Experience with high frequency oscillation ventilation during the 2009 H1N1 influenza pandemic in Australia and New Zealand.

During the 2009 H1N1 pandemic, large numbers of patients had severe respiratory failure. High frequency oscillation ventilation was used as a salvage technique for profound hypoxaemia. Our aim was to compare this experience with high frequency oscillation ventilation during the 2009 H1N1 pandemic with the same period in 2008 by performing a three-month period prevalence study in Australian and New Zealand intensive care units. The main study end-points were clinical demographics, care delivery and survival. Nine intensive care units contributed data. During 2009 there were 22 H1N1 patients (17 adults, five children) and 10 non-H1N1 patients (five adults, five children), while in 2008, 18 patients (two adults, 16 children) received high frequency oscillation ventilation. The principal non-H1N1 high frequency oscillation ventilation indication was bacterial or viral pneumonia (56%). For H1N1 patients, the median duration of high frequency oscillation ventilation was 3.7 days (interquartile range 1.8 to 5) with concomitant therapies including recruitment manoeuvres (22%), prone ventilation (41%), inhaled prostacyclins (18%) and inhaled nitric oxide (36%). Seven patients received extracorporeal membrane oxygenation, six having H1N1. Three patients had extracorporeal membrane oxygenation concurrently, two as salvage therapy following the commencement of high frequency oscillation ventilation. In 2008, no high frequency oscillation ventilation patient received extracorporeal membrane oxygenation. Overall hospital survival was 77% in H1N1 patients, while survival in patients having adjunctive extracorporeal membrane oxygenation was similar to those receiving high frequency oscillation ventilation alone (65% compared to 71%, P = 1.00). Survival rates were comparable to published extracorporeal membrane oxygenation outcomes. High frequency oscillation ventilation was used successfully as a rescue therapy for severe respiratory failure. High frequency oscillation ventilation was only available in a limited number of intensive care units during the H1N1 pandemic.

The effect of dexmedetomidine on agitation during weaning of mechanical ventilation in critically ill patients.

Ventilated patients receiving opioids and/or benzodiazepines are at high risk of developing agitation, particularly upon weaning towards extubation. This is often associated with an increased intubation time and length of stay in the intensive care unit and may cause long-term morbidity. Anxiety, fear and agitation are amongst the most common non-pulmonary causes of failure to liberate from mechanical ventilation. This prospective, open-label observational study examined 28 ventilated adult patients in the intensive care unit (30 episodes) requiring opioids and/or sedatives for >24 hours, who developed agitation and/or delirium upon weaning from sedation and failed to achieve successful extubation with conventional management. Patients were ventilated for a median (interquartile range) of 115 [87 to 263] hours prior to enrolment. Dexmedetomidine infusion was commenced at 0.4 microg/kg/hour for two hours, after which concurrent sedative therapy was preferentially weaned and titrated to obtain target Motor Activity Assessment Score score of 2 to 4. The median (range) maximum dose and infusion time of dexmedetomidine was 0.7 microg/kg/hour (0.4 to 1.0) and 62 hours (24 to 252) respectively. The number of episodes at target Motor Activity Assessment Score score at zero, six and 12 hours after commencement of dexmedetomidine were 7/30 (23.3%), 28/30 (93.3%) and 26/30 (86.7%), respectively (P < 0.001 for 6 and 12 vs. 0 hours). Excluding unrelated clinical deterioration, 22 episodes (73.3%) achieved successful weaning from ventilation with a median (interquartile range) ventilation time of 70 (28 to 96) hours after dexmedetomidine infusion. Dexmedetomidine achieved rapid resolution of agitation and facilitated ventilatory weaning after failure of conventional therapy. Its role as first-line therapy in ventilated, agitated patients warrants further investigation.

Early at-risk alcohol intake. Definitions and physicians' role in modifying behaviour.

OBJECTIVE: To learn from a sample of general practitioners and their patients how they define early at-risk alcohol intake and what they perceive the physician's role in helping patients with early at-risk alcohol intake to be. DESIGN: Survey questionnaire. SETTING: Family practices in Kamloops, BC, and the Department of Family Practice at Vancouver General Hospital. PARTICIPANTS: Thirty-one family physicians and 860 of their patients. MAIN OUTCOME MEASURES: Demographic variables and definitions of alcohol intake, opinions on appropriate interventions for physicians. RESULTS: Patients' median estimate for the limit of early, at-risk drinking for a 75-kg man was two drinks per day an 11 drinks per week; doctors' estimate was 1.5 drinks per day and nine drinks per week. For a 55-kg woman, patients set risk to begin at 1.5 drinks per day and nine drinks per week; doctors set it at 1.2 per day and eight per week. However, patients thought there should be 4.3 alcohol-free days each week and doctors thought 3.5, both answers inconsistent with the daily and weekly limits set. Most (85%) patients and 97% of doctors think doctors should ask about drinking behaviour; yet only 42% of these patients recalled ever being asked how much they drank. CONCLUSIONS: Both physicians and patients have stringent definitions of early at-risk drinking and believe physicians should intervene. Physicians appear to be intervening less often than expected.

Spindle cell hemangioendothelioma: a case presentation and literature review of a rare lower extremity tumor.

