Duplex sonography of the mesenteric vessels--a critical evaluation of inter-observer variability.

INTRODUCTION: The number of publications concerning mesenteric Doppler sonography (mesDS) is immense and does not correlate with the frequency of its use in clinical practice. This is astonishing since it provides real time blood flow (perfusion) information without side effects. Despite uncontrollable parameters like the technical limitations in some situations the optimization of (possibly) controllable parameters like standardization, production of normal values and reduction of the investigator variability by evaluating stable parameters could change the situation. PATIENTS AND METHODS: 10 investigators experienced in abdominal sonography ("DEGUM-Seminarleiter") performed mesenteric Doppler sonography in 5 healthy subjects with 5 different machines. RESULTS: The portal vein at the confluence and the common hepatic artery provide a significant portion of investigations with intromission angles of more than 60°. Values of diameter, resistance index and pulsatility index of the celiac trunc could be obtained with inter-observer variability values below 25 %. The proper and the common hepatic artery show no differences in inter-observer variability values, whereas the intrahepatic measure point of the portal vein showed a higher reproducibility. DISCUSSION: We define frame conditions for future mesenteric Doppler studies: the portal vein should be investigated at the intrahepatic measure point. Pathophysiological studies should refrain from velocity parameters except in the case of larger vessels running in a straight course towards the probe.

Responsible corporate change: detecting and managing employee stress.

BACKGROUND: All 120 health and safety inspectors employed by the New Zealand regulatory agency had their jobs disestablished during a restructuring process and were required to undergo an assessment process with tight time frames. AIMS: To report on psychological morbidity during the transition to change. METHODS: The Hospital Anxiety and Depression Scale (HADS) questionnaire was emailed to all 120 current inspectors to measure levels of anxiety (HAD-A) and depression (HAD-D). A score of <7 is in the normal range, scores of between 8 and 10 are suggestive of an anxiety (HADS-A) or mood (HADS-D) disorder and a score of >11 is indicative of a clinical disorder. RESULTS: Replies were received from 36% (43) of the inspectors. Of the 40 usable responses, 47% (19) and 55% (22), respectively, had HAD-A and HAD-D scores greater than the case cut-off. Only 28% (11) and 15% (6), respectively, had scores that would be considered normal. CONCLUSIONS: The high scores evident in this sample are comparable to those found in patients with serious psychopathology. Change managers should recognize that the onus for primary prevention lies with the organization, in this case designing an assessment process that takes place over a reasonable time frame. They should also realize the requirement for the active monitoring of stress.

Bowel Obstruction: Sonographic Evaluation.

Learning objectives: Sonographic examination concept in the case of suspicion of bowel obstruction. Recognition of the sonographic criteria of a bowel obstruction. Ability to detect the level of a bowel obstruction. Sonographic detection of typical causes of bowel obstruction. Detection of sonographic signs of complicated bowel obstruction. Ability to sonographically define important differential diagnoses. Further diagnostic procedures in unclear situations.

Statement of the section internal medicine of the DEGUM - ultrasound obtains pole position for clinical imaging in acute diverticulitis.

This paper reviews and interprets the role of ultrasonography in view of the recently published Guideline on diverticular disease of the Consensus conference of the German Societies of Gastroenterology (DGVS) and Visceral Surgery (DGAV) implying a new classification of diverticular disease (CDD). Qualified US is not only equipotent to qualified CT and frequently effectual for diagnosis but considers relevant legislation for radiation exposure protection. Unsurpassed resolution allows detailed resolution thereby allowing to differentiate and stratify the relevant types of diverticular disease. Subsequently, US is considered the first choice of imaging in diverticular disease. Vice versa, CT has definite indications in unclear / discrepant situations ­ or insufficient US-performance.

Importance of Abdominal Ultrasound in 17 Patients with Histologically Confirmed Autoimmune Pancreatitis (AIP).

