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Background: Anesthesia during surgery often induces an inflammatory response. The aim of this study was to establish and compare differences in inflammatory response among colorectal cancer surgery patients receiving either total intravenous anesthesia (TIVA) with propofol and remifentanil or inhalational anesthesia (INHAL) with sevoflurane and fentanyl., Methods: After randomization, we included fifty consecutive patients undergoing colorectal cancer surgery in our study. TIVA patients received total intravenous anesthesia with propofol and remifentanil, while INHAL patients received inhalation anesthesia with sevoflurane in O2/air and fentanyl. Plasma concentrations of IL-8, IL-17, MPO, ICAM-1, V-CAM and L-selectin were quantified. Blood loss, body temperature and blood glucose levels were measured in patients both before and after surgery., Results: In both groups, levels of IL-8, MPO, ICAM-1 and L-selectin decreased 60 min after the start of surgery (P<0.05, P<0.01, respectively) and 30 min post-surgery (P<0.05 for both groups). In the INHAL group, V-CAM levels were significantly lower 60 min after the start of surgery (P<0.01) and 30 min post-surgery (P<0.05). At 24 h post-surgery, V-CAM levels were significantly higher in both groups (P<0.01), while IL-17 levels significantly increased only in the INHAL group (P<0.05). Higher blood glucose levels were also observed in the INHAL group compared to that in the TIVA group (P<0.01)., Conclusion: TIVA with propofol and remifentanil and INHAL with sevoflurane and fentanyl induced similar inflammatory responses during colorectal cancer surgery. We found that IL-17 cytokine levels were higher in patients anesthetized with sevoflurane and fentanyl.

SciVerse is the new combined portal from Elsevier that services their ScienceDirect collection, SciTopics, and their Scopus database. Using SciVerse to access ScienceDirect is the specific focus of this review. Along with advanced keyword searching and citation searching options, SciVerse also incorporates a very useful image search feature. The aim seems to be not only to create an interface that provides broad functionality on par with other database search tools that many searchers use regularly but also to create an open platform that could be changed to respond effectively to the needs of customers.

Serum erythropoietin (sEPO) level is known to increase as hemoglobin (Hb) concentration decreases during and after preoperative autologous blood donation (PAD). The endogenous erythropoietin (EPO) production after allogeneic blood transfusion has not to our knowledge, been studied. The aim of the present study was to determine whether there is, after surgery, any change in sEPO concentration after allogeneic blood transfusion, and whether there is any difference in EPO response after autologous or allogeneic blood transfusion. Thirty-one patients approaching total hip-joint replacement surgery, were randomized to receive either allogeneic red blood cells (n = 15) or predeposited autologous whole blood transfusion (n = 16). The relationship between Hb, sEPO, and reticulocytes in the recipients were repeatedly analyzed before, during and after surgery. The Hb followed an expected pattern, with a decreased concentration after PAD in the autologous group, then in both groups after surgery. The sEPO concentration was significantly higher in the allogeneic than in the autologous group on day one and day 4-5 postoperatively. The reticulocyte level, on the contrary, was higher in the autologous patients before, one hour after, and one day after surgery. The study showed a greater increase in sEPO concentration after allogeneic blood transfusion than after autologous blood transfusion. There may be an inverse relationship between sEPO and the reticulocyte level.

Methods: Fourteen children aged 4-15 months were studied after corrective cardiac surgery. Heart rate was increased by 20% with an external pacemaker. Cardiac output (CO) was measured with thermodilution. Oxygen saturation was measured in systemic artery (SaO2), central vein (ScvcO2) and pulmonary artery (SvO2). Inspiratory to endtidal oxygen difference (FI-ETO2) was measured using a paramagnetic technique. SvO2 was measured continuously using a spectrophotometric technique., Results: CO increased in three patients and decreased in 11 patients during pacing. Regression between DeltaCO and Delta(1/Sa-vO2), Delta(FI-ETO2/Sa-vO2), Delta(FI-ETO2/Sa-cvcO2) showed r=0.70, r=0.76 and r=0.75, respectively. DeltaCO exceeded 10% in 17 of 26 interventions. Changes in FI-ETO2 of equal direction as changes in CO occurred in 12 of these 17 interventions., Conclusion: Estimations of CO changes, based on SvO2, can be enhanced if changes in FI-ETO2 are also measured. ScvcO2 instead of SvO2 gives equivalent results. Sudden changes in FI-ETO2 after pacemaker initiation or termination can predict the direction of CO changes.

Purpose: To determine whether salvaged autologous blood collected postoperatively contains complement split products (SC5b-9), and pro-inflammatory cytokines (IL-6 and IL-8) and whether there are any differences between blood collected during hip or knee surgery., Methods: Fifty-eight consecutive patients undergoing hip or knee replacement surgery were studied. Thirty-eight had postoperative bleeding large enough to require infusion of salvaged blood. The salvaged blood was filtered during collection through a 200 microm filter and before infusion a 40 microm filter was used. Samples for complement and cytokine determinations were drawn from the circulation and from the collected blood., Results: High concentrations of SC5b-9, IL-6, and IL-8 were found in salvaged blood. The concentrations were higher than in the circulation (P < 0.05). The circulating concentrations of IL-6 and IL-8 were increased 60 min and 12-18 hr after transfusion. There were no differences regarding SC5b-9, IL-6, and IL-8 in the blood collected after hip or knee surgery., Conclusion: Blood collected from a surgical wound contains large concentrations of inflammatory mediators. There were no differences between blood collected during hip or knee surgery.

