[Tension pneumoperitoneum as complication in a case of perioperative barotrauma]. / Neumoperitoneo a tensión como complicación en un caso de barotrauma peroperatorio.

Tension pneumoperitoneum is rare complication that causes severe changes in respiratory and cardiocirculatory function. We report the case of an 84 year old woman who developed tension pneumoperitoneum soon after cholecystectomy by subcostal laparotomy. Tension pneumoperitoneum presented with barotrauma, bilateral pneumothorax, extensive subcutaneous and pneumomediastinum and was accompanied by severe worsening of hemodynamic variables and gas exchange. After confirming the diagnosis by emergency CT scan, the first therapeutic action was decompression of the peritoneal. This fast, simple maneuver was followed by rapid hemodynamic and respiratory improvement. Tension pneumoperitoneum similar to the case we report has been described as a complication of mechanical ventilation and barotrauma; however, the possibility that the clinical picture might be caused by perforation of a hollow viscera has given rise to a variety of suggested therapeutic alternatives, including exploratory laparotomy, which has sometimes later proven to have been unnecessary. In the light of the case we report and the literature, we suggest a therapeutic sequence starting with emergency abdominal decompression and to fulfill two objectives: a) to remove the threat to life, and b) to limit the practice of emergency exploratory laparotomy to cases in which that technique is truly indicated.

Neumoperitoneo a tensión como complicación en un caso de barotrauma peroperatorio / Tension pneumoperitoneum: a complication in a case of barotrauma

El neumoperitoneo a tensión es una rara complicación que causa graves alteraciones en las funciones respiratoria y cardiocirculatoria. Describimos el caso de una mujer de 84 años de edad que presentó este cuadro en el postoperatorio inmediato de una colecistectomía practicada por laparotomía subcostal. El neumoperitoneo a tensión se manifestó, en el contexto de un cuadro de barotrauma, asociado a neumotórax bilateral, neumomediastino y enfisema subcutáneo extenso, y se acompañó de un grave deterioro hemodinámico y del intercambio de gases. Tras confirmar el diagnóstico mediante TAC abdominal urgente, la primera medida terapéutica consistió en la descompresión de la cavidad peritoneal mediante la inserción de un sistema de punción-lavado peritoneal. Esta maniobra, sencilla y de rápida ejecución, se siguió de una rápida mejoría hemodinámica y respiratoria. Aunque, como en el caso que presentamos, el neumoperitoneo a tensión ha sido previamente descrito como una complicación ligada a la ventilación mecánica y al barotrauma, las dudas sobre un posible origen en una perforación de víscera hueca han llevado, en algunos casos, a aplicar alternativas más agresivas, como la laparotomía exploratoria, que a posteriori han resultado innecesarias. A la luz de la experiencia que describimos y la bibliografía disponible, proponemos una secuencia terapéutica que, iniciándose en la descompresión abdominal urgente, tiene como objetivos: a) superar la situación de riesgo vital, y b) limitar la práctica de laparotomías exploratorias urgentes a los casos en que se hallen realmente indicadas (AU)

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Use of and interest in alternative therapies among adult primary care clinicians and adult members in a large health maintenance organization.

During spring 1996, random samples of adult primary care physicians, obstetrics-gynecology physicians and nurse practitioners, and adult members of a large northern California group practice model health maintenance organization (HMO) were surveyed by mail to assess the use of alternative therapies and the extent of interest in having them incorporated into HMO-delivered care. Sixty-one percent (n = 624) of adult primary care physicians, 70% (n = 157) of obstetrics-gynecology clinicians, and 50% (2 surveys, n = 1,507 and n = 17,735) of adult HMO members responded. During the previous 12 months, 25% of adults reported using and nearly 90% of adult primary care physicians and obstetrics-gynecology clinicians reported recommending at least 1 alternative therapy, primarily for pain management. Chiropractic, acupuncture, massage, and behavioral medicine techniques such as meditation and relaxation training were most often cited. Obstetrics-gynecology clinicians used herbal and homeopathic medicines more often than adult primary care physicians, primarily for menopause and premenstrual syndrome. Two thirds of adult primary care physicians and three fourths of obstetrics-gynecology clinicians were at least moderately interested in using alternative therapies with patients, and nearly 70% of young and middle-aged adult and half of senior adult members were interested in having alternative therapies incorporated into their health care. Adult primary care physicians and members were more interested in having the HMO cover manipulative and behavioral medicine therapies than homeopathic or herbal medicines.

Measuring Beam Sizes and Ultra-Small Electron Emittances Using an X-ray Pinhole Camera.

A very simple pinhole camera set-up has been built to diagnose the electron beam emittance of the ESRF. The pinhole is placed in the air next to an Al window. An image is obtained with a CCD camera imaging a fluorescent screen. The emittance is deduced from the size of the image. The relationship between the measured beam size and the electron beam emittance depends upon the lattice functions alpha, beta and eta, the screen resolution, pinhole size and photon beam divergence. The set-up is capable of measuring emittances as low as 5 pm rad and is presently routinely used as both an electron beam imaging device and an emittance diagnostic.

Effects of methoxamine on spontaneous uterine activity and blood flow of the rat uterus 'in vivo'.

The vascular (blood pressure, heart rate and peripheral blood flow) and uterine (spontaneous motility) responses to intravenous methoxamine were studied in anaesthetized rats pre-treated with diethylstilboestrol. Methoxamine produced an increase (0.5-2 mg/kg) or did not modify (0.01 and 3 mg/kg) spontaneous uterine motility. The alpha 1-agonist also induced a hypertensive effect (0.1-3 mg/kg) accompanied by bradycardia at the highest doses, and a decrease in blood flow significantly greater in intestinal than uterine tissues. These effects were abolished by prazosin. The uterine action of methoxamine in vivo appears to result from the balance between myometrial alpha 1-excitatory effect and vascular alpha 1-vasoconstriction which induced uterine inhibition. The oestrogens appear to protect the alpha 1-mediated vasoconstriction.