PURPOSE: Autoimmune pancreatitis (AIP) is an independent, underdiagnosed, rare form of chronic pancreatitis. The goal of this study is to document ultrasound findings in histologically confirmed AIP in order to determine the diagnostic value of ultrasound. MATERIALS AND METHODS: 6 of 74 DEGUM instructors for internal medicine (level 3 and 2) provided anonymized clinical and sonographic data from 17 patients with histologically confirmed AIP. RESULTS: 9/17 patients had diffuse AIP, 8/17 had focal AIP, 14/17 suffered from upper abdominal pain, 9/17 had jaundice, and 3/9 had an elevated IgG4 level. Ultrasound showed diffuse hypoechoic organ enlargement in 9/17 cases and a hypoechoic tumor with an unclear border in 8/17 cases. AIP was verified by ultrasound-guided percutaneous core biopsy in 14 cases, by biopsy of the bile duct in 1 case, and by surgical biopsy in 2 cases. Involvement of the hepatobiliary system was present in 7/17 patients and autoimmune cholangitis was verified in 5 cases. All patients experienced remission after immunosuppressive treatment. The pancreatic duct had a normal width in 11 cases, was dilated in 5 cases, and was stenosed over a long stretch in 3 cases. Contrast-enhanced ultrasound did not show uniform signal increase but also no significantly reduced or absent perfusion. CONCLUSION: Ultrasound can be diagnostically useful if the clinical manifestations of AIP are known. While the diffuse form allows an ad-hoc suspected diagnosis, the focal form can only be suspected in the case of additional extrapancreatic involvement. Contrast-enhanced ultrasound (CEUS) contributes greatly to the differentiation from ductal adenocarcinoma in the case of focal AIP.

Benefit of Contrast-Enhanced Ultrasound (CEUS) in the Follow-Up Care of Patients with Colon Cancer: A Prospective Multicenter Study.

PURPOSE: According to the German guidelines on colorectal cancer, unenhanced ultrasound is recommended for follow-up. On the other hand, ultrasound and radiology societies specify the use of contrast-enhanced ultrasound for ruling out liver metastases. Studies focusing on the follow-up of cancer patients are lacking. The goal of this multicenter study initiated by the German Ultrasound Society (DEGUM) was to determine the potential benefit of contrast-enhanced ultrasound in the follow-up of patients with colon cancer. MATERIALS AND METHODS: Follow-up patients with colon cancer (UICC > IIa) were investigated. As scheduled according to the German guidelines, unenhanced ultrasound was performed followed by contrast-enhanced ultrasound. All liver lesions were recorded. In case of additional metastases detected on contrast-enhanced ultrasound, contrast-enhanced CT, MRI or biopsy was performed to confirm additional liver metastases. RESULTS: A total of 45 liver metastases were detected in 26/290 patients (= 9 %) using unenhanced ultrasound. A further 28 metastases were detected on contrast-enhanced ultrasound in these 26 patients. In 18 patients showing no liver metastases, 40 additional metastases were detected on unenhanced ultrasound. This means that 44 patients with a total of 113 liver metastases were detected on contrast-enhanced ultrasound (p = 0.0006). CONCLUSION: Contrast-enhanced ultrasound should be recommended in the follow-up of patients with colon cancer in addition to unenhanced ultrasound - the up-to-date standard.

Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study).

PURPOSE: To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study). MATERIALS AND METHODS: Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards. RESULTS: 8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333). CONCLUSION: This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

A prospective clinical multicentre study on adult pulmonary Langerhans' cell histiocytosis.

BACKGROUND: To date the clinical picture of pulmonary Langerhans' cell histiocytosis has been described only in retrospective reports. For a better understanding, the German Scientific Study Group on the Treatment of Lung Disease (WATL) conducted an open, prospective, clinical observation study. METHODS: During the period between 1994 and 2002 77 patients (40 men and 37 women) were recruited. The median observation period was 38.2 (3.2-86.7) months. RESULTS: At the initial examination 50 patients were active smokers, 26 ex-smokers and 1 had never smoked. 36% of the patients showed reduced vital capacity, 28% signs of airways obstruction. On chest radiography, 74% of the patients who stopped smoking (24/50) showed regression, while 13% remained unchanged and 13% revealed progression. In the group that continued to smoke (25/50) chest radiography showed regression in 58% of cases, no change in 25% and progression in 17%. The difference was not significant, which was also true for lung function values. 3 patients died within the observation period. CONCLUSION: The data underline the key role of smoking as the sole known risk factor. A significant effect of smoking cessation on the course could not be confirmed. The overall prognosis was good in this series as compared to previous reports.

