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Nurses in chemotherapy administration settings are constantly challenged to increase utilization while maintaining patient safety. A performance improvement project was carried out to identify barriers to patient throughput and opportunities to improve utilization while not compromising patient safety. We found ways to safely increase the number of patients from 92 to 108 per day; however, patient tardiness and staff vacancies had a negative impact on patient wait times and nursing staff overtime. [ABSTRACT FROM AUTHOR]

Between October 1986 and November 1987, 208 total hip arthroplasties were performed with use of the cementless Zweymüller stem and a threaded cup in 200 consecutive patients. Of 102 patients (108 hips) who were available for follow-up at a minimum of 180 months postoperatively, eighty-three (eighty-nine hips) had the primary joint replacement still intact. No stem had been revised because of aseptic loosening, but we found various degrees of osteolysis around sixteen (18%) of the implants. The probability of survival of the stem at fifteen years was 0.98 (95% confidence interval, 0.96 to 1.00). The probability of survival of the cup was 0.85 (95% confidence interval, 0.79 to 0.91). [ABSTRACT FROM AUTHOR]

Objective: While COVID-19 symptoms impact rhinology (anosmia) and laryngology (airways), two major disciplines of the otolaryngology armamentarium, the virus has seemed to spare the auditory system. A recent study, however, reported changes in otoacoustic emission (OAE) signals measured in SARS-COV-2 positive patients. We sought to assess the effect of COVID-19 infection on auditory performance in a cohort of recovered SARS-COV-2 patients and controls. To avoid a potential bias of previous audiological dysfunction not related to SARS-COV-2 infection, the study encompasses patients with normal auditory history. We hypothesized that if SARS-COV-2 infection predisposes to hearing loss, we would observe subtle and early audiometric deficits in our cohort in the form of subclinical auditory changes., Study Design: Cross-sectional study., Setting: Tertiary referral center., Patients: The Institutional Review Board approved the study and we recruited participants who had been positive for SARS-COV-2 infection, according to an Reverse Transcription Polymerase Chain Reaction (RT-PCR) test on two nasopharyngeal swabs. The patients included in this study were asymptomatic for the SARS-COV-2 infection and were evaluated following recovery, confirmed by repeated swab testing. The control group comprised healthy individuals matched for age and sex, and with a normal auditory and otologic history., Interventions: The eligibility to participate in this study included a normal audiogram, no previous auditory symptoms, normal otoscopy examination with an intact tympanic membrane, and bilateral tympanometry type A. None of our volunteers reported any new auditory symptoms following SARS-COV-2 infection. Ototacoustic emissions (OAE) and auditory brainstem response (ABR) measurements were used to evaluate the auditory function., Main Outcome Measures: OAE and ABR measurements., Results: We have found no significant differences between recovered asymptomatic SARS-COV-2 patients and controls in any of transitory evoked otoacoustic emission (TEOAE), distortion product otoacoustic emissions (DPOAE), or ABR responses., Conclusions: There is no cochlear dysfunction represented by ABR, TEOAE, and DPOAE responses in recovered COVID-19 asymptomatic patients. Retrocochlear function was also preserved as evident by the ABR responses. A long-term evaluation of a larger cohort of SARS-COV-2 patients will help to identify a possible contribution of SARS-COV-2 infection to recently published anecdotal auditory symptoms associated with COVID-19., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2020, Otology & Neurotology, Inc.)

Coagulative disorders, especially clotting during extracorporeal membrane oxygenation, are frequent complications. Direct visualization and analysis of deposits in membrane oxygenators using computed tomography (CT) may provide an insight into the underlying mechanisms causing thrombotic events. However, the already established multidetector CT (MDCT) method shows major limitations. Here, we demonstrate the feasibility of applying industrial micro-CT (µCT) to circumvent these restrictions. Three clinically used membrane oxygenators were investigated applying both MDCT and µCT. The scans were analyzed in terms of clot volume and local clot distribution. As validation, the clot volume was also determined from the fluid volume, which could be filled into the respective used oxygenator compared to a new device. In addition, cross-sectional CT images were compared with crosscut oxygenators. Based on the µCT findings, a morphological measure (sphericity) for assessing clot structures in membrane oxygenators is introduced. Furthermore, by comparing MDCT and µCT results, an augmentation of the MDCT method is proposed, which allows for improved clot volume determination in a clinical setting.

