Online Learning and Echocardiography Boot Camp: Innovative Learning Platforms Promoting Blended Learning and Competency in Pediatric Echocardiography.

Mastering pediatric echocardiography (PE) requires a substantial knowledge base of echo theory and congenital heart disease (CHD), along with technical proficiency. Online self-directed learning has become increasingly utilized among medical trainees to promote competency within medical subspecialties. We sought to evaluate the impact of online learning combined with lecture-based and hands-on teaching on the acquisition of PE knowledge and confidence in pediatric cardiology and pediatric critical care fellows. We prospectively enrolled 124 learners from 2016 to 2019. These included 40 incoming cardiology and critical care fellows at Texas Children's Hospital (TCH) as well as 84 national and international participants recruited from our online echo education website. All participants completed online learning modules through our website ( www.pedecho.org ), which covers pediatric echo physics, Doppler, technique, normal anatomy, atrial septal defects, and ventricular septal defects. TCH cardiology and critical care fellows subsequently participated in an Echo Boot Camp (BC), a 3-day training program with hands-on workshops and didactic lectures. Knowledge was assessed using an 80-question pre and post-test multiple choice exams. The online learning group demonstrated improvement in exam scores following online learning (PRE 49.1 ± 15.3 vs. POST 67.8 ± 17%; p ≤ 0.01). Echo Boot Camp fellows were noted to have further incremental improvement in test scores following BC (PRE 48% ± 13% vs. POST MODULE 68.6% ± 15% vs. POST BC 75.7% ± 13%; p ≤ 0.01). Self-assessment regarding confidence in context areas showed a substantial gain in self perceived interpretive confidence across all groups as well as procedural confidence in BC participants. Online learning significantly promotes the acquisition of echocardiography knowledge. Additional lecture-based and hands-on teaching in the form of an Echo Boot Camp can further enhance knowledge and interpretative skills. Both of these learning platforms appear to work in concert as powerful and effective tools in fellow education.

Pilot study of chronic maternal hyperoxygenation and effect on aortic and mitral valve annular dimensions in fetuses with left heart hypoplasia.

OBJECTIVE: Acute maternal hyperoxygenation (AMH) results in increased fetal left heart blood flow. Our aim was to perform a pilot study to determine the safety, feasibility and direction and magnitude of effect of chronic maternal hyperoxygenation (CMH) on mitral and aortic valve annular dimensions in fetuses with left heart hypoplasia (LHH) after CMH. METHODS: Gravidae with fetal LHH were eligible for inclusion in a prospective evaluation of CMH. LHH was defined as: sum of aortic and mitral valve annuli Z-scores < -4.5, arch flow reversal and left-to-right or bidirectional atrial level shunting without hypoplastic left heart syndrome or severe aortic stenosis. Gravidae with an affected fetus and with ≥ 10% increase in aortic/combined cardiac output flow after 10 min of AMH at 8 L/min 100% fraction of inspired oxygen were offered enrollment. Nine gravidae were enrolled from February 2014 to January 2015. The goal therapy was ≥ 8 h daily CMH from enrollment until delivery. Gravidae who were cared for from July 2012 to October 2014 with fetal LHH and no CMH were identified as historical controls (n = 9). Rates of growth in aortic and mitral annuli over the final trimester were compared between groups using longitudinal regression. RESULTS: There were no significant maternal or fetal complications in the CMH cohort. Mean gestational age at study initiation was 29.6 ± 3.2 weeks for the intervention group and 28.4 ± 1.8 weeks for controls (P = 0.35). Mean relative increase in aortic/combined cardiac output after AMH was 35.3% (range, 18.1-47.9%). Median number of hours per day on CMH therapy was 9.3 (range, 6.5-14.6) and median duration of CMH was 48 (range, 33-84) days. Mean mitral annular growth was 0.19 ± 0.05 mm/week compared with 0.14 ± 0.05 mm/week in CMH vs controls (mean difference 0.05 ± 0.05 mm/week, P = 0.33). Mean aortic annular growth was 0.14 ± 0.03 mm/week compared with 0.13 ± 0.03 mm/week in CMH vs controls (mean difference 0.01 ± 0.03 mm/week, P = 0.75). More than 9 h CMH daily (n = 6) was associated with better growth of the aortic annulus in intervention fetuses (0.16 ± 0.03 vs 0.08 ± 0.02 mm/week, P = 0.014). CONCLUSIONS: CMH is both safe and feasible for continued research. In this pilot study, the effect estimates of annular growth, using the studied method of delivery and dose of oxygen, were small. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Dose ranging study on the effect of preoperative dexamethasone on postoperative quality of recovery and opioid consumption after ambulatory gynaecological surgery.

