Dilated cardiomyopathy associated with chronic overuse of an adrenaline inhaler. Endogenous catecholamines in excess are known to cause dilated cardiomyopathy. A patient presented with dilated cardiomyopathy after many years of overusing an adrenaline inhaler. Pathological features and a considerable improvement in myocardial function after withdrawal implicated the exogenous catecholamine excess in the pathogenesis of the cardiomyopathy.


Validation of the beat to beat measurement of blood velocity in the human ascending aorta by a new high temporal resolution Doppler ultrasound spectral analyser. To develop and validate a high temporal resolution spectral analysis system for Doppler measurements of blood velocity in the ascending aorta. An observational laboratory and clinical study comparing Doppler velocity-based measurements with fluid collection, electromagnetic flow catheters and probes, and thermodilution. Tertiary referral cardiology unit and cardiac catheter laboratory. Patients undergoing routine cardiac catheterisation for ischaemic heart disease, cardiac failure, and primary pulmonary hypertension. There was good agreement between Doppler-derived and electromagnetic cuff or catheter measurements of velocity in an experimental flow rig (SD of differences 4.75% for velocity integral) and in the patients (SD of differences 4% for velocity integral). There was also reasonably good agreement between simultaneous Doppler-derived and thermodilution-estimated cardiac output measurements in patients undergoing cardiac catheterisation (SD of differences 12.6%). This new method of high temporal resolution spectral analysis improves the resolution of rapidly changing blood velocities and may improve the ability to describe blood velocity patterns in the ascending aorta.


A new system for ambulatory pulmonary artery pressure recording. To develop a complete system for the measurement, recording, and analysis of ambulatory pulmonary artery pressure. The new system consists of a pulmonary artery catheter, an ambulatory recorder, and a desktop computer. Pulmonary artery pressure is measured by a micromanometer tipped catheter with an in vivo calibration system to allow correction for zero drift. This catheter is plugged into a small battery powered recorder. The recorder has two input channels, one for pressure and one for an event marker. The pressure wave is sampled 32 times/s, processed by an in built computer, compressed, and stored in semi-conductor memory. On completion of a recording, data is transferred from the ambulatory recorder through a serial data link to an Acorn Archimedes desktop computer on which further data processing, statistical analysis, graphics, and printouts can be obtained. The system has been used in 18 patients, with technically successful recording in 14, less than 15 minutes of data loss in three, and 12 hours of data loss in one. A new system for ambulatory pulmonary artery monitoring has been developed and used clinically with success. It may provide new perspectives on the pathophysiology of disease as it applies to everyday life.


Calculation of aortic regurgitation orifice area by Doppler echocardiography: an application of the continuity equation. The evaluation of aortic regurgitation by current echocardiographic techniques has been qualitative and load-dependent. The area of the regurgitant orifice, which is theoretically independent of haemodynamic conditions, has not been determined non-invasively. In 20 patients with various degrees of aortic regurgitation, this area was determined by use of the continuity equation applied during diastole. The velocity-time integrals were determined at the supravalvar (VTIs) and regurgitant orifice (VTIj) levels by pulsed and continuous wave Doppler respectively. The cross sectional area at the supravalvar level (As) was also measured by cross sectional echocardiography. The regurgitant orifice is given by: (As x VTIs)/VTIj. Other non-invasive measurements of the aortic regurgitation severity were also recorded: (a) an overall echo score (1-5+) given blindly by two echocardiographers, (b) the maximal proximal jet width by colour Doppler, (c) left ventricular end systolic and end diastolic volumes and left ventricular mass. The regurgitant area ranged from 0.25 to 1.7 cm2 and this area accorded with the overall echo score and the maximal proximal jet width measured by colour Doppler. The aortic regurgitation orifice area can be calculated non-invasively and it may be a quantitative measure of the severity of aortic regurgitation.


Cost effectiveness of the implantable cardioverter defibrillator: a preliminary analysis. An implantable cardioverter defibrillator (ICD) may be effective in reducing the risk of sudden cardiac death. The high cost of ICD treatment, however, compared with alternatives raises the question of whether this new technology is an efficient use of scarce health care resources. To estimate the incremental cost effectiveness of the implantable cardioverter defibrillator compared with drug treatment with amiodarone in the management of patients at high risk of sudden cardiac death. A cost effectiveness model was constructed from data already published and other secondary sources. Differences in patient survival were calculated from life tables for comparable ICD and amiodarone patient series. Costs were based on typical patient management protocols derived from current United Kingdom practice and interviews with physicians. Cost effectiveness of ICD treatment was computed over 20 years; all future costs and effects were discounted at 6% per year. Estimated life expectancy was 11.1 and 6.7 years with ICD and amiodarone respectively; the discounted 20 year difference lies in the range 1.7 to 3.7 years. Discounted 20 year treatment costs were 28,400 pounds for the ICD and 2300 pounds for amiodarone. Cost effectiveness of ICD treatment lies in the range of 15,400 pounds to 8200 pounds per life-year gained. Cost effectiveness of ICD treatment is similar to some existing cardiac programmes funded under the NHS but uncertainty exists due to limitations of the data. Costs of ICD treatment may fall in the future as the life of the device increases and less invasive implantation methods are needed. The effectivess of ICD compared with amiodarone is currently being studied by a randomised controlled trial.


Coronary occlusive disease and late graft failure after cardiac transplantation. Coronary occlusive disease is the main cause of late mortality after cardiac transplantation. It has both similarities and differences compared with conventional atherosclerotic coronary disease. The pathophysiology of late graft failure from coronary occlusive disease is unclear at present. We reviewed the experience of this disorder in our cardiac transplant programme. A retrospective analysis of angiographic and pathological data. A regional cardiothoracic centre and transplant unit. Of a population of 383 orthotopic cardiac transplant recipients operated upon between January 1979 and June 1990, 447 coronary angiograms were available for review in 193 patients. Thirteen of a possible 18 results of post mortem examinations from patients dying from coronary occlusive disease were available. Coronary occlusive disease was defined as any evidence of disease on coronary angiography. Post mortem examinations were performed with standard techniques. The angiographic prevalence of coronary occlusive disease was 3% (1/32 patients) and 40% (19/47 patients) at one and five years respectively. Twenty six grafts failed due to coronary occlusive disease compared with 132 graft failures from all causes during this period. Acute thrombosis was present in a large vessel in seven of 13 fatal cases undergoing necropsy (54%). Noticeable large vessel involvement with disease in smaller distal vessels was present in four patients (31%). The remaining two patients (15%) had small vessel disease alone. Twelve of the 13 patients had significant cardiomegaly (cardiac weight > or = 400 g) with a mean weight of 510 (range 370-740) g. Coronary occlusive disease is the main late complication after cardiac transplantation. A combination of coronary thrombosis, ischaemia from stenoses of large and small coronary vessels, and cardiomegaly contribute to the graft failure of these patients.


Impairment of coronary flow reserve in orthotopic cardiac transplant recipients with minor coronary occlusive disease. Coronary occlusive disease is the major long-term complication after cardiac transplantation. The relation between minor angiographic abnormalities and myocardial perfusion has not been previously assessed in a large number of cardiac transplant patients. Prospective study. Coronary flow reserve was measured with an intracoronary Doppler flow probe in the proximal left anterior descending coronary artery in each patient. A dose of intracoronary papaverine producing maximal vasodilation was then administered. A regional cardiothoracic centre and a supraregional transplant unit. Seven patients with chest pain but normal coronary anatomy (controls), and 61 cardiac transplant patients between three months and 10 years after operation (median 4.5 years). Twenty one cardiac transplant patients had angiographic evidence of minor coronary occlusive disease (mean (SD) percentage stenosis diameter 23% (6%)) in a primary or secondary coronary vessel (group 1), with 12 of these in the left anterior descending coronary artery (stenosis diameter (mean (SD) 24% (8%)). The remaining 40 transplant patients had normal coronary angiograms (group 2). Coronary flow reserve was defined as the ratio of the peak flow velocity after papaverine to the resting flow velocity. Group 1 patients had a noticeably impaired coronary flow reserve (2.6 (1.1)) compared with control patients (3.9 (0.4), p = 0.05) and, after adjusting for year after operation, compared with group 2 patients (3.8 (1.0), p < 0.001). No other variables were associated with a reduction in coronary flow reserve. Mean resting flow velocity was similar in all three groups (controls, 7.4 (4.6) cm/s; group 1, 7.5 (5.9) cm/s; and group 2, 7.3 (3.9) cm/s). Mean peak flow velocity response to papaverine was reduced in group 1 patients (18.1 (13.5) cm/s) relative to group 2 patients (27.5 (15.4) cm/s, p = 0.05) but not controls (28.4 (15.1) cm/s, p = 0.1). Coronary flow reserve and the peak flow response to the coronary vascular smooth muscle relaxant papaverine are impaired in cardiac transplant patients with minor coronary occlusive disease. This disturbance of cardiac microvascular function may contribute to the late morbidity and mortality seen in cardiac transplant patients with coronary occlusive disease.


Nuclear magnetic resonance spectroscopy of excised human hearts. Phosphorus nuclear magnetic resonance spectroscopy has been proposed as a method of studying the metabolism of the myocardium in patients. Little is known about 31P nuclear magnetic resonance spectroscopy of diseased human hearts. Two donor hearts meeting the requirements for heart transplantation and 11 diseased hearts were removed during a transplantation procedure and were studied in a horizontal 2.35 T superconducting magnet. Spectra were obtained at 0 degrees C about 30 minutes after the excision. The areas of the inorganic phosphate peak (Pi) and of the phosphocreatine peak (PCr) were summed and expressed as a ratio with respect to the area of the beta ATP peak. The ratio (Pi + PCr)/beta ATP was found to be significantly lower in five hearts with a myocardial infarct (0.77 (0.18)) than in hearts with dilated cardiomyopathy (1.25 (0.29)) and in normal hearts (1.69 (0.11)). The area of the phosphodiester peak was expressed as a ratio with respect to the area of the beta ATP peak: no differences were found between the three groups. These results suggest that the phosphocreatine concentration is lower in ischaemic heart disease than in dilated cardiomyopathy and that the phosphodiester peak is probably not useful in distinguishing between these two types of heart disease.


