Telehealth mitigates COPD disease progression compared to standard of care: a randomized controlled crossover trial.

BACKGROUND: We showed excellent adherence and satisfaction with our telehealth care (TC) approach for COPD. Here, the results of a consecutive randomized controlled trial are presented. METHODS: Patients were randomly assigned to TC or standard care (SC). During TC, patients answered six daily questions online, and focused on the early recognition of exacerbations, in addition to SC. RESULTS: The mean increase in COPD assessment test (CAT) was 1.8 vs. 3.6 points/year in the TC and SC groups, respectively (P = 0.0015). Satisfaction with care (VAS) at baseline was 8.2; at the end of SC, 8.5 (P = 0.062); and after TC, 8.8 (P < 0.001). We detected significantly more moderate exacerbations during TC. CONCLUSION: Whilst receiving TC, the slope of the CAT increase - an indicator of the naturally progressive course of COPD - was reduced by 50%. Satisfaction with care increased with TC. The higher number of detected moderate exacerbations probably indicates a higher diagnostic sensitivity than without TC.

Right ventricular myocardial protection through intracavitary cooling in cardiac operations.

In an attempt to protect the right ventricle, we designed and tested a closed cooling system that circulates cold saline through a double-lumen, balloon-tipped catheter positioned in the right ventricular cavity. Fourteen sheep were randomly assigned to two groups. In group A (n = 7), the right ventricular cooling catheter system was used in addition to coronary cardioplegic perfusion and systemic hypothermia for myocardial protection. Group B (n = 7) served as a control group. In group A, the right ventricular temperatures were significantly lower than those of the control group (16.1 degrees +/- 0.3 degrees C versus 23.9 degrees +/- 0.4 degrees C; p less than 0.0001, Student's t test). The most common temperature range was 12 degrees to 18 degrees C (67.1%, frequency distribution analysis), and 63.2% of temperatures were below 16 degrees C. The catheter system also maintained the temperatures of the interventricular septum at a lower level than those recorded in the control group and prevented septal rewarming, which was significant in group B (from 16.5 degrees +/- 1.5 degrees C to 25.0 degrees +/- 0.9 degrees C; p less than 0.04, Mann-Whitney U test). Left ventricular temperatures were not changed by the catheter system. By better cooling the right ventricle and the septum, the right ventricular cooling catheter system should decrease the prevalence of right ventricular failure and allow more time to safely complete multiple coronary anastomoses in coronary artery bypass graft operations.

Real-time pachymetry during photorefractive keratectomy using optical low-coherence reflectometry.

Optical low-coherence reflectometry (OLCR) was used as a noncontact method to measure the central corneal thickness of three patients intraoperatively during photorefractive keratectomy. Continuous on-line measurements were performed on the intact cornea immediately before the beginning of surgery, after the removal of the corneal epithelium, during laser tissue photoablation, and for 3 min after the ablation process. Corneal thinning due to evaporation was studied on a separate patient with the OLCR instrument, and it was found to be -0.14 microm/s during the first 5 min after epithelium removal. This baseline corneal thinning rate was used as a fit parameter to calculate actual from measured ablation depths. The measurements showed a maximum difference of +/-10 microm between planned ablations (34-92 microm) and measured ablation depths.

Use of a scapular free flap for reconstruction of the cricoid cartilage in pharyngolaryngeal oncology.

A newly developed technique for cricoid reconstructive surgery is presented and discussed. This method allows us to increase the number of patients presenting with squamous cell carcinoma who may benefit from partial laryngectomy. The method is based on the transfer of a vascularized scapular flap to reconstruct half a resected cricoid. Two alternatives may be used whether anterior laryngectomy preserves the half posterior cricoid and both arytenoids or a hemilateral laryngectomy leaves one arytenoid and half the cricoid. Complementary radiotherapy may be performed after surgery. Satisfactory results are reported from an initial series of three patients.

Scavenging anesthetic gas from a membrane oxygenator during cardiopulmonary bypass.

Concerns remain about the acute and chronic effects on personnel of waste anesthetic gases in the operating room environment. This study demonstrates a simple and effective means of scavenging waste anesthetic gases when halogenated anesthetics are administered through the pump oxygenator during cardiopulmonary bypass. This technique safeguards workers' health by reducing ambient anesthetic levels below the National Institute for Occupational Safety and Health (NIOSH) recommended exposure limits.

