Enhanced recovery after surgery program for elective abdominal surgery at three Victorian hospitals.

The aim of this study was to evaluate the anaesthesia care of an enhanced recovery after surgery (ERAS) program for patients having abdominal surgical in Victorian hospitals. The main outcome measure was the number of ERAS items implemented following introduction of the ERAS program. Secondary endpoints included process of care measures, outcomes and hospital stay. We used a before-and-after design; the control group was a prospective cohort (n=154) representing pre-existing practice for elective abdominal surgical patients from July 2009. The introduction of a comprehensive ERAS program took place over two months and included the education of surgeons, anaesthetists, nurses and allied health professionals. A post-implementation cohort (n=169) was enrolled in early 2010. From a total of 14 ERAS-recommended items, there were significantly more implemented in the post-ERAS period, median 8 (interquartile range 7 to 9) vs 9 (8 to 10), P <0.0001. There were, however, persistent low rates of intravenous fluid restriction (25%) and early removal of urinary catheter (31%) in the post-ERAS period. ERAS patients had less pain and faster recovery parameters, and this was associated with a reduced hospital stay, geometric mean (SD) 5.7 (2.5) vs 7.4 (2.1) days, P=0.006. We found that perioperative anaesthesia practices can be readily modified to incorporate an enhanced recovery program in Victorian hospitals.

An in situ single-pass perfusion model for assessing absorption across the intestinal mucosa of the brushtail possum.

AIM: To develop an in situ animal model for assessing absorption of molecules across the intestinal mucosa of possums. METHODS: A surgical preparation was used to perfuse known concentrations of reference compounds (fluorescein and luteinising hormone-releasing hormone; LHRH) through measured sections of selected regions (jejunum, caecum, proximal colon) of the intestinal tract of 19 possums, over a 2-h period. Plasma concentrations of the compounds, which were perfused either with or without co-administration of a permeation enhancer (sodium deoxycholic acid; SDA), were determined in the perfusion effluent, peripheral and in some instances in the pre-hepatic circulation by spectrofluorometry (fluorescein) or radioimmunoassay (LHRH). Pharmacokinetic parameters of both compounds in the possum were determined over a period of up to 4 h in a further 30 animals (fluorescein, n = 6; LHRH n = 24), from their plasma profiles following intravenous (I/V) administration of a bolus dose. RESULTS: In animals perfused with 25 mg/ml fluorescein (Perfusion Experiment (PE) 1), the mean plasma concentration was 2.8 (SE 0.12) microg/ml in post-hepatic blood samples. When possums were perfused with 2.5 mg/ml fluorescein and 7 microg/ml LHRH (PE 2), mean plasma concentrations were 0.3 (SE 0.01) and 7.8 (SE 1.64) microg/ml fluorescein and 0.1 (SE 0.02) and 6.3 (SE 0.45) ng/ml LHRH, in the absence and presence of permeation enhancer, respectively. There was a poor correlation between pre-hepatic and post-hepatic concentrations. CONCLUSIONS: The single-pass in situ perfusion technique provided a useful model for investigating basic information on the absorption of biocontrol agents across the intestinal tract of possums, but had limitations that must be recognised.

Effect of oestradiol treatment on mast cell populations and microflora in the vaginal cul-de-sac of seasonally anoestrous brushtail possums (Trichosurus vulpecula).

Mast cell populations in the vaginal cul-de-sac of female brushtail possums do not appear to be related to microbial invasion but changes in their density occur at oestrus, indicating a hormonal influence. The present study examined the effect of treatment with oestradiol on microflora and on mast cell numbers and their spatial location in cul-de-sac tissue of seasonally anoestrous brushtail possums. Tissue was collected from seasonally anoestrous brushtail possums (n = 6 per group) that were either untreated (anoestrous group) or were subjected to 6 days of treatment with oestradiol (oestradiol group) administered via subcutaneous implants or with the oil vehicle alone (control group). Tissue was collected aseptically for microbiological procedures and the fractionator and optical disector were used to quantify mast cell populations. Microflora populations were low (< 4.0 x 10(4) organisms g(-1)) and numbers of mast cells were similar in all groups. Mast cell density was greatest in epithelial and connective tissues from seasonally anoestrous and control animals and lowest in oestradiol-treated possums, in which there was a significant increase in cul-de-sac mass and volume. There is an inverse relationship between circulating oestrogen concentrations and mast cell density in possum cul-de-sac tissue, which is probably the result of an increase in tissue volume.