Intravascular ultrasound imaging of the coronary arteries: an in vitro evaluation of measurement of area of the lumen and atheroma characterisation. To assess the accuracy of measurement of area of the lumen, and sensitivity, and specificity of detection of atheroma in coronary arteries in vitro with a commercially available 20 MHz intravascular ultrasound system. A teaching hospital department of cardiology with the support of the department of cardiovascular pathology. 10 segments of coronary artery were removed from cadaver hearts. Intravascular ultrasound imaging was performed at fixed levels and the vessels were then sectioned and photographed before histological preparation. An independent blinded observer measured luminal area and assessed the presence of atheroma on the intravascular ultrasound images of 76 vessel sections (304 quadrants). The sensitivity and specificity of detection of atheroma was assessed in comparison with the histologically prepared sections. Luminal areas from intravascular ultrasound, photographs of cross sections of the vessels and histological sections were compared with the technique of limits of agreement. Overall 36% of the 304 quadrants studied histologically had identifiable atheroma. Intravascular ultrasound sensitivity for atheroma was 0.593 and the specificity was 0.839. The positive predictive value was 0.674, and the relative risk 3.139. Values for area of the vessel lumen were on average 9.4 mm2 (confidence interval (CI) 8.6-10.2 mm2) larger than those measured from photographs and 10.7 (CI 9.8-11.6 mm2) larger than those measured from the histological sections. The intravascular ultrasound system assessed in this study significantly overestimated coronary vessel luminal area and had low sensitivity and specificity for detection of atheroma. Improvements in image resolution are required before this system can provide useful information on coronary artery size and morphology.


Lower threshold for adenosine-induced chest pain in patients with angina and normal coronary angiograms. To investigate whether patients with angina-like chest pain and normal coronary angiograms are more sensitive to adenosine as an inducer of chest pain. Increasing doses of adenosine were given in a single blind study as intravenous bolus injections. Chest pain and the electrocardiographic findings were noted. Eight patients with angina-like chest pain but no coronary stenoses (group A), nine patients with angina and coronary stenoses (group B), and 16 healthy volunteers (group C). In the absence of ischaemic signs on the electrocardiogram adenosine provoked angina-like pain in all patients in groups A and B. The pain was located in the chest, and its quality and location were described as being no different from the patient's habitual angina. In group C, 14 of 16 subjects reported chest pain. The lowest dose resulting in chest pain was lower in group A (0.9 (0.6) mg) than in group B (3.1 (1.5)mg) (p < 0.005) and in group C (6.2 (3.7) mg) (p < 0.005). The maximum tolerable dose was lower in group A (4.7 (2.1) mg) than in group B (9.2 (3.8) mg) (p < 0.05) and in group C (12.0 (4.1) mg) (p < 0.005). Patients with angina-like chest pain and normal coronary angiograms have a low pain threshold and low tolerance to pain induced by adenosine.


Detection of myocardial ischaemia by transthoracic leads in ambulatory electrocardiographic monitoring. To determine the best sites for ambulatory monitoring leads to detect myocardial ischaemia. 50 consecutive patients recovering from myocardial infarction. Six patients were excluded because of unsatisfactory recordings or baseline electrocardiographic abnormalities that influenced the diagnostic accuracy of ST segment depression. In 38 patients important ST segment changes were seen before the study recordings. Reproducibility of detecting the electrocardiographic ST segment changes with 12 bipolar leads alone or in combination. The highest reproducibility rate was found in infarcts involving both the anterior and inferior left ventricular walls (80%). The reproducibility decreased as the extent of ventricular wall involvement decreased and was lowest in inferior infarcts (31%) (p < 0.001). For large infarcts the detection rate was almost equal for the 12 study leads, whereas disparity between leads increased as the infarct size decreased. The highest overall reproducibility was found in a transthoracic lead (V2, V9R) (76%). This lead was significantly better (p = 0.03) than lead CM5 (50%). When the transthoracic lead was combined with an inferior lead, the reproducibility increased (82%) and was significantly better than the combination of CM5 and an inferior lead (58%) (p = 0.02). Extensive ischaemic electrocardiographic changes are better detected than smaller ones and anterior infarcts better than inferior. A transthoracic lead (V2, V9R) was significantly better than CM5 both alone and when CM5 and the transthoracic lead were combined with an inferior lead.


Optimal control of myocardial ischaemia: the benefit of a fixed combination of atenolol and nifedipine in patients with chronic stable angina. To study the effects on myocardial ischaemia of 50 mg of atenolol, 20 mg of slow release nifedipine, and their fixed combination given 12 hourly. A treadmill exercise test and 24 hour ambulatory electrocardiographic monitoring were carried out after a period of five days off treatment (control) and at the end of three weeks of each treatment period. 23 patients with stable angina pectoris, documented coronary artery disease, and a positive exercise test were randomised in a double blind, three way, cross over study. Compared with the control, nifedipine significantly induced an increase in resting heart rate of (mean (SEM)) 14 (2) beats/min whereas atenolol and the combination significantly reduced it by 24 (2) and 20 (1) beats/min respectively. The number of exercise tests rendered negative after each intervention was five for nifedipine, nine for atenolol, and 11 for the combination. Compared with the control the time to the start of myocardial ischaemia (1 mm ST segment depression) during exercise significantly increased by 3.2 (0.6) min after nifedipine, by 4.6 (0.4) min after atenolol, and by 4.6 (0.5) min after the combination; rate-pressure product (beats/min. mm Hg) at 1 mm ST segment depression increased by 2824 (970) after nifedipine but fell by 4436 (900) and 4501 (719) after atenolol and the combination. The weekly frequency of angina was reduced from a mean of five while taking nifedipine, to three while taking atenolol, and to two while taking the combination. The total ischaemic time during ambulatory monitoring was significantly reduced from 69 (17) min during control to 37.5 (9.8) min during nifedipine, to 15.6 (5.5) min during atenolol, and to 6.5 (2.7) min during the combination. The undesirable effect of a high basal heart rate induced by nifedipine was neutralised by its combination with atenolol. Whereas atenolol and the combination were equally efficacious in controlling exercise induced ischaemia, the combination was more effective in reducing total ischaemic burden.


Usefulness of Doppler echocardiographic assessment of diastolic filling in distinguishing "athlete's heart" from hypertrophic cardiomyopathy. In some athletes with a substantial increase in left ventricular wall thickness, it may be difficult to distinguish with certainty physiological hypertrophy due to athletic training from hypertrophic cardiomyopathy. The purpose of the present investigation was to determine whether assessment of left ventricular filling could differentiate between these two conditions. Doppler echocardiography was used to obtain transmitral flow velocity waveforms from which indices of left ventricular diastolic filling were measured. Normal values were from 35 previously studied control subjects. Athletes were selected mostly from the Institute of Sports Science (Rome, Italy), and patients with hypertrophic cardiomyopathy were studied at the National Institutes of Health (Bethesda, Maryland). The athlete group comprised 16 young competitive athletes with an increase in left ventricular wall thickness (range 13-16 mm; mean 14). For comparison, 12 symptom free patients with non-obstructive hypertrophic cardiomyopathy were selected because their ages and degree of hypertrophy were similar to those of the athletes. In the athlete group, values for deceleration of flow velocity in early diastole, peak early and late diastolic flow velocities, and their ratio were not significantly different from those obtained in untrained normal subjects; furthermore, Doppler diastolic indices were normal in each of the 16 athletes. Conversely, in patients with hypertrophic cardiomyopathy, mean values for Doppler diastolic indices were significantly different from both normal subjects and athletics (p = 0.01 to 0.003), and one or more indices were abnormal in 10 (83%) of the 12 patients. Doppler echocardiographic indices of left ventricular filling may aid in distinguishing between pronounced physiological hypertrophy due to athletic training and pathological hypertrophy associated with hypertrophic cardiomyopathy.


Protrusion of the device: a complication of catheter closure of patent ductus arteriosus. To assess the medium term results of percutaneous transvenous closure of patent ductus arteriosus, in particular with regard to protrusion of the device with or without turbulence of the bloodflow. Clinical examination and echocardiographic study (cross sectional Doppler, and colour Doppler examination) within 24 hours of and at least 6 months after implantation (range 6-26 (mean 15) months). Multicentre study at the departments of paediatric cardiology of three academic hospitals. Tertiary clinical care of the first group of patients in the Netherlands treated by the percutaneous transvenous method. 36 patients (12 male, 24 female) mean age 8.2 years, (range 1.7-58.3), mean weight 25.5 kg (range 11-67.8 kg). The total group consisted of 46 patients. In one the implantation had failed and nine others were not available for regular follow up. All 36 patients underwent non-surgical closure of the patent ductus arteriosus with a Rashkind double umbrella prosthesis. Diagnosis or exclusion of protrusion of the Rashkind device with or without turbulence of the blood flow with follow up of changes in protrusion and turbulence. In 17 patients the prosthesis protruded into an arterial lumen: the aorta in 13 and the (left) pulmonary artery in four, with turbulence in seven and two cases respectively. After six months the aortic protrusion disappeared in three, including one who had had turbulent blood flow. At the end of follow up the prosthesis still protruded into the aorta in 10 but in three the turbulence had vanished. In two of the three remaining patients with turbulence in the descending aorta the degree of turbulence had decreased. There was no lessening of turbulence in the four patients in whom the device protruded into the pulmonary artery. The Rashkind double umbrella can protrude into the descending aorta and the left pulmonary artery without causing turbulent blood flow. Turbulence and the protrusion itself can disappear. Endocarditis prophylaxis may be required for as long as the device causes turbulence.


Subclinical cardiomyopathy in Becker muscular dystrophy. To investigate the prevalence, age distribution, and spectrum of cardiac involvement in a cohort of patients with Becker muscular dystrophy. A prospective non-invasive study with clinical, electrocardiographic, and echocardiographic assessment. 19 patients (age range 16-41 years) with Becker muscular dystrophy attending the Muscle Clinic at Hammersmith Hospital and 22 healthy controls (age range 22-36 years). 17 patients (89%) were symptom free; two had exertional dyspnoea. Three had a past history of acute pericarditis. The electrocardiogram was abnormal in 14 patients (74%). Intraventricular conduction delay or right bundle branch block was present in eight (42%). Three (16%) had tall R waves (R/S > 1) in lead V1 in the absence of right bundle branch block and eight (42%) had Q waves in the lateral and inferolateral leads. The PQ interval was significantly shorter in patients with Becker muscular dystrophy (p < 0.01). Echocardiography showed left ventricular dilatation in seven patients (37%) and 12 (63%) had subnormal systolic function caused by global hypokinesia (fractional shortening < 27%). Six of these patients were under the age of 22 years. Patients with Becker muscular dystrophy had significant reduction of both fractional shortening and corrected mean velocity of circumferential shortening compared with controls. No correlation was found between fractional shortening and age. The third filling fraction was significantly reduced in patients with Becker muscular dystrophy (p < 0.05), although other indices of diastolic function (isovolumic relaxation time and E/A ratios) were not significantly different. Though most patients with Becker muscular dystrophy were symptom free, a high percentage had evidence of a subclinical cardiomyopathy. Electrocardiography showed that the inferolateral and posterior segments of the left ventricle tended to be affected and may show evidence for conduction tissue disease. Echocardiography showed that most patients had left ventricular dilation and global hypokinesia. The severity of left ventricular disease was unrelated to age; some younger patients had severe left ventricular dysfunction. All patients with Becker muscular dystrophy should have echocardiographic assessment of left ventricular function.