Objectives: Some loss of blood occurs during blood salvage. We hypothesized that plasmapheresis filtering would damage blood much less than centrifugation techniques do, thereby allowing more red blood cells to be transfused., Material and Methods: Laboratory study in which 16 units of whole donor blood were distributed randomly in two groups and processed either by a conventional "cell-saver" method or by hemofiltration using recirculation through a 100,000 dalton filter. We analysed hemoglobin, hematocrit, free hemoglobin, extracellular potassium, platelets, leukocytes, protein and albumin in whole blood before and after processing, and in the waste bag in each group., Results: The recovery of hemoglobin and red blood cell volume was about 80% with both methods. More free plasma hemoglobin was found in the waste bag with the filtration technique. Hemolysis in processed blood was low, less than 0.1% in both groups. Platelet recovery with conventional centrifugation and filtration was 11 and 49%, respectively. Albumin, total protein and extra-cellular potassium were recovered at a rate of about 20% with the filtration technique, whereas recovery of these elements was minimal with the cell saver method., Conclusions: Both methods of autotransfusion caused moderate loss of red blood cells and low plasma levels of free hemoglobin in processed blood. Recovery of platelets, albumin, total protein and potassium was better with filtration than with the "cell-saver" method.

Purpose: To investigate ventilation and gas elimination during the emergence from inhalational anesthesia with controlled normoventilation with either sevoflurane/N2O or sevoflurane alone., Methods: Twenty-four ASA I-II patients scheduled for abdominal hysterectomy were randomly allocated to receive either 1.3 MAC sevoflurane/N2O (n = 12) or equi-MAC sevoflurane (n = 12) in 30% oxygen (O2). Expired minute ventilation volumes (V(E)), end-tidal (ET) concentrations of O2, carbon dioxide (CO2), sevoflurane and N2O as well as pulse oximetry saturation (SpO2) and CO2 elimination rates (VCO2) were measured. The ET concentrations of sevoflurane and N2O were converted to total MAC values and gas elimination was expressed in terms of MAC reduction. Time to resumption of spontaneous breathing and extubation were recorded and arterial blood gas analysis was performed at the end of controlled normoventilation and at the beginning of spontaneous breathing., Results: Resumption of spontaneous breathing and extubation were 8 and 13 min less, respectively, in the sevoflurane/N2O than in the sevoflurane group. Spontaneous breathing was resumed in both groups when pH had decreased by 0.07-0.08 and PaCO2 increased by 1.3-1.5 kPa. Depression of V(E) and VCO2 were less, and MAC reduction more rapid in the sevoflurane/N2O than in the sevoflurane group., Conclusions: Respiratory recovery was faster after sevoflurane/N2O than sevoflurane anesthesia. Changes in pH and PaCO2 rather than absolute values were important for resumption of spontaneous breathing after controlled normoventilation. In both groups, the tracheas were extubated at about 0.2 MAC.

Objective: Fast paramagnetic oxygen analyzers have made it possible to measure inspiratory to end-tidal oxygen concentration difference (P(I-ET)O2) breath-by-breath. It is now frequently displayed on monitors during routine anesthesia. We wanted to study the effects of major changes in metabolism, ventilation and circulation on P(I-ET)O2., Methods: Ten healthy male volunteers were studied under exercise. P(I-ET)O2 was measured with a fast-response paramagnetic differential oxygen sensor. Cardiac output was measured with non-invasive transthoracic electrical bioimpedance. Metabolism was measured with indirect calorimetry and ventilation with a side stream spirometer. After a rest period, the subjects cycled at 30 W and 60 W, 6 minutes on each work load and were then observed during 10 minutes of rest., Results: P(I-ET)O2 corresponded well to VO2/VA (the oxygen uptake to alveolar ventilation quotient) correlation showed r = 0.79. P(I-ET)O2 was influenced by changes in cardiac output which occurred primarily at the start and at the end of exercise. Expired minute ventilation (VE) multiplied by P(I-ET)O2 was related to cardiac output with a high intrapersonal correlation., Conclusion: P(I-ET)O2 is a good measure of adequate ventilation in relation to the oxygen consumption level and multiplied by VE it might offer a non-invasive bedside parameter indicating changes in cardiac output.

Background: Allogeneic blood transfusions cause immunosuppression. The aim of this study was to determine whether complement anaphylatoxins, cytokines, or both are released in the recipient, after blood transfusions in general, and after autologous blood transfusions in particular., Methods: Thirty-one patients having total hip joint replacement surgery were randomized to receive either allogeneic red blood cells (n = 15) or predeposited autologous whole blood transfusion (n = 16). Plasma concentrations of the anaphylatoxins C3a and C5a, the terminal C5b-9 complement complex, and cytokines IL-6 and IL-8 in the recipients were repeatedly analyzed before, during, and after surgery., Results: Significantly increased concentrations of IL-6 and IL-8 appeared in both groups, with a significantly greater increase in the autologous blood group. Patients in both groups developed a moderate but significant increase of C3a without a significant difference between them. C5a and terminal C5b-9 complement complex were not greatly changed., Conclusions: The study showed a greater increase in cytokine concentration after autologous blood transfusion than after allogeneic blood transfusion. The lower response in the latter may result from transfusion-induced suppression of cellular immunity.