BACKGROUND: Glucocorticoids are commonly administered before ambulatory surgery, although their effects on quality of recovery are not well characterized. The purpose of this study was to evaluate the dose-dependent effects of dexamethasone on patient recovery using the Quality of Recovery 40 questionnaire (QoR-40) after ambulatory surgery. METHODS: This prospective, double-blind trial studied 106 female subjects undergoing outpatient gynaecological laparoscopy. Subjects were randomized to receive saline, dexamethasone 0.05 mg kg(-1) or dexamethasone 0.1 mg kg(-1) before induction. The primary outcome was global QoR-40 at 24 h. Postoperative pain, analgesic consumption, side-effects, and discharge time were also evaluated. RESULTS: Global median (IQR) QoR-40 after dexamethasone 0.1 mg kg(-1) 193 (192-195) was greater than dexamethasone 0.05 mg kg(-1) 179 (175-185) (P=0.004) or saline, 171 (160-182) (P<0.005). Median (IQR) morphine equivalents administered before discharge were 2.7 (0-6.3) mg after dexamethasone 0.1 mg kg(-1) compared with 5.3 (2.4-8.8) mg and 5.3 (2.7-7.8) mg after dexamethasone 0.05 mg kg(-1) and saline (P=0.02). Time to meet discharge criteria was 30 min shorter after dexamethasone 0.1 mg kg(-1) compared with saline (P=0.005). At 24 h, subjects receiving dexamethasone 0.1 mg kg(-1) had consumed less opioid analgesics, reported less sore throat, muscle pain, confusion, difficulty in falling asleep, and nausea compared with dexamethasone 0.05 mg kg(-1) and saline. CONCLUSIONS: Dexamethasone demonstrated dose-dependent effects on quality of recovery. Dexamethasone 0.1 mg kg(-1) reduced opioid consumption compared with dexamethasone 0.05 mg kg(-1), which may be beneficial for improving recovery after ambulatory gynaecological surgery.

Outcome of pregnancy following intervention for coarctation of the aorta.

There are limited data regarding the outcome of pregnancy in women after intervention for coarctation of the aorta (CoA). The Texas Children's Hospital Cardiac Database was used to identify female patients with CoA born before 1980 who had undergone balloon angioplasty or surgery. Patients with Turner's syndrome and cyanotic congenital heart disease were excluded. A chart review and telephone interview were performed. Data collected included age at intervention, type of intervention, the need for reintervention, functional status, number of pregnancies, and pregnancy outcomes. Seventy-four patients met our criteria and we were able to contact 52. Eighteen patients (39%) were pregnant a total of 36 times. There were 3 spontaneous and 4 elective abortions. Preeclampsia complicated 4 pregnancies in 3 women (17% of primigravidas). One patient had systemic hypertension. Eleven infants were delivered by Cesarean section. There were 29 births, with an average weight of 3.0 kg. There were 5 preterm births, 4 to a teenage mother. Only 1 child (3%) had a congenital heart defect. Thus, in women with an arm-to-leg blood pressure gradient of <20 mm Hg after CoA repair, pregnancy is successful. The occurrence of congenital heart disease in the offspring was 3%. Preeclampsia was similar to that in the general population.

