Practices and perspectives of primary care physicians in Japan and the United States about diagnosing dementia: a qualitative study.

BACKGROUND: While dementia is a common problem in Japan and the US, primary care physicians' practices and perspectives about diagnosing dementia in these different healthcare systems are unknown. METHODS: Qualitative research was conducted in an ethnographic tradition using semi-structured interviews and thematic analysis in primary care settings across Japan and in the Midwest State of Michigan, US. Participants were a total of 48 primary care physicians, 24 each from Japan and the US participated. Both groups contained a mixture of geographic areas (rural/urban), gender, age, and years of experience as primary care physicians. RESULTS: Participants in Japan and the US voiced similar practices for making the diagnosis of dementia and held similar views about the desired benefits of diagnosing dementia. Differences were found in attitudes about the appropriate timing of formally diagnosing dementia. Japanese physicians tended to make a formal diagnosis when problems that would benefit from long-term care services emerged for family members. US physicians were more proactive in diagnosing dementia in the early stages by screening for dementia in health check-ups and promoting advance directives when the patients were still capable of decision-making. Views about appropriate timing of diagnostic testing for dementia in the two systems reflect what medical or nursing care services physicians can use to support dementia patients and caregivers. CONCLUSIONS: Benefits of making the diagnosis included the need to activate the long-term care services in Japan and for early intervention and authoring advance directives in the US. Testing to establish an early diagnosis of dementia by primary care physicians only partly relates to testing and treatment options available. Benefits of making the diagnosis included the need to activate the long-term care services in Japan and for early intervention and authoring advance directives in the US.

Gastric emptying for liquids of different compositions in children.

BACKGROUND: Pre-operative fasting balances safety against patient discomfort. We compared the gastric emptying profiles of a novel clear, high protein drink against a "traditional" clear and a non-clear fluid. METHODS: We conducted a prospective cross-sectional study with 48 healthy volunteers, eight to 14 yr of age, fasted overnight and without risk factors for abnormal gastrointestinal motility. Subjects were randomized in equal ratio to ingest 296 ml of apple juice, 2% milk or Ensure Clear. The gastric antrum was seen by ultrasound in the right lateral decubitus position at baseline, after ingestion, then every 30 min thereafter until return to baseline or six h. Gastric antral cross-sectional area was measured independently by two anaesthetists, and compared between drinks. RESULTS: Gastric emptying differed between apple juice, 2% milk and Ensure Clear by analysis of co-variance (P<0.0001), and was faster in males than females (P<0.01). The terminal phase however was similar using interval-censored time to gastric emptying in a survival model (P=0.17) or by comparing proportions with empty stomach vs not empty at 90 min (P=1.0), 120 min (P=0.32), 150 min (P=0.11), 180 min (P=0.76) or 210 min (P=1.0). CONCLUSIONS: Despite early differences, clearance from the stomach of apple juice, 2% milk or Ensure Clear is similar at the terminal phase, which is the period of greatest relevance to preoperative fasting recommendations. The stomach is essentially clear by 3-3.5 h for all three drinks studied. The differentiation between liquids in current guidelines is not supported by this study. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov NCT02938065 clinicaltrials.gov/ct2/show/NCT02938065.

Intravenous tramadol compared to propacetamol for postoperative analgesia following thyroidectomy.

We compared the efficacy and side effects of propacetamol (P), an injectable prodrug of acetaminophen, 2 g and tramadol (T), a weak synthetic opioid, 1.5 mg.kg-1, given intravenously following thyroidectomy. 80 patients were randomly assigned to blindly receive one dose of P or T on request in the PACU. Residual pain was treated with i.v. PCA morphine. Pain and patient satisfaction were assessed with Visual Analog Scales. Demographic and peroperative data were comparable in both groups. Although the morphine consumption was comparable (p = 0.71), the decrease in VAS pain scores was significantly higher following tramadol (p = 0.03). More patients complained of nausea and vomiting (p = 0.01) during the first two hours following injection of tramadol, but there was no difference throughout the whole study. Oversedation was not observed in any group. We conclude that a single dose of tramadol provides a better quality of analgesia than propacetamol during the first six hours after thyroidectomy, but fails to ensure optimal analgesia, since VAS pain scores failed to fall below 3 despite the use of supplemental morphine.

Pediatric nuclear medicine: a practical approach.

This paper is devoted to the practical aspects of pediatric nuclear medicine, particularly the controversy about drug sedation. The authors conclude that drug sedation should be exceptionally used. There is an alternative way, consisting in an adequate approach of the patient: good information to the parents and the child; taking care of the child's environment, starting from the first contacts in the waiting room; specific education of technologists: this includes injections and blood sampling, but also proper handling of the child during the procedure and adequate psychological attitudes toward child and parents. Taking these factors into account, it is exceptional that a test has to be postponed because of the lack of collaboration of the patient; good quality images, using the recommended paediatric amounts of radioactivity can be achieved even for procedures of prolonged duration.

Antiemetic effect of subhypnotic doses of propofol after thyroidectomy.