Fourteen patients with liver tumor malignancy and sixteen patients with malignant melanoma localized to one limb were studied regarding leukocyte activation with the release of polymorphonuclear neutrophilic (PMN) elastase and of neopterin and formation of cytokines (TNF-alpha and IL-6) during the surgical treatment. Patients undergoing liver resection (n = 10), abdominal hysterectomy (n = 10), or hip replacement surgery (n = 10) served as control groups. Isolated hyperthermic liver perfusion was performed with cytostatic-containing perfusate (melphalan and cisplatinum). Patients with recurrent malignant melanoma confined to one limb underwent isolated hyperthermic limb perfusion with cytostatic-containing perfusate (melphalan). Blood samples for determination of PMN elastase, neopterin, TNF-alpha, and IL-6 were drawn from the patients preoperatively, 1 minute before the start of the perfusion, 60 and 120 minutes after the start of the perfusion, and 24 hours postoperatively. Samples from the perfusate were drawn 60 minutes after the start of the perfusion. High concentration of plasma PMN elastase were found in both patients undergoing liver and limb perfusion and in patients undergoing liver resection surgery. Elevated concentrations of IL-6 were found in the patients undergoing liver perfusion and in patients undergoing liver resection. In none of the patients were there increased concentrations of neopterin or TNF-alpha. The perfusate contained high concentrations of PMN elastase, neopterin, and IL-6. This study also demonstrated that major surgery leads to elevated concentrations of PMN elastase and IL-6. An increase of PMN elastase and IL-6 was seen in response to perfusion and to surgical trauma.

25 patients undergoing total hip replacement surgery were studied in an investigation of release of cytokines (interleukin-1 beta, IL-1 beta; interleukin-6, IL-6; interleukin-8, IL-8; and tumor necrosis factor-alpha, TNF-alpha), PMN elastase and terminal C5b-9 complement complexes (TCC) at the time of collection and transfusion of autologous blood. 15 patients received wound blood that was washed and centrifuged before being transfused as an erythrocyte suspension. In this blood there were no elevations in the concentrations of cytokines, TNF-alpha, PMN elastase or TCC, and there was no increase in these variables in plasma after transfusion of wound blood. 10 patients received postoperatively-collected drainage blood. There were high amounts of cytokines, PMN elastase and TCC in this blood, and filtration of the collected drainage blood did not reduce the concentrations of these factors, except those of TCC. When the collected drainage blood was infused, elevated plasma concentrations of IL-6, IL-8 and PMN elastase were observed 1 and 60 minutes after completing the transfusion. No differences regarding blood pressure, oxygen saturation (SpO2), and hemoglobin concentration between the groups were recorded.

Long angioplasty inflations have been reported using an autoperfusion system that delivers oxygenated blood distal to the balloon segment. The safety and efficacy of this system has been demonstrated in anatomically selected patients. The clinical use, however, is frequently to stabilize intimal dissection in unselected patients. We reviewed 12-lead continuous electrocardiographic (ECG) recordings in 40 patients in whom prolonged salvage with autoperfusion was attempted. Sub-optimal results were stabilized in 36 of 40, while 4 patients had urgent bypass. The presence of ischemia, as > or = 100 uV ST elevation over the 12 lead ECG, and the total ST deviation over all leads over the entire inflation period (total ischemic "burden") were compared within each patient between the longest standard balloon and autoperfusion inflations. Median duration of inflation was 3.03 min. with balloon vs. 15.6 min. with autoperfusion (p < 0.00002). Of the 40 patients, 35 (87%) had ECG ischemia with balloon vs. 18 (45%) with autoperfusion (p < .00002). Median severity of peak ST deviation was 321 uV with balloon vs. 132 uV with autoperfusion (p = 0.0001). Median extent of ST elevation was 3 leads with balloon vs. 0 leads with autoperfusion (p = 0.0001). Median total ischemic burden was similar with balloon (1173 uVmin) and autoperfusion (1083 uVmin, NS) despite the fivefold longer inflation duration with autoperfusion. Thus, in patients selected by clinical necessity rather than optimal anatomy, severity and extent of ST elevation were significantly reduced, although not entirely eliminated, by autoperfusion.

We assessed the inspiratory to end-tidal oxygen difference (PIO2-PE'O2) during voluntary hyperventilation in 10 healthy male volunteers. The oxygen difference was measured with a fast-response paramagnetic differential oxygen sensor. As simultaneous changes in metabolism and cardiac output also influence (PIO2-PE'O2), oxygen uptake was measured with indirect calorimetry and non-invasive transthoracic electrical bioimpedance was used for measurement of cardiac output. After a rest period, subjects were instructed to double their minute ventilation volume (VE) and after 5 min triple their resting VE for another 5 min. (PIO2-PE'O2) decreased from a zero value of 6.4 kPa to 3.9 kPa at 5 min (P < 0.01) and 2.9 kPa at 10 min (P < 0.01). At 15 min (i.e. 5 min after the end of hyperventilation) there was an increase in (PIO2-PE'O2) to 8.3 kPa (P < 0.05). Regression analysis between (PIO2-PE'O2) (kPa) and VE (litre m-2 min-1) gave the formula: (PIO2-PE'O2) = 1/(0.059 + 0.034 VE), r = -0.92, n = 158. Oxygen uptake and cardiac output did not change significantly during hyperventilation, but decreased in the post-hyperventilation period. An oxygen difference of more than 8 kPa was associated with significant arterial desaturation.