Magnetic resonance imaging of hearts with atrioventricular valve atresia or double inlet ventricle. To investigate the effectiveness and limitations of magnetic resonance imaging in defining cardiac anatomy in patients with double inlet ventricle or atrioventricular valve atresia. Magnetic resonance images were reviewed retrospectively without reference to other morphological data. A tertiary referral centre for paediatric cardiology. 18 patients (aged 8 days to 27 years) with a suspected univentricular atrioventricular connection. Imaging by a 1.5 T whole body magnetic resonance system with imaging planes adjusted to individual patient anatomy to best define the cardiac morphology. A complete sequential diagnosis obtained from an independent interpretation of the images was compared with the diagnosis obtained from cross sectional echocardiography and angiocardiography. There was substantial accord between the diagnosis from magnetic resonance alone and that from other methods. In the six instances where there was not accord the magnetic resonance diagnosis was considered to be correct in two cases and incorrect in three cases. In the remaining case no consensus could be reached. In eight patients magnetic resonance imaging provided anatomical information additional to that from other methods. The strengths of magnetic resonance were in imaging the pulmonary arteries and their abnormalities and identifying juxtaposed atrial appendanges but there were some deficiencies in identifying Blalock-Taussig shunts. Magnetic resonance imaging provided detailed information about all aspects of cardiac morphology in patients with a suspected diagnosis of univentricular atrioventricular connection. Often it provided additional information to echocardiography. Its use in selected patients should give valuable complementary information.


Successful repair of pulmonary atresia with ventricular septal defect without the use of a conduit: a new surgical option. Report of two cases. A new technique for the restoration of continuity between the pulmonary artery and the right ventricle in pulmonary atresia with ventricular septal defect without the use of a conduit is described. This was accomplished by anastomosing the inferior margin of the distal pulmonary artery to the apex of a T-shaped infundibular ventriculotomy to form the posterior wall of the reconstructed right ventricular outflow tract. A winged patch of bovine pericardium was then used for the anterior wall to complete reconstruction of the transannular right ventricular outflow tract. This technique was used successfully in two patients.


Fabry's disease with complete atrioventricular block: histological evidence of involvement of the conduction system. A 63 year old man with complete atrioventricular block was diagnosed as having Fabry's disease. A short PR interval is a common electrocardiographic finding in Fabry's disease, but complete atrioventricular block is a very rare complication. Necropsy indicated that lipid accumulation in the atrioventricular conduction system was the probable cause of this patient's atrioventricular block.


Right-sided endomyocardial fibrosis with recurrent pulmonary emboli leading to irreversible pulmonary hypertension. A 26 year old Saudi man with features of both Loeffer's endocarditis and endomyocardial fibrosis presented with mild symptoms and pulmonary emboli. Echocardiographic examination showed obliteration of the right ventricular apex by an attached mass. The results of haemodynamic studies were somewhat abnormal and medical treatment was started. Despite anticoagulation with warfarin the patient's condition deteriorated rapidly over a four month period after a further episode of pulmonary embolism and the development of pulmonary hypertension. Two haemodynamic studies performed four months apart were typical of pulmonary hypertension and later right ventricular failure; they showed none of the characteristics of restriction. Pulmonary embolectomy was attempted but there was no cleavage plane between the organised thrombi and the endothelium of the pulmonary artery. The patient died of severe pulmonary hypertension and right ventricular failure several days after operation. Surgical intervention in the early stages of right-sided endomyocardial fibrosis might have prevented the development of pulmonary embolism and pulmonary hypertension.


Anomalous origin of the right coronary artery from the pulmonary artery in association with congenital aneurysm of the sinus of Valsalva: angiographic diagnosis of a rare association. A 37 year old man presenting with acute heart failure, hypotension, and acute renal failure was diagnosed by cardiac catheterisation and angiography to have the rare combination of congenital aneurysm of the non-coronary sinus of Valsalva rupturing into the right ventricle, and an anomalous origin of the right coronary artery from the main pulmonary artery. The diagnosis could not be confirmed by transthoracic echocardiography in this patient. This combination of defects, confirmed at cardiac surgery, has not been reported before, and this case report highlights the importance of preoperative definition of congenital defects associated with an aneurysm of the sinus of Valsalva.


Cardiac assistance from skeletal muscle: a critical appraisal of the various approaches. We review here various ways in which cardiac assistance might be derived from a patient's own skeletal muscle. Calculations based on experimental data and optimistic estimates of the efficiency of the energy conversions involved suggest that the continuous assist available would be limited to about 2 litres a minute if a muscle were used to energise an electromechanical device. It would be more efficient to couple the energy mechanically or hydraulically, but these approaches still pose problems of anatomical placement, muscle attachment, fluid leakage, and cost. Unless these issues can be addressed, the use of skeletal muscle as an internal power source for mechanical circulatory assist devices will remain an unworkable concept. Configurations that couple skeletal muscle contraction directly to the circulation would be more efficient and less costly. In terms of the energy available, a skeletal muscle ventricle could be designed to provide a continuous partial assist of 1-2 l/min, with flows of up to 8 l/min sustainable for limited periods. Such an approach offers new possibilities for the surgical treatment of chronic cardiac failure.


A note on the anatomy of the supraspinatus muscle. The muscles and tendons of the rotator cuff of 37 fixed cadaver shoulder joints were dissected. In ten shoulder joints devoid of gross pathological lesions it was found that the supraspinatus muscle was inserted at two points--mainly into the major tubercle and partly into the lesser tubercle of the humerus. In one case of six, an additional insertion clearly occurred in a shoulder joint with rotator cuff tear.


Autogenously vascularised bone allografts. Experimental model of a new bone-muscle composite graft. Conventional bone allografts carry a high incidence of complications such as infections and pseudarthroses due to immunological rejection and avascularity of grafts. In vascularised grafts healing and remodelling of bone is quicker and more complete. However, vascularised allografts need immunosuppression for prevention of rejection with vascular occlusion. Autogenously vascularised allografts are formed after implantation of bone in muscle of the recipient, allowing vascularisation from this muscle. A muscle-bone composite graft is thus obtained that can be transferred as a pedicled or free graft with microvascular anastomosis. In this study donors were DA and recipients Lewis rats. The bone grafts were implanted in the adductor muscles and transferred after 6 weeks into a femoral defect. A higher number of osteocytes were found in the autogenously vascularised group than in non-vascularised grafts. "Creeping substitution" was found in all cortical layers in vascularised grafts, whereas in conventional allografts bone resorption predominated. The experimental data suggest that in rat autogenously vascularised bone allografts show a remodelling pattern comparable with that of conventional vascularised bone autografts. The advantage of the autogenously vascularised bone allograft is that it allows transfer of a vascularised bone allograft together with its well-vascularised recipient bed without immunosuppressive treatment.


Prostaglandin E2 level in tissue surrounding aseptic failed total hips. Effects of materials. Production of inflammatory mediators (IM) by cells and specifically macrophages around loosened implants may be responsible for their loosening. Our hypothesis was that different materials give rise to different amounts of these IM. It is thought that alumina/alumina for total hip replacement (THR), which has been used for 15 years in our orthopedic department, may produce less IM than other systems. We initiated a clinical prospective study to measure the level of prostaglandin E2 (PGE2) in tissue surrounding loosened prostheses to quantify PGE2 production regarding the types of material involved in the friction couple, i.e., alumina/alumina versus metal/polyethylene, and the type of fixation, i.e., cemented versus cementless. A total of 29 THR revisions were performed in 28 patients. Four implant groups were identified: alumina/alumina cemented, alumina/alumina cementless, metal/polyethylene cemented, and metal/polyethylene cementless. For each revision, tissues surrounding the failed implants were harvested and processed, and the PGE2 was measured in a blind manner using an immunoassay technique. As the measuring technique was difficult, at least three determinations for each sample were necessary. Some samples were excluded from the analysis for various reasons, for example, second or further revisions involving many different materials in the past, conjunction of metallic and alumina debris and samples taken from non-loosened components. Finally, 15 samples were considered adequate for inclusion in this study. Two groups were analyzed and compared: the alumina/alumina couple and the metal/polyethylene couple. Tissue surrounding the first group demonstrated a PGE2 level of 69 +/- 56 fmol/mg wet weight compared to 202 +/- 156 fmol/mg for the second.(ABSTRACT TRUNCATED AT 250 WORDS)


Collagen stabilization induced by natural humic substances. Humic substances are polyphenolic compounds. They have antiviral as well as desmutagenic effects and react with biopolymers such as collagen; thereby they have no toxic side effects by oral administration. In vitro incubation with humic substances raises the breaking point of the tail tendon of the rat by about 75%. The chemical resistance of the collagen fibres in tail tendon collagen is also increased by in vitro incubation with humic substances, at least insofar as the ultrastructurally and biophysically measurable destruction of the collagen fibres by 4 M guanidinium chloride is inhibited. As humic substances increase the mechanical and chemical resistance of collagen fibres and promote their "maturity", it seems likely that this effect of humic substances depends upon their interaction with the hydrogen bonding and covalent bonding of the collagen fibres. Such a conclusion is confirmed by the results of X-ray diffraction analysis.