Purpose of Review: The alternative model for personality disorders in DSM-5 and the upcoming ICD-11 stimulated an increased interest in the concept of personality functioning for the diagnosis of personality disorders. Furthermore, the impact of personality functioning on other mental disorders has become the focus of recent research efforts. The purpose of this review is to provide a comprehensive and critical study of the empirical literature on the relationship between personality functioning and anxiety disorders., Recent Findings: Recent studies predominantly show a positive association of anxiety symptoms and disorders with an impairment in personality functioning. However, no evidence was found for different levels of personality functioning according to the type of anxiety disorder. Anxiety disorders can occur at all levels of personality organization., Summary: Anxiety disorders are associated with significant impairment in personality functioning. As the underlying personality structure is known to play a crucial role for treatment outcome, the evaluation of personality functioning should be a central part of a comprehensive diagnostic process and treatment planning in patients with anxiety disorders.

Objective: The aim of this study was to examine the effect of cochlear implant (CI) site infection and its subsequent management on CI mapping and CI performance. Risk factors for CI infections and pathogens causing infections were reviewed. Treatment options for CI infections were examined., Study Design: Retrospective case review., Setting: Tertiary referral center., Patients: Adult patients with a significant CI soft tissue infection from the Northern Cochlear Implant Programme, New Zealand over a 10-year period (August 2004 until August 2014)., Intervention: Patients were treated with intravenous antibiotics, washout and debridement or ex-plantation and reimplantation of CI., Main Outcome Measure: CI mapping results and implant performance before and after management of CI infections were compared., Results: There were nine CI infections. Most patients (7/9) were treated with washout and debridement. One patient required removal of the CI and one patient was deemed medically unfit for a general anaesthetic and was managed conservatively with antibiotics alone. Seven patients received long-term antibiotics. Four patients were able to maintain CI performance after salvage treatment of the CI infection. Three patients had poorer CI performance after salvage treatment. One patient had reimplantation and became a nonuser due to only partial reinsertion., Conclusion: The pathophysiology of CI infections is complex. Infections can occur many years after CI surgery. The most common bacteria identified were Staphylococcus aureus, Pseudomonas aeruginosa, and skin commensals. Biofilms are present around implants that are removed from patients and biofilms may play a role in CI infections, but the mechanism of infection is not clear.

Objective: To explore the role and yield of multigene evaluation in children recently diagnosed with unilateral sensori-neural hearing loss (SNHL)., Study Design: Retrospective cohort study., Setting: Tertiary level pediatric institution., Patients: Sixty children diagnosed with unilateral SNHL between January 2005 and December 2015., Intervention: Targeted mutation analysis was performed in 51 children using DNA microarray for genotyping 11 different genes known to be correlated with nonsyndromic SNHL., Main Outcome Measure: Multigene testing results., Results: Average age at diagnosis was 4.3 years. All children appeared to have nonsyndromic hearing loss (HL). HL was categorized as mild (17 children), moderate (17 children), severe (7 children), or profound (19 children). Genetic testing was performed in 51 (85%) children. Sixteen children (31.3%) were tested positive to connexin 26 (GJB2). One patient (2%) from this subgroup was homozygous and 15 were heterozygous. The average age of GJB2 positive children was 6 years and their average pure tone audiometry (PTA) was 75 dB. Computed tomography (CT) and/or magnetic resonance imaging (MRI) scans were performed in 43 children (71.66%). Out of the children who had a scan, 27 patients (62.8%) had negative findings on either CT or MRI scans. Sixteen (37.2%) patients had positive scan finding/s., Conclusions: Significant proportion of children with unilateral SNHL may have positive genetic testing while the vast majority of these children present with heterozygous mutations of connexin 26 (GJB2). Findings suggest that genetic evaluation has a role as a complementary modality in HL evaluation for pediatric unilateral SNHL although it may not be necessary to analyze for various abnormalities other than connexin 26 when practising in a limited resources environment.

