Cortisol level after dexamethasone suppression test in patients with non-functioning adrenal incidentaloma is positively associated with the duration of reactive hyperemia response on microvascular bed.

PURPOSE: Data on endothelial derangements in patients with non-functioning adrenal incidentaloma (NFAI) are scarce. METHODS: We investigated if NFAI patients present clinical, biochemical and endothelial alterations compared to individuals without an adrenal lesion and also the associations among these variables. Forty-two NFAI and 40 controls were evaluated. NFAI diagnosis and controls were defined according to the current guidelines and based on a normal adrenal imaging exam, respectively. Body composition was evaluated by dual emission X-ray absorptiometry. Endothelial reactivity was assessed by two methods: tonometry (Endo-PAT®) and laser speckle contrast imaging (LSCI). RESULTS: There were no differences between groups regarding age, gender, ethnicity, smoking status, and statin use. The frequency of metabolic syndrome according to the International Diabetes Federation criteria was 69% and 57.9%, respectively in NFAI and controls (p = 0.36), whereas the atherosclerotic cardiovascular disease (ASCVD) risk was 63.4% and 66.7% (p = 0.81). The clinical, laboratory, and anthropometric characteristics, as well as body composition, were similar between the groups. Additionally, any differences between groups were observed on endothelial reactivity tests. Nevertheless, we noted an association between cortisol levels after 1 mg-dexamethosone suppression test (1 mg-DST) and the duration of post-occlusive reactive hyperemia tested on microcirculation (r = 0.30; p = 0.03). NFAI patients require more antihypertensive drugs to achieve blood pressure control (p = 0.04). The number of antihypertensive drugs used to control blood pressure correlated with cortisol levels after 1 mg-DST (r = 0.29; p = 0.03). CONCLUSIONS: Since both groups herein investigated had a high frequency of metabolic syndrome and ASCVD risk, it might explain similarities observed on endothelial reactivity. Nevertheless, prolonged reactive hyperemia response on microcirculation was correlated with cortisol levels under suppression.

The ASA Physical Status Classification: inter-observer consistency. American Society of Anesthesiologists.

The American Society of Anesthesiologists (ASA) physical status classification system has previously been shown to be inconsistently applied by anaesthetists. One hundred and sixty questionnaires were sent out to all specialist anaesthetists in Hong Kong. Ten hypothetical patients, identical to those of a similar study undertaken 20 years ago, each with different types and degrees ofphysical disability were described. Respondents were asked about their country of training and type of anaesthetic practice and to assign an ASA classification status for each patient. Ninety-seven questionnaires were returned (61%) after two mailings. Agreement for each patient within groups, between groups and overall comparisons were made. Percentage of agreement was between 31 to 85%. Overall correlation was only fair in all groups (Kappa indices: 0.21-0.4). We found that the current pattern of inter-observer inconsistency of classification was similar to that 20 years ago and exaggerated between locally and overseas trained specialists (P<0.05). The validity of the ASA system, its usefulness and the need for a new, more precise scoring system is discussed.

Halting the progression of renal disease: where we stand?

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Simplified citrate anticoagulation for continuous renal replacement therapy.

BACKGROUND: Regional anticoagulation with trisodium citrate is an effective form of anticoagulation for continuous renal replacement therapy (CRRT) for patients with contraindications to heparin. However, because of the metabolic complications of trisodium citrate, it is a complicated technique requiring specialized dialysis solutions. We have designed a simplified protocol for citrate regional anticoagulation for CRRT. METHODS: Two percent trisodium citrate was delivered at 250 mL/h via the prefilter port of a COBE PRISMA device, with the rate adjusted to maintain a postfilter ionized calcium (iCa++) <0.5 mmol/L. A central calcium gluconate infusion was used to maintain a systemic iCa++ at 1.1 mmol/L. A standard dialysate solution consisting of 0.9% saline, KCl 3 mmol/L, and MgSO4 1 mmol/L was delivered at 1000 mL/h. We retrospectively reviewed the outcomes and complications associated with this protoco1 in 29 patients treated from July 1999 to October 1999, evaluating the frequency of clotting of the dialyzer, bleeding complications, citrate toxicity, and patient mortality. RESULTS: The Kaplan-Meier curve for dialyzer survival demonstrated a 61% survival rate at 48 hours. There were no episodes of significant bleeding or citrate toxicity. Seventy-two percent of patients died for reasons unrelated to CRRT. CONCLUSIONS: A CRRT protocol using regional 2% trisodium citrate anticoagulation is not associated with significant bleeding complications or citrate toxicity, and represents a simplified approach compared with previous applications using 4% trisodium citrate.

Patient maintained alfentanil target-controlled infusion for analgesia during extracorporeal shock wave lithotripsy.