[Anaphylaxis to muscle relaxants. Predictive value of intradermal tests and study of crossed anaphylaxis]. / Anaphylaxie aux myorelaxants. Valeur prédictive des intradermoréactions et recherche de l'anaphylaxie croisée.

37 patients were studied, all of whom presented with anaphylaxis to a muscle relaxant. The diagnosis was made after simultaneous intradermal testing (IDT), human basophil degranulation tests (HBDT) and Prausnitz-Küstner tests (PK) of passive cutaneous anaphylaxis. Three tests were positive in 6 patients, both IDT and PK in 9, and both IDT and HBDT in 8. In 14 patients, the IDT, repeated twice, were positive both times. A search for crossed anaphylaxis to the other muscle relaxants was carried out in all the patients during a second series of tests, a few months to years after the first one. The drugs tested, at dilutions of the pharmaceutical preparation of 10(-3) or more, were: suxamethonium, gallamine, alcuronium, pancuronium, vecuronium, d-tubocurarine. The reliability of IDT in the diagnosis of anaphylaxis is discussed in terms of the small reactive concentration, the producibility of the tests, the one HBDT that did become positive later, and in one case the occurrence of shock by crossed anaphylaxis. Skin reactivity seemed to remain constant with time, so allowing the use of IDT as a diagnostic tool, in cases of old anaphylactoid shocks, occurring during general anaesthetics. The frequency of crossed anaphylaxis was assessed to be about 84%. The sensitivity to one or other drugs varied with each patient. Pancuronium and vecuronium appeared to be the least likely drugs to cause crossed anaphylaxis. The predictive use of these tests is discussed. It is also suggested that muscle relaxants with only one quaternary ammonium group should be used, this chemical characteristic probably reducing the risks of sensitization.

[The histaminic and anaphylactic risks of atracurium]. / Le risque histaminique et anaphylactique de l'atracurium.

The histamine releasing potential of atracurium was assessed by testing skin reactivity in ten patients who had previously suffered from a preanaesthetic anaphylactoid accident, but in whom the diagnosis of anaphylaxis had not been confirmed. Atracurium was injected intradermally in increasing concentrations so as to determine the reactivity level, comparing it in the same patient with that due to d-tubocurarine and alcuronium given in the same way. Skin tests with histamine and 48/80 were also carried out at the same time. When a positive reaction was obtained with atracurium, the injection was repeated 4 h after, the patient having taken 50 mg hydroxyzine p.o. The results showed that the skin reactivity level with d-tubocurarine was obtained with 1 in 100 dilution and with atracurium 1 in 10, with nine patients out of ten reacting positively. Alcuronium is the least histamine releasing drug, as it gave rise to a positive reaction in only two patients at a dilution of 1 in 10. Histamine release due to atracurium was greatly reduced by giving hydroxyzine. The allergizing potential was also studied in six other patients who had a tone anaphylaxis to a muscle relaxant and in whom crossed anaphylaxis was being tested for. All the commercial muscle relaxants together with atracurium were tested, even though none of the patients had ever received this last. Anaphylaxis was confirmed when the intradermal reaction was positive with a dilution of 1 in 1,000 and beyond. These tests showed that five patients out of the six had a crossed anaphylaxis, and one of these five was sensitive to all four muscle relaxants (atracurium included).(ABSTRACT TRUNCATED AT 250 WORDS)

[The value of prick tests in the detection of anaphylaxis caused by muscle relaxants]. / Intérêt des prick-tests dans le dépistage de l'anaphylaxie aux myorelaxants.

Intradermal tests (IDR) are a sure diagnostic procedure for confirming the IgE origin of anaphylactoid accidents due to muscle relaxant drugs. Because carrying these out and interpreting them correctly is difficult, epidermal prick-tests (PT) could be used if they proved as sure as IDR. To ascertain this, IDR and PT were carried out in 38 patients who had a shock after being given a muscle relaxant 6 months to 5 years previously; for these tests, increasing concentrations of five muscle relaxants were used (suxamethonium, gallamine, alcuronium, pancuronium and vecuronium). The PT were also carried out with the five same pure and diluted muscle relaxants in a group of 147 volunteer controls. For the 38 patients, PT and IDR were always positive for the same drugs, but at different concentrations, the epiderm seeming less sensitive than the derm (with a ratio of 1 to 100). In the control group, all the tests were negative, even with the pure drug. PT with muscle relaxants were sensitive, specific of anaphylaxis, and permanent. Easy to carry out, easily interpreted, they could be useful as tests for predicting latent sensitisation in risk patients requiring muscle relaxants. But all muscle relaxants must be tested, and not just the one the anaesthetist is likely to use.