Severe clinical phenotype due to an interstitial deletion of the short arm of chromosome 1: a brief review.

We report on a newborn girl with malformed ears, bilateral cleft lip and cleft palate, complex congenital heart disease, absent left thumb, and rib abnormalities. Cytogenetic analysis demonstrated a de novo interstitial deletion of the short arm of chromosome 1 [46,XX,del(1)(p21p22.3)]. Reports of interstitial deletions on the short arm of chromosome 1 are rare. However, when comparing this patient's phenotype to others with deletions of 1p, we found that the current case was much more severely affected than previously reported cases.

A profile of symptomatic patients with silicone breast implants: a Sjögrens-like syndrome.

Exposure of breast tissue to silicone has been associated with autoimmune diseases in the medical literature since the 1960's. Japanese women injected with raw silicone had features of a collagen vascular disease but did not meet criteria for a specific diagnosis. Subsequently, we have seen women with silicone breast implants that have similar problems. We performed a prospective noncontrolled study on women with silicone breast implants. Results from the first 50 consecutive women revealed the most prominent complaints in this group were fatigue (89%), generalized stiffness (75%), poor sleep (71%), and arthralgias (78%). Other problems included Raynaud's phenomenon, alopecia, adenopathy, night sweats, and frequent sore throats. Unexpectedly, half of these women complained of dry eyes and dry mouths. Positive antinuclear antibodies and or rheumatoid factors were discovered in 38% of patients although the anti-SSA antibody was found in only one patient and anti-SSB in none. Labial salivary gland biopsies in 5 cases showed mononuclear cell infiltrates compatible with Sjögren's syndrome in 4. The infiltrating cells were predominantly CD68 positive monocyte/macrophages, which is different from what is found in Sjögren's syndrome. These findings may indicate the presence of a unique syndrome associated with silicone implants that is characterized by musculoskeletal pain and autoimmune features.

Harmonic imaging in fetal echocardiography.

Noncontrast harmonic imaging (HI) has been shown to improve image quality in adults with poor acoustic windows. The utility of fetal echocardiography may be limited by suboptimal acoustic windows, and the use of HI in fetal echocardiography has not previously been defined. The purpose of this study was to compare the quality of fundamental imaging (FI) and HI in fetal echocardiography. Sixty-two fetal echocardiograms, including 44 (71%) with limited acoustic windows, were performed with the use of FI and HI. Image quality and visualization of the ventricles, valves, and the aortic and ductal arches were evaluated and compared between FI and HI. Mean HI scores were higher than mean FI scores for all the structures evaluated. Compared with FI, HI improved the image quality and visualization of cardiac structures in this group of fetuses with predominantly suboptimal acoustic windows. Harmonic imaging is a useful adjunct to FI in echocardiography, and the benefits of HI extend to cardiac imaging in the fetus.

Myocardial infarction in the guinea pig: cellular electrophysiology.

The cellular electrophysiology of left ventricular preparations from guinea pig hearts was studied 1 hour, 24 hours, and 4-6 weeks after myocardial infarction produced by 6-8 single ties of the distal left coronary artery system or after sham operation. Microelectrode recordings were used to monitor cells from the endocardial surface of each preparation in tissue bath. All coronary ligated preparations displayed accelerated spontaneous activity compared to normal and sham operated preparations. Single and multiple premature ventricular depolarizations occurred frequently in coronary ligated and rarely in normal and sham operated preparations. Premature stimuli delivered to areas overlying and bordering the area of infarction, induced short bursts of self-terminating rapid repetitive ventricular activity in 4 of 8 (50%) acute (1-hour), 5 of 9 (55%) subacute (24-hour), and 14 of 20 (70%) healed (4-6-week) infarcted preparations. Such activity could not be induced in normal and sham operated preparations. The preparations with healed infarction were unique in that they demonstrated runs of self-terminating repetitive ventricular activity which occurred spontaneously or was inducible with premature stimulation. Recordings from multiple sites in acute, subacute, and healed preparations revealed a variety of transmembrane action potential abnormalities (i.e., reduced action potential amplitude and resting potential, decreased and increased action potential duration, and depressed maximum rates of phase 0 depolarization) in cells overlying and bordering areas of infarction. Only Purkinje fiber action potentials were recorded over the healed infarcts. These data demonstrate that a spectrum of electrophysiological alterations occur in response to ischemic injury and persist after healing of the injury in this new model of myocardial infarction utilizing the guinea pig.