Postoperative nausea and vomiting (PONV) are unpleasant, often underestimated side effects of anaesthesia and surgery, not devoid of medical complications. Prevention with antiemetics is only partially effective. Propofol has been shown recently to possess antiemetic properties in several situations. In this prospective, randomized, controlled trial, we have compared the antiemetic efficacy of subhypnotic doses of propofol, with Intralipid as placebo, after thyroidectomy. We studied 64 patients of both sexes, aged 22-71 yr, ASA I or II, undergoing thyroidectomy. After premedication with a benzodiazepine, balanced anaesthesia was produced with isoflurane and nitrous oxide in oxygen, and supplementary analgesia with fentanyl i.v. as required. Postoperative analgesia was provided with non-opioids, and piritramide 0.25 mg kg-1 i.m. on demand. Patients were allocated randomly and blindly to receive a 20-h infusion of either propofol or 10% Intralipid 0.1 ml kg-1 h-1. Intralipid, the excipient of propofol, was chosen as placebo as it is devoid of antiemetic effects. Sedation scores, respiratory and cardiovascular variables, and incidence of PONV were assessed every 4 h for 24 h. Pulse oximetry and ECG were monitored continuously. Both groups were comparable in characteristics, surgical and anaesthesia procedures, amount of opioids given during and after operation, and total amount of the study drug infused after operation. Occurrence of PONV was similar before the start (propofol 41%, Intralipid 50%) and after completion (propofol 0.64%, Intralipid 1.6%) of infusion and decreased with time in both groups during the infusion. However, symptoms were reduced to nil with propofol but persisted and were more severe with Intralipid during infusion (P < or = 0.01). The overall incidence of PONV during infusion was 10% (three of 32 patients) in the propofol group and 65% (21 of 32 patients) in the Intralipid group. Cardiovascular and respiratory variables, and SpO2 were unaltered, and sedation decreased similarly with time in both groups. We conclude that propofol, given at subhypnotic doses, effectively reduced the incidence of PONV without untoward sedative or cardiovascular effects.

Intramuscular buprenorphine for pain relief after abdominal surgery: a comparison between on-demand and prophylactic administration.

The efficacy of intramuscular (i.m.) buprenorphine, given either at the end of anaesthesia or to treat established pain was investigated on 60 patients scheduled for major abdominal surgery receiving isoflurane anaesthesia. During skin closure (1st injection), patients were given either i.m. buprenorphine 0.3 mg or i.m. saline. Pain was assessed every hour in the post-anaesthetic care unit by the patient using a numerical rating scale. Patients were given 0.3 mg of i.m. buprenorphine (2nd injection) on request. The study was completed when a 3rd injection of i.m. buprenorphine 0.3 mg was required. The overall impressions of patients, nurses and doctors were recorded on a scale ranging from 1 to 5 at the end of the study. The interval between the 1st and 2nd injection was significantly longer (P < 0.001) following administration of buprenorphine (5 h 18 min) than saline (1 h 3 min). Mean pain scores were significantly lower after buprenorphine compared to saline (P < 0.01). There was no significant difference in duration of action or mean pain scores following buprenorphine given either at wound closure or on first demand. However, overall impressions recorded at the end of the study were significantly better when buprenorphine was given preventatively. Prophylactic buprenorphine proved to be a suitable analgesic after an inhalational anaesthesia.

[Peroperative recovery of blood]. / La récupération sanguine peropératoire.

With the first autotransfusion systems blood was aspirated by the surgeon, anticoagulated and immediately reinfused to the patient. Modern devices convert salvaged blood to a concentrated red cell solution almost devoid of anticoagulant and free hemoglobin. Autotransfusion reduces blood bank requirements in aortic, cardiac and orthopedic surgery; however septic and/or neoplastic contamination of the surgical field precludes the use of this technique. Massive autotransfusion may induce dilution of platelets and coagulation factors sometimes responsible of coagulopathy. Widespread use of autotransfusion is still limited not only by the cost of the devices but also by the need for trained staff to operate the system.

Continuous infusion of midazolam or bolus of diazepam for postoperative sedation in cardiac surgical patients.

Sedation and recovery were studied in 14 patients requiring overnight ventilation in the ICU after aortocoronary bypass surgery performed under high-dose fentanyl anesthesia (120 micrograms/kg). Patients received either IV bolus of diazepam (group D) or a combination of IV bolus with a continuous infusion of midazolam (group M). In the 2 groups, an on-demand mode of administration was used to provide optimal sedation. In the ICU, dosages of plasma catecholamines and serum benzodiazepines were performed. After cessation of benzodiazepine administration at midnight, the rapidity of recovery and time of extubation were recorded. Results showed that in the 2 groups, the association of a high-dose fentanyl anesthesia with a profound postoperative sedation maintained the epinephrine and norepinephrine concentrations at low levels during the whole postoperative period. After benzodiazepine discontinuation, recovery and extubation were faster in group M, which correlated with the significant decrease (p less than 0.05) in blood concentration of midazolam observed the first postoperative day whereas at the same time the blood concentration of diazepam did not fall significantly.