Types I and III procollagen extension peptides in serum respond to fracture in humans. Markers of types I and III collagen turnover were measured in serial blood samples in 16 patients with a Colles' fracture. The collagen markers were the carboxy-terminal extension peptide of type I procollagen (PICP) and the amino-terminal extension peptide of type III procollagen (PIIINP). Significant increases were found of PIIINP within 1 week and of PICP within 2 weeks. This sequential appearance of PIIINP and PICP was found to be in agreement with the appearance of types III and I collagen during early fracture healing as demonstrated in previous animal experimental studies. PICP had levelled off after 9 months, whereas PIIINP remained elevated. Osteocalcin, a serum marker of osteoblast activity, increased within 1 week and levelled off after 9 months. Correlations between the change in osteocalcin and those in PICP and PIIINP, respectively, were weak. These new biochemical markers may prove relevant as non-invasive markers of normal and pathological fracture healing in humans.


Biomechanical analysis of the mechanism of interlocking nail failure. From December 1986 to May 1989, 412 patients with 274 femoral and 144 tibial fractures were treated with Grosse-Kempf interlocking nails at our hospital. 324 cases (78.6%) were followed-up for at least 1 year (average 23 months). There were 13 breakages in the locking nails in femora and none in tibiae. The recorded incidence of breakage in the femur is therefore 4.7% (13/274). The mechanisms of locking nail failure are stress concentration around screw hole and nail slot, nicking of the nail during drilling of the screw holes, too close proximity of the screw hole to the fracture, and larger loading over the proximal femur. The incidence of failure is 4.9% in the upper third, 1.9% in the mid-third, and 8.2% in the distal third (P greater than 0.05, chi 2 test). The site most at risk is the first screw hole of the distal third, especially if it is near the fracture site. Prevention of failure involves using a nail of larger diameter and sufficient length, improving the surgical drilling technique, and allowing only protected weight bearing. Management of nail breakage by insertion of a new implant and supplementary cancellous bone grafting can gain satisfactory results.


Anterior cruciate ligament allograft transplantation for intraarticular ligamentous reconstruction. A multiplicity of surgical operations have been developed in an attempt to achieve satisfactory function after anterior cruciate ligament (ACL) repair. None of these procedures have been able to reproduce the fiber organization anatomy of attachment site, vascularity, or function of the ACL. Twenty-nine foxhounds received a deep-frozen bone-ACL-bone allograft and a ligament augmentation device (LAD). Biomechanical, microvascular, and histological changes were evaluated 3, 6, and 12 months following implantation. The maximum loads of the allograft/LADs were 34.3% (387.2 N) after 3 months, 49.3% (556.6 N) after 6 months, and 61.1% (698.8 N) after a year. The maximum load was 69.1% (780 N). In general, after 6 months the allografts showed normal collagen orientation. The allografts demonstrated no evidence of infection or immune reaction. No bone ingrowth into the LAD was observed. Polarized light microscopy and periodic acid-schiff staining showed that the new bone-ligament substance interface had intact fiber orientation at the area of the ligament insertion. Microvascular examination using the Spalteholtz technique revealed revascularization and the importance of an infrapatellar fat pad for the nourishment of ACL allografts.


Range of motion after total condylar knee arthroplasty. In this study the function of the knee measured at a medium-follow-up of 5-6 years was correlated with influencing factors concerning the implant of total condylar knee prosthesis in 90 patients. The only variable affecting postoperative extension was the preoperative range of extension whereas postoperative flexion was influenced by the preoperative flexion, valgus deviation of the preoperative AP tibial-femoral angle, position of the patella, and thickness of the resection of the distal femur cut.


Idiopathic Charcot's arthropathy. Report of one case. The authors describe a case of idiopathic Charcot's joint in a 67-year-old lady. The diagnosis was made after a careful screening that ruled out all the common causes, known so far, of Charcot's joint.


Tumoral calcinosis of the ischium.

Tumoral calcinosis of the ischium. The authors report on a case of tumoral calcinosis of the ischium in a 63-year-old female. By means of this particular case a general review of the literature on pathogenesis, histological characteristics, the possible way of treatment and the prognosis of tumoral calcinosis is presented.


Bilateral scapular fractures secondary to electrical shock. Fractures of the scapula are rare injuries. Usually the scapula requires a high-energy impact to sustain a fracture. Various fractures have been noted as a result of convulsive seizures. We report bilateral scapular fractures caused by electric shock and discuss their pathomechanical origin.


An unusual stress fracture of the fibula in a long-distance runner. A stress fracture of the proximal fibula in a young long-distance runner is reported. Such fractures are rare. The literature is reviewed and diagnosis and treatment are discussed.


Use of a posterior calf fasciocutaneous flap with distal pedicle to reconstruct a huge ankle defect. A distally based posterior calf fasciocutaneous flap was successfully used to reconstruct a major ankle defect with exposed bones and joints. The flap, which reaches easily this region, can also be used as a free flap for coverage of heel and ankle when the forefoot is not involved in the injury.


Traumatic hemipelvectomy. A case report and comments on associated injuries. The twenty-fifth reported case of survival following traumatic hemipelvectomy is presented. Our patient is the fourth female survivor and the second who escaped associated injuries to either the genito-urinary system or the rectum.


Humanizing the intensive care unit experience. When the pregnant woman becomes critically ill, it is essential that she and her fetus receive the care that a specialized intensive care unit (ICU) provides. This unit is the setting for an expert medical, nursing, and technical staff to use sophisticated, state-of-the-art equipment for intensive monitoring and the immediate life-saving interventions that may be necessary. However, care in an ICU sometimes becomes focused on the machinery, rather than on the patient. It is imperative that the humanizing aspects of critical care be addressed in caring for a pregnant patient and her family. Obstetric critical care can benefit from the data in the critical care literature that addresses family and patient needs in an ICU. Obstetric literature and past experiences in implementing family-centered maternity care also can be used to identify the need for humane care and to enhance the ICU experience.


Principles in hemodynamic assessment.

Principles in hemodynamic assessment. Use of invasive hemodynamic monitoring provides more thorough assessment of hemodynamic function and may reveal abnormal data before the development of adverse clinical signs and symptoms. The obstetric nurse caring for critically ill patients is responsible for understanding the principles associated with hemodynamic monitoring and interpretation of data to better plan and implement nursing care.


Technical aspects of hemodynamic pressure monitoring. Invasive hemodynamic pressure monitoring may be used in the care of the critically ill pregnant woman. The critical care obstetric nurse must have a thorough understanding of the indications for monitoring and interpretation of acquired data and must develop the skills necessary to operate and trouble-shoot the related equipment. This article provides a review of technical aspects of a hemodynamic pressure monitoring system.


Principles of oxygen transport in the critically ill obstetric patient. Invasive hemodynamic monitoring is commonly used in critically ill patients in whom cardiorespiratory compromise is evident. The information acquired assists the clinician in the assessment of cardiac and intravascular status. However, many patients have complex pathophysiologic conditions that dictate the evaluation of their oxygen transport system. This article provides a discussion of the principles of oxygen transport, including the concepts of oxygen content, oxygen affinity, oxygen delivery, and oxygen consumption. Clinicians providing care for critically ill pregnant women should have a thorough understanding of the physiology of oxygen transport, its alterations in specific disease process, and interventions necessary to improve the individual components of oxygen transport.


Mechanical ventilation during pregnancy. Mechanical ventilatory support is a significant component in the delivery of critical care. With increasing frequency, obstetric critical care nurses face the challenge of caring for women who require mechanical ventilation during pregnancy. It is important that those caring for such patients understand fundamental principles of mechanical ventilation, associated complications, and specific nursing care measures.


Renal dialysis in pregnancy.

Renal dialysis in pregnancy. Dialysis may be needed, either acutely or on a chronic basis, during pregnancy for a variety of reasons. Advances in erythropoietin, transplant, and hormonal therapies may increase the chances of pregnancy in women with chronic renal failure. Providing care to this population of patients is a challenge to nephrology and obstetric nurses. It is important for the obstetric nurse to understand the fundamental principles of dialysis to collaborate in the planning and implementation of care for these patients.


Perinatal hypertensive crisis.

Perinatal hypertensive crisis. Women with severe pregnancy-induced hypertension or chronic hypertension with superimposed preeclampsia are at risk for the development of hypertensive crisis. Hypertensive crisis is an emergent situation that carries great maternal and fetal morbidity and mortality. Effective assessment and comprehensive care of the patient in hypertensive crisis requires a thorough understanding of the underlying disease preeclampsia, common hemodynamic findings, and therapies available. Nurses in any perinatal environment must be prepared to respond immediately to this critical obstetrical circumstance.


Pulmonary hypertension.

Pulmonary hypertension. Pulmonary hypertension may be primary, of unknown etiology, or secondary to existing cardiorespiratory disease. In general, the prognosis is poor, but the superimposed physiologic changes of pregnancy, labor, and delivery may produce a lethal condition. Pregnancy prevention is better than any proposed care. If pregnancy occurs, termination is suggested in the first or early second trimesters. If the choice is to continue the pregnancy, a well-coordinated intensive management plan is necessary. This plan should include midsecond trimester hospital admission of the patient, continuous hemodynamic monitoring during the intrapartum period and immediately after delivery, and preferably elective induction with hemodynamically stable epidural anesthesia for labor and delivery.


The impact of pregnancy on the woman with congenital heart disease: considerations for intrapartum nursing care. Many women with congenital heart disease can successfully tolerate the profound hemodynamic changes associated with pregnancy and birth with a collaborative team approach to management of their disease. This article provides a discussion of the interaction between pregnancy and congenital heart disease (including left-to-right shunts, obstructive lesions, and cyanotic defects), focusing on maternal risks and strategies for intrapartum hemodynamic management. Nurses providing intrapartum care for women with congenital heart disease must understand the applicable cardiac pathophysiology, the risks imposed by pregnancy and the birth process, and appropriate medical and nursing interventions to prevent complications.


Myocardial infarction.

Myocardial infarction. Myocardial infarction (MI) during pregnancy occurs approximately once in 10,000 pregnancies. The normal cardiovascular alterations associated with pregnancy may make the diagnosis of MI difficult. Nursing care focuses on astute assessment skills, provision of adequate oxygenation, and prolongation of the healing phase to prepare for the stress of delivery. Nurses caring for patients experiencing MI during the perinatal period require advanced cognitive knowledge and clinical skills to facilitate optimal maternal and fetal outcome.


Pulmonary edema during pregnancy.

Pulmonary edema during pregnancy. Physiologic changes in the pulmonary system during pregnancy place the pregnant woman at risk for having pulmonary edema. Cardiogenic and non-cardiogenic pulmonary edema have similar clinical signs and symptoms; however, treatments may differ greatly. Understanding the types of pulmonary edema enables the obstetric nurse to provide improved care for this group of patients.