Trust in leadership and team performance: evidence from NCAA basketball.

This study empirically examined the relationship between trust, leadership, and team performance with 2 objectives. The 1st objective was to empirically examine an assumption found in several literatures--that a team's trust in its leader has a significant effect on the team's performance. The 2nd objective was to explore a more complex and dynamic relationship between trust and team performance whereby trust in leadership mediates the relationship between past team performance and future team performance. This relationship is derived by combining theories of trust with an attributional theory of leadership. Survey and archival data from a sample of men's college basketball teams provides support for both hypotheses, indicating that trust in leadership is both a product and a determinant of team performance.

The effects of interpersonal trust on work group performance.

This study explored 2 questions: Does the level of trust within a group affect group performance? If so, how does this relationship operate? An experimental method was used to examine 2 roles through which interpersonal trust could affect group performance: a main effect and a moderating effect. The data do not support the main effect that has dominated the literature on interpersonal trust. The data do support the moderating role: Trust seems to influence how motivation is converted into work group processes and performance. On the basis of these findings, it is suggested that trust may be best understood as a construct that influences group performance indirectly by channeling group members' energy toward reaching alternative goals.

The influence of vegetation on the horizontal and vertical distribution of pollutants in a street canyon.

Space constraints in cities mean that there are only limited opportunities for increasing tree density within existing urban fabric and it is unclear whether the net effect of increased vegetation in street canyons is beneficial or detrimental to urban air quality at local scales. This paper presents data from a field study undertaken in Auckland, New Zealand designed to determine the local impact of a deciduous tree canopy on the distribution of the oxides of nitrogen within a street canyon. The results showed that the presence of leaves on the trees had a marked impact on the transport of pollutants and led to a net accumulation of pollutants in the canyon below the tree tops. The incidence and magnitude of temporally localised spikes in pollutant concentration were reduced within the tree canopy itself. A significant difference in pollutant concentrations with height was not observed when leaves were absent. Analysis of the trends in concentration associated with different wind directions showed a smaller difference between windward and leeward sides when leaves were on the trees. A small relative increase in concentrations on the leeward side was observed during leaf-on relative to leaf-off conditions as predicted by previous modelling studies. However the expected reduction in concentrations on the windward side was not observed. The results suggest that the presence of leaves on the trees reduces the upwards transport of fresh vehicle emissions, increases the storage of pollutants within the canopy space and reduces the penetration of clean air downwards from aloft. Differences observed between NO and NO(2) concentrations could not be accounted for by dispersion processes alone, suggesting that there may also be some changes in the chemistry of the atmosphere associated with the presence of leaves on the trees.

Contrast-enhanced ultrasound for the characterization of focal liver lesions--diagnostic accuracy in clinical practice (DEGUM multicenter trial).

PURPOSE: To evaluate the diagnostic benefit of contrast-enhanced ultrasound for the differential diagnosis of liver tumors in clinical practice. MATERIALS AND METHODS: From May 2004 to December 2006 1349 patients (male 677, female 672) with a hepatic tumor lacking a definite diagnosis based on B-mode ultrasound and power Doppler ultrasound were examined at 14 hospitals by contrast-enhanced ultrasound using a standardized protocol (pulse/phase inversion imaging, mechanical index < 0.4). The Tumor status was assessed based on the vascularity pattern and contrast enhancement seen in focal lesions during the arterial, portal, and late phase. The diagnosis established after contrast-enhanced ultrasound was compared to histology (> 75% cases) or in some cases to CT or MRI. RESULTS: The final diagnosis of hepatic tumors included 573 benign hepatic tumors (hemangiomas n = 242, focal nodular hyperplasia n = 170, hepatocellular adenoma n = 19, other benign lesions n = 142) and 755 malignant hepatic tumors (metastases n = 383, hepatocellular carcinoma n = 279, other malignant lesions n= 93). The overall diagnostic accuracy of contrast-enhanced ultrasound in comparison to the correct final diagnosis based on the combined gold standard was 90.3%. Contrast-enhanced ultrasound was able to correctly assess 723/755 malignant lesions (sensitivity 95.8%) and 476/573 benign lesions (specificity 83.1%). The positive predictive value of contrast-enhanced ultrasound for the diagnosis of a malignant tumor was 95.4% and the negative predictive value of contrast-enhanced ultrasound was 95.7%. CONCLUSION: Contrast-enhanced ultrasound clearly improves the differential diagnosis of hepatic tumors and is very helpful in clinical practice when B-scan or power Doppler morphological criteria are missing.