Background: Local anesthetics, especially bupivacaine, have myotoxic effects in clinically used concentrations and context. Detailed mechanisms of these effects are unknown, but an increase in intracellular calcium levels is suspected to be the most important trigger. Dantrolene and caffeine modify cellular calcium release from the sarcoplasmic reticulum. The aim of our study was to investigate the effect of dantrolene and caffeine on bupivacaine-induced myotoxicity in vitro., Methods: A cell culture model of primary muscle cells of BALB/c AnNCrl mice was established. Cells were incubated simultaneously with increasing concentrations of bupivacaine, dantrolene, and caffeine. The fraction of dead cells was calculated after staining with propidium iodide and analysis by flow cytometry. The half-maximal inhibitory concentration of bupivacaine was calculated for each concentration. Group differences were determined by using 1-way analysis of variances with subsequent post hoc 1-way Dunnett t test., Results: Both dantrolene and caffeine alone had no effect on muscle cell survival. Increasing concentrations of bupivacaine caused increasing cell death. Dantrolene dose-dependently reduced the fraction of necrotic cells, whereas caffeine dose-dependently increased the fraction of dead cells., Conclusions: Dantrolene attenuated, and caffeine enhanced, bupivacaine-induced myotoxicity, presumably by modifying sarcoplasmic calcium release. This indicates that intracellular calcium release is an important factor for local anesthetic-induced cell death.

Objective: This study describes a subset of necrotizing otitis externa (NOE) patients with a refractory disease and negative cultures. In these cases, we decided to use a polymerase chain reaction (PCR) assay from surgically obtained tissue under sterile conditions to improve pathogen detection sensitivity., Study Design: Retrospective case review., Setting: Academic medical center., Patients: Nineteen consecutive patients diagnosed with NOE between January 2008 and January 2014 inclusive. Three patients of this cohort presented a culture-negative disease., Interventions: Diagnostic., Main Outcome Measures: Positive detection of pathogens using a PCR assay in cases with a complicated course of NOE and clinical resolution of the disease after targeted therapy according to PCR results., Results: Surgical samples were obtained under sterile conditions from three patients with negative cultures and a refractory disease course of NOE. PCR assays were performed using pan-bacteria and pan-fungi protocols. In all three samples, a positive result for a fungal pathogen was recorded and followed by successful empirical targeted therapy., Conclusion: Patients who present with a refractory culture-negative NOE should be suspected as suffering from a fungal disease. The PCR assay may be an important laboratory adjunct in detecting pathogens responsible for NOE and can aid to promote therapy and disease resolution.

Background: Cardiovascular resuscitation upon intoxication with lipophilic ion channel-blocking agents has proven most difficult. Recently, favorable results have been reported when lipid rescue therapy is performed, i.e., the infusion of a triglyceride-rich lipid emulsion during resuscitation. However, the mechanism of action is poorly understood., Methods: The authors investigate the effects of a clinically used lipid emulsion (Lipovenös® MCT 20%; Fresenius Kabi AG, Bad Homburg, Germany) on the block of the fast Na current (INa) induced by the lipophilic local anesthetic bupivacaine in adult rat left ventricular myocytes by using the whole cell patch clamp technique., Results: Bupivacaine at 10 µm decreased INa by 54% (-19.3 ± 1.9 pApF vs. -42.3 ± 4.3 pApF; n = 17; P < 0.001; VPip = -40 mV, 1 Hz). Addition of 10% lipid emulsion in the presence of bupivacaine produced a 37% increase in INa (-26.4 ± 2.8 pApF; n = 17; P < 0.001 vs. bupivacaine alone). To test whether these results could be explained by a reduction in the free bupivacaine concentration by the lipid (lipid-sink effect), the authors removed the lipid phase from the bupivacaine-lipid mixture by ultracentrifugation. Also, the resulting water phase led to an increase in INa (+19%; n = 17; P < 0.001 vs. bupivacaine), demonstrating that part of the bupivacaine had been removed during ultracentrifugation. The substantially less lipophilic mepivacaine (40 µm) reduced INa by 27% (n = 24; P < 0.001). The mepivacaine-lipid mixture caused a significant increase in INa (+17%; n = 24; P < 0.001). For mepivacaine, only a small lipid-sink effect could be demonstrated (+8%; n = 23; P < 0.01), reflecting its poor lipid solubility., Conclusion: The authors demonstrate lipid rescue on the single-cell level and provide evidence for a lipid-sink mechanism.