Sixteen patients with acute and chronic liver disease undergoing OLT were studied regarding the role of the liver and the gut in complement activation. Also, the relation between complement activation and clinical manifestations during the liver transplantation reperfusion period was investigated. Blood samples for measurement of complement anaphylatoxin C3a (C3a), complement anaphylatoxin C5a (C5a), and terminal C5b-9 complement complex (TCC) were taken simultaneously from the central venous catheter and the radial arterial line before starting the operative procedure, 1 min before declamping, and 1-2 min, 5 min, 30 min and 6-12 hr after declamping. Simultaneous blood sampling from the radial arterial line, central venous catheter, portal vein, and hepatic vein was performed 1-2 min and 5 min after completed unclamping. Elevated plasma levels of C3a and TCC were found upon reperfusion, while C5a levels remained unchanged throughout the operation compared with the preoperative levels. The levels of C3a in the portal vein were higher compared with the levels in the simultaneously obtained samples from the radial artery. The results indicate complement cascade activation located to the gut during the reperfusion phase of OLT. Seventy-five percent of the patient studied suffered from the postreperfusion syndrome, indicated by profound hypotension upon reperfusion of the transplanted liver. There was a significant correlation between high concentration of C3a anaphylatoxin and development of profound hypotension.

We have studied, in 10 patients undergoing hip replacement surgery, the release of cytokines (tumour necrosis factor-alpha (TNF-alpha), interleukin-1 alpha (IL-alpha), interleukin-1 beta (IL-1 beta), interleukin-4 (IL-4), interleukin-6 (IL-6) and interleukin-8 (IL-8)) in association with retransfusion of autologous shed blood. The patients were reinfused with whole blood collected after operation. The median volume returned to the patients was 300 ml whole blood (25-75% range = 300-425 ml). Before reinfusion, blood was filtered. Plasma concentrations of IL-6 increased 1 and 60 min after retransfusion (P < 0.05). The plasma concentrations of TNF-alpha, IL-1 alpha, IL-1 beta, IL-4 and IL-8 did not change significantly after retransfusion of shed wound blood. However, there were increased concentrations of IL-1 alpha, IL-1 beta, IL-6 and IL-8 in the collected blood (P < 0.001). The filtration procedure did not reduce significantly the concentrations of these factors. This study shows that whole blood collected from a surgical wound contains large concentrations of cytokines. Filtration of the shed wound blood did not reduce significantly these levels and retransfusion caused increased plasma concentrations of IL-6.

Objective: The purpose of this investigation was to study the N2 flux between the patient and the breathing circuit, and the excess gas during N2O anesthesia with the low, fresh gas flow technique., Methods: Forty patients were studied. After a 6-minute high, fresh gas flow denitrogenation period, the O2 fresh gas flow was set at about 4 ml/kg/min and the N2O fresh gas flow was set to maintain an inspired O2 fraction of 0.30. The excess gas flow and N2 excretion were measured by a variant of the Douglas bag method., Results: The mean inspired N2 concentration reached a peak of 5.9% at 40 minutes. The estimated mean N2 excretion was 39 ml/min at 10 minutes, declining to 18 ml/min at 60 minutes. A calculation of N2 homeostasis during closed-circuit anesthesia based on the results of the patient study indicated that sampling for gas analysis actually reduces the gas costs if the sampled gas is scavenged instead of returned to the circle system, since intermittent flushing with high, fresh gas flow for denitrogenation is unnecessary in the former situation., Conclusions: Regardless of the fresh gas flow used, sampled gas need not be returned during N2O anesthesia.

We studied the elimination rate of nitrous oxide in 36 patients undergoing orthopaedic surgery. They were allocated randomly to one of six groups which differed in time of nitrous oxide exposure and mode of ventilation. In order to simulate recovery conditions, nitrous oxide administration was discontinued after 30, 60 or 120 min of exposure. Either normoventilation or hypoventilation was used. The mean excretion rate was 1 litre min-1 at 1 min, declining to 100 ml min-1 at 30 min, with relatively small effects of different modes of ventilation and times of exposure. In spite of an FIO2 of 0.30, there were significant decreases in SpO2 during both normo- and hypoventilation. The smallest end-tidal oxygen concentrations were reached at 10-15 min in the groups with hypoventilation, after 1 or 2 h of nitrous oxide exposure.

The estimation of oxygen consumption and carbon dioxide elimination is essential for predicting the metabolic activity and needs of any patient having anaesthesia. During anaesthesia oxygen consumption can be measured and compared to a predicted value. However, oxygen uptake is affected by anaesthetic agents, which complicates the interpretation of measured oxygen uptake rate. The purpose of this study was to investigate whether there are any differences in respiratory gas exchange during anaesthesia with enflurane and isoflurane and also to assess the effects of spontaneous versus controlled ventilation. METHODS. Forty orthopedic patients were randomized to enflurane or isoflurane anaesthesia in nitrous oxide with either spontaneous or controlled ventilation. A fresh low-gas-flow technique was used. Inspiratory oxygen and end-tidal carbon dioxide concentrations and expiratory minute ventilation were measured in a circle absorber system between the y-piece and the endotracheal tube with a sampling analyser. Between the mixing box and the absorption canister, carbon dioxide concentration was continuously measured. The carbon dioxide elimination was calculated from mixed expired concentration and expiratory minute ventilation. Excess gas was collected every 10 min in a non-permeable mylar plastic bag connected to the excess valve. The excess gas flow was calculated and the oxygen uptake rate was assumed to be the difference between the oxygen fresh gas flow and the oxygen excess gas flow. RESULTS. The grand mean oxygen uptake rate was 2.5 ml.kg-1 x min-1 or 100 ml.min-1 x m-2. There were no statistically significant differences in oxygen uptake between enflurane and isoflurane anaesthesia or between spontaneous and controlled ventilation. The mean oxygen uptake rate at 10 min was between 2.0 and 2.2 ml.kg-1 x min-1 in all groups. At 30 min the mean oxygen uptake rates were 2.6 to 2.8 ml.kg-1 x min-1. Carbon dioxide elimination was closely associated with expired minute ventilation, with a carbon dioxide excretion of about 30 ml per litre gas exhaled, irrespective of ventilatory mode employed.