[Mitral valve prolapse: a factor exacerbating peranesthetic anaphylactic shock]. / Prolapsus de la valve mitrale: facteur aggravant le choc anaphylactoïde peranesthésique.

Initial cardiac failure in anaphylactoid shock is rare, classically related to cardiac anaphylaxis occurring in a highly sensitized patient. However, this anaphylaxis is not always found; the case described here of a histamine shock with ventricular fibrillation after the injection of thiopentone is a good example of this. The severity of the shock may be explained by the presence of a prolapse of the small flap of the mitral valve.

[Risk factors in anaphylactoid reactions to muscle relaxants. A retrospective study of 103 cases of shock]. / Facteurs de risque des réactions anaphylactoïdes aux myorelaxants. Etude rétrospective à partir de 103 chocs.

A homogeneous series of 103 cases of shock due to muscle relaxants has been used to identify the risk factors in anaphylactoid shocks due to either true anaphylaxis or to non-specific histamine release. Clinical atopy (asthma) and sub-clinical atopy as shown up by skin tests with mites and pollens, as well as a history of IgE-dependent drug allergy, were present with a significantly greater frequency in the history of patients presenting with anaphylaxis. Abnormal histamine release and reactivity to histamine, as assessed by skin tests with 48/80 and histamine, were often found in those patients who presented with non-specific histamine release induced by muscle relaxants. Whatever the mechanism for the shock, the frequency of spasmophilia was increased. A history of non-immunological intolerance to acetyl salicylic acid and other non-steroid anti-inflammatory drugs was more often found than in the reference drugs was more often found than in the reference population. However, 25% of the patients studied did not have any of these risk factors. Several possibilities of preventing anaphylactoid reactions are given, if one or more of these risk factors are found in the history: a better choice of anaesthetic drugs, in the light of previous anaesthetic protocols, the relief of anxiety by appropriate premedication, antihistamine premedication and the prevention of bronchospasm.

[Change in skin reactivity in anaphylaxis to muscle relaxants and hypnotics after administration of anti H1, anti H2 and tritoqualine]. / Modification de la réactivité cutanée dans l'anaphylaxie aux myorelaxants et hypnotiques après administration d'anti H1, d'anti H2 et de tritoqualine.

Inhibition of allergic skin reactivity was studied by the technique of thresholds in 35 patients presenting with an anaphylaxis to muscle relaxants. This method was useful to determine the anti-histamine or anti-anaphylactic effects of different substances. The best results were obtained with hydroxyzine. Associating it with an anti H2 drug (cimetidine or ranitidine) did not improve these results. Skin reactivity was never entirely abolished. This confirmed that no premedication could avoid the occurrence of an anaphylactic shock, or even reduce its magnitude. However, premedicating before general anaesthesia with anti H1 and anxiolytic drugs must be continued for all high risk patients: the prevention of non-specific histamine release appeared to be much more efficient than that of anaphylaxis.

[Radioimmunoassay method for the detection of IgE antibodies specific to alcuronium]. / Méthode radio-immunologique de détection des IgE spécifiques à l'alcuronium.

A radio-immunoassay (RIA) was used to screen for specific IgE to myorelaxants. Alcuronium was coupled to epoxy-activated Sepharose. Sixteen patients with anaphylaxis to alcuronium (n = 2), gallamine (n = 2) or suxamethonium (n = 12) were studied. The diagnosis was established by intradermal tests (ID), passive cutaneous anaphylaxis tests and human basophil degranulation tests. The amount of non specific label retained by Sepharose-ethanolamine (with sera of patients) and Sepharose-alcuronium (with sera of 11 control subjects) was estimated. The RIA was positive 10/16 (8/14 patients having reacted to a muscle relaxant other than alcuronium). The RIA seemed to be useful in the diagnosis of anaphylaxis to muscle relaxants. Drug-reactive antibodies were specific of the quaternary ammonium radical, which was the common allergenic determinant of all molecules of muscle relaxants. This test accounted for in vitro cross-reactivity, but had no predictive value for the clinical risk of crossed-anaphylaxis. This risk was best assessed by ID; it was positive in three cases. Although it was not possible to compare ID and RIA, the interpretation of which was different, both tests should be recommended for the detection of sensitivity to muscle relaxants.