Background: The 2 local anesthetics (LAs) bupivacaine and ropivacaine have acute cytotoxic effects on different tissues. In this respect, LA-induced myotoxicity has been subject to various studies; however, the exact mechanisms are still not fully understood. Most in vitro studies use immortalized cell lines because of feasibility. Thus, establishing a primary cell line might result in more accurate results. In this study, we examined the effects of immortalization on bupivacaine- and ropivacaine-induced myotoxicity in vitro., Methods: An immortalized (N = 6) and a primary cell line (N = 8) of the same tissue and species were established, and differentiation in myotubes was induced. Cells were exposed to increasing concentrations of bupivacaine and ropivacaine for 1 or 2 hours, respectively. Twenty-four and 48 hours after treatment, the fractions of dead and vital cells were measured using flow cytometry. Significance was tested through 1-way analysis of variance with post hoc Dunnett T3 test. Medians of dataset pairs were compared by T test., Results: In both cell lines, increasing concentrations of both LAs resulted in decreased cell survival (e.g., P < 0.001 for 5000 ppm bupivacaine, 1 or 2 hours of incubation, and 24 hours recovery in both cell lines). For the same LA concentrations, survival was significantly higher in the immortalized cell culture (e.g., P < 0.001 for 2500 ppm ropivacaine, 1 hour of incubation, and 24 hours recovery). In addition, equal concentrations of bupivacaine resulted in significantly fewer vital cells compared with ropivacaine (e.g., P = 0.032 for 2500 ppm ropivacaine, 1 hour of incubation, and 24 hours recovery). Two hours of incubation resulted in a significantly higher rate of dead cells compared with 1 hour of incubation (e.g., P = 0.004 for C2C12 cells, 2500 ppm bupivacaine, and 24 hours recovery)., Conclusions: Primary skeletal muscle cells are more vulnerable to LAs than immortalized cells. The higher myotoxic potential of bupivacaine compared with ropivacaine in vivo can be reproduced in vitro. Incubation time has an influence on cell survival.

Background: Acid aspiration is a serious complication that can occur during general anesthesia. Studies show that beta-agonists have beneficial effects on lung injury. Therefore, we tested the effect of the nebulized beta-agonist fenoterol on lung variables in a rodent model of acid-induced lung injury., Methods: In a prospective, randomized, and controlled study, we evaluated the effects of fenoterol inhalation on lung oxygenation, inflammation, and pulmonary histology in a rat model of acid-induced lung injury. Sprague-Dawley rats underwent sevoflurane anesthesia with tracheotomy and carotid catheter insertion. Lung injury was induced by instillation of 0.4 mL/kg 0.1 M hydrochloric acid. The lungs were ventilated for 6 h and randomized to receive either fenoterol inhalation 10 microg or saline inhalation, both at 15 and 180 min after acid aspiration. Mean arterial blood pressures and peak airway pressures were documented, arterial blood gases were determined at 30, 90, 180, 270, and 360 min, and postmortem histology was subsequently examined. Additionally, fenoterol concentrations in bronchoalveolar lavage fluid (BALF) and plasma were determined by liquid chromatography/tandem mass spectroscopy. After 360 min tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 were determined in the BALF, and lungs were dried for determination of the wet/dry ratio., Results: Inhalation treatment with 10 microg fenoterol significantly increased oxygenation after 270 and 360 min when compared with placebo. Fenoterol-treated rats showed a significant decrease in IL-6 and TNF-alpha levels and in the wet/dry weight ratio of the lungs. The histologic appearance showed significantly less interstitial edema and leukocyte infiltration in the fenoterol group. The concentration of fenoterol was 10.3 microg/L (median) in the BALF and <1 microg/L in the plasma., Conclusions: Fenoterol inhalation improved oxygenation after 270 and 360 min, attenuated the release of TNF-alpha and IL-6, and diminished the lung edema and infiltration of polymorphonuclear leukocytes.

Unlabelled: Although the protein-sparing effect of neuraxial blockade after abdominal surgery is well established, its metabolic effect after operations on the lower extremities remains unclear. In this study, we tested the hypothesis that combined spinal and epidural blockade (CSE) inhibits amino acid oxidation after hip surgery. Sixteen patients undergoing hip replacement surgery received either general anesthesia followed by IV patient-controlled analgesia with piritramide (control; n = 8) or CSE using bupivacaine 0.5% for spinal anesthesia and ropivacaine 0.2% with 0.5 microg/mL of sufentanil for postoperative epidural analgesia (CSE; n = 8). Glucose and protein kinetics were assessed by stable isotope tracer technique ([6,6-2H2]glucose, L-[1-13C]leucine) on the day before and one day after surgery. Plasma concentrations of glucose, lactate, free fatty acids, cortisol, glucagon, and insulin were also determined. CSE prevented the increase in plasma glucose concentration during and immediately after the operation (60 min after skin incision: CSE 4.9 +/- 0.7 versus control 6.2 +/- 0.7 mmol/L; P < 0.05; postanesthesia care unit: CSE 5.0 +/- 0.9 versus control 7.3 +/- 1.1 mmol/L; P < 0.05). Intraoperative cortisol plasma concentrations were smaller in the CSE group than in the control group. One day after the operation, however, glucose plasma concentration, glucose production, and glucose clearance were comparable in both groups. CSE inhibited the postoperative increase in leucine oxidation rate (CSE 30 +/- 12 versus control 43 +/- 8 micromol.kg(-1).h(-1); P < 0.05). There were no differences between the groups in protein breakdown, whole body protein synthesis, and plasma concentrations of lactate, free fatty acids, insulin, and glucagon. In conclusion, CSE prevents hyperglycemia during hip surgery and inhibits protein catabolism thereafter., Implications: We studied the effect of combined spinal/epidural blockade (CSE) on protein and glucose metabolism during and after hip surgery. In comparison to general anesthesia followed by intravenous patient-controlled analgesia, CSE inhibits the increase in glucose plasma concentration during surgery and prevents protein loss on the first postoperative day.