Follicle development in cyclic, anoestrous and FSH-treated brushtail possums (Trichosurus vulpecula).

The common brushtail possum (Trichosurus vulpecula) is a pest of considerable economic importance in New Zealand. Attempts to develop methods of suppressing reproduction in this species are currently hampered by the lack of reliable methods to synchronise oestrus and ovulation in this species. The objective of this study was to compare antral follicle populations in anoestrous and cyclic brushtail possums and to assess the efficacy of exogenous FSH to induce follicle development in anoestrous animals. Ovaries were recovered from anoestrous possums after administration of either exogenous FSH (1.0 mg/injection) or the saline vehicle alone (0.5 ml/injection) at 12-h intervals for 3 days (n = 6/group), and from cyclic animals (n = 6) that were euthanised in mid-follicular phase (5 days after removal of their pouch young). All antral follicles > or =1.0 mm in diameter were dissected free of extraneous tissue, incubated in vitro to measure oestradiol production, and then processed for histological assessment of health status. Mean weight of ovaries and vaginal cul-de-sac tissues were both significantly greater (P<0.001) in FSH-treated anoestrous females (24.2+/-5.1 mg and 6.50+/-1.34 g, respectively), but did not differ significantly between saline-treated anoestrous possums (12.4+/-3.0 mg and 1.31+/-0.27 g) and cyclic animals (13.5+/-1.6 mg and 2.62+/-0.95 g). Mean uterine weights in both cyclic (889+/-161 mg) and FSH-treated (1098+/-184 mg) animals were significantly heavier(P<0.001) than those of anoestrous possums (414+/-61 mg). The mean number of follicles (> or =1.0-mm diameter) present was significantly greater (P<0.001) in FSH-treated, than in cyclic and anoestrous possums (38.0+/-4.4, 23.2+/-3.2 and 10.7+/-3.4 follicles/animal, respectively). Cyclic animals had significantly more (P<0.01) follicles than anoestrous possums. The proportion of follicles that were classified as healthy, was significantly lower (P<0.01) in cyclic possums(38%) than in anoestrous (69%) and FSH-treated (88%) animals. The mean diameter of the largest healthy follicle present was 2.5+/-0.41, 2.1+/-0.08, and 3.1+/-0.15 mm for cyclic, anoestrous and FSH-treated animals, respectively. None of the follicles harvested from saline-treated anoestrous possums produced measurable levels of oestradiol in vitro, whereas 7% and 59% of those from cyclic and FSH-treated animals did so. In summary, cyclic possums had more antral follicles present than anoestrous animals, but a lower percentage of these follicles were healthy. Less than 10% of healthy follicles from cyclic possums, and none of those from anoestrous animals, were capable of producing oestradiol when incubated in vitro. Treatment with ovine FSH promoted follicle development in anoestrous possums, to significantly increase the number of follicles present, the proportion that were healthy and the percentage capable of producing oestradiol.

How many tests are required to diagnose growth hormone (GH) deficiency in adults?