Pulmonary embolism.

Pulmonary embolism. A major cause of maternal morbidity and mortality during pregnancy and the puerperium is thromboembolic disease. Pregnancy is a hypercoagulative state that predisposes the gravida to thrombus formation. Once a thrombus forms in the venous system of the lower extremities, it can travel to the pulmonary arterial bed, which can lead to hypoxemia or death. Maternal mortality associated with pulmonary embolism (PE) is approximately 14%. Most gravidas who have PE during or after pregnancy have no history of thromboembolic disease at the time of insult.


Amniotic fluid embolism.

Amniotic fluid embolism. Pulmonary embolism is the leading cause of maternal death in the United States. Amniotic fluid embolism (AFE) represents the least preventable and most lethal of complications. AFE has a reported mortality of 86% and an associated fetal demise of 50%. AFE is widely accepted as a clinical entity but is not completely understood. A combination of clinical presentation, laboratory findings, and exclusion of other abnormalities leads to the diagnosis of AFE. The mainstays of treatment are oxygenation, maintenance of cardiac output, and correction of coagulopathy. The prognosis for the patient experiencing AFE remains bleak because the course of the disorder is largely unpredictable, and AFE cannot be corrected. Only supportive measures can be given.


Adult respiratory distress syndrome.

Adult respiratory distress syndrome. Adult respiratory distress syndrome (ARDS) is an acute form of noncardiogenic respiratory failure that often occurs in previously healthy individuals who have sustained severe physiologic insult that is pulmonary or nonpulmonary in origin. The perinatal nurse can help increase the survival of the maternal-fetal dyad by prompt recognition of the syndrome and early institution of therapeutic measures.


Cystic fibrosis in pregnancy.

Cystic fibrosis in pregnancy. Previously considered a pediatric disorder, cystic fibrosis (CF) is becoming a more common complication of pregnancy as these patients have increasing life expectancies. CF produces profound physiologic alterations in major organ systems. These alterations augment the physiologic changes of pregnancy. Perinatal nurses can meet the complex needs of these patients by increasing their understanding of the disease process, pregnancy-related alterations, and current treatment modalities.


Neurologic emergencies in pregnancy.

Neurologic emergencies in pregnancy. Neurologic emergencies during pregnancy are not encountered often but contribute significantly to maternal mortality. This chapter reviews neurologic emergencies with an emphasis on pathophysiology and related nursing care for patients with epilepsy, status epilepticus, eclampsia, intracranial hemorrhage, increased intracranial pressure, ischemic stroke, myasthenia gravis, autonomic hyperreflexia, Wernicke's encephalopathy, and chorea gravidarum.


Principles of intracranial pressure monitoring. Increased intracranial pressure (ICP) is a life-threatening condition that requires immediate recognition and therapeutic intervention. The obstetric nurse must have in-depth knowledge of the physiologic changes occurring during pregnancy, the relationship between these changes and cerebrovascular accidents, and the pathophysiology of increased intracranial pressure to provide the most comprehensive nursing care. This chapter describes fundamental principles of intracranial pressure monitoring.


Liver disease in pregnancy.

Liver disease in pregnancy. This article discusses two liver diseases that are unique to pregnancy: hepatic rupture and acute fatty liver of pregnancy. Pathophysiology, signs and symptoms, and medical and nursing management during the period of critical illness are addressed for both disorders. Although maternal mortality is associated with these diseases, women often recover completely after delivery. A major goal of medical and nursing management is to support the system until the liver can heal and resume the myriad of vital functions for which it is responsible.


Diabetic ketoacidosis.

Diabetic ketoacidosis. Diabetic ketoacidosis (DKA) is a form of decompensated diabetes. When it occurs during pregnancy, it may lead to maternal and fetal morbidity and mortality. DKA is defined by accelerated gluconeogenesis and ketogenesis and occurs most often in the presence of one of four predisposing factors: insulin deficiency (absolute or relative); excess counter regulatory hormones; fasting; and dehydration. Infection is a common catalyst. Once the disorder is diagnosed, intensive obstetrical nursing care is required. The principles of management include rehydration, insulin therapy, electrolyte replacement, and identification and treatment of the underlying cause. A plan for assessment of the pregnant patient with diabetes and in DKA and treatment guidelines are presented.


Trauma during pregnancy.

Trauma during pregnancy. The active roles assumed by most pregnant women today put them at risk for vehicular accidents, falls, industrial accidents, violence, and other injuries. Trauma during pregnancy increases the maternal and fetal mortality and morbidity risks. Knowledge of the physiology of pregnancy is essential to establishing priorities and providing optimum care for the woman and fetus. Assessments and care from trauma and obstetric perspectives are essential; however, treatment priorities for the pregnant trauma patient are the primary consideration and are identical to those for nonpregnant trauma patients. Pregnancy does not limit or restrict any resuscitative, diagnostic, or pharmacologic treatment indicated after trauma. Fetal survival is dependent on maternal survival, so the woman must receive immediate intervention and condition stabilization for optimum fetal outcome.


Disseminated intravascular coagulation.

Disseminated intravascular coagulation. In normal hemostasis, a balance exists between coagulation and fibrinolysis. Disseminated intravascular coagulation (DIC) is a condition characterized by the excessive formation of fibrin clots; it involves all aspects of the coagulation system. In view of its potential for major morbidity and mortality, an understanding of the disorder is essential. Management of DIC in pregnancy should include removal of the triggering mechanism and aggressive blood and fluid replacement.


Cardiopulmonary resuscitation during pregnancy. Cardiopulmonary arrest during pregnancy, although relatively rare, poses a unique challenge to the obstetric nurse. Resuscitation measures attempt to restore maternal hemodynamic stability and promote fetal well-being. Prognosis is improved when those caring for such women possess the knowledge and skills necessary to implement basic and advanced resuscitation protocols. This chapter reviews significant physiologic alterations in pregnancy that have an impact on resuscitation and cardiopulmonary resuscitation (CPR) algorithms for selected pulseless rhythms. As critical care capabilities continue to develop within obstetric units, it is reasonable to predict that obstetric nurses will face this challenge with increasing frequency.


Pain sensation and nociceptive reflex excitability in surgical patients and human volunteers. Pain threshold, nociceptive flexion reflex (NFR) threshold and responses to suprathreshold stimulation were investigated in 15 female patients (mean age 32 yr (range 22-48 yr)) before and 68 (range 48-96) h after gynaecological laparotomy. Control measurements were performed in 17 healthy human volunteers (five males, age 30 yr (range 24-41 yr)). In the surgical patients, pain threshold decreased and pain to suprathreshold stimulation increased significantly (P = 0.006 and P = 0.04, respectively) from before to after surgery. A corresponding trend was demonstrated in neurophysiological measurements, although the decrease in NFR threshold and increase in NFR amplitude to suprathreshold stimulation were not significant (P = 0.08 and P = 0.24, respectively). The correlations between the relative change in pain and reflex thresholds, and time from surgery, were statistically significant (pain threshold: rs = 0.53, P = 0.04; NFR thresholds: rs = 0.54, P = 0.04). In the healthy volunteers, no significant differences in thresholds and responses to suprathreshold stimulation were observed between two recordings with an interval of at least 48 h. The allodynia and hyperalgesia observed in postsurgical patients may be related to postoperative sensitization of central neurones.


Auditory evoked response and awareness: a study in volunteers at sub-MAC concentrations of isoflurane. We have investigated the relationship between the auditory evoked response (AER) and simple tests of conscious awareness at four end-expiratory concentrations (0.0, 0.1, 0.2 and 0.4 MAC) of isoflurane in oxygen in each of eight anaesthetist volunteers, in random order, at least 1 week apart. The early cortical AER was recorded from electrodes at the vertex and inion. Amplitudes of the waves Pa, Nb and Pc and latencies of the waves Na, Pa, Nb, Pb and Nc were measured. All the AER variables were highly significantly related to end-expiratory anaesthetic concentration. Amplitudes decreased and latencies increased progressively with increasing anaesthetic concentration. The AER variables were also highly significantly related to the level of response. Amplitudes were greatest and the latencies shortest when there was full response to command. (Nb latency increased from 47.5 to 54.5 ms between partial and no response.) The close correlation between the effects of concentration and level of response, and between concentration and the AER implied that it was difficult to demonstrate those changes in the AER which specifically relate to changes in response. At 0.2 MAC, however, which was the concentration at which all subjects showed some deficit, the response to a shock word was distinguished clearly by Nb latency. In eight of 24 possible comparisons (eight AER variables and three types of psychological test) the AER fitted the response more closely than concentration.


Some effects of isoflurane on I waves of the motor evoked potential. We have investigated the effects of isoflurane anaesthesia on the motor evoked potential recorded in the extradural space during corrective spinal surgery in 15 patients. Isoflurane was added to a nitrous oxide in oxygen mixture supplemented with fentanyl and a neuromuscular blocking agent. Isoflurane was administered to achieve end-tidal concentrations of 2%, 1% and 0% in all patients, and also of 1.5% and 0.5% in nine patients. Transcranial electrical stimulation of the motor cortex was used to elicit descending volleys in corticospinal axons (the motor evoked potential). With stimuli of 450-750 V and no isoflurane, multiple I waves were always seen following the D wave. In all patients the number of I waves decreased and individual I waves became smaller in amplitude the greater the isoflurane concentration, but there were only minor changes in the D wave. The greatest depressant effect on I waves occurred at an end-tidal concentration of 0.5%. Given that I waves are an index of synaptic transmission, anaesthetic-induced changes in I waves may provide a useful model for the neuronal events underlying anaesthesia-induced unconsciousness.


Risk factors for oxygen desaturation during sleep, after abdominal surgery. The postoperative period after major abdominal surgery is known to be a period of increased episodic oxygen desaturation. In order to assess the risk factors for episodic desaturation, we have studied 29 surgical patients using pulse oximetry during the preoperative night (Npre) when they received benzodiazepine premedication and breathed air, and also during the first three nights after operation when they received nasal oxygen supplementation. Modal oxygen saturation (SpO2) exceeded 95% during all nights studied. The time spent at less than 90% (t90) and 85% (t85) SpO2 and the average SpO2 nadir (SpO2, nadir) did not differ each night. Heart rate was greater (mean 90.1 (SD 16.6) vs 68.2 (12.0) beat min-1, P < 0.001) during the second night after operation (N2) than during Npre. Before operation, the number of desaturations, t90 and t85 correlated with pharyngeal hypertrophy (P = 0.003, P = 0.002, P = 0.001, respectively). At the same time, t90 and t85 correlated with body mass index (P = 0.02 and P = 0.05, respectively). During N2, t90 correlated with radiological lung consolidation (P = 0.05) and SpO2, nadir correlated with FEV1 (P = 0.03). We conclude that there are several mechanisms responsible for oxygen desaturation and that these mechanisms differ before and after surgery.