Managers frequently seek ways to create effective and lasting change among employees. When attempting change, each manager must consider what will motivate a particular employee at a particular time. To create lasting change, it is believed that a change in attitudes, beliefs, or values may be necessary. Cognitive dissonance is purported to be a powerful motivator for change. People find consistency comfortable and prefer to be consistent in their thoughts, beliefs, emotions, values, attitudes, and actions. When inconsistency exists, an individual feels an imbalance or dissonance. To reduce this feeling of imbalance, individuals may change their attitude or behavior to regain the feeling of consistency. This article explores cognitive dissonance theory and discusses a situation in which it was used to produce effective and lasting change in a nursing work unit.

Implications: The fluoride inhibition of mivacurium hydrolysis by pseudocholinesterase increases in hypothermia, but it will very rarely occur in clinical practice because it requires rather large fluoride concentrations (>50 micromol/L) and very low temperatures (<28 degrees C).

Background: Volatile anesthetics are frequently used during cardiopulmonary bypass (CPB) to maintain anesthesia. Uptake and elimination of the volatile agent are dependent on the composition of the oxygenator. This study was designed to evaluate whether the in vivo uptake and elimination of isoflurane differs between microporous membrane oxygenators containing a conventional polypropylene (PPL) membrane and oxygenators with a new poly-(4-methyl-1-pentene) (PMP) membrane measuring isoflurane concentrations in blood., Methods: Twenty-four patients undergoing elective coronary bypass surgery with the aid of CPB were randomly allocated to one of four groups, using either one of two different PPL-membrane oxygenators for CPB or one of two different PMP-membrane oxygenators. During hypothermic CPB, 1% isoflurane in an oxygen-air mixture was added to the oxygenator gas inflow line (gas flow, 3 l/min) for 15 min. Isoflurane concentration was measured in blood and in exhaust gas at the outflow port of the oxygenator. Between-group comparisons were performed for the area under the curve (AUC) during uptake and elimination of the isoflurane blood concentrations, the maximum isoflurane blood concentration (C(max)), and the exhausted isoflurane concentration (F(E))., Results: The uptake of isoflurane, expressed as AUC of isoflurane blood concentration and a function of F(E), was significantly reduced in PMP oxygenators compared to PPL oxygenators (P < 0.01). C(max) was between 8.5 and 13 times lower in the PMP-membrane oxygenator groups compared to the conventional PPL-membrane oxygenator groups (P < 0.01)., Conclusions: The uptake of isoflurane into blood via PMP oxygenators during CPB is severely limited. This should be taken into consideration in cases using such devices.

A morphologic study of connective tissue structures in clubfoot, with special emphasis on the presence of myofibroblasts, was undertaken to investigate the theory of retracting fibrosis as an etiologic factor. Nine idiopathic clubfeet from six patients were studied. Specimens from the medial and lateral capsule, medial and lateral fascia, spring and lacinate ligaments, and flexor digitorum longus, flexor hallucis longus, posterior tibialis, and Achilles tendon sheaths were investigated. Fifty specimens were examined using light microscopy and hematoxylin and eosin staining, and 26 were examined by transmission electron microscopy. Light microscopy failed to reveal any myofibroblast-like cells or any qualitative differences between specimens from capsule, fascia, ligaments, and tendon sheath. Using transmission electron microscopy, the authors identified two cell types: fibroblasts and mast cells. Some fibroblasts contained a network of microfilaments but all lacked microbundles, basal lamina, or plasmalemmal attachment plaques seen in typical myofibroblasts. Mast cells were rarely identified in capsular specimens. The absence of myofibroblast-like cells or typical myofibroblasts in clubfoot connective tissue structures does not support the theory of retracting fibrosis as a likely cause of contracture in idiopathic clubfoot.