OBJECTIVE: The diagnosis of GH deficiency in adults relies on the results of GH provocative testing. Whilst in some patients the testing strategy is clear, this is not the case in all patients. The objective of this study was to further examine the concordance between the GH responses to two different provocative stimuli, to correlate this with the number of additional pituitary hormone deficits, and to produce guidelines as to which patients require two GH provocative tests and which require only one. STUDY DESIGN AND PATIENTS: The results of GH provocative tests were reviewed in 103 patients (mean age 28 years, 48 male), with documented or potential hypothalamic-pituitary disease and 35 normal volunteers (mean age 21 years, 18 male). All patients and normal volunteers underwent an insulin tolerance test (ITT) and an arginine stimulation test (AST). Severe GH deficiency was defined as a GH response to an ITT of < 5 mU/l and a GH response to an AST of < 2 mU/l, utilizing data from previous studies in this unit. Patients were divided into four groups according to the number of anterior pituitary hormone deficits present other than possible GH deficiency: no other pituitary hormone deficits (GHD0) or one, two or three other hormone deficits (GHD1, GHD2 or GHD3). RESULTS: The 103 patients were divided between the four groups as follows: 69 (67%) in GHD0, 15 (14. 6%) in GHD1, six (5.8%) in GHD2, and 13 (12.6%) in GHD3. There was a significant decline in the median GH peak to both the ITT and the AST with increasing numbers of other pituitary hormone deficits (P < 0.0001). If the magnitude of the difference between each individual's GH response to the ITT and AST is plotted against the mean GH value a clear trend is seen (Spearmans rank correlation = 0. 88, P < 0.0001) indicating that the magnitude of the difference between the GH responses to an ITT and AST increases with the underlying mean GH value. These data allow the estimation of the median ITT/AST ratio as 1.17 (CI 0.98, 1.39). None of the control subjects and 14.1% (10), 26.7% (four), 83% (five) and 92.3% (12) of groups GHD0, 1, 2 and 3, respectively, had severe GHD. The concordance between the AST and ITT (percent of patients in whom both tests confirmed or refuted the biochemical diagnosis of severe GHD) was 100%, 76.8%, 66.6%, 83.3%, and 92.3% in the controls, GHD0, 1, 2, and 3, respectively. Thus, 16/69 GHD0, 5/15 GHD1, 1/6 GHD2 and 1/13 GHD3 patients were misclassified by one or other test. CONCLUSION: We have demonstrated that a constant ratio links the GH response to an ITT and AST in an individual, rather than a constant difference, and that the difference between the GH responses to two provocative stimuli is greater in those patients with milder degrees of GH deficiency or insufficiency. These patients tend to have one or no additional pituitary hormone deficits and may be misclassified if a single GH provocative test is performed. We suggest that whilst a single GH provocative test can be used with confidence in patients with two or three additional pituitary hormone deficits, in patients with suspected isolated GH deficiency or with only one additional pituitary hormone deficit, two GH provocative tests should be performed.

Plasma gonadotropin concentrations in the cyclic female brushtail possum (Trichosurus vulpecula).

Changes in plasma concentrations of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), and their relationship to antral follicle development and ovulation, were determined in female brushtail possums (Trichosurus vulpecula) in experiments in which pouch young were removed (RPY) from lactating females to promote ovarian activity. In Experiment 1 (n = 8), the development of preovulatory follicles and ovulation was monitored by laparoscopy. In Experiment 2 (n = 15) estrus and mating were monitored by cytology of urine. Ovulation occurred in 4/8 (Experiment 1) and 9/16 (Experiment 2) possums, and in these animals, plasma FSH concentrations fell progressively over the period of preovulatory follicle development and returned to pretreatment levels after ovulation. With the exception of samples taken at the time of the preovulatory gonadotropin surge, mean plasma LH levels remained basal. In those possums that failed to ovulate, plasma FSH concentrations were elevated while plasma LH concentrations were low; these patterns remained unchanged throughout the sampling period. It was not possible to distinguish between animals that would ovulate and those that would not ovulate after RPY on the basis of gonadotropin profiles at the time of RPY. A further group of possums (Experiment 3, n = 10) were blood-sampled at hourly intervals for 48 h to characterize preovulatory gonadotropin surges, using laparoscopy to monitor preovulatory follicular development and predict ovulation. A preovulatory LH surge (max. conc. 10.2-43.5 ng/ml, duration 7-9 h) was recorded in 4 animals, with a coincident preovulatory FSH surge (max. conc. 1.4-21.4 ng/ml, duration 3-11 h) observed in 3 of these possums. The patterns of gonadotropin secretion in the cycling brushtail possum conform to those reported for eutherians that ovulate spontaneously and appear to be regulated by similar mechanisms.

Presence of males affects the incidence of ovulation after pouch young removal in brushtail possums (Trichosurus vulpecula).