[Anesthetics responsible for anaphylactic shock. A French multicenter study]. / Substances anesthésiques responsables de chocs anaphylactiques. Enquête multicentrique française.

Combined allergological and anaesthetic consultations have been started in the last few years in eight French Teaching Hospitals so as to explore peranaesthetic anaphylactoid shocks. A survey was carried out in these centers in order to collect patients investigated with the same protocol, for the assessment of the incidence of anaphylaxis in France, as well as the involved drugs. Investigations were always carried out at least 6 to 8 weeks after the accident. The tests used to diagnose IgE-dependent anaphylaxis were skin tests (prick and intradermal tests, carried out in all eight centers), the radioimmunological assay of specific anti-quaternary ammonium IgE, together with an inhibition test with thiopentone and propofol (six centers), leukocyte histamine release (five centers) and human basophil degranulation tests (three centers) for those drugs for which no specific antibody assay exists. The collected data involved 1,240 patients, investigated within the last four years. Anaphylaxis was diagnosed in 821 patients (66.2%). Muscle relaxants were responsible in 668 cases (80% of cases of anaphylaxis). Suxamethonium was the main cause (54.3% of shocks due to muscle relaxants), followed by vecuronium (15.3%). General anaesthetics (hypnotics and benzodiazepines) were responsible for 9.2% of all cases of anaphylaxis opioids for 2.6%. There were only three cases of shock due to local anaesthetic agents. Latex and ethylene oxide are becoming increasingly involved. It would therefore seem mandatory to carry out after any anaphylactoid accident an assessment with sensitive and specific tests for anaphylaxis. Diagnosing anaphylaxis means that the involved drug should be used never again in that patient. Because muscle relaxants are by far the most involved drugs, anaesthetists should use them only when really required.

[An original technique of reconstruction of the cricoid cartilage by vitalized scapular flap. Application to pharyngolaryngeal carcinology]. / Technique originale de reconstruction du cartilage cricoïde par lambeau vitalisé de scapulaire. Application en carcinologie pharyngo-laryngée.

A personal technique for cricoid reconstructive surgery is presented and discussed. A transfert of a free living scapular flap by microvascular anastomoses is used for reconstructing half cricoid resection. We can with this technique increase the number of partial laryngectomy in patients with squamous cell carcinoma. Two techniques are possible: The half anterior laryngectomy conserves only the half posterior cricoid and the twice arytenoids. The half lateral laryngectomy conserves one arytenoid and a half cricoid.

[Leukocyte histamine liberation tests for the diagnosis of anaphylactic reaction to curare-like agents]. / Intérêt du test de libération d'histamine leucocytaire dans le diagnostic de l'anaphylaxie aux curarisants.

Anaphylaxis to myorelaxants is the main etiology of adverse reactions to anesthetics and adjuvants. The diagnosis relies on skin tests--prick or intradermal tests--radio-immunoassays for series specific IgE, human basophil degranulation tests and leucocyte histamine++ release. 28 patients with an anaphylaxis to myorelaxants have been studied, using the two tests. Skin tests are the more specific and accurate ones. ARIA using a quaternary ammonium hydrated gel, is highly specific and its sensitivity reaches 80%. The leucocyte histamine release may be interest in evaluating anaphylaxis especially when another drug might be involved. The sensitivity of HBDT is low, indicating that HBDT is to be discarded as far as other tests have been developed, for myorelaxants. However, its usefulness for other drugs has to be compared to leucocyte histamine release.

[The amount of histamine released in vivo by hypnotics (thiopental, methohexital, propofol) studied by assays of plasma histamine]. / Etude du pouvoir histaminolibérateur in vivo des hypnotiques (thiopental, méthohexital, propofol) par dosages d'histamine plasmatique.

Accidents observed during induction of anaesthesia are most often linked to non-specific histamine liberation. The sale of new hypnotics (Methohexital and Propofol), has brought the hope that their histamine-liberation potential would be lower. The study was done in patients who were at risk of histamine-liberation (atopics, drug allergies etc.). Two series of patients were studied after anti H1 and tranquilizer premedication. Histamine liberation by Propofol versus Thiopental as the inducer was studied in the first group. In the second, the combination was Methohexital versus Thiopental. In both series studied the new hypnotics Propofol and Methohexital did not release histamine non-specifically in atopics at risk. Neither clinical reactions non increase of histamineamia were seen. It is concluded that these two new drugs are safe.