The authors present a rare soft tissue mass of the lower extremity that has been presented in the podiatric literature only once. Spindle cell hemangioendothelioma was first identified 9 years ago, and approximately 45 cases have been documented in the literature. This lesion presents as a slow growing and often painless lesion of the extremities, with low malignant potential and high local recurrence. This patient was treated with surgical excision after a mass, which had been present for more than 10 years, began enlarging and became painful. A review of the literature and the case presentation will be given.

Mobilizing physicians to conduct clinical intervention in tobacco use through a medical-association program: 5 years' experience in British Columbia.

During the last 5 years, a program run by the medical association in British Columbia has recruited 23% of the province's general practitioners (GPs) to take an active, systematic approach to clinical intervention in tobacco use. Another 9% of GPs (considered "semi-active") regularly use the program's educational materials for patients, and another 25% have been trained in intervention or have been given intervention materials or both. If the cessation rate (rate of patients who quit smoking who would not otherwise have done so) was 4% among physicians actively involved in intervention and 2% among physicians considered semi-active, in 1995 an estimated 4700 smokers quit and were followed by their GPs as a result of the program. Another 135,000 smokers received brief counselling from their GPs and were also followed. This article reviews the strategies and methods used in this program to mobilize physicians.

Helping patients to quit smoking.

Years ago, the tobacco leaf offered its users many social and ceremonial benefits. But today, throughout the world, the manufactured cigarette wreaks biological havoc. Clinically, physicians can make a small, but significant, contribution to their patients' stopping smoking. Family physicians who want to offer systematic aid to their smoking patients should assess the amount of time and energy they are willing to invest in patients' smoking and the probable rewards of such efforts. Behavioural change comprises four stages: a pre-motivational phase, a motivational phase, a behavioural-change phase, and a maintenance phase. Anyone who has ever smoked belongs to one of these phases and should be treated accordingly. Paradoxically, the physician should support consonant smoking (the patient freely choosing to smoke) except when the smoker is actively engaged in changing behaviour.

Comparison of continuous transcutaneous and continuous intravascular PO2 measurement in fetal sheep.

Continuously monitored carotid arterial PO2 (PaO2) and transcutaneous PO2 (tcPO2) from the scalp of fetuses from ewes not in labor have been compared under epidural anesthesia at different levels of fetal oxygenation. A reasonably good correlation existed between the two readings at normal and high PO2 values. In sharp contrast, at low PaO2 levels there was a considerable bias between the two. Since this bias was variable, the failure of tcPO2 to reflect PaO2 accurately at low PaO2 renders the use of the tcPO2 electrode questionable in the very situation for which it was advocated, namely, the prediction of fetal compromise.

Ultrastructural changes in the placenta of the ewe after fetal pituitary stalk section.

Binucleate cells are a normal component of the ovine chorionic epithelium, but are usually separated from the fetal-maternal interface by a thin layer of cytoplasm derived from the principal or uni-nucleate cells of the trophoblast. They are distinguished not only by two distinct and separate nuclei, but also by conspicuous membrane-bound cytoplasmic inclusions in the form of haloed droplets. After fetal pituitary stalk section binucleate cells move up to and participate in the formation of the fetal-maternal interface; furthermore they extend clear blunt-ended pseudopodia into the maternal epithelial syncytium. These activities do not appear to be supppressed by fetal infusion of cortisol or ACTH. The apparent motility of binucleate cells, together with the presence of haloed droplets within the maternal epithelial syncytium, suggests that after fetal pituitary stalk section binucleate cells invade the uterine syncytium, lose their limiting membranes and discharge their contents into the syncytial cytoplasm. Large molecules such as ovine placental lactogen may be transported from fetal to maternal tissues by this mechanism.

Pituitary stalk-section and some of its effects on endocrine function in the fetal lamb.

A detailed description is given of a method to section the pituitary stalk of the fetal lamb after 105 days gestational age. The approach to the stalk is made through a window in the frontal bone. In order to prevent regeneration of the hypothalamo-pituitary connections a silicone plate is introduced through the probe used to fracture the stalk. The surgical outcome and viability of 11 pituitary stalk sectioned fetuses is described over periods of up to 23 days. The presence of pituitary infarction following stalk section was related to damage of the anterior hypophysial vesssels if the probe was deviated from the mid-line at any time in its course. The effect of this procedure on fetal plasma T4 and PRL concentrations and the initiation of premature labour by the continuous infusion of cortisol into the fetus is described.

The significance of isolating low numbers of mycobacterium tuberculosis in culture of sputum specimens.

Because fewer than five Mycobacterium tuberculosis colonies were isolated from single sputum specimens from several patients with little clinical evidence of pulmonary tuberculosis, we reviewed all of our low colony isolates (LCIs) from an 18-month period. Thirty-one patients had 35 LCIs and were separated easily into groups that either appeared to have tuberculosis by clinical criteria or appeared to be uninfected. Patients in the "tuberculosis likely" group reasons such as concurrent antituberculosis therapy or an interstitial location of their pulmonary lesion to account for their LCIs. In contrast, patients in the "tuberculosis unlikely" group were all culture-negative when reevaluated two to four months after their first culture, and they had no evidence of tuberculosis on chest x-ray film despite having received no antituberculosis therapy. Half had negative tuberculin reactions, without generalized anergy. Epidemiologic study showed that most had been cultured the same day as patients with smear-positive tuberculosis, and the possibility of cross-contamination was investigated.