The traditional method for inducing and synchronising oestrus in the brushtail possum (Trichosurus vulpecula) is by removal of their suckling pouch young (RPY). However, our studies have recently shown that, in addition to wide variation between animals in the time of ovulation after RPY, a proportion of animals failed to ovulate. Evidence from several mammalian species indicates that the presence of males can stimulate ovarian activity and synchronise oestrus in females. The aim of this study was to determine the effect of the male on the oestrous cycle of the female brushtail possum after RPY. A total of 67 adult female brushtail possums were treated as three replicates. In order to observe the day of preovulatory follicle emergence and ovulation, animals underwent laparoscopic examination at 1-4 day intervals over a period from 0-21 days after RPY. The first replicate (N = 18, May/June 1995) involved only animals kept in isolation from males, whereas the two remaining replicates compared ovarian responses between animals kept with ( N = 10, July 1995; N = 14, June 1996) or in isolation from ( N = 10, July 1995; N = 15, June 1996) males. The incidence of ovulation after RPY was significantly higher in females that were housed with males than in those kept in isolation from males (100%, 92.8% vs. 50.0%, 66.7%, 14.3%; P < 0.001). Every animal that ovulated, had previously had a preovulatory follicle present at the site where the corpus luteum formed. Conversely, none of the animals that failed to ovulate, developed a preovulatory follicle during the period of the study. The range of mean day of preovulatory follicle emergence (6.00-6.86 days), of ovulation (11.80-12.20 days) and the synchrony of ovulation between animals (range 8-17 days) after RPY, were not significantly affected by the presence of males. This study demonstrates for the first time, that the presence of males significantly increases the incidence of ovulation after RPY in the brushtail possum. However neither the timing of reproductive events nor the synchrony of ovulation were affected by presence of the male.

Preovulatory follicle development and ovulation in the brushtail possum (Trichosurus vulpecula) monitored by repeated laparoscopy.

The common method for synchronizing oestrus in brushtail possums is by removal of their pouch young (RPY). However, there is little information on the ovarian response to this treatment, the timing and incidence of ovulation is poorly defined, and methods of identifying oestrus are unreliable. In this study, the development of preovulatory follicles, ovulation and reproductive tract changes following RPY were monitored by repeated laparoscopic observation. A total of 120 adult female possums underwent laparoscopy at intervals of 1-4 days over the period from 0 to 21 days after RPY. Tissue was collected from a further 30 animals for correlative histology of ovarian structures, and to quantify changes in reproductive tract organs. Only 80 of 120 animals ovulated, and the time of ovulation ranged from 7 to 18 days following RPY. In most animals, enlargement of vaginal cul-de-sac and uterine tissue occurred within 10 days. Correlative histology supported the macroscopic classification of ovarian structures, and healthy and atretic follicles could be identified by laparoscopy. Vaginal smears and plasma progesterone concentrations verified the occurrence of ovulation as observed by laparoscopy. A 'presumptive' preovulatory follicle, first identifiable approximately 5 days before ovulation, was recorded in all animals that ovulated and in none that failed to ovulate. Changes to its surface morphology indicated impending ovulation. This study has enabled the day of ovulation to be identified accurately for the first time in this species. It has also shown that there is wide variation in follicle development, lack of synchrony in the time of ovulation in the brushtail possum, and that some animals fail to ovulate following RPY.

Bone surface concentrations and dose rates 11 years after massive accidental exposure to 241Am.

Alpha-particle spectrograms of bone samples from USTUR Case 246 were analyzed to determine the depth in tissue from which the 241Am alpha-particles were emitted. In four samples of bone, the lack of energy straggling in the alpha spectra indicated that essentially all the 241Am was deposited directly on the exposed bone surface, and none had been translocated to within bone volume. These findings agree well with the results of autoradiographic examination of bone samples from the same case, but are in marked contrast to findings on another case (USTUR Case 102) who had been exposed to a much smaller amount of 241Am at a younger age and survived approximately twice as long after the exposure. It is problematical whether the lack of 241Am redistribution, and therefore the implied absence of bone remodeling, in Case 246 was due to his advanced age at exposure or to a deterministic effect of alpha-irradiation on bone metabolism, but the observation of radiation effects on bone metabolism in former radium workers supports the latter.

Developmental changes in spinal cord neurite-promoting activity from chick muscle extracts.

Muscle extracts from embryonic chicks aged 10-18 days of embryogenesis produced an increase in 6-day embryo spinal cord neurite initiation. A maximal effect was observed with 18-day extract. Extracts from older chicks produced no effect. These neurite promoting factors are produced at a time in which neuromuscular junctions are forming and becoming stabilized in ovo and may act to control terminal branching, selection, and maintenance of axonal endings.

Effects of hormonal, sexual, and social history on mating and pair bonding in prairie voles.