Effect of speed of injection of 0.5% plain bupivacaine on the spread of spinal anaesthesia. We have studied the influence of two different speeds of injection on the spread of spinal anaesthesia of bupivacaine in 40 orthopaedic patients. In a random order, 0.5% plain bupivacaine 3 ml was administered in 10 or 180 s into the subarachnoid space using a 27-gauge needle with the patients in a lateral horizontal position. The slower speed produced a higher spread of spinal anaesthesia (median difference 2.5 segments, P < 0.05).


Elimination of bupivacaine and pethidine from the rabbit feto-placental unit. Bupivacaine 12.5 mg and pethidine 12.5 mg were administered as an i.v. infusion over 80 min in 15 near-term pregnant New Zealand white rabbits. After the infusion, pups were removed via individual hysterotomies every 30 min. Bupivacaine and pethidine were measured by gas chromatography in amniotic fluid, placenta, fetal plasma, fetal brain and maternal plasma, sampled as each fetal sac was opened. Pethidine was cleared from all compartments more rapidly than bupivacaine and for both drugs elimination rates were maternal plasma > placenta > amniotic fluid > fetal brain > fetal plasma. Concentrations of both drugs in fetal plasma correlated significantly only with those in fetal brain and not with those in maternal plasma, placenta or amniotic fluid, while there were positive correlations between the last three compartments. Nested analysis of covariance showed that only maternal plasma and placental concentrations of the two drugs decreased significantly with time. Maternal plasma half-lives for pethidine and bupivacaine were 1.0 and 2.0 h, and placental half-lives 1.9 and 2.5 h, respectively. The apparent fetal plasma half-life of pethidine was 9.9 h while there was apparently no net elimination of bupivacaine from fetal plasma.


Comparison of the maternal and fetal effects associated with intermittent or continuous infusion of extradural analgesia. Eighty normal primigravidae received an extradural dose of 0.25% bupivacaine and were then allocated randomly to receive "top-ups" of 0.25% bupivacaine (group A) or an infusion of 0.125% bupivacaine (group B). Group B received supplementary top-ups if required. Group A required more top-ups (147 vs 80) (P < 0.01). No maternal advantage was demonstrated from each regimen. Fetal state was assessed by analysis of the cardiotocograph during labour and the condition of the fetus at delivery. Three different patterns of late deceleratory episodes were identified (grades 1-3). Total numbers of episodes per group were similar (group A, 71; group B, 69). More episodes in group A were related to top-ups (42/71 vs 18/69; P < 0.01) but the incidence of episodes after a top-up was similar (group A, 42/147 (28.6%); group B, 18/80 (22.5%)). In group A, 31/42 events (73.8%) were transient compared with 11/18 persistent episodes (61.1%) (> 10 min duration) in group B. However, the difference in the deceleratory patterns did not influence the condition of the fetuses at delivery.


Thrombelastography after aspirin ingestion in pregnant and non-pregnant subjects. The thrombelastograph (TEG) and bleeding time were performed before and 6 h after a single oral dose of aspirin 600 mg in a group of eight healthy volunteers and 12 pregnant patients. Measured TEG variables (r, k, r+k times and maximum amplitude) were unaltered after aspirin although there was a significant prolongation of the bleeding time in both groups. Although the TEG appeared not to detect aspirin-induced changes in platelet function, the TEG measures all phases of coagulation and the unaltered TEG after aspirin suggested a functioning coagulation system.


Hypnotic and anaesthetic interactions between midazolam, propofol and alfentanil. We have examined interactions between midazolam, propofol and alfentanil using two end-points of light sedation (hypnosis) and anaesthesia. Quantal dose-response curves were determined in 400 female patients for the drugs individually and in combination. At the hypnotic end-point, interactions were analysed by fitting the data to a mathematical model where the response depended on the doses of the three drugs with additional terms included to describe non-additive interactions of the various combinations of the three drugs. There were significant interactions for hypnosis; the decrease in expected ED50 for the various combinations were: midazolam-propofol = 37%, midazolam-alfentanil = 46%, propofol-alfentanil = 20%, midazolam-propofol-alfentanil = 42%. Whilst all responses to the two-drug combinations were synergistic, the three-drug combination led to a response that was less than that expected from the effects of the individual agents and their two drug interactions. For anaesthesia, dose-related effects could not be demonstrated for midazolam or alfentanil when used alone. The decrease in ED50 of propofol in the presence of the other compounds was propofol-midazolam = 52%, propofol-alfentanil = 73%, propofol-midazolam-alfentanil = 82%. When comparing the different combinations, the responses varied markedly at each end-point assessed and could not be predicted from the responses of the individual agents.


Pharmacodynamic stability of a mixture of propofol and alfentanil. We studied 40 patients undergoing body surface surgery in a double-blind manner to compare the pharmacodynamic stability of either mixed or separate infusions of propofol and alfentanil. No differences were found between the two groups in respiratory or cardiovascular variables during operation, or in requirements for analgesia after operation. The power of the study to determine a difference of 10 mm Hg in mean arterial pressure with a probability of 0.05 was 0.82 and for a difference of 1 kPa in end-tidal carbon dioxide partial pressure 0.89. We conclude that propofol and alfentanil may be administered by infusion from a single syringe without diminished or delayed effect of the opioid during anaesthesia and the first 4 h after operation.


Changes in cardiac index and estimated systemic vascular resistance during induction of anaesthesia with thiopentone, methohexitone, propofol and etomidate. Changes in cardiac index (CI) and estimated systemic vascular resistance (ESVR) were assessed non-invasively using pulsed Doppler ultrasound during induction of anaesthesia. Ninety-six ASA I patients were allocated randomly to one of four groups to receive alfentanil 8 micrograms kg-1 followed by a dose of thiopentone, methohexitone, propofol or etomidate sufficient to obtund the eyelash reflex. CI increased significantly by 8% 1 min after administration of both methohexitone (P < 0.05) and propofol (P < 0.05), returning to pre-induction values thereafter. CI increased after thiopentone but the increase was not statistically significant. There was a significant decrease in CI of 16% after induction with etomidate (P < 0.001). ESVR decreased significantly from pre-induction values by 18% after methohexitone (P < 0.001) and 23% after propofol (P < 0.001). ESVR in the thiopentone group decreased, but this was not statistically significant. ESVR increased significantly by 12% 1 min after induction of anaesthesia with etomidate (P < 0.05) and then decreased towards pre-induction values. The results suggest that the cardiostability of etomidate may not be as complete in all groups of patients as previous studies have suggested.


Propofol anticonvulsant activity in experimental epileptic status. We have examined the anticonvulsant properties of propofol in high doses in two experimental models of status epilepticus: generalized pentylenetetrazol (PTZ)-induced seizures and partial, cortically applied penicillin G-induced seizures. Propofol was administered either as a single bolus injection or as a bolus injection followed by an infusion for 1 h. When administered as a single bolus injection, propofol 12 mg kg-1 suppressed electrical and clinical seizures in PTZ generalized epileptic status, and an infusion of 50 mg kg-1 h-1 prevented the reappearance of electrical and clinical signs. In focal epileptic status, the single dose stopped paroxysmal activity and the associated clonic jerks for a few seconds. When the bolus dose was followed by an infusion, the firing bursts were replaced by isolated spikes, and contralateral jerks became sporadic and feeble. The greater efficacy of propofol against PTZ convulsions may be a reflection of the opposite action of the two drugs on neural membrane conductance: PTZ induces paroxysmal neural discharge by enhancing membrane conductance while propofol appears to decrease membrane conductance, thus suppressing paroxysmal discharge. There was no close relationship between blood concentration of the anaesthetic and its clinical effects, at least after a short-term infusion, as used in the present experiments. We suggest that propofol may be a potentially useful drug in status epilepticus in patients in whom benzodiazepines, barbiturates and phenytoin have failed.


Video surveillance of oxygen administration by mask in postoperative patients. Patients may not receive prescribed oxygen because the oxygen face mask becomes displaced. Using video, we have observed the position of the face mask in 20 postoperative patients and recorded the timing and the events associated with mask displacement. Correct placement of the mask was confirmed at the start of the 8-h study period from 22:00 on the first night after operation. The mask remained on continuously and positioned correctly in only one patient. In the other 19 patients, it was removed 64 times (range 1-10 times per patient). The mask was removed 45 times for nursing tasks such as mouth care and temperature measurement and these represented 70% of the total number of times that the mask was not in position. Other reasons for removal were vomiting, retching and removal by the patient. The mask remained off a median time of 6 min 55 s per episode (range 46 s to 7 h 46 min 57 s) and per patient a median of 1 h 6 min 48 s (range 1 min to 7 h 46 min 57 s). Mask removal resulted in an average decrease in oxygen saturation of 4%. Oxygen by mask at 4 litre min-1 maintained an average saturation > or = 95% in most, but not all, of the patients.


Learning during general anaesthesia: implicit recall after methohexitone or propofol infusion. Forty-four patients undergoing coronary artery surgery were allocated randomly to receive an infusion of propofol or methohexitone as a hypnotic supplement to a fentanyl-based anaesthetic technique. A taped message was played to the patients, consisting of 10 words associated with prompt sentences and a suggestion for a specific postoperative behavioural response. Twenty patients (10 propofol and 10 methohexitone) (perioperative group) were exposed to the taped message during surgery and in the immediate postoperative period and the other 24 patients (postoperative group) were exposed to the tape only in the postoperative period, after return to the intensive care unit (ICU). No patient had explicit recall of any events during the period when the tape was played. The patients in the propofol group who heard the tape during surgery had significant implicit recall of the word associations compared with the equivalent 10 methohexitone patients (P = 0.004), when tested 48 h after surgery. The patients who were played the tape whilst receiving identical infusion regimens for sedation in the ICU did not demonstrate implicit recall of the word associations in either the propofol or the methohexitone groups. There was no evidence of a response to the specific behavioural suggestion during the postoperative interview. The results confirm that auditory perception can occur during clinically adequate anaesthesia, and that suppression of auditory awareness or learning is a function of both the pharmacological degree of sedation and the degree of surgical stimulation.


