Evoked release of norepinephrine and serotonin from brain slices: inhibitoon by lithium.

Slices of mammalian brain accumulate H(3)-norepinephrine and H(3)-serotonin when incubated in a physiologic medium containing these tritiated monoamines. When these tissues are subjected to mild electrical stimulation of short duration, which is associated with depolarization of nerve membranes, a striking increase in the rate of efflux of the exogenous labeled monoamines occurs. Stimulation-induced release of both labeled monoamines is diminished by the presence of lithium ions in the perfusing medium; related monovalent cations had no such effect. Evoked release from slices of brain from animals treated intraperitoneally with lithium chloride for 3 days was also reduced.

Asterixis following metrizamide myelography.

Two patients seen after lumbar myelography with metrizamide demonstrated transient confusion and asterixis. Metabolic etiologies were excluded. To our knowledge, these are the first reported cases of asterixis following myelography with metrizamide.

CNS listeriosis: rhomboencephalitis in a healthy, immunocompetent person.

A previously healthy woman had a febrile illness resembling aseptic meningoencephalitis. With the exception of mild increase in both CSF pressure and protein concentration, initial findings were normal, including negative bacterial cultures. Bilateral pyramidal and cerebellar signs with multiple lower cranial nerve pareses developed over a 48-hour period beginning on the tenth hospital day. Repeated blood and CSF studies had previously been nondiagnostic, but at that time, cultures became positive for Listeria monocytogenes. No underlying systemic disease or immunodeficiency was discovered. With appropriate antibiotic and supportive therapy, she made slow but significant improvement and, by the time of discharge from the hospital, had only minimal residual neurologic deficit. Clinical aspects of CNS listeriosis including the rare pontomedullary involvement are discussed.

Multistage analysis of exercise radionuclide angiography in coronary artery disease.

The hypothesis that serial assessment of left ventricular function during exercise radionuclide angiography provides improved diagnostic criteria for coronary artery disease (CAD) was examined. Fifty-eight consecutive patients without previous myocardial infarction were prospectively scheduled for cardiac catheterization and multistage radionuclide angiographic exercise studies. Forty-one patients had significant CAD. The traditional criterion--failure to achieve a 5% increment in ejection fraction (EF) during exercise compared with the value at rest--had 85% sensitivity but only 41% specificity for CAD. In 12 patients, EF increased early in exercise by at least 4% and then decreased a mean of 7.5%, often with worsening regional wall motion. This "up-down" EF pattern was applied as a diagnostic test in the overall study group. Analysis of changes in EF from the maximal value achieved to that at the end of exercise resulted in criteria with greater sensitivity (p less than 0.0001) for CAD than analysis of changes from rest, with similar specificity. Regional wall motion abnormalities occurring during the first exercise stage resulted in 94% specificity for CAD (p = 0.05 vs end-stage analysis), although sensitivity was low. Analyzing the maximal EF during exercise results in improved sensitivity, while analyzing the early onset of regional dysfunction results in high specificity for CAD.

Prognostic significance of severe narrowing of the proximal portion of the left anterior descending coronary artery.

To determine the prognostic importance of significant narrowings involving the proximal left anterior descending coronary artery (LAD), 866 medically treated patients with significant coronary artery disease (CAD) were followed after cardiac catheterization for a mean of 17 months (range 1 to 46). Coronary narrowings in all patients were evaluated based on site relative to large branches and on angiographic severity. Prognosis was best predicted by the presence of at least 70% diameter reductions in the LAD before the first 2 large branches (chi 2 = 16, p = 0.0001). At 3 years, there was a 94% cumulative survival rate in patients with less than 70% stenoses at this location, but an 82% survival rate in patients with 70% or more stenoses (p less than 0.0001). In addition, although the presence of proximal LAD narrowings was the best predictor of prognosis in patients with a low global ejection fraction, this was not so in patients with normal ejection fractions, as this subgroup had an excellent overall prognosis. Thus, the presence and severity of significant stenoses in the proximal LAD are stronger predictors of prognosis than stenoses elsewhere in the major coronary arteries. The presence of an angiographically significant narrowing in this anatomic location is highly correlated with an increased 1- to 3-year mortality rate.

Critical analysis of the application of Bayes' theorem to sequential testing in the noninvasive diagnosis of coronary artery disease.

The utility of Bayes' theorem in the noninvasive diagnosis of coronary artery disease (CAD) was analyzed in 147 patients who underwent electrocardiographic stress testing, thallium-201 perfusion imaging and coronary angiography. Eighty-nine patients had typical anginal chest discomfort and 58 had atypical chest pain. Sensitivity and specificity of the tests and prevalence of CAD at each level of testing were tabulated and compared with the results generated from Bayes' theorem. The sensitivity of electrocardiographic stress was higher in patients with multivessel CAD than in patients with 1-vessel CAD. Sensitivity, but not specificity, of each test was dependent, in part, on the result of the other test. However, the probabilities calculated from Bayes' theorem when used for sequential testing are remarkably close to the tabulated data. Thus, Bayes' theorem is useful clinically despite some evidence of test dependence. Sequential test analysis by Bayes' theorem is most useful in establishing or ruling out a diagnosis when the pretest prevalence is approximately 50% and when the 2 tests are concordant.

Preoperative diagnosis of a ruptured intracranial dermoid cyst by computerized tomography. Case report.

A case of ruptured intracranaial dermoid cyst in the right middle fossa is reported. A definitive diagnosis of the lesion and the fact that it had ruptured was made possible by specific computerized tomographic findings. The findings were confirmed at surgery.

Hemodynamic stability and patient satisfaction after anesthetic induction with thiopental sodium, ketamine, thiopental-fentanyl, and ketamine-fentanyl.