A large academic cancer center devised a performance improvement plan for special procedures and sedation. A group of interdisciplinary professionals convened to address data collection, complications, and outcomes for non-surgical procedures and sedation. Administrative, medical, and nursing representatives from all areas in which these procedures are performed gathered to assess existing data and data collection methods and to develop an improvement plan. Gastroenterology, pulmonary, diagnostic imaging, intensive care, gynecology, genitourinary, hematology, and anesthesiology specialties were represented. The group was facilitated by staff from the institution's Office of Performance Improvement and co-chaired by an anesthesiologist and a pulmonary specialist. A representative from the Practice Outcomes Department was also an active participant. This article describes group process, design efforts, pilot testing, and analyses for this project. Pilot data are presented as well as a discussion of staff involvement.

Unlabelled: We evaluated dynamic cardiovascular control by spectral analytical methods in 20 young adults anesthetized with propofol (2.5 mg/kg, followed by continuous infusion of 0.1 mg/kg/min) and in an awake control group during cyclic stimulation of the carotid baroreceptors via sinusoidal neck suction at 0.2 Hz (baroreflex response mediated mainly by vagal activity) and at 0.1 Hz (baroreflex response mediated by vagal and sympathetic activity). During anesthesia and mechanical ventilation at 0.25 Hz, major underdampened hemodynamic oscillations occurred at 0.055 +/- 0.012 Hz. The response of RR intervals to baroreceptor stimulation at 0.2 Hz was markedly decreased during anesthesia (median of transfer function magnitude between neck suction and RR intervals 3% of the awake control). Blood pressure response to baroreceptor stimulation at 0.1 Hz was significantly decreased during anesthesia to 26% (systolic blood pressure), and 44% (diastolic blood pressure) of the awake control. There was a significant delay in baroreflex effector responses during anesthesia. Our results demonstrate a markedly depressed vagally mediated heart rate response and an impaired blood pressure response to cyclic baroreceptor stimulation during propofol anesthesia in mechanically ventilated patients. The disturbed baroreflex control is accompanied by an irregular dynamic behavior of cardiovascular regulation, indicating a decreased stability of the control system., Implications: An irregular dynamic behavior of the cardiovascular control system, associated with an impaired baroreflex control of heart rate and blood pressure, can be observed during propofol anesthesia in mechanically ventilated subjects.

Background: The pharmacodynamic differences in time to onset and dissipation of effect of sufentanil, fentanyl, and alfentanil probably result from different rates of blood-brain equilibration. The authors investigated this hypothesis in humans., Methods: After simultaneous central venous bolus application of sufentanil (10 microg), fentanyl (100 microg), and alfentanil (1,000 microg), arterial and jugular bulb blood samples were drawn simultaneously at 20, 30, 45, 60, 75, 90, 105, 120, 140, 160, 180, 210, 240, 300, 360, and 420 s from 19 patients during the postacute stage of head injury with normal intracranial pressure, cerebral perfusion pressure, and cerebral oxygen metabolism during normocapnia., Results: Peak brain concentration, indicated by equilibrium between arterial and jugular bulb opioid concentrations, was achieved for alfentanil at 45 s, for sufentanil at 5 min, and for fentanyl at 6 min. The corresponding median time intervals (fifth and ninety-fifth percentiles) to reach 50% of peak brain concentration were 15 (14-18), 25 (18-38) and 35 (25-45) s, respectively. Uptake was highest 20 s after bolus and decreased continuously for fentanyl and sufentanil, whereas alfentanil uptake was biphasic. The ratio of the relative amounts of sufentanil, fentanyl, and alfentanil retained in the brain at peak brain concentration was 1x:x6x:x90., Conclusions: The differences in the time lag between changes in serum concentrations and drug effect after bolus application of nearly equipotent doses of sufentanil, fentanyl, and alfentanil originate from the different times required to reach blood-brain equilibration, mainly depending on different levels and different time profiles of arterial blood concentrations caused by the different tissue distribution volumes.