The importance of activity and pretreatment in the prevention of suxamethonium myalgias. We have studied the effectiveness of pretreatment with atracurium 0.05 mg kg-1 and placebo before administration of suxamethonium, in the prevention of postoperative myalgia in inpatients having surgery in which rapid postoperative mobilization was possible (vaginal hysterectomy). On the second day after operation, the patients pretreated with atracurium had significantly fewer postoperative myalgias than those receiving placebo (P < 0.025). All patients were significantly more active on the second day compared with the first day after operation (P < 0.025). Possible causal relationships are discussed.


Training in fibreoptic tracheal intubation in the north of England. Twenty-nine departments of anaesthesia in the North of England were questioned about the availability and teaching of fibreoptic tracheal intubation techniques. While 27 departments had both suitable equipment and trained consultant staff, only one offered formal teaching to all its junior anaesthetists.


Skin injury in an infant with pulse oximetry. An 11-month-old girl received 23 propofol anaesthetics for radiation treatment of a retinoblastoma. After the first two anaesthetics, a skin injury appeared on the pulp of the toes, where the light source of a pulse oximeter probe had been placed. During the remaining 21 anaesthetics the light source of the probe was placed over the nails, and no other skin lesions occurred. Examination of the equipment revealed no malfunction. Thermal and other possible causes of the skin injury are discussed.


Sternocleidomastoid muscle contractility at different levels of isoflurane anaesthesia in humans. We have measured force-frequency curves of the sternocleidomastoid muscle in six patients at three different levels of isoflurane anaesthesia (1.0, 1.4 and 1.8 MAC). Spontaneous ventilation was suppressed by mild hypocapnia induced by mechanical ventilation. An anterior force vector of the sternocleidomastoid muscle was measured during isometric contraction induced by supramaximal electrical stimulation at 20, 50 and 100 Hz to the i.m. accessory nerves of the muscle. The force response at 20 Hz and 50 Hz did not change with an increase in isoflurane concentration, but it decreased at 100 Hz as isoflurane concentration increased. The reduction in the force at 100 Hz may be caused mainly by impaired neuromuscular transmission.


Synergistic interaction between midazolam and propofol. We gave either midazolam or propofol for induction of anaesthesia to 140 ASA I or II female patients (18-60 yr). ED50 values were obtained by probit analysis for three clinical end-points: loss of response to command; loss of eyelash reflex; failure to respond to application of an anaesthetic face mask delivering 1% isoflurane. Propofol ED50 values (95% confidence intervals) were 1.25 (0.99-1.48) mg kg-1, 1.61 (1.29-1.94) mg kg-1 and 1.51 (1.20-1.82) mg kg-1, respectively. ED50 values for midazolam were 0.26 (0.20-0.37) mg kg-1, 0.29 (0.23-0.47) mg kg-1 and 0.25 (0.20-0.32) mg kg-1, respectively. An additional 92 similar patients received one of nine dose combinations of midazolam and propofol for induction of anaesthesia, propofol being administered 2 min after midazolam. Success of induction was based on the clinical end-point of loss of response to command. Administration of 25% of the ED50 of midazolam followed by 50% of the ED50 of propofol resulted in loss of response to command in 50% of patients, while 50% of the ED50 of midazolam, followed by 25% of the ED50 of propofol had the same effect. A probit regression model specifying a synergistic interaction between midazolam and propofol fitted the data significantly better than a model specifying no interaction.


EEG and memory effects of low-dose infusions of propofol. The purpose of this study was to identify EEG changes associated with low-dose propofol infusion producing only sedative effects, and to describe the memory effects of low-dose propofol infusion. Ten healthy volunteers underwent EEG monitoring (at Fz, Cz, Pz and Oz electrode sites) before, during and after propofol 0.5 mg kg-1 i.v. bolus and 75 micrograms kg-1 min-1 as an infusion. Mean serum concentration of propofol during infusion was 0.86 (SD 0.14) micrograms ml-1. The EEG changed significantly during infusion, with increased power in the beta 1 (15-20 Hz), beta 2 (20.5-30 Hz) and delta (1-3.5 Hz) frequencies. Beta 1 and beta 2 power changes were most marked at the Fz and Cz electrodes. Subjects were sedated, but able to complete cognitive tasks. Visual analogue scales of attention and sleepiness were obtained throughout the study and demonstrated a sedative effect during propofol infusion, but were not a significant factor in memory performance or EEG changes. A verbal learning task (Rey Auditory-Verbal Learning Task) administered before, during and after infusion showed a marked reduction in short-term memory capacity and dramatically impaired free recall and recognition during infusion. Nine of 10 subjects had partial amnesia for complex visual scenes presented during infusion, recalling less than 50% of the material. Stronger cueing was required to retrieve information presented during propofol infusion, with an increase in mean retrieval time from 95.4 (41.2) s to 426.8 (83.1) s. EEG and memory effects resolved quickly after the end of infusion.(ABSTRACT TRUNCATED AT 250 WORDS)


Recovery of cognitive functions after anaesthesia with desflurane or isoflurane and nitrous oxide. We studied recovery in 25 adult patients, ASA I, undergoing elective orthopaedic procedures after anaesthesia with 0.65 MAC desflurane (n = 16) or isoflurane (n = 9) with 60% nitrous oxide in oxygen. Early emergence from anaesthesia was assessed in the operating room by measuring time to spontaneous movement, cough, response to painful pinch, tracheal extubation, opening of the eyes and stating correct age, name and body parts. The return of cognitive functions in the late recovery phase was assessed in the post-anaesthesia care unit (PACU) by post-anaesthesia recovery scores (PARS), the Trieger dot test (TDT), and the digit substitution test (DST). In the early recovery phase, time to tracheal extubation, opening eyes, telling correct name, age and body parts occurred significantly faster in the desflurane group than in the isoflurane group (P < 0.05). The mean "triple orientation" time (to name, age, body parts) was 10.9 (SEM 0.9) min for desflurane, compared with 18.6 (2.5) min for isoflurane (P < 0.01). In the late recovery phase, desflurane patients had significantly greater PARS, more correct responses to the DST and fewer error responses to the TDT. Recovery times were not increased by increased duration of desflurane anaesthesia. The desflurane patients showed no delirium, minimal sedation and less shivering during the entire postoperative course. We conclude that desflurane anaesthesia was superior to isoflurane anaesthesia, not only in emergence, but also in the recovery of cognitive functions.


Blood concentrations of sevoflurane and isoflurane on recovery from anaesthesia. We studied 16 healthy ASA physical status I patients (aged 13-71 yr for sevoflurane and 22-74 yr for isoflurane) to determine maximum blood concentrations on awakening (MBCawake) from sevoflurane and isoflurane anaesthesia, and determined if age and duration of anaesthesia significantly influenced MBCawake. After operation, the end-tidal concentration of anaesthetics was decreased gradually. During recovery from anaesthesia, patients were asked repeatedly to open their eyes. We obtained blood samples to measure the anaesthetic concentration when patients first opened their eyes. MBCawake of sevoflurane and isoflurane (ml of anaesthetic gas per ml of blood) were 0.40 (SE 0.04)% and 0.53 (0.04)%, respectively. MBCawake values of sevoflurane and isoflurane correlated significantly with age (P < 0.05) but not with duration of anaesthesia. Blood:gas partition coefficients of sevoflurane and isoflurane were 0.65 (SD 0.05) and 1.36 (0.09), respectively. There was no significant correlation between age and blood:gas partition coefficient for sevoflurane and isoflurane. Awakening alveolar concentrations (MACawake) calculated from MBCawake were 0.61 (SE 0.05)% for sevoflurane and 0.39 (0.02)% for isoflurane, and correlated significantly with age. The ratios of awakening alveolar concentration to MAC were reasonably constant--0.33 for sevoflurane and 0.33 for isoflurane.


Effect of ketanserin on global cerebral blood flow and cerebral oxygen metabolism during midazolam-fentanyl or isoflurane anaesthesia. We have studied the effect of ketanserin on cerebral blood flow (CBF), cerebral oxygen metabolism (CMRO2) and cerebrovascular carbon dioxide reactivity in 19 adult patients undergoing lumbar disc operation--10 during midazolam-fentanyl anaesthesia (group A) and nine during isoflurane anaesthesia (group B). Measurements were made in each patient whilst awake, during anaesthesia, during anaesthesia with ketanserin and during anaesthesia with ketanserin and hyperventilation. CBF was measured by the i.v. xenon-133 technique. CMRO2 was calculated as the product of CBF and the cerebral arterio-venous oxygen content difference. In the awake state, CBF was 52 and 51 ml/100 g min-1 and CMRO2 3.8 and 3.5 ml/100 g min-1 in groups A and B, respectively. After induction of anaesthesia, CBF decreased 37% in group A and 22% in group B (P < 0.05); CMRO2 decreased 26% in group A and 51% in group B (P < 0.05). Adding ketanserin did not change CBF or CMRO2 in either group. The carbon dioxide reactivity of the cerebral vessels during anaesthesia with ketanserin was 15.4% kPa-1 in group A and 24% kPa-1 in group B. We concluded that ketanserin, in a clinically recommended dose, administered during midazolam-fentanyl or isoflurane anaesthesia had no effect on global CBF, CMRO2 or the relationship between the two factors. Cerebrovascular carbon dioxide reactivity was preserved.


Comparison of intubating conditions after administration of Org 9246 (rocuronium) and suxamethonium. We have assessed intubating conditions after administration of Org 9426 (rocuronium) 600 micrograms kg-1 at 60 or 90 s in groups of 20 patients anaesthetized with thiopentone, nitrous oxide in oxygen and small doses of fentanyl, and compared the data with those obtained after suxamethonium 1 mg kg-1 in similar groups of patients. The influence of prior suxamethonium administration on the potency of Org 9426 was studied also by constructing a dose-response curve. Intubating conditions after Org 9426 were found to be clinically acceptable (good or excellent) in 95% of patients at 60 s and in all patients at 90 s and in all patients at both times after suxamethonium. The average time for the onset of block following Org 9426 at this dose was 89 s (which is shorter than with any of the currently available non-depolarizing neuromuscular blocking drugs); the duration of clinical relaxation (25% recovery of twitch height) 30 min. Prior administration of suxamethonium did not appear to influence the potency of Org 9426.