[Differential diagnosis of severe hypoechoic oedema of the small bowel]. / Zur Differenzialdiagnose segmentaler echoarmer Odeme des Dünndarms.

PURPOSE: To demonstrate the different causes of a marked and hypoechoic edema of the small bowel. MATERIALS AND METHODS: The study comprises patients over a period of 6 years with hypoechoic oedema of the intestinal tract, especially with cystic appearance of the valvulae conniventes. The causes of severe oedema were analysed retrospectively. Examinations were performed with ATL-, Siemens-, and GE-units using convex transducers (2 - 5 MHz) and high-frequency linear transducers (5 - 13 MHz). RESULTS: Hypoechoic oedema of the small bowel with thickening of the valvulae conniventes was observed in 37 patients. The most frequent diagnoses in our series were small-bowel obstruction (n = 8), gastroenteritis (n = 5), peritonitis (n = 5), mesenteric venous thrombosis (n = 4), hereditary angiooedema (n = 3), tumorous infiltration of the mesentery (n = 3), and small bowel ischaemia (n = 2). Other reasons included one case of mesenteritis, renal insufficiency, vasculitis, use of ACE inhibitors, chemotherapy, intravenous drip after surgery, and protein loss in coeliac disease, respectively. CONCLUSION: Severe oedema of the gastrointestinal tract is caused by many different diseases. Hypoechoic thickening of the valvulae conniventes is the typical sonographic sign. Additional clinical, anamnestic and pathohistological data are necessary in order to make a specific diagnosis.

[Multiple circular liver foci in chronic hepatic porphyria: two sonographic case reports]. / Multiple Leberrundherde bei chronisch hepatischer Porphyrie: Zwei sonographische Kasuistiken.

UNLABELLED: Appearance of liver foci in patients with chronic hepatic porphyria has been described in literature several times since 1988. We present two impressive examples of multiple coin-like lesions in the liver of patients with till than unknown porphyria. A 61-year-old women was hospitalized with suspected liver metastases: sonography showed multiple ring-like liver foci up to 2 cm. In a 52-year-old man sonography incidentally detected multiple liver foci, in this case homogeneous hyper-echogenic. In both patients a liver tumor was excluded by biopsy, the histologic examination of the specimens only showed uncharacteristic alterations. DISCUSSION: Sonographic findings in hepatic porphyria most times are only uncharacteristic alterated. But 10% of the patients show multiple hyper-echogenic hepatic foci: these lesions typically have a well marked rim, some times they even appear like a ring. In color doppler examination hepatic vessels are not affected by the lesions. The lesions themselves do not show an increased vascularisation. This allows to discriminate from other liver tumors, especially from liver metastases. Histologic findings are not pathognomonic, laboratory research is subsequently required. Strictly avoiding alcoholic drinks the presented discoveries are in principle reversible.

[Sonography in hereditary angioedema: typical findings demonstrated by the example of 3 cases]. / Sonographie beim hereditären Angioödem: Typische Befunde anhand dreier Kasuistiken.