PURPOSE: The purpose of this study was to determine whether alfentanil given by a pharmacokinetic-based target controlled infusion (TCI) system under patient control is a suitable analgesic technique for extracorporeal shock wave lithotripsy (ESWL). METHODS: The design was an open, unblinded, noncomparative, prospective study. Forty outpatients undergoing ESWL were given patient maintained alfentanil TCI. Pain, nausea and sedation were assessed every 300 shocks. Vital signs were recorded every three minutes, pulse oximetry and electrocardiography being monitored continuously. Blood alfentanil concentration was measured for comparison with the predicted value. RESULTS: Alfentanil consumption (median 1.34 mg, range 0.8-3.6) and measured levels following treatment (median 60 ng.ml-1, range 15.6-134.3) varied widely. The precision of the TCI system and the median prediction error (bias) were both 49%. The median of pain scores recorded during treatment was 4 (range 0-8). The median respiration rate was 15 bpm (range 10-23), three patients required oxygen (SaO2 < 92%) cardiovascular measurements were stable and there was no excessive sedation. The incidence of nausea was 15%. All patients were ready for hospital discharge within one hour following treatment. CONCLUSIONS: Patient maintained alfentanil TCI provides good analgesia for ESWL in the majority of patients with little sedation. Respiratory depression is uncommon but supplementary oxygen should be given prophylactically. There is considerable interindividual variation in demand for alfentanil indicating the usefulness of the patient control method. The TCI system underestimated alfentanil blood concentrations but this did not affect its clinical usefulness.

Analysis of tasks performed by certified ophthalmic medical personnel.

BACKGROUND: Proper delegation of routine tasks to trained personnel might increase cost efficiency by freeing the physician to concentrate on the medical and judgmental aspects of patient care. In ophthalmology, certified ophthalmic medical personnel (OMP) assist the physician by performing many tasks. The Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO) selected 77 specific tasks performed by OMP and conducted a task analysis survey to determine the importance of these tasks to ophthalmic practice. Individual and practice demographics were surveyed simultaneously to compare the effect of individual and practice differences on task importance. METHODS: Certified OMP and their sponsoring ophthalmologists were surveyed independently. Each group was asked to rate the importance of the 77 selected tasks using a five-point scale of importance. Importance ratings from each survey group were used independently to generate a rank order listing of tasks. RESULTS: Only 3 of the 77 tasks differed significantly in importance between ophthalmologists and OMP. The same five tasks were rated as most important by both groups, whereas the second group of the five most important tasks varied only by +/-4. CONCLUSIONS: The similarity in task importance rankings indicates a common perception between ophthalmologists and OMP concerning the role played by OMP in ophthalmic eye care.

Rotation fasciocutaneous flap repair of lower limb defects.

The rotation design was applied to fasciocutaneous flap repair of lower limb defects to produce a functional and aesthetic result superior to that obtained by the transposition design. A prospective, consecutive series of 21 patients is reported, 14 males and 7 females, ranging in age from 17 to 81 years (mean 43 years). The primary defects, 8 traumatic, 12 cutaneous malignancy excisions, and 1 radionecrotic ulcer, ranged in size from 3.5 x 3 cm to 10 x 8 cm (mean 6.6 x 5 cm). The rotation fasciocutaneous flap base ranged from 5 to 25 cm (mean 12 cm), and the radius ranged from 4.5 to 20 cm (mean 9 cm). The inclusion of a back-cut at the flap base permitted direct donor-site closure in all but one patient, obviating the need for a split-thickness skin graft and avoiding the otherwise inevitable significant contour defect. Postoperative bed rest ranged from 3 to 7 days (mean 5 days). Three minor and no major complications occurred, and there was complete survival of all flaps. The results in this series indicate a role for the rotation fasciocutaneous flap in the management of traumatic and excisional defects in the lower limb. It has proved reliable, gives good aesthetic results, and reduces treatment costs.

Ondansetron for prevention of postoperative nausea and vomiting following minor oral surgery: a double-blind randomized study.

The efficacy and safety of ondansetron in preventing postoperative nausea and vomiting following minor oral surgery was evaluated in a prospective randomized double-blind study. Of a total of seventy-seven patients, randomly 38 had 4 mg of ondansetron and 39 had normal saline as placebo intravenously immediately prior to induction of anaesthesia. A standard general anaesthetic with thiopentone, suxamethonium, fentanyl, nitrous oxide and isoflurane was employed. Postoperatively nausea was assessed verbally and on a visual analog scale at 1, 4 and 24 hours from the time of awakening. Episodes of vomiting were recorded. Eight patients (21.1%) in the ondansetron group compared to 19 (48.7%) in the placebo group had nausea (P < 0.05) and 1 (2.6%) in the ondansetron group compared with 9 (23.1%) in the placebo group vomited (P < 0.05). Patients who vomited twice or more and the number who required a rescue antiemetic were significantly fewer in the ondansetron group (P < 0.05). Cardiovascular parameters were stable and showed no significant difference in the two groups. There were no significant adverse effects that could be directly attributable to ondansetron.

Evaluation of an end-tidal carbon dioxide detector in the aeromedical setting.