Twelve patients with end-stage liver disease undergoing liver transplantation were studied regarding complement activation and formation of anaphylatoxins (C3a and C5a) and terminal C5b-9 complement complexes (TCC) after reperfusion of the grafted liver. Blood samples for complement variables (C1INH, C3, C4, C5, C3a, C5a, and TCC) were drawn preoperatively, before the anhepatic phase, 1 min before, and 2, 15, and 60 min after the start of reperfusion of the grafted liver. Activation of complement was observed during the operation. The C1INH, C3, C4, and C5 plasma concentrations decreased during the entire operation while the anaphylatoxin C3a and the terminal C5b-9 complement complex increased after the reperfusion of the grafted liver. Activation of complement with the formation of biologically active substances like anaphylatoxins and terminal C5b-9 complement complexes may be one explanation for circulatory complications often seen in patients undergoing orthotopic liver transplantation.

Objective: To investigate whether an association exists between the probability of a cesarean delivery and the level of malpractice claims risk faced by hospitals and physicians., Design: Survey of computerized discharge data linked with physician and hospital malpractice claims records based on stratified, random sample of hospitals., Setting: Acute care hospitals in New York State in 1984., Population: All deliveries (60 490) at 31 hospitals., Results: After controlling for the clinical risk of a cesarean delivery, patient socioeconomic status, and physician and hospital characteristics, cesarean delivery was positively associated with physician malpractice premiums (odds ratio [OR], 3.00; 95% confidence interval [CI], 2.13 to 4.24 for the difference between upstate and New York City levels), with the number of physician claims opened per 100 physicians at the hospital level (OR, 1.15; 95% CI, 1.02 to 1.30 for a 1-SD change), and with the number of hospital claims opened per 1000 discharges (OR, 1.26; 95% CI, 1.10 to 1.43 for a 1-SD change). Measures of physician-perceived risk of suit also showed a significant association with cesarean delivery (OR, 1.96; 95% CI, 1.53 to 2.52, upstate vs New York City). Within hospitals, there was no significant association (OR, 1.15; P = .126) between the odds of cesarean delivery and the claims history (none vs one or more) of an individual physician., Conclusion: Results support previous speculations of a positive association between malpractice claims risk and the rate of cesarean delivery.

Objectives: The purpose of this study is to describe the outcome in cardiogenic shock treated with aggressive reperfusion therapy and to identify factors predictive of in-hospital and long-term mortality., Background: Cardiogenic shock is the most common cause of death in patients admitted to the coronary care unit. Although studies have reported lower mortality rates in shock treated with angioplasty, few studies have described a cohort of patients with shock who were not selected because they were most likely to benefit from reperfusion therapy., Methods: A consecutive series of 200 patients admitted with acute myocardial infarction complicated by cardiogenic shock were studied., Results: The in-hospital mortality rate was 53%. Variables with significant univariable association with in-hospital death included patency of the infarct-related artery, patient age, lowest cardiac index, highest arteriovenous oxygen difference and left main coronary artery disease. The most important independent predictors of in-hospital death were patency of the infarct-related artery, cardiac index and peak creatine kinase, MB fraction. The mortality rate in patients with patent infarct-related arteries was 33% versus 75% in those with closed arteries and 84% in those in whom arterial patency was unknown. Patients who survived to hospital discharge were followed up for a median of 2 years, with a mortality rate of 18% after 1 year. The best descriptors of the relation between these variables and postdischarge mortality included age, peak creatine kinase, ejection fraction and patency of the infarct-related artery., Conclusions: In a large consecutive series of patients with cardiogenic shock with complete follow-up, patency of the infarct-related artery was most strongly associated with in-hospital and long-term mortality. This finding supports an aggressive interventional strategy in patients with cardiogenic shock.

Several formulas have been proposed to adjust the QT interval for heart rate, the most commonly used being the QT correction formula (QTc = QT/square root of RR) proposed in 1920 by Bazett. The QTc formula was derived from observations in only 39 young subjects. Recently, the adequacy of Bazett's formula has been questioned. To evaluate the heart rate QT association, the QT interval was measured on the initial baseline electrocardiogram of 5,018 subjects (2,239 men and 2,779 women) from the Framingham Heart Study with a mean age of 44 years (range 28 to 62). Persons with coronary artery disease were excluded. A linear regression model was developed for correcting QT according to RR cycle length. The large sample allowed for subdivision of the population into sex-specific deciles of RR intervals and for comparison of QT, Bazett's QTc and linear corrected QT (QTLC). The mean RR interval was 0.81 second (range 0.5 to 1.47) heart rate 74 beats/min (range 41 to 120), and mean QT was 0.35 second (range 0.24 to 0.49) in men and 0.36 second (range 0.26 to 0.48) in women. The linear regression model yielded a correction formula (for a reference RR interval of 1 second): QTLC = QT + 0.154 (1-RR) that applies for men and women. This equation corrects QT more reliably than the Bazett's formula, which overcorrects the QT interval at fast heart rates and undercorrects it at low heart rates. Lower and upper limits of normal QT values in relation to RR were generated.(ABSTRACT TRUNCATED AT 250 WORDS)