Hereditary angioedema (HAE) is a hereditary disorder (deficiency of C1 esterase inhibitor) with spontaneous cutaneous and subcutaneous edemas, which involve the gastrointestinal tract in 50 - 75 %. Recurrent abdominal pain attacks in younger patients with an ultrasonographic evidence of aszites (up to 1 - 2 litres are frequent), should always let think of a HAE. Additionally in one female patient we found pleural effusion repeatedly during the episodes. HAE typically shows segments of GI-tract with a marked wall thickening. In our patients stomach (2 x), small bowel (2 x) and colon (1 x) were involved. Obstruction of the lumen by the edema may cause vomiting or ileus. By means of high-resolution sonography we could show for the first time that only mucosal and submucosal layer were affected, the L. muscularis propria was preserved. Characteristic was a hypoechoic thickening of the interior layers of the wall: In one patient we found anechoic lacunae within the mucosal layer, probably corresponding to a bullous edema. An accurate ultrasonic examination enables a reliable judgement of the severity level of HAE. It can contribute in this way to the decision whether the application of C1-INH-concentrate is necessary or not.

[An unusual cause of gastrointestinal hemorrhage: pseudoaneurysm of the gastroduodenal artery in chronic pancreatitis]. / Eine ungewöhnliche gastrointestinale Blutungsquelle: Pseudoaneurysma der A. gastroduodenalis bei chronischer Pankreatitis.

Pseudoaneurysm of the peripancreatic arteries is a typical cause of gastrointestinal bleeding (GIB) in patients with chronic pancreatitis. 1-10% of chronic pancreatitis are associated with an a pseudoaneurysm, especially of the splenic or gastroduodenal artery. Endoscopy often is not successful in finding the cause of bleeding. Sonography, especially color Doppler ultrasound, is the best diagnostic tool, indicating the need for celiac angiography. We report on a 59-year-old woman with recurrent severe GIB since 1995. In 1998 another bleeding occurred and sonography showed a pseudoaneurysm of the gastroduodenal artery. Typical criteria are an echo-free, pulsatile lesion with an ring-like border. Color Doppler proves a turbulent perfusion inside and shows the feeding vessel. A transcatheter embolization with stainless steel coils was successful, six months later the pseudoaneurysm was mainly obliterated.

[Nutritional behavior of non-insulin-dependent type II diabetes patients using the KALI 2.1.2 computer program]. / Untersuchungen zum Ernährungsverhalten von tablettenpflichtigen Typ-II-Diabetes-Patienten mit Hilfe des Computer-Programms KALI 2.1.2.

Forty patients with non-insulin-dependent diabetes mellitus (NIDDM) were investigated regarding their individual diet history, including dietary pattern and dietary habits. The energy intake in men was 2,180 +/- 460 kcal/day. The carbohydrate content was 192 +/- 57 g/day (38 +/- 7%), protein 93 +/- 20 g/day (19 +/- 3%) and fat 96 +/- 26 g/day (43 +/- 7%). Nutritional intake of saturated fatty acids was 37 +/- 11 g/day, whereas the intake of polyenic acid was 14 +/- 5 g/day. Thus the p/s-quotient was 0.4 +/- 0.1. The cholesterol intake amounted to 396 +/- 165 mg/day. The dietary fibre content was 33 +/- 21 g/day. The caloric intake of women was 1,800 kcal/day. The daily amount of carbohydrate was 154 +/- 46 g/day (37 +/- 6%), of protein 82 +/- 21 g/day (20 +/- 4%), of fat 82 +/- 32 g/day (43 +/- 6%). Saturated fatty acids were 33 +/- 14 g/day, polyenic acid 11 +/- 5 g/day, the p/s-quotient 0.4 +/- 0.2. The cholesterol intake was calculated to be 341 +/- 118 mg/day. The supply of electrolytes, trace elements and vitamins was often marginal. We found that usually practiced diabetes diet is too fatty, rich in cholesterol and poor in carbohydrate and fibre. As a result of the high amount of fat, which comprises 43% of the total calories and the low p/s-quotient of 0.4, the diet must be considered atherogenic.

Fatal Hemorrhage following perforation of the aorta by a barb of the Gianturco-Rösch esophageal stent.