Objective: To determine the plasma elimination of methohexitone in patients with critically elevated intracranial pressure (ICP) who received the drug in high doses for several days., Design: Drug-monitoring study., Setting: Intensive care unit at a university hospital., Patients: Twelve intensive care unit patients with brain injuries who received methohexitone as a final therapeutic approach after routine therapy had proved to be insufficient in controlling critically elevated ICP., Measurements and Main Results: Plasma samples were taken during methohexitone infusion, before cessation, and in distinct, short increments after discontinuation of the infusion. Methohexitone was determined in plasma by reverse-phase high-pressure liquid chromatography and photometric detection. The median duration of infusion of methohexitone was 137 hrs (minimum, 27 hrs; maximum, 445 hrs), with a median infusion rate of 62.5 microg/kg/min (minimum, 22.5 microg/kg/min; maximum, 116.2 microg/kg/min). Plasma concentrations of methohexitone at burst suppression under concomitant analgesic sedation ranged from 1.6 to 17.3 microg/mL (median, 4.7 microg/mL). After cessation of methohexitone infusion, the decline of plasma concentrations followed a biexponential function. Clearance rates, volume of distribution at steady state, context-sensitive half-time, and initial and terminal elimination half-times were calculated. Pharmacokinetic data showed remarkable interindividual variability that could not be correlated to the infusion rate, to the duration of the infusion, or to obvious differences in physiology or the disease states of these patients. Even in patients with high plasma concentrations who received the drug for a considerable length of time, the initial decline in plasma concentration was exponential, indicating redistribution., Conclusions: We conclude that the elimination kinetics of methohexitone after long-term, high-dose infusion in critically ill patients with brain injuries may favor the use of methohexitone over thiopentone for controlling critically elevated ICP by allowing for a more timely neurologic examination after cessation.

The authors evaluated the efficacy of neoadjuvant carboplatin chemotherapy before external-beam irradiation in patients who had histologically proven glioblastoma multiforme. Twenty-five patients were treated with carboplatin, 600 mg/m2, intravenously once every 4 weeks for a total of 4 planned cycles. External-beam irradiation (60 Gy involved field) was planned after carboplatin. Of 15 patients who had residual tumor assessable for response, seven had stable disease, six had partial responses, one had a complete response, and one had progressive disease. Two of the patients who had partial responses progressed before radiotherapy. Of 10 who had gross total resections, two progressed after 3 to 4 cycles. The median time to tumor progression was 8.4 months. Median survival was 19.2 months. Myelotoxicity and other side effects of treatment were modest. Carboplatin chemotherapy after biopsy or resection of glioblastoma multiforme before irradiation is feasible. These results warrant further clinical investigation of the role that carboplatin chemotherapy may have in the treatment of patients who have newly diagnosed glioblastoma multiforme.

Colon cancer is a leading cause of death in the United States and is estimated to cause 56,500 deaths during 1998. Most cancers evolve from adenomatous polyps. Screening asymptomatic average-risk individuals is recommended to reduce colorectal cancer mortality by detection and removal of adenomatous polyps.

According to the National Cancer Institute, 138,200 new cases and more than 55,000 deaths from colorectal cancer occurred in the U.S. in 1995. A high percentage of early cancers can be detected by screening asymptomatic persons older than age 50 with a digital rectal exam, fecal occult blood testing, and sigmoidoscopy. Evidence suggests that a decrease in mortality from colorectal cancer is associated with regular screening by sigmoidoscopy in an average risk population. As the population ages, more persons are eligible for colorectal cancer screening. Physician endoscopists are not available in all areas, and changes in reimbursement rates have caused some to discontinue this service. For these reasons, the Veterans Administration Medical Center in Buffalo, NY, developed a Colorectal Cancer Screening Program managed by a gastroenterology Clinical Nurse Specialist (CNS). Through study and supervision, the CNS has become proficient in the performance of 60-cm flexible sigmoidoscopic techniques and the diagnosis of multiple colon disorders, including sessile and pedunculated polyps, diverticulosis, tumors, hemorrhoids, and other conditions.

This case-control study, which examines maternal perinatal characteristics and behaviors during pregnancy, was an initial step to determine whether an association exists between breast feeding, oral contraceptive use, smoking habits during pregnancy, and the incidence of Crohn's disease. The population studied was mothers whose children were diagnosed with Crohn's disease before the age of 22. Population controls were selected by each case mother, who solicited two friends or neighbors with a child of similar age. Case mothers differed significantly on the variables of allergies (p = .05) and family history of inflammatory bowel disease (p = .001). No significant differences were found regarding feeding, oral contraceptives, or smoking. Using a forward step-wise logistic regression method, only family history remained in the equation.

