An adrenal cyst associated with 19-nor-deoxycorticosterone excess and low renin hypertension.

Adrenal cysts are rare, but they have been disproportionately associated with hypertension. This report describes a hypertensive patient with increased levels of 19-nor-deoxycorticosterone (19-nor-DOC), a potent mineralocorticoid. The patient was a thirty year old man with hypokalemia, moderately severe hypertension, suppressed PRA, and low aldosterone secretion. Following surgical removal of a 10 cm adrenal cyst, the hypertension improved, the hypokalemia resolved, and the PRA and the aldosterone secretion normalized. Urinary 19-nor-DOC pre-op was elevated 4.6 microgram per day (normal less than 1.0 microgram/day and subsequently became normal at 0.7 microgram per day following surgery. The adrenal cyst was a fibrous walled structure containing mucinous straw-colored fluid. Pericystic adrenocortical tissue demonstrated increased 19-OH-DOC production (a 19-nor-DOC precursor) which may have been responsible for the 19-nor-DOC excess. We hypothesize that compressive adrenal damage from the cyst may produce a form of adrenal regeneration hypertension which is known to be associated with 19-nor-DOC excess.

An access-oriented negotiated fee schedule. The Caterpillar experience.

This paper describes the system used by Caterpillar Corporation (CAT) in Peoria, Illinois, to reimburse surgeons. The CAT system assures access for Caterpillar employees and their families to a selection of qualified surgeons, while achieving cost savings through improvements in processing of surgical claims and negotiation of selected fees. CPT-4 codes are recorded for greater accuracy, when indicated, surgical services that have been incorrectly unbundled are rebundled, and the appropriateness of surgical assistant charges is reviewed. A "degree of difficulty" relative value scale (DODRVS) of surgical services is periodically revised as technology changes. The DODRVS multiplied by a regional factor, determined by local market research, establishes the fee that CAT will pay the surgeon. Balance billing is permitted if the patient (1) is informed in advance by the surgeon that the fee will be higher than CAT will pay, and (2) knows that the service can be obtained from other local surgeons who will accept the CAT fee. The goal of the CAT method of surgeon reimbursement is to gain physician support for an access-oriented, market-driven negotiated fee schedule. Compared with a resource-based relative value scale RBRVS) methodology, the CAT system is not formula-driven and depends on physician acceptance.

Endorphins in primate hemorrhagic shock: beneficial action of opiate antagonists.

The endogenous opiate beta-endorphin is released concomitantly with adrenocorticotropin from the pituitary during stress. In the present study we investigated the possible involvement of opiate receptors in the cardiovascular depression associated with hypovolemic shock in the nonhuman primate. Changes in circulating levels in beta-endorphin were monitored during hemorrhagic shock in 18 female baboons. Plasma levels of beta-endorphin increased significantly during hemorrhagic shock and were significantly correlated with a decrease in cardiac output (P less than 0.05). Single bolus administration of the opiate receptor antagonist naloxone (2 or 5 mg/kg) produced a transient but significant improvement in cardiac output (P less than 0.05) and mean arterial pressure (P less than 0.05). Hemodynamic improvement was maintained with a constant infusion of naloxone. Opiate receptor blockade with the longer acting antagonist naltrexone (2 or 5 mg/kg) significantly increased mean arterial pressure (MAP; P less than 0.05), and CO (P less than 0.05), and decreased heart rate. Our results suggest that the baboon is an excellent model for the study of hemorrhagic shock and provide further evidence for endogenous opiate involvement in the cardiovascular pathophysiology of hemorrhagic shock.

A consensus process to determine the relative complexity-severity of frequently performed surgical services.

Current prevailing fees represent initial charges inflated over time, and it is well known that some services, such as surgical treatment of the coronary arteries, are less demanding services today than in the early days of the specialty, when morbidity, mortality and operative stress were extremely high. Resource costs are difficult to measure accurately and time is an inappropriate indicator of complexity and severity. If society is looking for ways in which physicians will support changes in reimbursement, the C-S index resulting from the consensus process which has been described herein could provide an acceptable basis for a variety of payers to assess services. We plan to validate this consensus method in other geographic areas and will report the results in appropriate publications. We hope that the C-S index will be valuable in future policy discussions about the basis for physician fees, as well as for other health policy purposes.

Prolonged disruption of plasma beta-endorphin dynamics following surgery.

The purpose of the present study was to examine the effects of surgery on plasma beta-endorphin dynamics. Plasma beta-endorphin levels were measured by liquid chromatography/radioimmunoassay in seven patients undergoing elective surgery. Blood samples were obtained every 4 hr for two 24-hr periods: one beginning 48 hr before surgery and the other beginning 48 hr after surgery. Computer analysis of beta-endorphin levels as a function of clock time demonstrated a true circadian rhythm preoperatively with a mean of 28.0 +/- 5.9 pg/ml. In the postoperative period mean beta-endorphin levels were significantly elevated (85.6 +/- 20.7 pg/ml, P less than 0.005). Surgical procedures caused significant phase shifting in the grouped mean circadian rhythm of plasma beta-endorphin (mean = 2.4 hr). When the data was analyzed individually, plasma circadian rhythms were found to be totally abolished in the three patients with the longest operative times (mean = 3.8 hr) and significantly displaced in time in the remaining four patients. These prolonged alterations in plasma endogenous opioid peptide levels following surgery have not been previously reported, and should be considered in the management of the postsurgical patient.