Randomized comparative multicenter study of hydroxyethyl starch versus albumin as a plasma expander in cirrhotic patients with tense ascites treated with paracentesis.

OBJECTIVE: Large-volume paracentesis associated with plasma volume expansion with albumin is an effective, safe, but costly therapy for ascites in patients with cirrhosis. The aim of this study was to compare the use of a synthetic plasma expander, hydroxyethyl starch (HES), with that of albumin. DESIGN: Sixty cirrhotic patients with ascites were studied. Patients were randomly assigned to be infused with either albumin (8 g/l of ascites removed, n = 33) or HES (200 ml/l of ascites removed, n = 27). None of the patients was treated with diuretics or had renal impairment or hyponatremia at entry. Clinical and laboratory data were obtained before and 1, 3 and 15 days after treatment. RESULTS: There were no significant differences in clinical and laboratory parameters between the two groups at entry into the study. None of the patients developed renal impairment during the trial. One patient (HES group) presented with hyponatremia. Plasma atrial natriuretic factor and aldosterone levels did not differ between the two groups at baseline or at 1 and 3 days after paracentesis. The volume of ascites removed did not differ between the albumin (7.9 +/- 4.4 l) and HES (6.9 +/- 5.3 l) groups. However, there was a significant difference in weight loss between the albumin and HES groups (7.9 +/- 5.2 kg vs 4.7 +/- 3.4 kg; p = 0.01). Clinical and laboratory parameters indicated that HES was well tolerated except for hypoalbuminemia. CONCLUSION: HES is well tolerated in patients with cirrhosis. There is no difference between HES and albumin in the prevention of complications related to large-volume paracentesis. The lesser degree of weight loss observed with HES needs further study.

Host and viral characteristics affecting the response to interferon therapy in chronic hepatitis C.

OBJECTIVE: To define parameters determined before and after 4 weeks of interferon therapy (3 MU three times per week for 24 weeks) which could be reliable predictors of a response to therapy. PATIENTS: Thirty-four patients with chronic hepatitis C virus (HCV) infection were investigated prospectively. METHODS: A complete response was defined as the normalization of serum alanine aminotransferase levels (ALT) at the end of treatment. The genotype of HCV was determined and the level of HCV-RNA was quantitated both before and after 4 weeks of treatment. RESULTS: After 4 weeks, 16 out of 20 responders [95% confidence interval (CI) 54-94%] and two out of 14 non-responders (95% CI 2-44%) normalized their ALT levels (P = 0.0002). The prevalence of genotype 1b was significantly (P < 0.04) higher among non-responders (eight out of 10; 95% CI 44-92%) than in responders (four out of 18; 95% CI 4-40%). Before treatment, the viraemia determined by branched DNA was significantly lower in responders than in non-responders (46.4 versus 116 x 10(5) eq virus/ml). After 4 weeks of treatment, the level of viraemia in responders was still significantly lower than that in non-responders (22.8 versus 66 x 10(5) eq virus/ml). In responders, a significant decrease in the level of viraemia was observed after 4 weeks of treatment. CONCLUSION: In a stepwise regression analysis only age and the normalization of ALT levels after 4 weeks of treatment were predictive of response to interferon at the end of treatment.

