Concentrations of remifentanil, propofol, fentanyl, and midazolam during rewarming from therapeutic hypothermia.

BACKGROUND: The clearance of sedatives and analgesics may be reduced by therapeutic hypothermia. However, little is known about the concentrations of such drugs during rewarming. The aim of this study was to describe the serum concentrations of sedatives and analgesics during rewarming from therapeutic hypothermia. METHODS: Blood samples were collected for quantification of drug concentrations in 22 patients given analgesia/sedation with either remifentanil/propofol or fentanyl/midazolam during rewarming from therapeutic hypothermia (33-34°C) after cardiac arrest. Samples for were drawn before (-2 h) and during rewarming (0-8 h). Linear mixed effects models were used to describe serum concentrations and adjust for rates of infusion during rewarming from therapeutic hypothermia. RESULTS: Subjects with samples analyzed were remifentanil (n = 8), propofol (n = 14), fentanyl (n = 8), and midazolam (n = 8). Age, body mass index, and simplified acute physiology score II [mean (standard deviation)] were 64 (14.2) years, 27.3 (3.7) kg/m(2), and 69 (13.2), respectively. While the concentration of fentanyl was not significantly affected by temperature, concentrations of remifentanil, propofol, and midazolam decreased with core temperature by 16%, 12%, and 11% (mean values) from 33°C to 37°C after adjusting for rates of infusion, respectively. CONCLUSION: Concentrations of remifentanil, propofol, and midazolam decreased during rewarming from therapeutic hypothermia when adjusting for rates of infusion. No changes were demonstrated for fentanyl.

Cognitive dysfunction and health-related quality of life after a cardiac arrest and therapeutic hypothermia.

BACKGROUND: Evidence-based treatment protocols including therapeutic hypothermia have increased hospital survival to over 50% in unconscious out-of-hospital cardiac arrest survivors. In this study we estimated the incidence of cognitive dysfunctions in a group of cardiac arrest survivors with a high functional outcome treated with therapeutic hypothermia. Secondarily, we assessed the cardiac arrest group's level of cognitive performance in each tested cognitive domain and investigated the relationship between cognitive function and age, time since cardiac arrest and health-related quality of life (HRQOL). METHODS: We included 26 patients 13-28 months after a cardiac arrest. All patients were scored using the Cerebral Performance Category scale (CPC) and Mini-Mental State Examination (MMSE). Twenty-five of the patients were tested for cognitive function using the Cambridge Neuropsychological Test Automated Battery (CANTAB). These patients were tested using four cognitive tests: Motor Screening Test, Delayed Matching to Sample, Stockings of Cambridge and Paired Associate Learning from CANTAB. All patients filled in the Short Form-36 for the assessment of HRQOL. RESULTS: Thirteen of 25 (52%) patients were classified as having a cognitive dysfunction. Compared with the reference population, there was no difference in the performance in motor function and delayed memory but there were significant differences in executive function and episodic memory. We found no associations between cognitive function and age, time since cardiac arrest or HRQOL. CONCLUSION: Half of the patients had a cognitive dysfunction with reduced performance on executive function and episodic memory, indicating frontal and temporal lobe affection, respectively. Reduced performance did not affect HRQOL.

Treatment of acute low back pain in Wisconsin: results of the State Medical Society's Medical Outcomes Research Project.

BACKGROUND: Acute low back pain is the fifth most common reason for physician visits. Multiple treatment options are available, but not all physicians and patients are satisfied with the results. This study evaluated treatment outcomes from patients' perspectives using standardized measures. METHODS: 368 patients with acute low back pain were enrolled in the study. Only 128 participants (35%) completed all 4 health outcome questionnaires (administered at baseline, 6 weeks, 3 months, and 1 year). RESULTS: Most participants reported improved health at 1-year follow-up,, with the most significant gains achieved by 3 months. However, 40% were not satisfied with their outcome. Patients with radicular low back pain scored lower on health outcome measures than patients without radicular symptoms. CONCLUSION: A sizeable percentage of patients with acute low back pain progress to chronic pain despite therapeutic intervention. Patients with radiculopathy may require nonstandard treatment to avoid unfavorable outcomes.

Prenatal and postpartum Pap smears: do we need both?

PURPOSE: The need to perform a Pap smear at the time of entry to prenatal care, as well as at the postpartum check-up, is questionable. A comparison of the rates of recovery of endocervical cells and the incidence of dysplasia on the prenatal and postpartum Pap smears may be helpful in determining an optimal preventive care protocol for patients who are pregnant. METHODS: Demographic and clinical data were collected from the records of 1,377 obstetrical patients at a midwest family practice residency. The yield of endocervical cells and the incidence of dysplasia was determined for both the prenatal and the postpartum Pap smears performed for this group of patients. RESULTS: In women having both exams, endocervical cells were recovered in 44.1% of prenatal Pap smears compared to 82.0% of postpartum smears. The incidence of dysplasia was 2.6% on prenatal Pap smears and 4.8% on postpartum smears. In this study population, 33% of women did not return for their postpartum check-up. CONCLUSIONS: The postpartum Pap smear is of value due to a significant yield of dysplasia. The sensitivity of the prenatal Pap test may be less than desired. Efforts directed toward increased patient compliance regarding the postpartum check-up are needed.