Beta-endorphin, cortisol and postoperative delirium: a preliminary report.

A transient delirium, including hallucinations and disorientation, occurred at some time during a 48 to 72 hr postoperative period in patients recovering from elective surgery in an intensive care unit. The occurrence of delirium in these patients was associated with a significant and unusually prolonged postoperative increase in circulating levels of beta-endorphin (B-endorphin) and cortisol, and a total disruption of normal plasma circadian rhythms of B-endorphin and cortisol. Postoperative mean 24-hr plasma levels of B-endorphin and cortisol were not significantly different from preoperative baseline levels in those patients who did not exhibit post-surgical delirium. Circadian rhythms of B-endorphin and cortisol in the non-delirious patients also remained normal following surgery, although peak plasma concentrations were significantly phase-shifted to later in the day. A disruption in circadian rhythms of the endogenous opiate/hypothalamic-pituitary-adrenal axis may represent an important component of post-operative psychological changes that are frequently observed in the intensive care unit setting.

Effect of an opiate antagonist (naloxone) and an agonist/antagonist (nalbuphine) in primate hemorrhagic shock: relationship to catecholamine release.

Recent evidence has suggested a relationship between the endogenous opioid peptides and the pathophysiology of various shock states. In the present study, we investigated the relationship between the effectiveness of naloxone (an opiate antagonist) and nalbuphine (an opiate agonist/antagonist), and the changes in circulating levels of catecholamines in the nonhuman primate subjected to hemorrhagic shock. Plasma levels of catecholamines were measured using high-performance liquid chromatography (HPLC) during hemorrhagic shock in 15 female baboons. Plasma levels of both epinephrine and norepinephrine increased significantly during hemorrhagic shock (p less than 0.05), which correlated with an increase in heart rate. Bolus administration of naloxone (5 mg/kg) significantly increased both plasma epinephrine (p less than 0.01) and norepinephrine (p less than 0.05) over shock levels along with a transient but significant increase in cardiac output (p less than 0.05) and mean arterial pressure (p less than 0.05), and a significant decrease in heart rate (p less than 0.05). Improvements in hemodynamics were maintained with a constant infusion of naloxone (5 mg/kg/hr), which also caused a further significant increase in plasma epinephrine (p less than 0.01). Administration of a single bolus of the opiate agonist/antagonist nalbuphine (5 mg/kg) dramatically decreased cardiac output and mean arterial pressure and had no effect on circulating catecholamines. Our results suggest that (1) the beneficial action of high-dose naloxone in primate hemorrhagic shock may be attributable in part to a drug-induced increase in circulating endogenous catecholamines; and (2) the failure of high-dose nalbuphine to improve cardiovascular function may be related to its partial agonist (cardiodepressant) properties at higher doses.

The effects of surgery on the circadian rhythms of cortisol.

The circadian rhythms of plasma cortisol levels are studied extensively. Frequent sampling techniques are used to examine the effects of surgical trauma on the circadian pattern of plasma cortisol in man. Five patients were studied, 48 hours before and 48 hours after major surgery. The normal preoperative cortisol rhythms of these patients did not disappear after surgical trauma but they were significantly phase-shifted. In addition, the mean cortisol concentrations were significantly elevated and the intracircadian cycles suffered complex changes in the postoperative period.

Temporal characteristics of cortisol metabolism in adrenalectomized primates.

The rhythmicities observed in the plasmatic levels of cortisol are generally attributed to rhythms of production and release of the hormone. Since the plasmatic concentration of any given substance is a function of its production and its removal from the circulation, it is conceivable that the metabolism of cortisol also occurs in an oscillating fashion. To test this hypothesis Rhesus monkeys were submitted to bilateral adrenalectomy; cortisol was replaced at a constant infusion rate while blood was sampled at hourly intervals for the measurement of cortisol plasma levels. Rhythmic oscillations in the cortisol levels were observed. These rhythms exhibited two major components: a circadian and an ultradian component. The authors suggest that these rhythms be considered whenever normal or pathologic hormone rhythmicities are analyzed.

Should we shrink the health care system?

As this director of a large eastern medical center has traveled about the country, talked many times on the subject of health cost management, and examined various cost-containment plans, he has come to realize that most, if not all, of those isolated programs stand little chance of more than marginal success. True cost management can come only from a hospital system shrinkage that involves loss of jobs and closings. There is no simple way out of that box, he argues, and people should begin to realize it. Whether there is the national resolve to put the lid on accelerating health costs is questionable, but at least a clear understanding of that fact and its consequences may lead to a few successful hardheaded programs and provide preventive medicine for the numerous trivial programs that no doubt will continue to spring up.