Bile levels of carcino-embryonic antigen in patients with hepatopancreatobiliary disease.

OBJECTIVE: To evaluate the value of biliary carcino-embryonic antigen (CEA) in the differential diagnosis of malignant and benign hepatopancreatobiliary disease. PATIENTS: One hundred patients were prospectively studied. Benign diseases were present in 39% of the patients while 61% had malignant diseases. METHODS: Samples of serum were taken from all patients just before endoscopic retrograde cholangiopancreatography (ERCP) and samples of biliary CEA were obtained during ERCP. RESULTS: The sensitivity of serum CEA and carbohydrate antigen 19-9 (CA 19-9) in detecting malignancy were 50% and 92%, respectively, while the respective specificities were 95% and 72%. The mean biliary CEA level of the benign group was significantly different from that of the malignant group (35.7 +/- 8.7 ng/ml vs 268 +/- 85.5 ng/ml), but there was considerable overlap between the two groups. With a cut-off level of 20 ng/ml, the sensitivity and specificity were 84% and 64% respectively. The mean bilirubinaemia value was significantly higher in malignant disease than in benign disease (57.4 +/- 13.9 mumol/l vs 235 +/- 19.8 mumol/l). Multidimensional analysis indicated that only bilirubinaemia (P < 109-3)) was independently predictive of malignant disease. CONCLUSION: Biliary CEA assessment seems useless in distinguished between benign and malignant causes of cholestasis.

Evaluation of flow rates for six disposable infusion devices.

The accuracy of flow was studied for six disposable infusion devices: Eclipse (Block Medical), Homepump (Block Medical), Intermate (Baxter Healthcare), MedFlo (Secure Medical), ReadyMED (McGaw), and SideKick (I-Flow). Each infusion device had a preset delivery rate of 100 mL/hr. Either 48 or 50 units of each device were filled with 100 mL of 0.9% sodium chloride injection. Flow was measured in a 60-mL syringe set 100 cm above the infusion device. The volume infused was recorded over 60 minutes at 5-minute intervals. Of the six devices tested, Homepump demonstrated the least variability in flow. The mean percentage of initial volume infused at 60 minutes was 93.7% for the Homepump, 92.4% for the MedFlo, 91.9% for the SideKick, 88.7% for the ReadyMED, 87.3% for the Eclipse, and 83.4% for the Intermate. The Intermate was the only device with a mean overall infusion rate outside the manufacturer's specifications of +/- 15%. The SideKick's mean infusion rate exceeded the +/- 15% range during the first half of the infusion. None of six disposable infusion devices delivered 100% of the volume to be infused within 60 minutes. Of the devices tested, the Homepump demonstrated the least variability in flow and the most complete volume delivery.

Multiple cutaneous granular cell tumors of the scrotum.

A 55-year-old black man with two firm intradermal nodules of the scrotum is presented. On histopathologic examination, the nodules were determined to be cutaneous granular cell tumors. This was confirmed by strong immunohistochemical reactivity to S-100 protein. There are no previous reports of multiple granular cell tumors of the male genitalia. Only one report of a solitary granular cell tumor of the scrotum appears in the literature.

[Evaluation of nursing care during treatment of viral hepatitis C by interferon]. / Evaluation du rôle des soins infirmiers lors d'un traitement par interféron pour une hépatite virale C.