In order to evaluate the value of the inspiratory to end-tidal oxygen concentration difference (Io2-E'o2) as a monitor during general anaesthesia, we studied 40 orthopaedic patients allocated randomly to four groups: anaesthesia with enflurane or isoflurane in nitrous oxide with either spontaneous or controlled ventilation. (Io2-E'o2) followed an asymptotically increasing curve because of decreasing uptake of nitrous oxide. At 1 h, (Io2-E'o2) approached the end-tidal carbon dioxide concentration (E'o2). During spontaneous ventilation, (Io2-E'o2) correlated best with E'co2. During controlled ventilation, there was a negative correlation between (Io2-E'o2) and nitrous oxide uptake rate. Changes in oxygen uptake rate were reflected in (Io2-E'o2), provided that the total ventilation volume was constant and the nitrous oxide uptake rate approached steady state conditions.

Patients in whom early and stable reperfusion through the infarct artery fails after thrombolytic treatment might benefit from further revascularization therapy. A reliable noninvasive technique able to detect both reperfusion and reocclusion would be useful to test this hypothesis. However, no such technique presently exists. ST-segment recovery analysis using continuous digital 12-lead ST monitoring has been shown to be an accurate predictor of infarct artery patency in real time. This method was dependent on a trained clinician's analysis of the recordings on a personal computer. For optimal bedside application, salient principles of this ST-segment recovery analysis were converted into algorithms and built into the ST monitor software. The essentials of these algorithms are described in this report.

Isolated torsion of the fallopian tube was discovered during labor. Tubal torsion may occur in the absence of adnexal disease. Diagnosing this disorder is especially difficult in labor, when other causes, such as disruption of a prior uterine scar, may be considered.

Background: The treadmill exercise test identifies patients with different degrees of risk of death from cardiovascular events. We devised a prognostic score, based on the results of treadmill exercise testing, that accurately predicts outcome among inpatients referred for cardiac catheterization. This study was designed to determine whether this score could also accurately predict prognosis in unselected outpatients., Methods: We prospectively studied 613 consecutive outpatients with suspected coronary disease who were referred for exercise testing between 1983 and 1985. Follow-up was 98 percent complete at four years. The treadmill score was calculated as follows: duration of exercise in minutes--(5 x the maximal ST-segment deviation during or after exercise, in millimeters)--(4 x the treadmill angina index). The numerical treadmill angina index was 0 for no angina, 1 for nonlimiting angina, and 2 for exercise-limiting angina. Treadmill scores ranged from -25 (indicating the highest risk) to +15 (indicating the lowest risk)., Results: Predicted outcomes for the outpatients, based on their treadmill scores, agreed closely with the observed outcomes. The score accurately separated patients who subsequently died from those who lived for four years (area under the receiver-operating-characteristic curve = 0.849). The treadmill score was a better discriminator than the clinical data and was even more useful for outpatients than it had been for inpatients. Approximately two thirds of the outpatients had treadmill scores indicating low risk (greater than or equal to +5), reflecting longer exercise times and little or no ST-segment deviation, and their four-year survival rate was 99 percent (average annual mortality rate, 0.25 percent). Four percent of the outpatients had scores indicating high risk (less than -10), reflecting shorter exercise times and more severe ST-segment deviation; their four-year survival rate was 79 percent (average annual mortality rate, 5 percent)., Conclusions: The treadmill score is a useful and valid tool that can help clinicians determine prognosis and decide whether to refer outpatients with suspected coronary disease for cardiac catheterization. In this study, it was a better predictor of outcome than the clinical assessment.

Despite substantial basic and clinical efforts to address the problem of restenosis after percutaneous coronary intervention, effective preventive therapies have not yet been developed. Nevertheless, the accumulated information has provided much insight into the process of restenosis in addition to allowing standards to be developed for adequate clinical trials. The pathophysiology of restenosis increasingly appears to be distinct from that of primary atherosclerosis. Restenosis involves elastic recoil, incorporation of thrombus into the lesion and fibrocellular proliferation in varying degrees in different patients. Lack of an animal model that satisfactorily mimics restenosis is a major impediment to further understanding of the process. Clinical studies are hampered by difficulties in finding a single unifying definition of restenosis and by variable methods of reporting follow-up. Reporting of clinical outcomes of all patients in angiographic substudies would allow a more satisfactory interpretation of the results of clinical trials. Current noninvasive test results are not accurate enough to substitute for angiographic and clinical outcome data in intervention trials. In the majority of observational studies, only diabetes and unstable angina have emerged as consistently associated with restenosis; whereas most of the standard risk factors for atherosclerosis have a less consistent relation. Disappointingly, the new atherectomy and laser technologies have not affected restenosis rates. The one possible exception is coronary stenting, as a result of the larger luminal diameter achieved by the placement of the stent. In conclusion, although substantial continued effort is necessary to explore the basic aspects of cellular proliferation and mechanical alteration of atherosclerotic vessels, attention to the principles of clinical trials and observation are required to detect the impact of risk factors and interventions on the multifactorial problem of restenosis. Adequate sample sizes, collection of clinical and angiographic outcomes and factorial study designs hold promise for unraveling this important limitation of percutaneous intervention.