Implanted cardiac devices, pacemakers, and automatic cardioverter/defibrillators are becoming more common in the general population. There are more than one-half million persons with pacemakers living in North America, and approximately 20,000 patients have received automatic implantable cardioverter/defibrillators. As pacemaker and defibrillator patients experience common gastrointestinal afflictions, it is likely that more will require endoscopic procedures. Appropriate precautions must be undertaken during electrosurgical procedures in order to avoid damage and interruption of pacemaker/defibrillator devices. Through careful assessment, intervention, and discharge planning, the GI nurse and associate can reduce electrosurgical risks to the gastrointestinal patient with an implanted cardiac device. Specific recommendations for preprocedure patient assessment and intraprocedure interventions are discussed, and an actual case is presented to illustrate a successful plan of care.

The need to develop practice-related documents in an accurate, efficient, and economical manner is the responsibility of the Board of Directors of the Society of Gastroenterology Nurses and Associates (SGNA). When the results of large, randomized, controlled, clinical trials are available, documents can be based on the information published in scientific literature. GI nursing, however, is in a novice phase regarding controlled research trials; thus, other methods of obtaining reliable information are required. The Delphi technique was selected to obtain the consensus of experts. The Delphi technique enables a free and open exchange of ideas while respecting the economics of a deficit budget. This article describes the Delphi process and the manner in which it was used to prepare the SGNA position statement, "Responsibilities of the Gastroenterology Registered Nurse related to Conscious Sedation."

Post-traumatic stress disorder (PTSD) can be caused by experiencing or witnessing a variety of harsh traumatic events. Rape, burglary, war, torture, violence, and other catastrophic events have been known to precipitate flashbacks, nightmares, and inability to cope with the demands of daily life. The symptoms associated with PTSD can interfere with work, sleep, appetite, relationships, and health. In a Veterans Administration hospital population, PTSD is not an uncommon patient problem: it usually results from witnessing and/or participating in war or military service-related circumstances. This case study describes a 42-year-old man who was a prisoner of war in Vietnam. The form of torture his Vietnamese captors subjected him to presented a challenging situation when he required an endoscopic examination of the upper gastrointestinal tract. The purpose of this case study is to offer suggestions to the GI and endoscopy nursing staff who care for these patients, and to make GI health care providers aware of the special needs of this patient population.

A frequent complaint of patients asked to drink polyethylene glycol (PEG) colonic lavage solution is the salty flavor. This often results in failure to ingest the entire 4 liters of the solution and compromises bowel cleansing. The purpose of this study was to determine systematically whether the addition of a flavored drink mix sweetened with aspartame to the PEG lavage solution would improve palatability without significantly altering the osmolality of the solution. Eighty-seven (87) staff volunteers participated in a taste test of PEG lavage solutions containing varying amounts of commercially available drink mixes. The solution containing two packages of lemon-flavored KoolAid drink mix sweetened with aspartame was significantly more palatable than the others (p less than 0.005), while osmolality remained within the range specified by the manufacturer of Colyte.

We may have a role but find it difficult to specifically define it. As various specialties have emerged, roles have developed based on patient or physician need or practitioner innovation. This article is an attempt to present an organized structure of the contribution that can be made by the masters prepared gastroenterology nurse.

The SGNA members identified many concerns regarding malpractice, negligence and liability during the Roundtable Discussion, "When You Think the M.D. Is Wrong...", and in the 1988 SGA Legal Issues Survey. These concerns included: communication, documentation, patient and staff abuse, abandonment, personal liability and informed consent, to name a few. This article is the first in a series that will address those concerns. Many of the situations described by the members during the Roundtable Discussion and in the Survey centered around deficiencies in communication which led to conflict. This article discusses communication as your first line of defense to prevent conflict, and ultimately, a law suit. Resolution of disagreements or conflict can occur simply and professionally, in most instances, with everyone winning. In addition, a discussion relating to communication as a conflict management technique, which may ultimately result in the desired outcome, is also presented.

The rules and laws that govern lawsuits can differ greatly from state to state. This is especially true in the area of medical malpractice. In the last few years there have been a multitude of new laws enacted and an equal amount of legislation is under consideration as of this writing. This article is a general description of the legal process that occurs when an individual health care provide is sued.