OBJECTIVE: Interferon alpha treatment requires parenteral administration and some patients receive injections from nurses. The aim of this study was to evaluate the role of nursing care during ambulatory treatment of hepatitis C by interferon alpha. METHODS: A questionnaire was sent by mail to all nurses who practice ambulatory care in the Val de Marne region (n =545). RESULTS: One hundred fourteen questionnaires were returned (return rate: 20%). Among these nurses, only 42 (37%) were caring for at least 1 patient for the treatment of hepatitis C by interferon. In the 16 months before the survey, these 42 nurses had cared for 135 patients. The nurses cared for the patients throughout the entire treatment in 81% and only to teach them in 19% of cases. The time spent for each injection was 12 min 48 sec, 2 min 42 sec for the injection itself, 3 min 54 sec to answer to patient's questions, 3 min 30 sec for psychological support, and 2 min 48 sec for unspecific time. In relation to hepatitis C and interferon treatment, 74% and 64% of the nurses felt that patients asked questions they did not ask their physician. Seventy seven of the nurses felt they were did not have enough training to answer the questions. Psychological support for the patient was noted as important or very important by 38 % of nurses. CONCLUSIONS: The role of nurses during interferon treatment is not limited to injecting the drug. Advice and psychological support takes up most of the time spent with patients. Specific training and better collaboration with the physician who prescribes the treatment are needed.

[Screening of patients at risk for hepatitis C virus infection in general medicine]. / Dépistage des malades à risque d'infection virale C en médecine générale.

OBJECTIVES: The French consensus conference recommended targeted screening for hepatitis C virus infection in patients with a past history of intravenous drug use or transfusion of blood products before 1991. The aim of this study was to determine the feasibility and results of targeted screening by general practitioners. METHODS: For 2 weeks, 58 general practitioners systematically asked all their patients about a past (or current) history of intravenous drug use or transfusion of blood products before 1991. In patients who responded affirmatively, hepatitis C virus screening was proposed if it had not been performed previously. RESULTS: 8,292 patients were included. Blood transfusion and intravenous drug use were present in 383 (4.6%) and 116 (1.4%) patients respectively. Positive hepatitis C virus serology had been identified before the study, in 16 and 63 patients in these groups respectively. Tests were performed in 77% and 50% of patients with a history of blood transfusion and intravenous drug use. Systematic screening showed a positive hepatitis C virus serology in 7 and 4 patients with a history of blood transfusion and intravenous drug use (representing 2% and 15% of the tests performed during the study). Globally, 79 (88%) of the 90 patients with a positive serology had been identified before this systematic screening. CONCLUSIONS: Systematic targeted screening of hepatitis C virus infection only results in a diagnosis in a few cases. In the patients who consulted a general practitioner, 70% and 94% of cases of hepatitis C in patients with a history of blood transfusion or intravenous drug use respectively, were known before systematic screening.

[Viral hepatitis A with prolonged course in adults]. / Hépatite virale A d'évolution prolongée de l'adulte.

OBJECTIVE: The aim of this study was to determine the clinical and virological characteristics of patients with type A viral hepatitis and a protracted course. METHODS: Twenty-seven patients with hepatitis A virus and elevated serum ALT levels for more than 6 months were studied. Patients were tested for hepatitis C and E virus using conserved serums. RESULTS: A biological relapse was defined by a decrease of the serum ALT levels > or = 50% followed by a > or = 50% increase in the minimal value. Biological relapses occurred in all patients. The median time between the onset of the disease and the first relapse was 87 days. During relapse, jaundice and ascites were present in five and one patients, respectively. All patients recovered. Serum aminotransferase activities returned to the normal range in a median of 230 days. None of the 17 tested patients had hepatitis C virus antibodies. Sixteen patients were tested for hepatitis E virus antibodies; 8 were positive for IgG and one for IgM. Sixteen control patients with acute hepatitis A of short duration, matched for date and country of contamination, were also tested for antibodies to hepatitis E virus; 11 were positive for IgG and none for IgM. CONCLUSION: A protracted course of type A viral hepatitis is characterised by relapses with or without symptoms. The high frequency of a positive test for hepatitis E IgG associated with a negative test for IgM in patients with and without a protracted course does not suggest that hepatitis E virus plays a role in patients with a protracted course. These positive results might be due to either false positive results or to past contamination.