Self-expanding metal stents are an established option in the palliative treatment of malignant stenoses of the esophagus. Herein, we report on a 60-year-old man with a recurrent stenosis that developed 2 months after radiochemotherapy for a squamous cell carcinoma in the middle part of the esophagus. To relieve progressive dysphagia, a Gianturco-Rösch stent (Cook-Z stent, 10 cm, PE-covered, manufactured by William Cook Europe) was implanted. Six weeks later, precipitous massive hemoptysis leading to the collapse and death of the patient occurred. Autopsy showed that a barb in the middle of the stent had perforated the aortic arch, resulting in massive bleeding into the gastrointestinal tract, and aspiration. Although hemorrhage and esophageal perforation are known late complications of all types of metal stents, our case is the first description of a perforation involving a fixation barb. These barbs are a particular feature of the European version of the Cook-Z stent, and are intended to prevent stent migration. In future, any hemorrhage observed after stent implantation should prompt a search for perforation by a barb (autopsy!). If necessary, the European version of the Gianturco Z stent should be modified.

[Ligamentum arcuatum syndrome: color doppler ultrasound diagnosis in abdominal pain of unknown origin in young patients]. / Das Ligamentum arcuatum-Syndrom: Farbdopplersonographische Diagnose bei unklaren Abdominalbeschwerden junger Patienten.

PURPOSE: To assess the diagnostic potential and accuracy of CDS in the diagnosis and management of visceral artery stenosis in young patients with abdominal pain. METHOD: 126 patients < 45 y with abdominal pain were examined by CDS. Other diseases were excluded before. Systolic (Vmax.sys.) and end diastolic (Vmax.diast.) peak velocities in exspiration and inspiration were measured in the celiac (CA) and superior mesenteric artery (SMA). Vmax.syst. > 1.8 m/s in exspiration and inspiration was regarded as a respiratory fixed stenosis. This was followed by intraarterial digital subtraction angiography (i.a. DSA) including visualization of the pancreaticoduodenal artery (PDA), and, if fixed stenosis was confirmed, by operation. CDS was again performed in the follow-up. RESULTS: CA stenosis were found in 19 patients (mean age 28.9 y). 4 were respiratory fixed, 2 combined with SMA stenoses or occlusion, all proved by i.a. DSA. The others had no evidence of fixed CA stenoses. The 4 operated patients were postoperatively immediately well. One with intermediate pain again had a stenosis in the SMA-bypass which was successfully treated by PTA. The others were treated with dietary procedures and regularly controlled by CDS. CONCLUSION: Ligamentary CA stenosis in young patients is rare, but may lead to considerable abdominal pain and weight loss. Hemodynamicly significant stenoses are proved by CDS with respiratory fixed Vmax.syst. > 1.8 m/s and Vmax.diast. > or = 1 m/s; i.a. DSA often shows a retrograde perfusion of the PDA. Such patients should be treated surgically. CDS should be performed in the follow-up.

Comparison of two instructional methods on the levels of physiologic and psychologic stress as measured by blood cortisol and the State-Trait Anxiety Inventory.

This study was designed to determine whether a systematic or nonsystematic instructional strategy affected the levels of physiologic and psychologic stress as measured by blood cortisol levels and the State-Trait Anxiety Inventory (STAI) in students in the postsecondary educational setting. A convenience sample consisting of 43 subjects was randomly assigned to either a systematic or nonsystematic teaching group. The blood cortisol and STAI were measured 1 and 2 weeks before the treatment and following the treatment on the day of the study. Results of the study demonstrated that there were differential posttreatment increases in the amount of physiologic stress, as measured by blood cortisol levels produced by either instructional method. However, between the control measurement 1 week before the treatment and the posttreatment measurement, there were no effects observed for the psychologic STAI measures for either group. Accounting for the circadian rhythm effect of cortisol, there was a significant "buffering effect" in stress experienced by the subjects in the systematic teaching group. More specifically, the nonsystematic teaching group experienced a 55.42% rate increase in cortisol compared to a 10.74% rate increase for the systematic teaching group which was statistically significant. The systematic teaching method may be more effective in preventing physiologic stress in the educational setting and possibly in the clinical practice of anesthesia nursing. Additionally, the results suggested that the STAI may be inappropriate when used as an index of stress in certain educational settings.