress has been made, and where difference of opinion and divergence of approach remain. SUMMARY: From the referred studies, the review challenges the more practical problems of prevention of stress and burnout and provides some avenues for future investigations.

Lower stress responses after Newborn Individualized Developmental Care and Assessment Program care during eye screening examinations for retinopathy of prematurity: a randomized study.

OBJECTIVE: Screening examination for retinopathy of prematurity is distressing and painful. The aim of the present study was to investigate whether a Newborn Individualized Developmental Care and Assessment Program intervention during a retinopathy of prematurity examination results in less adverse behavioral, pain, and stress responses as compared with standard care. METHODS: The first 2 eye examinations in 36 preterm infants were evaluated. The infants were randomly assigned at the first eye examination to receive either Newborn Individualized Developmental Care and Assessment Program care or standard care. At the second examination, crossover of subject assignment was performed. The assessments included behavioral responses; recordings of heart rate, respiration, and oxygenation; pain scores (premature infant pain profile); and salivary cortisol at defined time points up to 4 hours after the eye examination. The nursing support given during the eye examinations (intervention score) were scored using predefined criteria. RESULTS: Altogether, 68 examinations were evaluated. Newborn Individualized Developmental Care and Assessment Program care was associated with better behavioral scores during the examination but there was no difference in heart rate, respiratory rate, oxygenation, or premature infant pain profile score between the 2 care strategies before or after the eye examination. Salivary cortisol increased from baseline to 30 minutes after the eye examination independent of care strategy and decreased significantly between 30 and 60 minutes when infants were subjected to Newborn Individualized Developmental Care and Assessment Program care but not after standard care. During the study period the intervention score for standard care increased and approached the score for Newborn Individualized Developmental Care and Assessment Program care at the later eye examinations. CONCLUSION: A Newborn Individualized Developmental Care and Assessment Program-based intervention during eye examination does not decrease pain responses but results in faster recovery, as measured by lower salivary cortisol 60 minutes after the examination. The differences were seen despite the influence from the Newborn Individualized Developmental Care and Assessment Program intervention on the standard care treatment that occurred during the study period.

Impact of endurance exercise on levodopa-associated cortisol release and force increase in patients with Parkinson's disease.

Levodopa (LD) application improves motor symptoms and reduces cortisol levels in patients with Parkinson's disease (PD). Endurance exercise enhances cortisol release in proportion to the intensity of the effort and thus may counteract the LD associated cortisol decrease. We measured levels of cortisol and LD over an 1-h long interval following administration of soluble 200 mg LD/50 mg benserazide with concomitant maximal grip strength assessment in 16 PD patients under cued conditions during rest and endurance exercise. The motor response, the plasma levels of cortisol and LD did not significantly differ between both conditions. Cortisol concentrations significantly decreased even during exercise. Grip strength only significantly went up during rest. Endurance exercise did not counteract the LD associated decreased cortisol release. Since cortisol improves muscle function, the lack of increase in maximal grip strength following LD administration during exercise may contribute to reduced exercise capacity, which is reported by PD patients.

Preventive effect of a traditional herbal medicine, Hochu-ekki-to, on immunosuppression induced by surgical stress.

PURPOSE: To examine the effect of preoperative administering of a Japanese traditional herbal medicine, Hochu-ekki-to (TJ-41), on immunosuppression induced by surgical stress in patients with gastrointestinal malignancies. METHODS: To monitor the immune functions, the mitochondrial membrane potential (MMP) and natural killer (NK) cell activity prior to and following operation were measured in peripheral blood lymphocytes (PBL) in patients with (n = 20) or without (n = 27) the preoperative administering of TJ-41 for 7 days. The plasma catecholamine and interleukin (IL)-6 levels were also analyzed prior to and following the operation. RESULTS: The numbers of MMP-high CD56-positive cells (NK cells) and NK cell activities in the TJ-41-treated group were significantly higher than those in the control group (P = 0.026 and P = 0.037, respectively). An elevation of plasma noradrenaline and IL-6 following surgery was also inhibited by the preoperative administering of TJ-41 (P = 0.023 and P = 0.039, respectively). A positive correlation between MMP-high CD56-positive cell numbers and NK cell activity in PBL treated with carbonyl cyanide m-chlorophenyl hydrazone (CCCP) in vitro suggested that MMP measurement in CD56-positive cells can serve as a convenient alternative to evaluate the NK cell activity. CONCLUSION: Our findings suggest that the preoperative administering of TJ-41 prevents surgical stress-induced immunosuppression by maintaining the NK cell activity and inhibiting the elevation of stress mediators.

[The preoperative medication: background and specific indications for the selection of the drugs]. / Charakteristika und Auswahl der Substanzen.

Prior to an operation, patients experience a high degree of stress and internal tension. Preoperative drug administration (premedication) is intended to reduce these stresses through anxiolytic and sedative effects. On account of their good anxiolytic actions, there excellent tolerability and only few side effects benzodiazepines are most frequently used for this purpose. To support the induction and continuation of sleep, premedication is usually initiated in the evening before operation with the administration of a benzodiazepine with middle- or long-term activity. The standard drug for the day of operation is the short-acting benzodiazepine midazolam, under the action of which the patient may be transferred to the operation room in a drowsy and calm state. The onset of action of drugs applied as preoperative medication is delayed. Thus, it is of major importance that the premedication be administered at the appropriate time point so that the patient really is shielded fro preoperative stress at the time of the drug's optimal effect. Although midazolam is not the ideal substance for all situations where an anxiolytic premedication is needed, with the exception of a few special indications, no decisive advantages over other drugs have been demonstrated in comparative trials.