[Hepatic toxicity of antitubercular agents. Role of different drugs. 199 cases]. / Toxicité hépatique des antituberculeux. Rôle des différents médicaments. 199 observations.

One hundred and ninety-nine cases of hepatic injury related to antituberculous treatment were analysed in order to assess the role played by each drug and to look for predisposing factors. This is a retrospective study of 169 cases reported in the literature and 30 cases reported to the regional pharmacovigilance centre of Paris Saint-Antoine. The mortality rate was related to the dose of isoniazid: it was 43 percent with a daily dose higher than 300 mg, and 9 percent with a daily dose of 300 mg or less (P < 0.001). Hepatic injury appeared significantly earlier in the case of rifampicin combination: 11 weeks without rifampicin and 2 weeks with rifampicin (P < 0.01). The role of pyrazinamide was difficult to determine because isoniazid and pyrazinamide were always used in combination. The influence of a preexisting liver disease could not be evaluated because of the small number of cases reported (8 cases). Alcoholism did not increase the mortality rate. Our results confirm the dose-dependent toxicity of isoniazid. Because of the short time elapsed before the apparent onset of hepatitis observed with the rifampicin combination, a close supervision of the patients should be exerted during the first weeks of treatment.

[Antral gastritis in chronic alcoholism. Role of cirrhosis and Helicobacter pylori]. / Gastrite antrale au cours de l'alcoolisme chronique. Rôle de la cirrhose et d'Helicobacter pylori.

OBJECTIVES: Antral gastritis is frequent in alcoholics. The role of H. pylori in the pathogenesis of gastritis in these patients is not well known. The aim of our study was to study the role of H. pylori and cirrhosis in the pathogenesis of antral gastritis in alcoholic patients. METHODS: Seventy-nine patients were included in the study. All underwent upper gastrointestinal tract endoscopy with antral biopsies, independently of the presence of abdominal pain, and had serological examination for H. pylori antibodies. RESULTS: Cirrhosis and gastritis were present in 50 and 40 patients respectively, H. pylori serological assay and histological identification of the bacterium were positive in 35 (44%) and 19 (24%) patients respectively. Discrepancy between the 2 tests were observed more frequently in cirrhotic patients. A positive serology with a negative histologic examination for H. pylori was present for 18 cirrhotic and 4 noncirrhotic patients (p < 0.05). A gastritis without evidence of H. pylori was more frequent in cirrhotic than in noncirrhotic patients. H. pylori was histologically present in 11 of 29 cirrhotic patients and in 8 of the 11 noncirrhotic patients with a gastritis (p < 0.05). CONCLUSIONS: Discrepancies between histological examination and H. pylori serology in patients with cirrhosis might be due to the inhospitable environment for H. pylori in case of portal hypertension; the positive serology could be in relation with a past infection.

AANA journal course: update for nurse anesthetists--carbon monoxide poisoning: role of the anesthesia machine's carbon dioxide absorption system.

Carbon monoxide is a colorless, odorless, and tasteless gas that, when inhaled, is toxic to humans. In 1965, Middleton reported the detection of carbon monoxide in the closed anesthetic circuits of patients undergoing surgery. In recent years, anesthesia providers from at least four American hospitals have reported instances of intraoperative carbon monoxide poisoning in anesthetized patients undergoing surgery. Although no deaths were associated with these incidents, carboxyhemoglobin levels ranged from 8.5% to 32%. In virtually all reported cases, the incidents occurred in surgical suites that had not been used for at least 2 days. This facet of the phenomenon advanced the theory that a slow chemical reaction, probably involving soda lime or barium hydroxide lime, was responsible for the liberation of carbon monoxide within the anesthesia circuit. Recent research has attributed this generation of carbon monoxide to the degradation of volatile anesthetic agents by desiccated carbon dioxide absorbents. Although carbon monoxide poisoning of patients undergoing anesthesia with volatile anesthetics is probably a rare occurrence, it is a potential problem for all anesthesia providers.