Cervical pregnancy often results in massive hemorrhage following curettage. Performance of uterine artery embolization before curettage is reported in three consecutive cases of cervical pregnancy. All patients had a successful outcome without significant hemorrhage.

The baseline electrocardiograms of 5,125 original subjects of the Framingham Heart Study were measured to examine the relation of the QT interval corrected for heart rate (QTc) to risk of total mortality, sudden cardiac death, and death due to coronary artery disease over a 30-year follow-up period. Quintiles of QTc (seconds) less than or equal to 0.36, 0.36 to 0.38, 0.39 to 0.40, 0.41 to 0.43 and greater than or equal to 0.44 were studied in relation to these outcomes. There were no significant differences in the risk of total mortality, sudden cardiac death or death due to coronary artery disease according to QTc. A similar lack of significant association between QTc and these 3 outcomes was observed among all persons studied and in the 2 sexes after using a multiple regression analysis to control for several potentially confounding characteristics including age, gender, cigarette smoking, serum total cholesterol, systolic systemic blood pressure and Framingham relative weight. The results of this study fail to demonstrate an association between baseline QTc and overall mortality, and deaths due to sudden cardiac events or coronary artery disease in a large population-based cohort of essentially healthy persons in whom pathologic forms of QTc prolongation are uncommon.

The diagnosis of a cervical ectopic pregnancy is often made intraoperatively in the presence of extensive hemorrhage during attempted evacuation. In some cases, hysterectomy has been the necessary treatment to control bleeding. We report two cases of cervical pregnancy detected by ultrasound. Before pregnancy termination, the uterine arteries were successfully embolized using angiographic techniques. As a result, surgical evacuation was performed with minimal hemorrhage; hysterectomy was not required and the patients' potential fertility was retained.

Eighteen patients undergoing total hip replacement (n = 13) or knee arthroplasty (n = 5) due to osteoarthritis or osteoarthrosis were prospectively studied in an investigation of complement activation and anaphylatoxin release in association with reinfusion of aspirated wound blood. Twelve of the patients needed blood transfusions and received an average of 390 +/- 75 ml (+/- SD) of autologous blood within 45 min. Plasma complement components, anaphylatoxins, and inhibitors were studied 1 min before and 15 min after the start of and 15 min after the completion of autologous transfusion. Samples also were taken from the collected blood, before and after passing it through a microporous filter. Blood gases and systemic complement samples were drawn simultaneously. There were no significant changes in systemic complement variables before, during, or after transfusion of autologous blood. However, in the aspirated blood, increased concentration of anaphylatoxins (C3a and C5a) and terminal complement complexes (TCC) were present (P less than 0.001). There were no differences observed between samples drawn before and after filtration of the blood. The concentration of C5 was less in the collected blood than in the systemic blood (P less than 0.05). No changes in blood gases were observed. This study demonstrated that postoperatively salvaged whole blood underwent anaphylatoxin formation and complement activation. However, after reinfusion of this blood, neither systemic complement activation nor clinical complications were observed.

To assess the relation of quantitative measures of coronary stenoses to the development of exercise-induced regional wall motion abnormalities, 34 patients with isolated, single vessel coronary artery lesions and normal wall motion at rest underwent exercise echocardiography and quantitative angiography on the same day. Although all 11 patients with a visually estimated stenosis greater than or equal to 75% had an ischemic response and 10 (91%) of 11 patients with a less than or equal to 25% visually estimated stenosis had a normal response by exercise echocardiography, among 12 patients with a visually estimated stenosis of 50%, 6 (50%) had an ischemic response and 6 (50%) had a normal exercise echocardiogram. Quantitative measurements of stenosis severity distinguished patients with ischemic (group 1) from normal (group 2) exercise echocardiographic responses as follows: minimal luminal diameter (mm), group 1 1.0 +/- 0.4 versus group 2 1.7 +/- 0.4, p less than 0.0001; minimal cross-sectional area (mm2), group 1 0.9 +/- 0.6 versus group 2 2.5 +/- 1.1, p less than 0.0001; percent diameter stenosis, group 1 68.3 +/- 14.2 versus group 2 42.2 +/- 12.1, p less than 0.0001; and percent area stenosis, group 1 87.5 +/- 7.8 versus group 2 64.8 +/- 15.9, p less than 0.0001. These data validate the utility of exercise echocardiography by demonstrating that 1) coronary stenosis severity measured by quantitative angiography is closely related to wall motion abnormalities detected by exercise echocardiography, and 2) exercise echocardiography can be used as a noninvasive means to assess the physiologic significance of coronary artery lesions.

To determine the feasibility and cost-saving potential of substituting outpatient for inpatient cardiac catheterization, 986 consecutive procedures were studied at a large referral hospital. Patients were classified prospectively as to their eligibility for outpatient cardiac catheterization according to published guidelines. Resource consumption was recorded, and cost savings were then calculated by analyzing the specific supply and personnel costs that could change as a result of inpatient versus outpatient status. Of the total of 986 patients who underwent diagnostic catheterization, 240 (24%) were outpatients, 279 (28%) were inpatients but had no exclusion criteria for outpatient catheterization and 467 (47%) were inpatients who had one or more exclusions for outpatient catheterization. The most common reasons for exclusion from outpatient catheterization were congestive heart failure (22%), unstable angina (15%), noncoronary heart disease (14%), recent myocardial infarction (11%) and severe noncardiac disease (9%). Inpatients with no exclusions for the outpatient procedure tended to be sicker than outpatients because they were older (p = 0.002), had a lower ejection fraction (p = 0.009) and had more triple vessel coronary artery disease (p less than 0.0001). The cost of the catheterization procedure itself was not different between inpatients and outpatients. Laboratory testing was more frequent among inpatients, however, and "room and board" costs were significantly higher. Although the difference in hospital charges for inpatients and outpatients was $580, a rigorous analysis indicated that the potential cost savings was only 38% of this amount, or $218 per eligible patient.(ABSTRACT TRUNCATED AT 250 WORDS)