Hepatotoxicity testing of atracurium and laudanosine in the isolated, perfused rat liver. The pharmacokinetics of atracurium, which is degraded by Hofmann decomposition and ester hydrolysis, is not altered by impaired liver function. Atracurium should, therefore, be ideal for patients with heptic failure, and is now widely used in clinical practice. However, some studies reported considerable hepatotoxicity after atracurium, especially from its breakdown products--for example, leakage of lactate dehydrogenase (LDH) from isolated rat hepatocytes. Therefore, we have studied, in an isolated perfused rat liver model, biochemical and morphological changes after administration of either atracurium or its main metabolite, laudanosine. Despite using extremely high concentrations of these substances, we could not detect, biochemically (release of LDH or aspartate amino-transferase (AST)) or histologically, any signs of liver cell damage.


Effect of dobutamine on oxygen supply and uptake in healthy volunteers. We have measured the changes in VO2 and the VO2:DO2 relationship during infusion of dobutamine in healthy volunteers. Nine healthy, adult, non-obese, male physicians were infused with an incremental infusion of dobutamine starting at 2.5 micrograms kg-1 min-1 increasing to 5.0 and then 7.5 micrograms kg-1 min-1 for 15 min each. VO2 and cardiac index were measured every five minutes. VO2I (VO2m-2) increased from a baseline of 128 (SEM 6.1) ml min-1 m-2 to 159 (8.0) ml min1 m-2 (P < 0.05) at the end of infusion with 7.5 micrograms kg-1 min-1. The corresponding changes for DO2I (DO2 m-2) were from 643 (35) ml min-1 m-2 to 1240 (142) ml min-1 m-2 (P < 0.05). The coefficient of correlation for pairs of VO2 and DO2 values, at baseline and each dobutamine infusion in individual subjects, ranged from 0.89 to 0.99 (mean 0.95, SD 0.03). Dobutamine has potent calorigenic effects; demonstration of a positive correlation between VO2 and DO2 after infusion of dobutamine does not necessarily imply an underlying tissue oxygen debt.


Indomethacin in the management of postoperative pain. We have examined the analgesic effects of indomethacin in a double-blind study of 56 patients undergoing surgery for lumbar disc prolapse. The patients were allocated randomly to receive either indomethacin 100 mg i.v. before surgery, followed by 100 mg rectally 6 and 12 h after surgery and at 08:00, 16:00 and 23:00 on the next day, or placebo. Postoperative pain was assessed using a 10-cm visual analogue scale at fixed times. Side effects and consumption of supplementary analgesics were recorded. Patients receiving placebo had significantly greater pain scores and significantly more patients in the placebo group required supplementary analgesics.


Regurgitation of gastric contents during general anaesthesia using the laryngeal mask airway. We have investigated the incidence of regurgitation of gastric contents during general anaesthesia administered via a laryngeal mask airway (LMA) or face mask and Guedel airway in 56 patients with no risk factors for regurgitation. Patients swallowed a gelatin capsule containing methylene blue 10 min before induction of anaesthesia. Fibreoptic laryngoscopy in the LMA group or conventional laryngoscopy in the face mask group was performed at the end of surgery. Dye was observed within the laryngeal mask in seven of 28 patients (25%). No patients in the face mask-Guedel airway group regurgitated dye (P = 0.005). There was no evidence of aspiration of dye.


Pain on injection of propofol: comparison of lignocaine with metoclopramide. We have conducted a randomized, double-blind study in 255 ASA I and II patients to compare the efficacy of lignocaine and metoclopramide in minimizing the pain of injection of i.v. propofol. When administered immediately before propofol into a dorsal hand vein, compared with placebo both drugs significantly reduced the incidence of pain on subsequent injection of propofol (P < 0.001). Twenty patients who had received metoclopramide (n = 85) experienced pain, compared with 18 who had received lignocaine (n = 85) and 42 who had been pretreated with saline (n = 85).


Comparison of the use of the laryngeal mask and face mask by inexperienced personnel. Ten junior doctors with no postgraduate anaesthetic experience attempted to ventilate the lungs of 50 anaesthetized patients, using either a laryngeal mask or a Guedel airway and face mask. Success was defined as the production of two successive tidal volumes exceeding 800 ml within 40 s. The failure rate was significantly greater using the laryngeal mask compared with the face mask (P < 0.05) and the average time was significantly longer with the laryngeal mask than with the face mask (P < 0.01). The results from this investigation suggest the laryngeal mask airway cannot be recommended as a resuscitation device for use by inexperienced operators.


Fatal tracheal compression after haemorrhage into the axilla. We report a case of fatal ventilatory obstruction as a result of haemorrhage into the axilla after a comminuted spiral fracture of the upper one-third of the humerus. Guidelines are presented as to the early recognition of such complications and their subsequent management.


Anaphylactoid or carcinoid?

Anaphylactoid or carcinoid? A patient with a carcinoid tumour and a history suggestive of carcinoid syndrome, but with no biochemical evidence in support, had a cardiovascular collapse during an anaesthetic with propofol and suxamethonium. Subsequent investigations suggested an anaphylactoid reaction to suxamethonium, but there were features in common with a carcinoid crisis. The necessity for a second anaesthetic soon afterwards posed a dilemma. In the event of a similar reaction during another anaesthetic, a management plan beforehand should include ready availability of appropriate drugs and the use of sympathomimetic drugs that are less likely to exacerbate the situation.


Pressure area care: monitoring standards. This article reviews the establishment of a Pressure Area Care Project Team in Gloucester Health Authority, with the aim of shifting the emphasis for care from treatment to prevention. A review of literature relating to the causes of pressure sores is followed by a description of the group's development of a research-based, written policy for prevention.


Street youth and the AIDS pandemic.

Street youth and the AIDS pandemic. Children responsible for their own survival exist in all countries. Despite social and cultural differences between street youth in developing countries versus homeless youth in developed countries, the predictors and correlates of homelessness are similar among youth. The AIDS pandemic is inextricably linked to homelessness and is a particularly devastating threat to the welfare of the world's disenfranchised youth, as they are continually forced into multiple HIV-related high risk situations and behaviors. Specific recommendations regarding clinical care, prevention programs, research, and the implications for policy and legislative action are discussed in relation to reducing the incidences and impact of HIV. For the world's populations of street children the issue of globally providing AIDS education and prevention within the context of health care services is emphasized, particularly by the promotion and training of physicians and other health professionals in street-based care.


Street youth and AIDS.

Street youth and AIDS. An attempt is made to characterize the population of homeless street youth who are living marginally and to describe aspects of this population's dynamics, motivations, values, and aspirations. Street youth, ranging in age from birth to 21, are on the street for one reason or another--dire poverty in the home, which necessitates their working on the street to supplement the family income, because they have been rejected by parents or guardians, because they have left home due to violence in the home, drug or alcohol use by family members, or because of lack of a place where they feel they can be "themselves." These conditions make street youths particularly vulnerable to HIV infection, not to mention malnutrition, stress, and drug use. Their violently accelerated emotional maturation, ignorance, alcohol- and drug-induced confusion, together with the exploitation and sexual abuse of which they are often victims, are additional factors that contribute to sexual practices that may lead to HIV infection.


High-risk behaviors among male street youth in Hollywood, California. High-risk sex and drug use behaviors are examined among 446 male street youth 14 to 23 years old in Hollywood, California (the area in Los Angeles County with the highest number of AIDS cases). Comparisons are made based on whether the sex behaviors occurred in situations of "survival sex" ("sex you gotta do") and "recreational sex" ("sex you wanna do"). Ninety-seven percent of the males were sexually active, with 27.1% involved in prostitution in the last 3 months. Involvement in prostitution is most common among older, gay identified males. The most prevalent risk factors seen among this group include inconsistent condom use (which also varies by social situation), high-risk sexual behaviors during both survival and recreational sex, large numbers of sexual partners, intravenous drug use, and the use of drugs and alcohol during all sex.


Lifetime sexual behaviors among predominantly minority male runaways and gay/bisexual adolescents in New York City. Lifetime sexual behaviors were examined among two samples of predominantly minority, male adolescents in New York City aged 12 to 18 (M = 16.3), believed to be at high risk for HIV infection: 59 runaway males in two residential shelters and 60 males attending a community agency (HMI) for gay and bisexual youths. Interviews regarding psychosexual milestones indicated that 93% of these youths had engaged in oral, anal or vaginal intercourse and/or anilingus, with a median of 11.0 female partners among runaway males and a median of 7.0 male partners among HMI males. Both groups initiated sexual activity at a relatively early mean age of 12.6 years. Each group reported a unique developmental sequence of psychosexual milestones. Consistent condom use was reported by 13% of the youths. One quarter of the youths reported involvement in prostitution. These findings detail the need for AIDS prevention programs for these youths.


Learning from Norwegian experience: attempts to mobilize the youth culture to fight the AIDS epidemic. This study describes to what extent Norwegian adolescents were aware of a campaign to combat the spread of AIDS, and their participation in the various components. The material comprised a nationwide representative sample of 3000 adolescents aged 17 through 19 years. Data were collected by means of self-administered, anonymous questionnaires. The response rate was 62.8%. The intention of the campaign was to mobilize the youth culture in the fight against AIDS with a view to internalizing existing knowledge about HIV and AIDS in the hope of improving consistency between knowledge and sexual behavior. The campaign included five elements connected to the use of media and activities in the adolescents' social environment. The campaign slogan--Talk about sex, about being in love and about love--was referred to AIDS only indirectly. The medium used to communicate the message was rock music. Over one quarter of the adolescents reported a general awareness of the campaign. Awareness of the different elements varied between 2.4% and 24.0%. Use of condoms was apparently no higher among adolescents who were generally aware of the campaign than among adolescents with no knowledge of it. The adolescents had not grasped any specific message from the campaign. The campaign would probably have been more successful if the message had been more direct and more specific to the context.


Assistance to AIDS orphans within the family/kinship system and local institutions: a program for East Africa. The rapid spread of HIV/AIDS infection in East Africa is devastating the adult population, leaving behind orphans in need of care. By 2015, there will be an estimated 16 million children orphaned by AIDS in Africa alone (Valeroy, 1991). Long-term and cost effective programs must be designed that will utilize available resources. AIDS orphans have traditionally been relocated within the extended family network, although this system is becoming overwhelmed by the large numbers of children needing care. In the present paper a family/kinship project to support and enhance existing traditional systems and thus ensure stable and long-term orphan care is outlined.