STUDY OBJECTIVE: To examine three commonly used anesthetic induction regimens (thiopental sodium, ketamine, and thiopental plus fentanyl) and one newly described regimen (ketamine plus fentanyl) with respect to hemodynamic stability and patient satisfaction. DESIGN: Randomized, double-blind study. SETTING: University-affiliated Veterans Administration Hospital. PATIENTS: Forty-eight ASA physical status I and II patients (47 males, 1 female) scheduled for surgery requiring general anesthesia. INTERVENTIONS: Patients were randomized to one of four groups to receive intravenous injections of thiopental 5 mg/kg (Group 1), ketamine 1.5 mg/kg (Group 2), thiopental 3 mg/kg plus fentanyl 4 to 6 micrograms/kg (Group 3), or ketamine 0.5 mg/kg plus fentanyl 4 to 6 micrograms/kg (Group 4) for induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Heart rate (HR) and mean arterial pressure (MAP) were measured during anesthetic induction. Evaluation of patient satisfaction/dissatisfaction and pleasantness/unpleasantness by the Anesthesia Experience Rating (AER) was carried out the day following surgery. Groups 3 and 4 showed the least increase from their baseline values in both HR and MAP after tracheal intubation, but only Group 4 exhibited no statistically significant change in hemodynamic parameters after induction but before intubation (p < 0.05). AER showed a higher level of pleasantness in Group 3 as compared with Group 2 (p < 0.03) and higher levels of satisfaction in Groups 3 (p < 0.03) and 4 (p < 0.02) as compared with Group 2. CONCLUSION: The combination of ketamine plus fentanyl provides superior hemodynamic stability with excellent patient satisfaction.

Intraoperative management of a patient with a chronic, previously undiagnosed traumatic diaphragmatic hernia.

Traumatic diaphragmatic hernia (TDH) occurs in approximately 5% of hospitalized motor vehicle accident victims and 10% of victims of penetrating chest injury. Although most such injuries are diagnosed at the time of initial trauma, approximately 10% become apparent only months or years later. The TDH patient is at risk for surgical complications, including pulmonary aspiration, hypoxemia, and hemodynamic instability. Diagnosis and proper management of TDH is essential in order to minimize such complications. The anesthetic management of a patient with a preexisting TDH presenting for lumbar laminectomy is discussed.

Prolonged neuromuscular blockade following vecuronium infusion.

Administration of vecuronium by infusion is an increasingly common technique, both in the operating room and in the intensive care unit (ICU), for patients requiring prolonged neuromuscular blockade and mechanical ventilation. The major advantage of vecuronium over older neuromuscular blocking agents is its rapid excretion and intermediate duration of action. Prior to the current case report, the longest reported continuous paralysis after the cessation of a vecuronium infusion was 90 hours. A case of an 81-year-old patient with renal failure and subclinical chronic cirrhosis of the liver, who remained paralyzed for 13 days following a vecuronium infusion, is described. Intensive monitoring of neuromuscular function is recommended whenever muscle relaxants are administered by continuous infusion.

A comparison of cocaine, lidocaine with epinephrine, and oxymetazoline for prevention of epistaxis on nasotracheal intubation.

The alpha-adrenergic agonist oxymetazoline was compared to cocaine and to lidocaine with epinephrine with respect to prevention of epistaxis on nasotracheal intubation. The nares of three groups of 14 patients each were topically pretreated with 4% lidocaine with 1:100,000 epinephrine (group 1), 10% cocaine (group 2), or 0.05% oxymetazoline (group 3) prior to nasotracheal intubation. After intubation, epistaxis was estimated on a scale of 0 to 3, with 0 indicating no bleeding, 1 representing blood on the nasotracheal tube only, 2 indicating blood pooling in the pharynx, and 3 representing blood in the pharynx sufficient to impede intubation. Only 29% of the patients in group 1 displayed no bleeding, whereas 57% of those in group 2 and 86% of those in group 3 had no bleeding. Nonparametric analysis showed a statistically significant difference (p less than 0.013) between oxymetazoline and lidocaine with epinephrine. In addition, heart rate (HR) and blood pressure (BP) were examined prior to administration of the medications; at 5 minutes, 10 minutes, and 15 minutes after administration of the medications; and after intubation. No significant differences were noted (p greater than 0.05) between the medications except for a slightly higher systolic BP for cocaine than for lidocaine with epinephrine at 15 minutes. The results of this double-blind, randomized trial demonstrate that the alpha-adrenergic agonist oxymetazoline is as effective as cocaine, and more effective than lidocaine with epinephrine, for the prevention of epistaxis associated with nasotracheal intubation.

The Addiction Treatment Unit: a dual diagnosis program at the California Medical Facility--a descriptive report.

The Addiction Treatment Unit is a dual diagnosis program which exists in the California Department of Corrections. It is housed in the California Medical Facility in Vacaville, California. Program residents must meet the diagnostic criteria of having a major mental disorder substantiated by a DSM-IV Axis I diagnosis and also meet the criteria for a substance abuse/dependence disorder. All patients are housed in one wing of the facility, which is based on the format of a modified therapeutic community and focuses on the concept of recovery. A multidisciplinary treatment team comprised of a psychiatrist, a psychologist, a social worker and a psychiatric technician delivers clinical interventions, including individual and group therapy as well as medication management. The focus of the drug treatment aspect is an Alcoholics Anonymous/Narcotics Anonymous approach based on 12-Step philosophy. Research involving other therapeutic communities running in prisons is discussed as is the aspect of dual diagnosis programs. Logistical and environmental constraints which pose challenges to running the Addiction Treatment Unit are considered. A summary section reflects on aspects which have been successful, what has not worked or has been changed and upcoming program revisions.