Endotracheal intubation is a lifesaving technique performed by flight crews often under difficult circumstances. Inadvertent unrecognized esophageal intubation is reported to occur up to 8% of the time. Recently a new disposable device has been developed to assist in determining proper endotracheal tube placement. The FEF end-tidal carbon dioxide detector (Fenem Co.) was evaluated in this study. From June 1989 to January 1990, all patients intubated or transported with endotracheal tubes in place by LifeStar, helicopter Emergency Medical Service, had the FEF detector positioned on the endotracheal tube. Flight crews continuously monitored changes in the indicator of the FEF during transport. On arrival to the emergency department, tube position was verified with direct laryngoscopy by an emergency department physician or trauma surgeon. Thirty-five patients were entered into the study. Thirty-four were identified by direct laryngoscopy as having proper placement of the their endotracheal tube and one was found to be intubated in the esophagus. The FEF device properly identified the single esophageal intubation and accurately identified proper position of the endotracheal tube in thirty-two patients. Of the three patients in cardiopulmonary arrest, the FEF device was accurate in detecting tube position in each case. The overall sensitivity of the FEF detector in this aeromedical setting was 94%. Specificity was calculated as 100%. The overall positive predictive value of the FEF detector was 100%. We therefore conclude that indication of a tracheal intubation by the FEF detector is reliable after six breaths in the aeromedical setting and advocate its use as an adjunct for monitoring tube position while in flight.

Emergency interhospital transport of the major trauma patient: air versus ground.

A prospective cohort study was undertaken to determine the effectiveness of air transport for major trauma patients when transferred to a trauma center from a rural Emergency Department. The null hypothesis evaluated was that there was no difference in outcome for patients transported by helicopter EMS (HEMS) when compared to patients transported by conventional ground EMS. The dependent variable of outcome was studied using the TRISS method in a group of 872 consecutive trauma patients admitted after long-distance transfer. Of this group, 110 patients transported by ground and 103 patients transported by air met the inclusion criteria. The ground EMS group had a mean TS of 14.4, a mean ISS of 25.2, and a mean Ps of 0.867. TRISS predicted 15 deaths and there were 15 actual deaths. The HEMS group had a mean TS of 11.4, a mean ISS of 34.9, and a mean Ps of 0.587. There were 46 predicted deaths and 33 actual deaths. This 25.4% reduction in predicted mortality was significant (Z = 3.95; p less than 0.001). Stratification of patients into Probability of Survival (Ps) bins allowed for outcome evaluation of groups with similar levels of injury severity. The benefit of HEMS transport was seen only in the patients with a probability of survival of less than 90%. We conclude that the major trauma patients transported by HEMS had a better outcome than those transported by ground EMS. The benefit seen with HEMS was directly related to injury severity and was demonstrated only in the patients with a Ps of less than 0.90.

A comparison of the speech results after early and delayed hard palate closure; a preliminary report.

An "early surgery" and a "delayed surgery" group of cleft palate cases' speech has been recorded and judged in two ways. Initially four different listener groups gave their "impressions" of the speech samples followed by the two speech therapist groups assessing specific aspects of speech. For analytical purposes the delayed surgery group was divided into "repaired" and "unrepaired" hard palate groups. The general conclusion was that delaying hard palate surgery may be responsible for the persistence of noticeable abnormal speech patterns until after hard palate repair. However, despite their higher frequency in the "delayed unrepaired" group, errors of tongue placement and airstream direction were common to all groups. The relative influence of maturation, surgery and speech therapy on speech progress has not been considered. It is suggested that a final review of oro-facial growth and speech as each subject reaches 17 years old would give more definitive results. Then the subjects might discuss the relative importance of facial appearance and speech results.

Quantitative rose bengal staining technique for external ocular diseases.

A new technique for quantitative assessment of rose bengal staining in ocular surface disorders is described. The globe is divided into 16 quadrants which represent clinically important regions of the eye. Each quadrant is graded numerically for intensity and area of rose bengal staining. This simple grading system facilitates mathematical study and computer analysis of ocular surface disease.

Acanthamoeba-contaminated hydrogel contact lenses. Susceptibility to disinfection.

Acanthamoeba keratitis has frequently been associated with contact lens use. In this study, contaminated hydrogel contact lenses of patients were subjected to disinfection by thermal hydrogen peroxide and chemical (quaternary ammonium) systems. New hydrogel contact lenses contaminated by incubation on Acanthamoeba polyphaga plates were similarly subjected to the disinfection systems described above. Thermal disinfection was universally effective in eradicating acanthamoeba, whereas hydrogen peroxide and quaternary ammonium disinfection were ineffective. Scanning electron microscope photomicrographs suggest that acanthamoeba may adhere to surfaces of hydrogel contact lenses. These findings have significant implications for soft contact lens users.

Extended use of the Mustardé dancing man procedure.

Webs other than epicanthal folds can be corrected by the Mustardé "dancing man" procedure. A series of 20 patients is presented in whom this method has been used to correct either minor degrees of congenital syndactyly or burn scar contractures in fingers.