The interactive effects of hormones, sexual history and cohabitation on sexual and social behaviors were examined in pairs of ovariectomized female and sexually experienced male prairie voles (Microtus ochrogaster). Monitoring with time lapse video tape revealed that females in estradiol benzoate (EB)-induced estrus, and their male partners engaged in high levels of sexual activity which continued intermittently for at least 3 days (until observations were arbitrarily terminated). In conjunction with other studies, these results indicate that the hormonal condition of the female at the time of testing is a major determinant of sexual activity. Prior hormonal, copulatory, or cohabitation experience did not significantly influence sexual responses between females and unfamiliar male partners. However, affiliative behaviors, such as side by side contact, were higher in pairs that were familiar due to prior sexual and cohabitational experience. These results indicate that social and sexual behaviors are independently regulated. Other behaviors, including nasogenital investigation and autogrooming were influenced by the hormonal and sexual history of the female. The implications of these behavioral patterns for reproductive activation, pair bonding, and incest avoidance are discussed.

The clinical investigation of dementia.

The clinical investigation of 63 patients with a hospital discharge diagnosis of dementia was reviewed. The review focused on the completeness of ancillary investigations to detect treatable causes of dementia, and on the follow-up examination to confirm the diagnosis. Patients admitted to specialized geriatric psychiatry beds were compared to those admitted to other hospital services. The clinical investigation of the groups did not differ significantly with the respect to the search for treatable dementias, and in this series no treatable cases were detected. The non-selective use of a battery of ancillary diagnostic tests is questioned. The most notable finding was the almost uniform absence of follow-up examinations to document progressive deterioration of cognitive function. The indication for such follow-up is discussed in the context of previously reported diagnostic inaccuracy in this syndrome.

Relationships among cognitive complexity, sex, and spatial task performance in college students.

This study examined the relationship between object differentiation (spatial ability) and social differentiation (cognitive complexity). Prior research had demonstrated a link between field independence and cognitive complexity, and between field independence and spatial ability. This raises the question whether some unitary cognitive style is involved in both spatial ability and cognitive complexity. The present study used a spatial task (a variation of Piaget & Inhelder's water level task) and several measures of cognitive complexity (the Barron Complexity scale, Intolerance of Ambiguity scale, and measures of self-differentiation and differentiation of other persons) to test the prediction that complexity will be positively related to performance on the water level task. On the basis of earlier findings, we also predicted that males would outperform females on the water level task. Thirty-eight male and 98 female undergraduates completed the water level task and the complexity measures. Results confirmed the predictions, except that the relationship between cognitive complexity and performance was different for males than for females. For males, the correlations between scores on the water level task and the several measures of complexity were considerably higher than for females. Such results suggest that for males spatial task performance can be related to a general construct such as cognitive style; for females, this does not appear to be the case.

Sarcoidosis and fluctuating hearing loss.

Neurological manifestations of sarcoidosis occur in 5% of affected patients. Of the cranial nerves, the eighth nerve is the fourth most frequently involved. The central nervous system lesion is presumed to be a granulomatous meningitis that directly infiltrates the cranial occur in concert with other neurological findings, but may be the only presenting complaint. Sarcoidosis is not generally recognized as a cause of fluctuating sensorineural hearing loss. The fluctuating quality of the hearing loss has been noted by other investigators, but no patient has been previously reported with hearing fluctuation as the initial complaint. A chest radiograph and eye examination are mandatory. The diagnosis may be suspected from hilar adenopathy and uveitis, and confirmed by node biopsy. The hearing will usually improve on steroid therapy. Sarcoidosis represents yet another disease entity the otolaryngologist must consider in the differential diagnosis of fluctuating hearing loss.

Survivorship and senile dementia.

It has been suggested that those having senile dementia are now living longer. To re-examine this suggestion a study was undertaken of those with senile dementia who had died in a home for the aged during a 10-year period. The results suggested that no change in survivorship was occurring. In general, 50% were dead after two years and 70% after four years. Sex, age on admission and year of admission had no bearing on the findings. Any comparison of survivorship for senile dementia between different periods of time and countries should be carefully qualified.

Left-handers' sensitivity to hand usage: theoretical note on saliency in the self-concept.

Etaugh and Brausam (1978) reported that left-handers were more sensitive than right-handers to hand usage by figures in a picture. Their interpretation emphasizes particular social experiences of left-handers. We propose a theoretically broader explanation--that there are general tendencies to characterize the self in terms of characteristics that are distinctive relative to others and to note in others those qualities salient in the self-concept.