To determine the value of a 6-month exercise treadmill test for detecting restenosis after elective percutaneous transluminal coronary angioplasty (PTCA), 303 consecutive patients with successful PTCA and without a recent myocardial infarction were studied. Among the 228 patients without interval cardiac events, early repeat revascularization or contraindications to treadmill testing, 209 (92%) underwent follow-up angiography, and 200 also had a follow-up treadmill test and formed the study population. Restenosis (greater than or equal to 75% luminal diameter stenosis) occurred in 50 patients (25%). Five variables were individually associated with a higher risk of restenosis: recurrent angina (p = 0.0002), exercise-induced angina (p = 0.0001), a positive treadmill test (p = 0.008), more exercise ST deviation (p = 0.04) and a lower maximum exercise heart rate (p = 0.05). However, only exercise-induced angina (p = 0.002), recurrent angina (p = 0.01) and a positive treadmill test (p = 0.04) were independent predictors of restenosis. Using these 3 variables, patient subsets could be identified with restenosis rates ranging from 11 to 83%. The exercise treadmill test added independent information to symptom status about the risk of restenosis after elective PTCA. Nevertheless, 20% of patients with restenosis had neither recurrent angina nor exercise-induced ischemia at follow-up. For more accurate detection of restenosis, the exercise treadmill test must be supplemented by a more definitive test.

Blood from 10 clinically healthy West Indian manatees (8 wild, 2 captive) was analyzed for the common blood chemical substances. No sex differences were found. The results were comparable for the most part to those of the common domestic mammals. Notable exceptions were the anion gaps, and total proteins and A/G ratios which were higher than those for domestic species. Some of these differences were no doubt due to the stress of capture.

4beta,5-Epoxy-5beta-androstane-3,17-dione (1a), 17beta-hydroxy-4beta,5-epoxy-5beta-androstan-3-one (1b) and 17beta-acetoxy-4beta,5-epoxy-5beta-androstan-3-one (1c) were treated with anhydrous hydrogen fluoride in pyridine (70% solution) at 55 detrees and yielded the corresponding 4-en-4-ols, e.g. 4-hydroxy-4-androstene-3,17-dione (2a). As the reaction temperature was lowered each epoxide formed a second product which, at -75 degrees, was the major component of the reaction mixture and was identified as the 5alpha-fluoro-4alpha-ol derivative of the parent enone, e.g. 4alpha-hydroxy-5-fluoro-5alpha-androstane-3,17-dione (3a). These fluorohydrins are thermally unstable, losing hydrogen fluoride. The acetates of -he fluorohydrins were also prepared, characterized, and shown to be more stable than the parent alcohols.

The humidity outputs of the Bain circuit, a traditional non-coaxial Mapleson D system, and a circle system with and without a soda lime absorber were evaluated in a laboratory model simulating a 70-kg subject. The breathing systems were tested with tidal volumes of 0.35 and 0.70 L and frequencies of 10-20 breaths/min to maintain an end-expiratory CO2 of 4.5%. There were small differences in inspiratory gas humidity between the Bain and the non-coaxial Mapleson D system. With a fresh gas flow of 5 L/min in the Bain circuit, the humidity was 9.8-16.5 mg H2O/L depending on tidal volume and respiratory frequency. The humidity output of the circle absorber system with fresh gas flows of 0.5 or 2 L/min was 21.6-25.2 mg H2O/L at 60 min. Therefore, this study does not support previous studies, which propose that the Bain circuit has superior humidifying properties compared with those of the circle absorber system.

Pregnancy outcome was examined in 59 clinically stable patients with rupture of the membranes at or before 26 weeks' gestation. The mean gestational age at rupture of the membranes was 23.2 weeks, and the mean latent period was 21.5 days. Delivery occurred within 7 days in 29 patients (49.2%), chorioamnionitis developed in 27 patients (45.8%), and operative delivery was required in 24 patients (40.7%). Sixty-three infants were delivered, with a perinatal mortality rate of 49.1%. Among survivors, 84% required newborn intensive care during the initial hospitalization, 77% were discharged with minor to moderate reversible sequelae, and 16% were discharged with sequelae that were likely to be of long-term duration. Obstetric factors present at rupture of the membranes were evaluated for their ability to predict maternal and neonatal morbid outcomes; obstetric interventions were evaluated for their ability to modify outcomes. These data suggest that outcomes in this subset of patients may not be uniformly dismal, and support clinical decision-making on an individualized basis.

In a laboratory model, humidity output was investigated in relation to the design of a circle absorber system. A 70-kg subject was simulated with fresh gas flows of 0.5, 2 or 5 litre min-1. Different circle systems, absorption canisters and tubings were studied. It was found that both the type of circle system (according to Eger's classification) and the size of the absorption canister, influenced the humidity of inspired gases. Coaxial tubing only moderately increased the humidity. If a fresh gas flow of 0.5 liter min-1 was used, optimum moisture contents were attained, irrespective of the circle system tested. Low fresh gas flows, a small canister and an Eger A type circle system, were factors which increased humidification.